Association between practice patterns and body mass index percentile in infants and young children with cystic fibrosis.

BACKGROUND: Few guidelines focus on the preventive and maintenance care of infants with cystic fibrosis (CF). We explored how practice variability at accredited CF centers affected nutritional outcomes. METHODS: A retrospective cohort study using Cystic Fibrosis Foundation registry data (1993-2004) from three CF centers compared the initial management with respiratory, antimicrobial, and nutritional agents in infants. Further, we examined the association between dornase alpha use prior to two years of age and BMI percentile over time accounting for several possible factors including gender, race, CF center, presentation, age at diagnosis, sweat value, F508del status, first Pseudomonas aeruginosa infection age, second-year weight percentile, supplemental feedings use, and pancreatic enzymes use. RESULTS: Patient characteristics and prescribed therapies were similar at all sites for 165 patients who met inclusion criteria. However, one CF center prescribed dornase alpha significantly more frequently, 82% vs. 10% (p<0.001), and supplemental feeds significantly less frequently, 56% vs. 78% (p=0.04). Dornase alpha prescription prior to age two was associated with a 10-percentile increase in BMI through age six compared to infants not prescribed dornase alpha. CONCLUSIONS: Treating infants less than two years old with dornase alpha may improve nutritional outcome through age six.

Evaluating the use of a computerized clinical decision support system for asthma by pediatric pulmonologists.

PURPOSE: To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center. METHODS: We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic. Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use. RESULTS: The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians. CONCLUSIONS: Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors. Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting.

Accuracy of a computerized clinical decision-support system for asthma assessment and management.

OBJECTIVE: To evaluate the accuracy of a computerized clinical decision-support system (CDSS) designed to support assessment and management of pediatric asthma in a subspecialty clinic. DESIGN: Cohort study of all asthma visits to pediatric pulmonology from January to December, 2009. MEASUREMENTS: CDSS and physician assessments of asthma severity, control, and treatment step. RESULTS: Both the clinician and the computerized CDSS generated assessments of asthma control in 767/1032 (74.3%) return patients, assessments of asthma severity in 100/167 (59.9%) new patients, and recommendations for treatment step in 66/167 (39.5%) new patients. Clinicians agreed with the CDSS in 543/767 (70.8%) of control assessments, 37/100 (37%) of severity assessments, and 19/66 (29%) of step recommendations. External review classified 72% of control disagreements (21% of all control assessments), 56% of severity disagreements (37% of all severity assessments), and 76% of step disagreements (54% of all step recommendations) as CDSS errors. The remaining disagreements resulted from pulmonologist error or ambiguous guidelines. Many CDSS flaws, such as attributing all 'cough' to asthma, were easily remediable. Pediatric pulmonologists failed to follow guidelines in 8% of return visits and 18% of new visits. LIMITATIONS: The authors relied on chart notes to determine clinical reasoning. Physicians may have changed their assessments after seeing CDSS recommendations. CONCLUSIONS: A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.

Healthy children with frequent fractures: how much evaluation is needed?

OBJECTIVE: We performed a case-control study to determine whether occult bone disease is associated with a history of frequent fractures in children. METHODS: Healthy children with > or = 2 incidences of low-energy fractures were recruited (n = 68). Children with no history of fractures served as control subjects (n = 57). Food logs, activity surveys, physical examinations, laboratory tests, and dual-energy radiographic absorptiometry were used. RESULTS: Bone mineral density z scores were significantly reduced in case subjects, compared with control subjects. Three case subjects (4.3%) and 1 control subject (1.8%) had bone mineral density z scores below the expected range. Of those 4 subjects, 2 had dairy avoidance and 2 had delayed puberty. An additional case subject had evidence of vitamin D deficiency. A significant number of subjects (20% of case subjects and 23% of control subjects) had idiopathic hypercalcuria, based on 24-hour urine collections. Among the case subjects, bone mineral density z scores were significantly lower for those with idiopathic hypercalcuria. Among the control subjects, the presence of idiopathic hypercalcuria did not affect bone mineral density. The case subjects with idiopathic hypercalcuria accounted for virtually all of the differences in bone mineral density between the case and control groups. Analysis of parathyroid hormone and 1,25-dihydroxy-vitamin D levels showed that children with frequent fractures and hypercalcuria had renal hypercalcuria, whereas children with no fractures and hypercalcuria had absorptive hypercalcuria. CONCLUSIONS: We identified a significant association between a history of frequent fractures and hypercalcuria in children. We propose that the appropriate screening evaluation for children who present with a history of frequent fractures consists of a dietary history targeted at calcium and vitamin D intakes, a physical examination to assess for pubertal delay, and urinary calcium concentration/creatinine ratio determination to assess for hypercalcuria. Children with abnormalities in this screening should undergo dual-energy radiographic absorptiometry and appropriate evaluation.

Factors influencing complementary and alternative medicine use in a multisite pediatric oncology practice.

PURPOSE: Complementary and alternative medicine (CAM) use in children is common although estimates of prevalence vary widely. We studied CAM use in our multisite pediatric oncology practice and evaluated factors influencing CAM use. PATIENTS AND METHODS: We conducted an anonymous cross-sectional survey of 274 parents of children treated at the combined Nemours oncology practice in Florida and Delaware. Prevalence of CAM use was determined and binary logistic regression was used to evaluate factors related to CAM use in children. RESULTS: The prevalence of CAM use among children and parents was 24.5% and 66.7%, respectively. Intensity of parent's use of CAM and geographic region were significantly associated with CAM use in children. The odds of CAM use in children increased with increasing use among parents. When parents used 6 or more therapies children were 33 times more likely to use CAM compared with those whose parents did not use CAM (odds ratio=33.3; 95% confidence interval, 10.4-106.2, P<0.01). Children in Florida were more likely to use CAM compared with children in Delaware (odds ratio=3.0; 95% confidence interval, 1.6-5.8, P<0.01). CONCLUSIONS: These results indicate that children's use of CAM is significantly related to the intensity of parent's use regardless of parent's race, sex, education, household income, or child's sex or age. Clinicians should consider parental use and intensity of CAM use. Assessing CAM use should include classifications established by the National Center for CAM and a standard format for inquiring about CAM use should be developed.

The relationship of body mass index and blood pressure in primary care pediatric patients.

OBJECTIVE: To determine whether an association of overweight, or risk of overweight, and blood pressure can be detected in children in the pediatric primary care practice setting. STUDY DESIGN: We examined electronic medical record (EMR) data from primary care practices on 18,618 children age 2 to 19 years. Each child was classified on the basis of age- and sex-specific body mass index (BMI) percentile as normal weight (BMI < 85th percentile), at risk for overweight (BMI > or = 85th and < 95th percentile), or overweight (BMI > or = 95th percentile). BMI Z-score and height Z-score were computed. Systolic and diastolic blood pressures were compared among age-sex-BMI groups. RESULTS: Among children in primary care pediatric practices, 16.7% were at risk of overweight and 20.2% were overweight. With increasing BMI status there was a significant increase in both systolic blood pressure (P < .001) and diastolic blood pressure (P < .001). The association of higher blood pressure with increasing BMI status was present in all age groups. CONCLUSIONS: Clinical data from pediatric primary care practices verify the high prevalence of childhood overweight. The effect of overweight on blood pressure is present in childhood and can be detected even in children as young as 2 to 5 years.

Decreased attendance at cystic fibrosis centers by children covered by managed care insurance.

OBJECTIVE: The evolution of managed care has raised concerns about differential access to care for children with cystic fibrosis (CF). We tested the hypothesis that children with CF with managed care attended CF centers less frequently compared with children with non-managed care. METHODS: We conducted a prospective cohort study by telephone every 4 months to measure access to care at CF centers among 630 randomly selected patients aged 6-18 years from 15 US CF centers. We analyzed data with unconditional logistic regression and generalized estimating equations. RESULTS: Attendance at CF centers was significantly reduced among children with managed care (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.57, 0.98; P=0.03) and among girls (OR=0.68; 95% CI=0.48, 0.97; P=0.04). CONCLUSIONS: Children with CF with managed care attended CF centers significantly less frequently than those with non-managed care. These findings suggest that children with CF with managed care may not have equal access to experts in CF as children with non-managed care. Families should consider this when selecting their medical insurance plan. These findings may apply to other children with special health care needs.