Screening and interventions for overweight in children and adolescents: recommendation statement

The U.S. Preventive Services Task Force (USPSTF) is an independent panel of non-federal experts in prevention and primary care that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This recommendation addresses the evidence for the accuracy of screening children and adolescents using BMI, the effectiveness of behavioral and pharmacologic interventions in improving health outcomes in these children, and the potential harms of routine screening and intervention. Using USPSTF methodology, an analytic framework with key questions was developed to guide the systematic review, which serves as the basis for this recommendation. The number of children and adolescents who are overweight has more than doubled in the last 25 years. Childhood and adolescent overweight is associated with increased health risks. The USPSTF found insufficient evidence for the effectiveness of behavioral counseling or other preventive interventions with overweight children and adolescents that can be conducted in primary care settings. Currently, available studies are limited by factors such as small sample sizes, poor generalizability, and variable follow-up. Based upon this critical gap in the evidence for effectiveness, the USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes ("I" recommendation). There are several gaps in the research evidence on screening and interventions for overweight children and adolescents in the primary care setting. Research is needed to provide well-defined and effective approaches to medical and psychological screening in children, as well as effective clinical approaches for the prevention and treatment of overweight in children that can be implemented by primary care clinicians.     

Imaging of pediatric pulmonary tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

Pediatric pulmonary malignancy can be primary or metastatic, with the latter being by far the more common. With a few exceptions, there are no well-established evidence-based guidelines for imaging pediatric pulmonary malignancies, although computed tomography (CT) is used in almost all cases. The aim of this article is to provide general imaging guidelines for pediatric pulmonary malignancies, including minimum standards for cross-sectional imaging techniques and specific imaging recommendations for select entities.     

Provider perspectives on electronic decision supports for obesity prevention

Despite the availability of national evidenced-based guidelines related to pediatric obesity screening and prevention, multiple studies have shown that primary care physicians find it difficult to adhere to them or are unfamiliar with them altogether. This article presents physicians' perspectives on the use of electronic decision support tools, an alert and Smart Set, to accelerate the adoption of obesity-related recommendations into their practice. The authors interviewed providers using a test encounter walk-through technique that revealed a number of barriers to using electronic decision supports for obesity care in primary care settings. Providers' suggestions for improving their use of obesity-related decision supports are presented. Careful consideration must be given to both the development of electronic decision support tools and a multilayered educational outreach strategy if providers are going to be persuaded to use such supports to help them implement pediatric obesity prevention and management best practices.     

Adolescent immunizations and other clinical preventive services: a needle and a hook?

Advances in technology have led to development of new vaccines for adolescents, but these vaccines will be added to a crowded schedule of recommended adolescent clinical preventive services. We reviewed adolescent clinical preventive health care guidelines and patterns of adolescent clinical preventive service delivery and assessed how new adolescent vaccines might affect health care visits and the delivery of other clinical preventive services. Our analysis suggests that new adolescent immunization recommendations are likely to improve adolescent health, both as a "needle" and a "hook." As a needle, the immunization will enhance an adolescent's health by preventing vaccine-preventable diseases during adolescence and adulthood. It also will likely be a hook to bring adolescents (and their parents) into the clinic for adolescent health care visits, during which other clinical preventive services can be provided. We also speculate that new adolescent immunization recommendations might increase the proportion and quality of other clinical preventive services delivered during health care visits. The factor most likely to diminish the positive influence of immunizations on delivery of other clinical preventive services is the additional visit time required for vaccine counseling and administration. Immunizations may "crowd out" delivery of other clinical preventive services during visits or reduce the quality of the clinical preventive service delivery. Complementary strategies to mitigate these effects might include prioritizing clinical preventive services with a strong evidence base for effectiveness, spreading clinical preventive services out over several visits, and withholding selected clinical preventive services during a visit if the prevention activity is effectively covered at the community level. Studies are needed to evaluate the effect of new immunizations on adolescent preventive health care visits, delivery of clinical preventive services, and health outcomes.     

Aeromedical transport services accepting pediatric patients and their abidance by published guidelines.

The number of aeromedical transport services accepting pediatric patients (ATSP) in the United States has increased greatly over the past decade. Most aeromedical transport services are primarily designed for adults but will also transport children. Suggested guidelines for ATSP were published by the American Academy of Pediatrics (AAP) in 1986. This survey of 65 ATSP and their abidance by the major AAP guidelines showed that two thirds of the ATSP were based at facilities with pediatric tertiary care capabilities; most ATSP were not directed by pediatric critical care (PCC) or pediatric emergency care (PEC) specialists; most transport team personnel were not trained in PCC or PEC; most ATSP had specific protocols for different clinical situations; most ATSP had separate equipment appropriate for pediatric patients; and there was little variation in transport team composition based on different clinical situations. In summary, all ATS surveyed transported children, but few were aware of the AAP guidelines, and only one in 65 was in complete abidance with the recommendations.     

Guidelines: state of the art and peculiar aspects in pediatric emergency

In recent years pediatric guidelines have increasingly become part of clinical practice, in Italy too. Aim of the present work is, on the basis of a review of national and international literature, to focus on the Italian situation about the use of guidelines in pediatric emergency, with particular respect to methodology, correct use, and related risks and benefits. The developing of efficient guidelines is achieved in different steps: 1) identifying and refining the topic for guidelines, in order to obtain an improvement of healthcare; 2) correct developing strategies, based on scientific evidence, leading to production of recommendations validated by external review; 3) adequate implementation and diffusion in local settings; 4) application with sensible and appropriate clinical discretion. Benefits obtained with the correct use of efficient pediatric guidelines, can be identified at different levels: patients' care (outcome improvement, increased patients' consciousness, influence on public healthcare policy); healthcare professionals (improving quality of clinical decisions, agreement on clinical and therapeutic strategies; medicolegal protection, representing a reference for prospective and retrospective audits); healthcare systems (standardising care, improving efficacy of care; optimising costs). Personal experience in systematic development of emergency pediatric guidelines, applied in a second level Emergency Department is also presented.     

Practical vaccination guidelines for children with cancer

The paediatrician or family physician usually provides primary care for children diagnosed with cancer. Immunizations are an important facet of this care, but guidelines for the immunization of these immunocom-promised children are difficult to locate and cumbersome to follow. The authors have developed immunization guidelines for children receiving chemotherapy for cancer that will hopefully facilitate the care of this group of children. Before initiating any immunizations in this group of children, communication with a cancer specialist is recommended. There is little evidence-based literature to support immunization guidelines in immunocompromised hosts; thus, the recommendations presented are derived from the available literature, existing guidelines and expert opinion.     

Primary Care Access to an Online Decision Support Tool is Associated With Improvements in Some Aspects of Pediatric Migraine Care

ObjectiveTo evaluate whether primary care provider (PCP) access to an online decision support tool is associated with a change in evidence-based primary care medical management of pediatric migraine.MethodsIn this prospective observational study, PCPs serving a target community were educated on the availability and use of an online clinical decision support tool that was developed to inform treatment of pediatric migraine. For 9 months before and after implementation of the decision tool, the proportions of children with migraine prescribed evidence-based and contraindicated medications by PCPs in the target region were monitored using electronic medical record query and statistically compared to these same proportions for patients in surrounding (control) regions. Rates of visits to the emergency department for migraine also were tracked pre- and postimplementation as an indirect measure of impact of the decision tool. Provider usage of the decision tool was monitored and summarized using web analytics.ResultsApproximately half (56%) of target region PCPs used the online tool at least once over the project period. Relative to control regions and baseline trends, the proportion of children residing in the target region who were prescribed recommended abortive and preventive medications for treating migraine was statistically significantly higher following implementation of the tool. No significant changes to frequency of emergency care visits for migraine by youth in the target region were observed.ConclusionsAvailability to PCPs of an online decision support tool for pediatric migraine is associated with a modest change in some aspects of evidence-based medical care.     

Pediatric hemorrhagic cystitis

PurposeTo review the current literature as it pertains to hemorrhagic cystitis (HC) in the pediatric bone-marrow transplant (BMT) population. By reviewing the pathophysiology of the disease, preventive methods, and therapeutic options, urologists may be better equipped to manage this challenging clinical scenario.Materials and methodsThe HC literature was reviewed using a MEDLINE/PubMed literature search, specifically focusing on the pediatric BMT population as it pertains to the incidence, pathophysiology, prevention, and treatment of HC.ResultsConservative estimates of HC incidence in recent retrospective studies of pediatric BMT populations still approach 10–20%. Several high-volume pediatric BMT centers have reported contemporary data on their experience with HC providing increased insight into incidence and pathophysiology. Accumulating evidence linking BK virus to HC is a significant development warranting further investigation. Other contributing agents/risk factors need identification in the likely multifactorial etiology of HC. Preventive and therapeutic strategies have made modest advances, but certainly need further validation with prospective randomized studies.ConclusionsPediatric BMT patients are susceptible for HC development despite preventive measures and improved insight into the pathophysiology. Unfortunately, there are no evidence-based treatment guidelines for this difficult clinical issue that frequently requires prolonged care and multiple treatment modalities necessitating judicious patience in the application of more aggressive interventions.     

Non-pharmacologic strategies to prevent and control infectious complications in pediatric hematology/oncology patients

Preventive strategies besides the use of prophylactic antibiotic or antifungal regimens are fundamental ingredients of infection control in pediatric hematology-oncology patients. The clinical spectrum and the routes of transmission of infectious diseases in children have to be considered and preventive strategies should be adjusted to host dependent risk factors, in particular to the degree and duration of severe immunosuppression (i.e. neutropenia). This article overviews practical guidelines to prevent exposure and to reduce external sources of infection in immunocompromised children. Scientific evidence from controlled randomized studies is lacking or incomplete for many of these measures. A systematic and pragmatic approach to the critical control points of patient care in pediatric hematology/oncology is prudent to solve this problem in clinical practice. The corresponding recommendations are categorized in IV different levels of evidence.     

Healthy Steps: a case study of innovation in pediatric practice

Healthy Steps (HS) represents a significant innovation in the way pediatric primary care can be delivered. Based on the standards and principles of Bright Futures and the American Academy of Pediatrics Health Supervision Guidelines, HS enhances and expands traditional pediatric care by including a child development specialist (Healthy Steps specialist) as part of the pediatric practice team. Services offered by this person, typically a nurse, early childhood educator, or social worker, include more time to spend discussing preventive issues during well-child visits, home visits, a telephone information line exclusively addressing developmental and behavioral concerns, new written materials, and more seamless linkages to community resources and parent support groups. The original HS cohort consisted of 15 pediatric practices in a variety of settings (private practices, health centers, pediatric training programs). Evaluated for the effects of HS on their family were 3737 intervention and comparison families. HS families received significantly more preventive and developmental services, compared to families in the control group. HS families were also less likely to be dissatisfied with their pediatric primary care. Additionally, HS had a positive impact on parenting in many areas including adherence to health visits, nutritional practices, developmental stimulation, appropriate disciplinary techniques, and correct sleeping position. Other outcome measures (such as initiation or duration of breastfeeding, child development knowledge, sense of competence, and reports of child language development at 2 years of age) did not differ between intervention and comparison group. Compared to other early childhood intervention efforts, HS offers a comparable positive impact on parenting at a relatively inexpensive cost: an estimated 400 dollars per family per year (compared to 4500 dollars from Early Head Start). Approximately 3 years after the evaluation of HS ended, 10 of the original 24 sites are still in operation, and an additional 24 sites have started up. Although funding and reimbursement remain an important barrier, continued growth of HS suggests an abiding interest in this approach to expand and enhance preventive and developmental care in pediatric primary care.     

The appropriate use of CT: quality improvement and clinical decision-making in pediatric emergency medicine

An increasing number of patients presenting to a shrinking number of hospital emergency departments has contributed to challenges to providing high-quality care, specifically care that is safe, efficient and effective. These challenges are magnified by trends in CT utilization with uncertain implications for care delivery. The utility of CT poses challenges to the pediatric emergency medicine physician to balance risk with potential benefit. We describe the process of evidence-based clinical decision-making to define the appropriate use of CT studies. Strategies for minimizing CT utilization in managing appendicitis, traumatic brain injury and cervical spine injuries are described. Clinical scores, clinical decision rules and evidence-based guidelines can assist the clinician in providing high-quality care through effective utilization of CT.     

Effect of compliance with health supervision guidelines among US infants on emergency department visits

BACKGROUND: There are few studies that demonstrate the health benefit of compliance with early periodic health supervision. OBJECTIVE: To examine the association between emergency department (ED) use and compliance with prevailing guidelines for periodic health supervision for conditions that potentially could be avoided among a national cohort of US children. DESIGN: This was a historic cohort study that combined maternal and primary care physician reports of the use of preventive care services for infants during the first 7 months of life from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-up study. A preventive care scale used in Cox proportional hazards survival regression predicted the time to the first ED visit for selected diagnoses and all-cause visits controlling for illness severity. RESULTS: Among children with incomplete well-child care in the first 6 months of life, there was an increased risk of having an ED visit for an upper respiratory tract infection (hazard ratio, 2.3; 95% confidence interval, 1.6-3.2), gastroenteritis (hazard ratio, 1.8; 95% confidence interval, 1.0-3.0), asthma (hazard ratio, 2.1; 95% confidence interval, 1.0-4.3), and all-cause ED visits (hazard ratio, 1.6; 95% confidence interval, 1.4-1.98). CONCLUSIONS: Because of the positive effect compliance with national guidelines for early well-child care has on lowering the risk of experiencing ED use, national efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children.     

EPSDT preventive services in a low-income pediatric population: impact of a nursing protocol

Medicaid mandates coverage of clinical preventive services for children under the Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT). This article assesses the usefulness of a nursing protocol for delivering comprehensive EPSDT services to pediatric patients during any primary care visit. Secondary data from a recent controlled trial were analyzed. An intervention group received the clinical protocol (n = 514 children in a low-income pediatric clinic), whereas data from a "usual care" comparison group were obtained from medical records (n = 115 children). The nursing protocol included 52 items corresponding to EPSDT services and was administered by a prevention nurse. In the intervention group, 11 605 out of 11 607 (approximately 100.0%) EPSDT service needs were initiated, as compared to 21.2% (572 out of 2695) in the comparison group (P < .001). The study demonstrates the feasibility of using a nursing protocol to integrate EPSDT clinical preventive services into pediatric visits.     

Financing of pediatric home health care. Committee on Child Health Financing, Section on Home Care, American Academy of Pediatrics

In certain situations, home health care has been shown to be a cost-effective alternative to inpatient hospital care. National health expenditures reveal that pediatric home health costs totaled $5.3 billion in 2000. Medicaid is the major payer for pediatric home health care (77%), followed by other public sources (22%). Private health insurance and families each paid less than 1% of pediatric home health expenses. The most important factors affecting access to home health care are the inadequate supply of clinicians and ancillary personnel, shortages of home health nurses with pediatric expertise, inadequate payment, and restrictive insurance and managed care policies. Many children must stay in the NICU, PICU, and other pediatric wards and intermediate care areas at a much higher cost because of inadequate pediatric home health care services. The main financing problem pertaining to Medicaid is low payment to home health agencies at rates that are insufficient to provide beneficiaries access to home health services. Although home care services may be a covered benefit under private health plans, most do not cover private-duty nursing (83%), home health aides (45%), or home physical, occupational, or speech therapy (33%) and/or impose visit or monetary limits or caps. To advocate for improvements in financing of pediatric home health care, the American Academy of Pediatrics has developed several recommendations for public policy makers, federal and state Medicaid offices, private insurers, managed care plans, Title V officials, and home health care professionals. These recommendations will improve licensing, payment, coverage, and research related to pediatric home health services.     

Importance of clinical and epidemiological research in defining the long-term clinical care of pediatric cancer survivors

With the increasing number of long-term survivors of childhood cancer, there continues to be a critical need for development and implementation of evidence-based recommendations for clinical follow-up. In order to establish and maintain health-related follow-up guidelines, it is important to recognize the attributes of research from which the recommendations may be formulated. Issues including study design and clinical research methodology, completeness of long-term follow-up for the applicable study population, approaches for assessment of treatment-related exposures, methods utilized for ascertainment and characterization of outcomes, and recognition of potential modifiers of risk (e.g., demographic or treatment-specific factors) are all important considerations when evaluating the results of available research. For the future, greater attention will not only need to be given to further development and maintenance of recommendations for follow-up, but to the scientific evaluation of the recommendations to determine the subsequent impact on health status and quality of life among pediatric cancer survivors.     

Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition.

BACKGROUND: Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. METHODS: The Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. RESULTS: The Subcommittee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Subcommittee also provided recommendations for management by the pediatric gastroenterologist. CONCLUSIONS: This report, which has been endorsed by the Executive Council of the North American Society for Pediatric Gastroenterology and Nutrition, has been prepared as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. It is not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.     

Sexual behavior in children: normal or not?

Sexual abuse is a problem of epidemic proportions in the United States. Given the scope of the problem of sexual abuse and the amount of media attention it receives, it is not unusual for parents or caretakers who witness a child exhibiting sexual behavior to become alarmed. Primary care providers, including pediatric nurse practitioners, may be the first professional parents contact with concerns regarding a child's sexual behavior. It is imperative that primary care providers understand childhood sexuality and respond appropriately when confronted with child sexual behaviors in their practice. Although the literature includes little research on the subject of normal child sexual development, certain guidelines have been identified to describe normal child sexual behaviors and those of concern. Case studies illustrate the response of two primary care providers when they are confronted with sexual behaviors in their patients. Implications for practice are discussed, with examples and guidelines provided for primary care providers to use when evaluating sexual behavior in their pediatric patients.     

Addressing Pediatric Mental Health Using Telehealth During Coronavirus Disease-2019 and Beyond: A Narrative Review

The pediatrician serves as a frontline provider addressing patients’ medical and mental health needs, yet coronavirus disease-2019 (COVID-19) is reshaping the way physicians deliver care. Pediatricians are increasingly faced with the challenge of delivering care, including mental health care, remotely. Given the rapidly evolving literature, we performed a narrative review of the use of telehealth for mental health care for pediatric populations during the COVID-19 pandemic. Areas of focus included 1) pediatric primary care settings, 2) special pediatric populations (eg, eating disorders, autism), 3) access and engagement in telehealth care, and 4) training opportunities available for mental health providers. Themes that emerged across studies included the importance of meeting patients’ needs (eg, access to technological resources) to optimize success in using telehealth tools and challenges around provider access to support tools for use during telehealth. Thus, we provided a summary of evidence-based tools (including COVID-19 specific resources) for improving the remote delivery of mental health care by pediatricians. We also reviewed future directions including trials currently underway to enhance understanding of future telehealth applications for pediatric mental health care.