Cultural relevance of fine motor domain of the ASQ in Guatemala.

Previous research suggests that the Ages and Stages Questionnaire-3rd ed. (ASQ) fine motor domain (FMD) may not be culturally relevant for developmental screening in a rural Guatemalan community, as the FMD accounts for 40% of all abnormal screenings after a needs assessment in this community. We hypothesize this is due to a lack of exposure to objects assessed in the questionnaire, such as blocks or light switches. The FMD scores of rural Guatemalan children (n = 56) participating in a child development program were compared with Spanish- and English-speaking Latinx-American children attending a US primary care clinic and screened at yearly well-child checks. Groups were matched for age gender, and socioeconomic status. Item-level analyses explored differences across the three groups. In the Guatemalan sample, the FMD abnormal score rates were 16%, 62%, and zero in the 12-, 24-, and 36-month-old children, respectively. Abnormal scores for the Guatemalan sample on the 24-month ASQ-3 significantly differed (p = .01) when compared to the Latinx-American groups. The 24-month questionnaire has more questions about objects than the 12- and 36-month questionnaires, which may explain the higher rates of abnormal scores. Developmental screening with ASQ-3 may not adequately capture the skills of children in similar communities.

La investigación previa ha sugerido que el dominio de motricidad fina (FMD) del Cuestionario de Edades y Etapas - Tercera edición (ASQ) pudiera no ser culturalmente relevante para examinar el desarrollo en una comunidad rural de Guatemala, ya que el FMD representa el 40% de todas las examinaciones anormales después de la evaluación de necesidades en esta comunidad. Nuestra hipótesis es que esto se debe a la falta de exposición a objetos evaluados en el cuestionario, tales como bloques o interruptores de luz. Se compararon los puntajes del FMD de niños de áreas rurales en Guatemala (n=56) que participan en un programa de desarrollo del niño con niños norteamericanos latin-x hablantes del español y del inglés, quienes asisten a una clínica de cuidado primario y son examinados en chequeos anuales de rutina para niños sanos. Se clasificaron los grupos según la edad, el género y la condición económica. Los análisis del nivel de cada punto exploraron las diferencias a lo largo de los 3 grupos. En el grupo muestra de Guatemala, los índices de puntajes anormales de FMD fueron 16%, 62% y cero en los niños de 12, 24 y 36 meses de edad, respectivamente. Los puntajes anormales para el grupo de Guatemala en el ASQ-3 a los 24 meses significativamente difirieron (p=0.01) cuando se les comparó con los grupos muestras norteamericanos latin-x. El cuestionario para la edad de 24 meses tiene más preguntas acerca de objetos que los cuestionarios para las edades de 12 y 36 meses, lo cual pudiera explicar los más altos índices de puntajes anormales. La examinación del desarrollo con ASQ-3 pudiera no captar adecuadamente las destrezas de niños en comunidades similares.

Les recherches précédentes suggèrent que le domaine de la motricité fine (FMD en anglais) du Questionnaire des Ages et des Etapes - 3e édition (ASQ en anglais) pourrait ne pas être pertinent sur le point culturel pour le dépistage développemental dans une communauté rurale du Guatémala puisque le FMD explique 40% de tous les dépistages anormaux après une évaluation des besoins dans cette communauté. Nous émettons l'hypothèse que cela est dû au manque d'exposition à des objets évalués dans le questionnaire, comme des blocs ou des interrupteurs (électricité). Les scores de FMD d'enfants de milieu rural au Guatémala (n=56) participant à un programme de développement de l'enfant ont été comparés à ceux d'enfants Latinx-Américains parlant espagnol et anglais, patients d'une clinique de soins primaires aux Etats-Unis d'Amérique et dépisté avec des contrôles de santé annuels. Les groupes ont été assortis par groupe de genre et de statut socioéconomique. Des analyses de précision ont exploré les différences entre les 3 groupes. Dans l'échantillon du Guatémala les taux de score anormal FMD étaient de 16%, 62% et zéro chez les enfants de 12, 24 et 36 mois, respectivement. Les scores anormaux pour l'échantillon du Guatémala pour le ASQ-3 à 24 moi a différé de manière importante (p=0.01) lors de la comparaison aux groupes Latinx-Américains. Le questionnaire de 24 mois a plus de questions sur les objets que les questionnaires de 12 mois et de 36 mois, ce qui peut expliquer les taux plus élevés de scores anormaux. Le dépistage développemental avec le ASQ-3 pourrait s'avérer ne pas capturer de manière adéquate les compétences des enfants dans des communautés similaires.

Engage, Develop, Learn: a pilot randomized clinical trial to test if a mobile application can enhance home support for early cognitive development among children living in poverty.

Background: Mobile applications (apps) exist to promote early child development; however, few studies have examined use of these apps among low-income families. Our objectives were to measure engagement with the Engage, Develop, Learn (EDL) app and determine if it promoted engagement and behavior change among low-income caregivers. Methods: We conducted a pilot study among English and Spanish-speaking, low-income families with children ages 12 to 15 months who received either the EDL app or injury prevention text messages. Baseline data were collected and interventions delivered over two home visits. App engagement was measured using messages opened. Caregiver development-promoting behaviors were measured with STIMQ score changes from baseline to follow-up at child age 2 years. We conducted key informant interviews among families randomized to receive the EDL app to identify barriers and facilitators to app use. Results: A total of 100 caregivers were recruited at their children's preventive care visit with 50 randomized to receive the EDL app and 50 to receive the injury prevention text messages; however, only 25 in the development app and 34 in the injury prevention group completed both home visits. Follow-up data were collected from 14 in the development app group and 30 in the injury prevention group. Over 10 weeks, 24% (6/25) remained engaged with the development app. STIMQ scores did not differ between groups. Barriers included technical difficulties accessing the app, social stressors, and 'forgetting' to use it. Conclusions: Our pilot randomized trial of a child development app suggests that it may not be effective for promoting behavior change among low-income caregivers due to low engagement. Trial Registration: This pilot trial was registered with ClinicalTrials.gov (ID NCT02717390).

A cumulative risk index for use in the medical home.

BACKGROUND AND OBJECTIVE: Previous studies have described the effect of sociodemographic factors on early development. We describe development of a simple cumulative risk index (CRI) based on four sociodemographic factors and explore the concurrent and predictive relationship of this index to a measure of the cognitive home environment in early childhood and to later school functioning. METHODS: This was a secondary data analysis of children from an urban pediatrics clinic. Baseline data were collected at 10-23 months (n = 324) with primary follow-up 6 months later at 18-35 months (n = 179) and secondary follow-up at 8-10 years (n = 68). A CRI score was derived at baseline using maternal education, marital status, race/ethnicity and child insurance. Baseline and primary follow-up included three subscales of the STIMQ, a measure of the cognitive home environment. Effectiveness of CRI was examined using analysis of variance (ANOVA) with linear contrasts. Chi-square examined differences in school function between children from CRI high-risk (CRI 3-4) and low-risk (CRI 0-2) families. RESULTS: CRI had a negative impact in early childhood on STIMQ subscale scores (p < 0.007-0.05) that increased as the number of risk factors increased (p < 0.05). Significantly more children from high-risk families (CRI 3-4) were rated as having poor school performance than children from low-risk families (CRI 0-2) (p < 0.05). CONCLUSIONS: We showed that a practice-friendly CRI, based on characteristics typically available in the medical record, could help identify families less likely to support development concurrently at 1 year of age and predictively at 2-3 years. School functioning at 8 to 10 years was also significantly better in children with a low CRI at 1 year. The CRI could be a useful tool for both clinicians and researchers needing a simple tool for risk assessment.

Group based learning among caregivers: assessing mothers' knowledge before and after an early childhood intervention in rural Guatemala.

BACKGROUND: The first three years of a child's life are a critical period for brain growth and development. Caregiver interventions during this period that improve early childhood health and development have the potential to enhance a child's physical, mental, and social well-being. METHODS: This was a pretest/posttest quasi experimental program evaluation. Early childhood education materials were adapted to create two separate interventions consisting of 30-page interactive flipchart talks to educate mothers on health and development topics relevant to 0-6 and 6-12 month old children. Three community health workers performed the talks with groups of 5-8 mothers. Short learning assessments were given individually to each mother pre-intervention (pretest), immediately post-intervention (posttest 1), and two weeks post-intervention (posttest 2). Demographic surveys and focus group discussions were conducted with all participants. RESULTS: Mothers (n = 77) had an average age of 33.6 years and had an average of 3.6 living children. Most of the mothers (71%) had received some primary education, but 23% had received no formal schooling. For the 0-6 months flipchart learning assessment (n = 38), the mean pretest score was 77% correct. The mean posttest 1 score improved to 87% (p < 0.0001), and the mean posttest 2 score improved further from the mean posttest 1 score to 90% (p = 0.01). For the 6-12 months flipchart learning assessment (n = 39), the mean pretest score was 78%. The mean posttest 1 score improved to 89% (p < 0.0001), and the mean posttest 2 score improved further from the mean posttest 1 score to 92% (p = 0.03). CONCLUSIONS: Mothers in an impoverished region of southwestern Guatemala significantly increased their knowledge about child health topics following a short interactive group talk. Mothers further increased their knowledge two weeks after the intervention, without specific re-exposure to the intervention materials, suggesting assimilation and informal reinforcement through group based learning with other mothers in their community.

Using Mobile Health to Promote Early Language Development: A Narrative Review.

In this narrative review, we first present a brief overview of known disparities in children's language development based on socioeconomic status and efforts in the primary care setting to promote children's language development. Next, we define mobile health (m-health) and review the limited, published literature regarding the effectiveness of m-health interventions in promoting children's health, in general, and language development, in particular. Finally, we discuss the potential role of smartphone applications to increase parental behaviors that promote their children's language development, as well as challenges that should be addressed as the field of m-health continues to grow.

Does a text-messaging program to promote early childhood development reach the highest risk families?

BACKGROUND: Bright by Three (BB3), a non-profit organization that promotes caregiver behaviors to support language development in young children was augmented with a text-messaging program, Bright by Text (BBT), in 2015. While some evidence suggests that text-messaging can promote early development, it is unknown if these interventions are reaching children at increased sociodemographic risk for developmental delay. The purpose of this study is to compare socio-demographic characteristics of caregivers who did and did not enroll in BBT. METHODS: Retrospective analysis of caregivers who received BB3 written materials and were eligible to sign up for BBT in 2016. Outcomes: (I) provision of a mobile phone number; (II) enrollment in BBT (receipt of 3+ messages). Predictors: education, marital status, race/ethnicity, insurance, language, and urban vs. rural residence. A multivariable generalized linear model was used to determine characteristics of caregivers more likely to sign up for BBT. RESULTS: A total of 18,145 caregivers received BB3 written materials; 10,843 (60%) provided a mobile phone number and 2,314 (21%) enrolled in BBT. The relative risk (RR) of enrollment was higher for caregivers who were non-minority (RR 1.15, 95% CI, 1.04-1.28), had higher education (1.60, 1.35-1.89), had private insurance (1.15, 1.15-1.28) and lived in urban areas (1.21, 1.06-1.37). Non-English speaking caregivers were less likely to enroll (0.73, 0.59-0.90). CONCLUSIONS: Caregivers with lower incomes and education, minorities and non-English speakers were less likely to enroll in BBT. Future research could identify ways to increase engagement among these populations and determine if BBT is effective in changing parent behavior and improving children's development.

Infant, Maternal, and Hospital Factors' Role in Loss to Follow-up After Failed Newborn Hearing Screening.

OBJECTIVE: Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening. METHODS: We conducted a retrospective study of all infants born in Colorado hospitals who failed the newborn admission hearing screening from 2007 to 2012 and a cross-sectional survey of NBHS coordinators at Colorado birthing hospitals. Neonatal intensive care unit infants were excluded. Outcomes included documented completion of the follow-up NBHS and completion by 1 month. Data sources comprised the electronic birth record, infant hearing integrated data system, and NBHS coordinator survey. Data were analyzed by logistic regression. RESULTS: A total of 13,904 newborns did not pass the newborn admission hearing screening from 2007 to 2012, and 11,422 (82%) had documentation of a completed follow-up screening. A total of 10,558 (76%) completed follow-up screening by 1 month. All 53 NBHS coordinators completed the survey. Maternal age, education, smoking, and birth country; and payer, race, birth order, and population density were associated with completion of follow-up hearing screening. Maternal education, payer, population density, birth weight, and cleft lip were associated with completion by 1 month of age. Only birth in a facility that charges a rescreening fee was associated with completion of follow-up screening. CONCLUSIONS: Low-income, rural, and minority infants are at risk for LTF. Further studies are needed to determine if adherence to guidelines can overcome barriers to follow-up.

High Background Congenital Microcephaly in Rural Guatemala: Implications for Neonatal Congenital Zika Virus Infection Screening.

BACKGROUND: Congenital microcephaly is the result of a disturbance in early brain development and can have multiple etiologies. Establishing background prevalence of microcephaly in Zika virus (ZIKV)-affected areas is important for improving identification of ZIKV-affected newborns. However, to date, there is limited consistent guidance for the accurate identification of microcephaly in infants of unknown gestational age, a common concern in low- and middle-income countries. METHODS: Occipital frontal head circumference (OFC) obtained from infants (0-13 days) of unknown gestational age at enrollment in a pregnancy registry in rural Guatemala from August 2014 to March 2016 were retrospectively reviewed. Trained community health nurses recorded anthropometry in an online database. In April 2015, ZIKV was identified in this population. Gestational age was approximated in 2 ways: presumed term and estimated using z-score of zero for height on modified Fenton growth curves. After which, z-scores for OFC and weight were obtained. Microcephaly and microcephaly background prevalence were estimated using 7 established microcephaly case definitions from national and international organizations and 3 proposed definitions using Fenton growth curves. Independent associations with microcephaly and OFC, including relationship with date of birth, were assessed with prevalence ratios and linear regression. RESULTS: For 296 infants, the mean OFC was 33.1 cm (range, 29.5 to 37 cm) and the mean OFC z-score was -0.68. Depending on case definition, 13 to 125 infants were classified as having microcephaly (background prevalence 439 to 4,223 per 10,000 live births), and 1 to 9 infants were classified as having severe microcephaly (<-3 standard deviation [SD]) (34 to 304 per 10,000 live births). Five (1.7%) infants met all the microcephaly case definitions. Weight ≤-1 SD (prevalence rate [PR], 3.77; 95% confidence interval [CI]: 1.6 to 8.8; P=.002) and small for gestational age (PR, 4.68; 95% CI, 1.8 to 12.3; P=.002) were associated with microcephaly. Date of birth was not associated with OFC z-score or OFC after adjusting for gestational age and gender. CONCLUSIONS: Estimated background microcephaly is high in rural Guatemala compared with reported rates in Latin America prior to ZIKV epidemic, which has important implications for neonatal screening programs for congenital ZIKV infection. Fenton growth curves offer a standardized approach to the identification of microcephaly in infants of unknown gestational age.

Missed Opportunities for Influenza Vaccination Among Hospitalized Children With Influenza at a Tertiary Care Facility.

OBJECTIVES: To identify the extent and characteristics of missed opportunities for influenza vaccination among children hospitalized with influenza at a tertiary children's hospital. METHODS: We conducted a retrospective cohort study of hospitalized patients with polymerase chain reaction-confirmed influenza admitted to Children's Hospital Colorado from 2010 to 2014. We reviewed medical records for vaccination status and previous visits. The primary outcome was the proportion of underimmunized patients hospitalized with influenza with at least 1 missed opportunity visit (visit before influenza diagnosis in which an eligible patient did not receive the influenza vaccine). The relationship between sociodemographic characteristics and the primary outcome were examined using χ(2) tests and nonparametric tests, and variables with P < .2 were entered into a multivariate logistic regression model. RESULTS: Among 322 patients hospitalized with influenza, 199 (61%) were undervaccinated; 83 of 199 (42%) had at least 1 missed opportunity for influenza vaccination. Multivariate analysis demonstrated that high-risk status (adjusted odds ratio 6.9, 95% confidence interval 3.8-12.4) was associated with increased odds of having a missed opportunity visit. Most missed opportunity visits were to subspecialty clinics (42%), and most visits (71%) occurred from September to November. CONCLUSIONS: More than 40% of hospitalizations for influenza in children are associated with at least 1 missed opportunity visit at a tertiary center. Our findings highlight the potential role of tertiary care institutions in increasing influenza vaccination rates among children.

Evaluating Enhancements to a Perioperative Nurse Liaison Program.

The impetus for the perioperative nurse liaison (PNL) program at our cancer center was to reduce anxiety for family members of patients undergoing surgery by improving communication between the family and the perioperative team. The purpose of our quality improvement project was to increase contact with family members during the patient's surgery and to support families and surgeons during the postoperative family consult when findings were unexpected. After implementing process changes, the PNLs evaluated the program using a short survey given to families after the postoperative consult. Families reported a reduction in stress and anxiety when intraoperative updates were received either in person or by telephone. In addition, when the PNL accompanied family members to the postoperative consult, the family felt supported when receiving unexpected findings. Further, family contact with the PNL increased from 77% to 98%, and the number of consults with surgeons that included the PNL rose from an average of 254 to 500 per year.

Rising Oseltamivir Use Among Hospitalized Children in a Postpandemic Era.

BACKGROUND: Oseltamivir prescribing among pediatric inpatients with influenza varied from 2% to 48% prior to the 2009 H1N1 pandemic. After the pandemic, prescribing guidelines were expanded, and studies reported benefits for hospitalized children. Post-pandemic prescribing practices among children are unclear. OBJECTIVES: To report the rate of oseltamivir use and to identify factors associated with its use among inpatients with confirmed influenza infection from 2010 to 2014 at a tertiary children's hospital. METHODS: We conducted a retrospective cohort study of inpatients with polymerase chain reaction-confirmed influenza from December 2010 to April 2014 at Children's Hospital Colorado. The primary outcome was oseltamivir use. Variables regarding demographics, underlying medical conditions, diagnoses, and hospital course were also explored. Univariate and multivariate logistic regression analyses were performed. RESULTS: Among 395 inpatients with influenza, 323 (82%) received oseltamivir. In univariate analyses, oseltamivir use was associated with admission within 48 hours of symptom onset (89% vs 77%), ICU admission (88% vs 79%), longer length of stay (90% for >6 days vs 77% for ≤2 days), and influenza A H1N1 infection (P < .05 for all). In multivariate logistic regression analysis, longer length of stay, illness during the 2013-2014 season, and admission within 48 hours of symptom onset were associated with higher odds of oseltamivir use. CONCLUSIONS: Oseltamivir use for children with influenza in the postpandemic era is increasing at our institution, aligning with official recommendations and reported benefits. We report highest use for patients in the 2013-2014 season, those who present early in their illness, and those requiring a prolonged hospital stay.

A comparison of H1N1 influenza among pediatric inpatients in the pandemic and post pandemic era.

BACKGROUND: The novel influenza A H1N1 (A[H1N1]pdm09) strain emerged in 2009, contributing to significant morbidity and mortality. It is not known whether illness associated with A(H1N1) pdm09 in the post-pandemic era exhibits a similar disease profile. OBJECTIVE: The objectives of this study were to compare the burden of disease of A(H1N1) pdm09 influenza from the 2009 pandemic year to the post-pandemic years (2010-2014), and to explore potential reasons for any differences. STUDY DESIGN: We conducted a retrospective cohort study of inpatients admitted to Children's Hospital Colorado with a positive respiratory specimen for influenza from May-December, 2009 and December, 2010-April, 2014. Univariate and multivariate analyses were conducted to compare the demographics and clinical characteristics of patients with H1N1 during the two periods. RESULTS: There were 388 inpatients with influenza A(H1N1) pdm09 in 2009, and 117 during the post-pandemic years. Ninety-four percent of all H1N1 during the post-pandemic era was observed during the 2013-2014 influenza season. Patients with A(H1N1) pdm09 during the post-pandemic year were less likely to have an underlying medical condition (P<0.01). Patients admitted to the ICU during the post-pandemic year had a lower median age (5 vs 8 years, P=0.01) and a lower proportion of patients were intubated, had mental status changes, and ARDS compared with the pandemic years, (P<0.01 for all), with decreased mortality (P=0.02). CONCLUSION: Patients with influenza A(H1N1) pdm09 during the post-pandemic years appeared to have less severe disease than patients with A(H1N1) pdm09 during the pandemic year. The reasons for this difference are likely multifactorial.

Relationship between the cognitive environment and vocabulary development during the second year of life.

OBJECTIVE: To examine the relationship between characteristics of the cognitive environment at age 10 to 18 months and vocabulary at age 18 to 30 months. DESIGN: Analysis of baseline and follow-up data on 157 families participating in a comparison of 2 anticipatory guidance programs. SETTING: Children's Hospital outpatient department serving low-income families. PARTICIPANTS: Parents of children aged 10 to 18 months at baseline who participated in a follow-up telephone interview at age 18 to 30 months. MAIN OUTCOME MEASURES: Three subscales of the StimQ (reading, parental involvement in developmental activities, and parental verbal responsivity [PVR]) and the short form of the MacArthur Communicative Development Inventories. RESULTS: Vocabulary score percentiles dropped significantly between baseline and follow-up, with scores for bilingual families showing a greater decrease than those for English speaking-only families. StimQ subscale scores increased with maternal education and increased between baseline and follow-up. Multiple regression analysis showed that baseline variables accounted for 25% of the variance in follow-up vocabulary score percentile, with significant contributions from baseline expressive vocabulary (P < .001), PVR (P = .01), and home language (P = .03) scores. Seventy-seven percent of children with PVR scores less than 4 had follow-up vocabulary scores at or less than the 25th percentile, with an associated likelihood ratio of 4.33. However, 35% of children with a PVR score of 4 also had vocabulary scores less than the 25th percentile at follow-up, with an associated likelihood ratio of 0.67. CONCLUSIONS: The StimQ is a clinically useful method for assessing early environmental factors that influence vocabulary development. The PVR subscale score was the best StimQ predictor of later vocabulary delay and may be useful in identifying children needing referral for evaluation.

Quantifying data quality for clinical trials using electronic data capture.

BACKGROUND: Historically, only partial assessments of data quality have been performed in clinical trials, for which the most common method of measuring database error rates has been to compare the case report form (CRF) to database entries and count discrepancies. Importantly, errors arising from medical record abstraction and transcription are rarely evaluated as part of such quality assessments. Electronic Data Capture (EDC) technology has had a further impact, as paper CRFs typically leveraged for quality measurement are not used in EDC processes. METHODS AND PRINCIPAL FINDINGS: The National Institute on Drug Abuse Treatment Clinical Trials Network has developed, implemented, and evaluated methodology for holistically assessing data quality on EDC trials. We characterize the average source-to-database error rate (14.3 errors per 10,000 fields) for the first year of use of the new evaluation method. This error rate was significantly lower than the average of published error rates for source-to-database audits, and was similar to CRF-to-database error rates reported in the published literature. We attribute this largely to an absence of medical record abstraction on the trials we examined, and to an outpatient setting characterized by less acute patient conditions. CONCLUSIONS: Historically, medical record abstraction is the most significant source of error by an order of magnitude, and should be measured and managed during the course of clinical trials. Source-to-database error rates are highly dependent on the amount of structured data collection in the clinical setting and on the complexity of the medical record, dependencies that should be considered when developing data quality benchmarks.

A perioperative nurse liaison program: CNS interventions for cancer patients and their families.

Cancer surgery causes stress and anxiety for families and patients. Knowing that communication between family and health care professionals is traditionally fragmented during the perioperative period, Memorial Sloan-Kettering Cancer Center developed a family-centered program to improve information exchange. This article describes the Perioperative Clinical Nurse Specialist program and the process by which ongoing communication of clinical information and psychosocial support for waiting relatives occurs. Good communication during the preoperative, intraoperative, and postoperative period is characteristic of quality care at a critical time. The subject program serves to bridge the gap in the continuum of perioperative care.