A Rapid MRI Protocol for the Evaluation of Acute Pediatric Musculoskeletal Infections: Eliminating Contrast and Decreasing Anesthesia, Scan Time, and Hospital Length of Stay and Charges.

BACKGROUND: Acute musculoskeletal infection affects >1 in 6,000 children in the United States annually. Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of musculoskeletal infection, but it traditionally requires contrast and anesthesia for children, delaying management. A rapid MRI protocol involves MRI without anesthesia and with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to identify abscesses. We hypothesized that a rapid MRI protocol would improve imaging and treatment efficiency for pediatric patients undergoing musculoskeletal infection evaluation without substantially affecting accuracy. METHODS: This was a single-center, retrospective study of patients undergoing evaluation for musculoskeletal infection before (60 patients in the traditional cohort [TC]) and after (68 patients in the rapid cohort [RC]) implementation of the rapid MRI protocol. Sociodemographic and clinical variables were extracted from electronic health records, and statistical comparisons were performed. RESULTS: The anesthesia rates were 53% for the TC and 4% for the RC, and the contrast administration rates were 88% for the TC and 0% for the RC. The median time to MRI after ordering was 6.5 hours (95% confidence interval [CI], 5.0 to 8.6 hours) for the TC and 2.2 hours (95% CI, 1.4 to 3.6 hours) for the RC (p < 0.01). The median duration of MRI was 63.2 minutes (95% CI, 56.8 to 69.6 minutes) for the TC and 24.0 minutes (95% CI, 21.1 to 29.5 minutes) for the RC (p < 0.01). The median hospital length of stay was 5.3 days (95% CI, 3.7 to 6.9 days) for the TC and 3.7 days (95% CI, 1.9 to 4.1 days) for the RC (p < 0.01). The median hospital charges were $47,309 (95% CI, $39,137 to $58,769) for the TC and $32,824 (95% CI, $22,865 to $45,339) for the RC (p < 0.01). Only 2 positive cases of musculoskeletal infection in the RC were missed on the initial imaging, but these instances were not attributable to the rapid protocol itself. Although 10 of 68 rapid MRI scans resulted in nondiagnostic outcomes due to patient motion, only 6 of 68 required repeat MRI with anesthesia. CONCLUSIONS: In patients evaluated for musculoskeletal infection, the rapid MRI protocol eliminated contrast and minimized anesthesia while improving MRI access and decreased scan and interpretation times, hospital length of stay, and hospital charges. The rapid MRI protocol had high sensitivity for diagnosing musculoskeletal infection and a low rate of imaging failure. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Screen Time, Sociodemographic Factors, and Psychological Well-Being Among Young Children.

Importance: Young children's screen time increased during the COVID-19 lockdown in 2020, but it is unknown whether their screen time returned to prepandemic levels in 2021. Knowledge of the relationship between screen time and child development and health will inform prevention and intervention targets and strategies. Objective: To evaluate screen time by family income and race and ethnicity in the prepandemic (ie, 2018, 2019) and pandemic (ie, 2020, 2021) periods and to examine the relationship between screen time and psychological well-being among young children in the US. Design, Setting, and Participants: Cross-sectional population-based web or mail survey study of 2018-2021 National Survey of Children's Health participants aged 6 months to 5 years. Exposure: Daily screen time (<1, 1, 2, 3, or ≥4 h/d) reported by participants' primary caregivers. Main outcomes and Measures: Flourishing and externalizing behaviors, as indicators of psychological well-being. All analyses were weighted, accounting for the complex survey sample design. Results: Of the 48 775 participants (50.7% female), the proportion of those with high screen time (defined as ≥1 h/d for children aged 6 months-1 year and ≥2 h/d for children aged 2-5 years) was 48.5% (95% CI, 46.3%-50.7%) in 2018, 49.2% (95% CI, 47.0%-51.5%) in 2019, 55.3% (95% CI, 53.4%-57.2%) in 2020, and 50.0% (95% CI, 48.3%-51.6%) in 2021. Among children living in poverty (federal poverty level <100%), the proportion of those with high screen time was 48.7% (95% CI, 42.8%-54.6%) in 2018, 52.0% (95% CI, 45.4%-58.6%) in 2019, 60.9% (95% CI, 55.4%-66.4%) in 2020, and 58.9% (53.7%-64.1%) in 2021. Adjusted odds ratio of flourishing was 0.66 (95% CI, 0.51-0.85), 0.81 (95% CI, 0.66-0.99), 0.68 (95% CI, 0.52-0.88), and 0.53 (95% CI, 0.42-0.69) for less than 1, 2, 3, and 4 or more hours per day vs 1 hour per day of screen time, respectively, among children aged 3 to 5 years. No association between screen time and flourishing was found among children aged 6 months to 2 years. An adjusted externalizing behavior score was higher by 0.2 points (95% CI, -0.1 to 0.5), 0.5 points (95% CI, 0.3 to 0.8), 1.3 points (95% CI, 1.0 to 1.6), and 2.1 points (95% CI, 1.7 to 2.5) for less than 1, 2, 3, and 4 or more hours per day vs 1 hour per day of screen time, respectively, among children aged 3 to 5 years. Conclusions and Relevance: In this multiyear cross-sectional study of a representative sample of young children in the US, the increased prevalence of high screen time in 2020 returned to prepandemic levels in 2021; however, it remained elevated in children living in poverty. Two hours or more of daily screen time was associated with lower psychological well-being among preschool-aged children.

Step cadence as a novel objective postoperative recovery metric in children who undergo laparoscopic appendectomy.

BACKGROUND: Daily step counts from consumer wearable devices have been used to objectively assess postsurgical recovery in children. However, step cadence, defined as steps taken per minute, may be a more specific measure of physiologic status. The purpose of this study is to define objective normative physical activity recovery trajectories after laparoscopic appendectomy using this novel metric. We hypothesized that patients would have a progressive increase in peak cadence until reaching a plateau representing baseline status, and this would occur earlier for simple compared with complicated appendicitis. METHODS: Children aged 3 to 18 years were enrolled after laparoscopic appendectomy for simple or complicated appendicitis between March 2019 and December 2022 at a tertiary children's hospital. Participants wore a Fitbit for 21 postoperative days. The peak 1-minute cadence and peak 30-minute cadence were determined each postoperative day. Piecewise linear regression was conducted to generate normative peak step cadence recovery trajectories for simple and complicated appendicitis. RESULTS: A total of 147 children met criteria (53.7% complicated appendicitis). Patients with simple appendicitis reached plateau postoperative day 10 at a mean peak 1-minute cadence of 111 steps/minute and a mean peak 30-minute cadence of 77 steps/minute. The complicated appendicitis recovery trajectory reached a plateau postoperative day 13 at a mean peak 1-minute cadence of 106 steps/minute and postoperative day 15 at a mean peak 30-minute cadence of 75 steps/minute. CONCLUSION: Using step cadence, we defined procedure-specific normative peak cadence recovery trajectories after laparoscopic appendectomy. This can empower clinicians to set data-driven expectations for recovery after surgery and establish the groundwork for consumer wearable devices as a post-discharge remote monitoring tool.

Injury Patterns in Highly Specialized Youth Athletes: A Comparison of 2 Pathways to Specialization.

CONTEXT: Sport specialization, commonly defined as intensive year-round training in a single sport to the exclusion of other sports, has been associated with an increased risk for overuse injury. Two pathways to becoming highly specialized are recognized: (1) having only ever played 1 sport (exclusive highly specialized) and (2) quitting other sports to focus on a single sport (evolved highly specialized). Understanding the differences in injury patterns between these groups of highly specialized athletes will inform the development of injury-prevention strategies. OBJECTIVE: To compare the distribution of injury types (acute, overuse, serious overuse) among evolved highly specialized athletes, exclusive highly specialized athletes, and low-moderately specialized athletes. DESIGN: Cross-sectional study. SETTING: Tertiary care pediatric sports medicine clinic between January 2015 and April 2019. PATIENTS OR OTHER PARTICIPANTS: A total of 1171 patients (age = 12.01-17.83 years, 59.8% female) who played ≥1 organized sports, presented with a sport-related injury, and completed a sports participation survey. MAIN OUTCOME MEASURE(S): Distribution of injury types (acute, overuse, serious overuse). RESULTS: The percentage of injuries due to overuse was similar between the exclusive and evolved highly specialized athletes (59.2% versus 53.9%; P = .28). Compared with low-moderately specialized athletes, exclusive and evolved highly specialized athletes had a higher percentage of overuse injuries (45.3% versus 59.2% and 53.9%, respectively; P = .001). Multivariate analysis of the highly specialized groups revealed sport type to be a significant predictor of a higher percentage of injuries due to overuse, with individual-sport athletes having increased odds of sustaining an overuse injury compared with team-sport athletes (odds ratio = 1.95; 95% CI = 1.17, 3.24). CONCLUSIONS: The distribution of injury types was similar between evolved and exclusive highly specialized youth athletes, with both groups having a higher percentage of injuries due to overuse compared with low-moderately specialized athletes. Among highly specialized athletes, playing an individual sport was associated with a higher proportion of overuse injuries compared with playing a team sport.

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy.

INTRODUCTION: Markers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis. METHODS: Children ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed. RESULTS: Eighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory. CONCLUSIONS: This study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease.

BACKGROUND: While intravenous fluid (IVF) therapy in patients with sickle cell disease (SCD) admitted for a vaso-occlusive episode (VOE) can help reduce red blood cell sickling, clinical practice varies across institutions. We examined the relationship between IVF therapy and hospital length of stay (HLOS), as well as adverse events, such as acute chest syndrome (ACS), pediatric intensive care unit (PICU) transfer, and 28-day re-admission. METHODS: This is a single-center retrospective analysis of SCD VOE hospitalizations between January 2015 and April 2020. Patients with SCD, age 0-30, with consecutive hospitalizations for VOE were included. For the first 3 days of each admission, an "IVF ratio" was calculated by dividing actual IVF rate administered by weight-based maintenance IVF (mIVF) rate. RESULTS: A total of 617 hospitalizations for 161 patients were included. Mean HLOS was 5.7 days, (SD 3.9), and mean IVF volume over the first 3 days of admission was 139.6 mL/kg/day (SD 57.8). Multivariate analysis showed that for each additional 0.5 times the mIVF rate, HLOS increased by 0.53 day (p < .001; 95% confidence interval [CI]: 0.609-0.989), but there was no significant association between IVF therapy and adverse events. History of chronic pain was associated with increased odds of re-admission (OR 6.4; 95% CI: 3.93-10.52). CONCLUSIONS: Despite the theoretical potential for IVF therapy to slow down the sickling process, our findings suggest that increased IVF therapy was associated with prolonged HLOS, which places a burden on patients, families, and the health system.

Using Wearable Devices to Profile Demographic-Specific Recovery After Pediatric Appendectomy.

INTRODUCTION: Counseling patients and parents about the postoperative recovery expectations for physical activity after pediatric appendectomy varies significantly and is not specific to patients' demographic characteristics. Consumer wearable devices (CWD) can be used to objectively assess patients' normative postoperative recovery of physical activity. This study aimed to develop demographic-specific normative physical activity recovery trajectories using CWD in pediatric patients undergoing appendectomy. METHODS: Children ages 3-18 y old undergoing laparoscopic appendectomy for acute appendicitis were recruited. Patients wore a Fitbit device for 21 d postoperatively and daily step counts were measured. Patients with postoperative complications were excluded. Segmented regression models were fitted and time-to-plateau was estimated for patients with simple and complicated appendicitis separately for each age group, sex, race/ethnicity, and body mass index category. RESULTS: Among 147 eligible patients; 76 (51.7%) were female, 86 (58.5%) were in the younger group, and 79 (53.7%) had complicated appendicitis. Patients 3-11 y old demonstrated a faster trajectory to a physical activity plateau compared to those 12-18 in both simple (postoperative day [POD] 9 versus POD 17) and complicated appendicitis (POD 17 versus POD 21). Males and females had a similar postoperative recovery trajectory in simple and complicated appendicitis. There was no clear pattern differentiating trajectories based on race/ethnicity. Overweight/obese patients demonstrated a slower recovery trajectory in simple appendicitis. CONCLUSIONS: This study demonstrates that factors other than the disease itself, such as age, may affect recovery, suggesting the need for more tailored discharge instructions. CWDs can improve our understanding of recovery and allow for better data-driven counseling perioperatively.

Racial and ethnic differences in physical activity among mothers of young children: 2011-2018 NHANES.

BACKGROUND: American women tend to reduce physical activity (PA) during the transition to motherhood. Their main barrier to participation in PA is lack of time due to new/increased parenting and housework responsibilities. Because there are known racial/ethnic variations in time spent on housework among American women, their PA changes during the transition to motherhood might also differ by racial/ ethnic background. This study aimed to compare PA between American mothers of young child(ren) under age 5 years (YC) and American women without children by their racial/ethnic background. METHODS: Secondary data analyses were conducted using 2011-2018 US National Health and Nutrition Survey data. The study sample included 4,892 women aged 20-45 years (Asian n = 760; Black n = 1,162; Hispanic n = 1,324; White n = 1,646). Participants completed a Physical Activity Questionnaire that asked about participation in transportation and leisure-time moderate- and vigorous-intensity PA (MVPA; minutes/week). Multivariable regression analyses were conducted to compare MVPA among women living without children and with YC (no older children) in each of the racial/ethnic groups. RESULTS: Overall, the prevalence of physical inactivity, defined as zero minutes of MVPA in a typical week, was 43% (95% CI = 38-49%) vs. 32% (95% CI = 29-35%) among women living with YC vs. without children. The adjusted odds of physical inactivity for women living with YC, compared to women living without children, was significantly higher among Asian (OR = 2.08 [95% CI = 1.37-3.17]) and White women (OR = 1.63 [95% CI = 1.11-2.38]), while it was statistically insignificant among Hispanic and Black women. Among women who reported participating in MVPA, Asian women living with YC had 35 fewer minutes/week of MVPA than their counterparts living without children (p = 0.06), while other racial and ethnic groups showed no significant differences. CONCLUSIONS: American mothers of YC were less likely to engage in transportation or leisure-time MVPA, compared to those living without children. This association was particularly strong among Asian women. The study results suggest that a PA reduction in the transition to motherhood may be particularly large among Asian American women, calling for targeted efforts for PA promotion among Asian American mothers of YC; e.g., culturally-tailored community-based physical activity programs for Asian American mothers.

Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure.

INTRODUCTION: The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS: This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS: Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS: We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.

Applying machine learning to consumer wearable data for the early detection of complications after pediatric appendectomy.

When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.

Physical activity and TV viewing parenting practices for toddlers among South Asian and white families in the UK: born in Bradford 1000 study.

BACKGROUND: Children of South Asian (SA) origin in the UK have lower levels of physical activity (PA), compared to their White counterparts. Parents play an important role in establishing PA habits among young children. The aim of this study was to compare PA and television (TV) viewing parenting practices for young children between SA British (SAB) and White British (WB) parents living in the UK. METHODS: We conducted a secondary analysis of the Born in Bradford (BiB) 1000 study, using survey data at child ages 24 and 36 months. The study sample included three groups of mothers (n = 1,149): foreign-born SAB (n = 458), UK-born SAB (n = 276), and WB (n = 455). Mothers completed a survey about parenting practices (i.e., PA supports, PA restrictions, TV viewing restrictions) at child age 24 months and child PA and TV viewing behaviors at child ages 24 and 36 months. Parenting practices were compared among the three groups. Multivariable linear regression analyses compared children's weekly walking frequency and daily TV viewing hours by parenting practices in the three groups. RESULTS: The foreign-born SAB group showed the lowest frequencies of PA-supportive parenting practices (verbal encouragement: 3.7 ± 3.1 times/week; logistic support: 1.5 ± 1.8 times/week) and the highest frequencies of PA-restrictive parenting practices (7.8 ± 7.7 times/week) among the three groups (p < 0.01). Children of Foreign-born SAB mothers had the most frequent TV watching during a mealtime (4.0 ± 3.1 times/week) among the three groups (p < 0.01). Less frequent PA-supportive parenting practices and SA ethnicity were associated with lower walking frequency at 24 and 36 months of age among children (p < 0.01). More frequent exposure to TV at mealtimes and SA ethnicity were associated with higher TV viewing time at 24 and 36 months of age among children (p < 0.01). CONCLUSIONS: This study demonstrated that SAB parents, particularly those who are foreign-born, apply parenting practices for their young children that are less supportive of PA and more supportive of TV viewing, and their children have lower PA and higher TV viewing time, compared with their WB counterparts.

Assessment of post-concussion emotional symptom load using PCSS and PROMIS instruments in pediatric patients.

OBJECTIVES: The purpose of this study is to evaluate the utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depressive symptom domains in conjunction with the Post-Concussion Symptom Scale (PCSS)for identifying pediatric patients with emotional symptoms following a concussion, and to identify predictors of higher emotional symptom loads. METHODS: We recruited English-speaking patients aged 8-17 years presenting to a tertiary-care concussion clinic from 2014 to 2018 (n = 458). Demographics and clinical data including PCSS, injury date, previous history of anxiety/depression, and Vestibular/Ocular-Motor Screen (VOMS) were collected from patients' electronic medical records. Participants completed surveys in the PROMISTM Pediatric Item Bank v1.1-Anxiety and Depressive Symptoms domains at their initial clinic visit. Multivariable linear regression identified predictors of higher emotional symptom loads. RESULTS: Overall, 425 (92.8%) reported ≥1 emotional symptom on either PROMIS or PCSS. Predictors of higher emotional symptom loads were abnormal VOMS, female sex, history of anxiety or depression, and longer time since injury. CONCLUSION: Our results suggest that adding PROMIS anxiety and depressive symptom surveys to pediatric concussion evaluations may identify more children with emotional symptoms, allowing clinicians to better direct post-concussion treatment and incorporate psychological support for patients if necessary. Future studies should examine whether earlier identification of emotional symptoms with these tools facilitates recovery and improves short- and/or long-term psychological outcomes in pediatric concussion.

Predictors for invasive home mechanical ventilation duration in bronchopulmonary dysplasia.

BACKGROUND: Children with bronchopulmonary dysplasia (BPD) who require invasive home mechanical ventilation (IHMV) are medically vulnerable and experience high caregiving and healthcare costs. Predictors for duration of IHMV in children with BPD remain unclear, which can make prognostication and decision-making challenging. METHODS: A retrospective cohort study of children with BPD requiring IHMV was conducted from independent children's hospital records (2005-2021). The primary outcome was IHMV duration, defined as time from initial discharge home on IHMV until cessation of positive pressure ventilation (day and night). Two new variables were included: discharge age corrected for tracheostomy (DACT) (chronological age at discharge minus age at tracheostomy) and level of ventilator support at discharge (minute ventilation per kg per day). Univariable Cox regression was performed with variables of interest compared to IHMV duration. Significant nonlinear factors (p < 0.05) were included in the multivariable analysis. RESULTS: One-hundred-and-nineteen patients used IHMV primarily for BPD. Patient median index hospitalization lasted 12 months (interquartile range [IQR] 8.0,14.4). Once home, half of the patients were weaned off IHMV by 36.0 months and 90% by 52.2 months. Being Hispanic/Latinx ethnicity (hazard ratio [HR] 0.14 (95% confidence interval [CI] 0.04, 0.53), p < 0.01) and having a higher DACT were associated with increased IHMV duration (HR 0.66 (CI 0.43, 0.98), p < 0.05). CONCLUSIONS: Disparity in IHMV duration exists among patients using IHMV after prematurity. Prospective multisite studies that further investigate new analytic variables, such as DACT and level of ventilator support, and address standardization of IHMV care are needed to create more equitable IHMV management strategies.

A Call to Expand the Scope of Digital Phenotyping.

Digital phenotyping refers to near-real-time data collection from personal digital devices, particularly smartphones, to better quantify the human phenotype. Methodology using smartphones is often considered the gold standard by many for passive data collection within the field of digital phenotyping, which limits its applications mainly to adults or adolescents who use smartphones. However, other technologies, such as wearable devices, have evolved considerably in recent years to provide similar or better quality passive physiologic data of clinical relevance, thus expanding the potential of digital phenotyping applications to other patient populations. In this perspective, we argue for the continued expansion of digital phenotyping to include other potential gold standards in addition to smartphones and provide examples of currently excluded technologies and populations who may uniquely benefit from this technology.

Examination of physical activity development in early childhood: protocol for a longitudinal cohort study of mother-toddler dyads.

BACKGROUND: Physical activity (PA) development in toddlers (age 1 and 2 years) is not well understood, partly because of a lack of analytic tools for accelerometer-based data processing that can accurately evaluate PA among toddlers. This has led to a knowledge gap regarding how parenting practices around PA, mothers' PA level, mothers' parenting stress, and child developmental and behavioral problems influence PA development in early childhood. METHODS: The Child and Mother Physical Activity Study is a longitudinal study to observe PA development in toddlerhood and examine the influence of personal and parental characteristics on PA development. The study is designed to refine and validate an accelerometer-based machine learning algorithm for toddler activity recognition (Aim 1), apply the algorithm to compare the trajectories of toddler PA levels in males and females age 1-3 years (Aim 2), and explore the association between gross motor development and PA development in toddlerhood, as well as how parenting practices around PA, mothers' PA, mothers' parenting stress, and child developmental and behavioral problems are associated with toddlerhood PA development (Exploratory Aims 3a-c). DISCUSSION: This study will be one of the first to use longitudinal data to validate a machine learning activity recognition algorithm and apply the algorithm to quantify free-living ambulatory movement in toddlers. The study findings will help fill a significant methodological gap in toddler PA measurement and expand the body of knowledge on the factors influencing early childhood PA development.

Paying Family Medical Caregivers for Children's Home Healthcare in Colorado: A Working Medicaid Model.

OBJECTIVE: To compare the characteristics and healthcare use of children with medical complexity who receive paid certified nursing assistant (CNA) care by a family member (family CNA) and by a traditional nonfamily member (nonfamily CNA). STUDY DESIGN: This was retrospective cohort study of children who received CNA care through Colorado's Medicaid paid family caregiving program between 2017 and 2019 by a home healthcare agency. We compared patient characteristics between the family CNA and nonfamily CNA groups. A multivariable Poisson regression model was used to compare hospitalization rates (days in the hospital per year), adjusting for patient age patient sex, nursing care, and complex chronic condition. RESULTS: Of 861 patients, 79% (n = 680) received family CNA care and 21% (n = 181) received nonfamily CNA care. Patient demographics and hospitalization did not differ between the groups, although patients who had family CNAs were less likely to receive additional nursing-level care (42% vs 60%, P < .01). Family and nonfamily CNA caregivers had similar characteristics, except that family CNA caregivers had substantially better 3-year retention (82% vs 9%, P < .01) despite lower average hourly pay ($14.60 vs $17.60 per hour, P < .01). Hospitalizations were rare (<10% of patients). In the adjusted model, patients who received family CNA care experienced 1 more hospitalized day per year, compared with patients who received nonfamily CNA care (P < .001). CONCLUSIONS: Paid family caregivers provided CAN-level care to children with medical complexity with a greater employee retention compared with nonfamily CNA caregivers, with marginally different hospitalization rates using a family-centered approach. This model may help address workforce shortages while also providing income to family caregivers.

The Joint Associations of Physical Activity and Sedentary Behaviors on Adiposity during Adolescence: The 1993 Pelotas (Brazil) Cohort Study.

A prior study conducted in high-income countries demonstrated that specific sedentary behavior, such as TV viewing, is prospectively associated with adiposity in both active and inactive adolescents. The aim of this study was to examine the joint associations of sedentary behaviors and moderate- and vigorous-intensity physical activity (MVPA) with adiposity among Brazilian adolescents. This prospective cohort study included 377 participants of the 1993 Pelotas (Brazil) Study who completed an accelerometry assessment at age 13 years and a dual-energy X-ray absorptiometry (DXA) assessment at age 18 years. Accelerometer-measured MVPA was dichotomized into high (≥60 min/day) and low (<60 min/day). Accelerometer-measured sedentary time (SED) was dichotomized into low (<49 min/h) and high (≥49 min/h) based on the median. Self-reported TV viewing time was also dichotomized into low (<3 h/day) and high (≥3 h/day) based on the median. We combined the two MVPA groups (high and low) and two SED groups (low and high) to form the four MVPA&SED groups: high&low, high&high, low&low, and low&high. We also created four MVPA&TV groups in the same manner. Fat mass index (FMI; kg/m2) was calculated using DXA-derived fat mass. Multivariable linear regression analyses compared FMI at 18 years among the four MVPA&SED groups and among the four MVPA&TV groups, adjusting for socioeconomic status, energy intake, and baseline adiposity. The analysis results showed that SED or TV viewing time was not prospectively associated with adiposity in both active and inactive Brazilian adolescents. This study suggests that the association between specific sedentary behaviors, such as TV viewing, and adiposity may differ across societal settings-in this case, high-income vs. middle-income countries.

Discordance between Subjective and Objective Assessments of Activity after Pediatric Appendectomy.

BACKGROUND: Physical activity recovery after pediatric surgery can be assessed using objective measures such as step counts, but practice currently relies on subjective assessment by proxy. It is unclear how subjective and objective assessments of activity relate. We compared caregiver assessment of return to normal physical activity after pediatric appendectomy to step count recovery measured by a Fitbit. METHODS: Pediatric patients who underwent appendectomy were recruited between 2020 and 2022 to be monitored for 21 d with a Fitbit. Patients were grouped by the postoperative day (POD) (7, 14, or 21) their caregiver first reported their activity was "back to normal." Objective return to normal step count was estimated for each group by modeling the inflection point from increasing steps to a plateau. These measures were determined discordant if the subjective report remained outside the modeled 95% confidence interval (CI) for the day the group plateaued. RESULTS: Thirty-nine simple appendicitis and 40 complicated appendicitis patients were recruited. Among simple appendicitis patients, daily steps plateaued on POD 10.8 (95% CI 7.4-14.3), POD 14.0 (95% CI 11.0-17.1), and POD 11.1 (95% CI 6.9-15.3) for the day 7, day 14, and day 21 groups, respectively. Complicated appendicitis groups plateaued on POD 12.8 (95% CI 8.7-16.9), POD 15.2 (95% CI 11.1-19.3), and POD 16.7 (95% CI 12.3-21.0), respectively. Significant discordance was observed between subjective and objective assessments for the day 7 and day 14 simple groups and for the day 7 complicated group. CONCLUSIONS: There was significant discordance between caregiver and accelerometer-assessed activity recovery after pediatric surgery. Development of objective measures of recovery could help standardize assessment of children's recovery after surgery.

Physical Activity among U.S. Preschool-Aged Children: Application of Machine Learning Physical Activity Classification to the 2012 National Health and Nutrition Examination Survey National Youth Fitness Survey.

Early childhood is an important development period for establishing healthy physical activity (PA) habits. The objective of this study was to evaluate PA levels in a representative sample of U.S. preschool-aged children. The study sample included 301 participants (149 girls, 3-5 years of age) in the 2012 U.S. National Health and Examination Survey National Youth Fitness Survey. Participants were asked to wear an ActiGraph accelerometer on their wrist for 7 days. A machine learning random forest classification algorithm was applied to accelerometer data to estimate daily time spent in moderate- and vigorous-intensity PA (MVPA; the sum of minutes spent in running, walking, and other moderate- and vigorous-intensity PA) and total PA (the sum of MVPA and light-intensity PA). We estimated that U.S. preschool-aged children engaged in 28 min/day of MVPA and 361 min/day of total PA, on average. MVPA and total PA levels were not significantly different between males and females. This study revealed that U.S. preschool-aged children engage in lower levels of MVPA and higher levels of total PA than the minimum recommended by the World Health Organization.

At-home end-tidal carbon dioxide measurement in children with invasive home mechanical ventilation.

BACKGROUND: Carbon dioxide concentration trending is used in chronic management of children with invasive home mechanical ventilation (HMV) in clinical settings, but options for end-tidal carbon dioxide (EtCO2 ) monitoring at home are limited. We hypothesized that a palm-sized, portable endotracheal capnograph (PEC) that measures EtCO2 could be adapted for in-home use in children with HMV. METHODS: We evaluated the internal consistency of the PEC by calculating an intraclass correlation coefficient of three back-to-back breaths by children (0-17 years) at baseline health in the clinic. Pearson's correlation was calculated for PEC EtCO2 values with concurrent mean values of in-clinic EtCO2 and transcutaneous CO2 (TCM) capnometers. The Bland-Altman test determined their level of agreement. Qualitative interviews and surveys assessed usability and acceptability by family-caregivers at home. RESULTS: CO2 values were collected in awake children in varied activity levels and positions (N = 30). The intraclass correlation coefficient for the PEC was 0.95 (p < 0.05). The correlation between the PEC and in-clinic EtCO2 device was 0.85 with a mean difference of -3.8 mmHg and precision of ±1.1 mmHg. The correlation between the PEC and the clinic TCM device was 0.92 with a mean difference of 0.2 mmHg and precision of ±1.0. Family-caregivers (N = 10) trialed the PEC at home; all were able to obtain measurements at home while children were awake and sometimes asleep. CONCLUSIONS: A portable, noninvasive device for measuring EtCO2 was feasible and acceptable, with values that trend similarly to currently in-practice, outpatient models. These devices may facilitate monitoring of EtCO2 at home in children with invasive HMV.