Use of a Group Text Messaging Application to Teach Developmental Milestones on a Pediatric Clerkship Publication date: Available online 21 October 2019 Source: Academic Pediatrics Author(s): Stephanie Berger

Parental Perceptions of the Internet and Social Media as a source of Pediatric Health Information Publication date: Available online 21 October 2019 Source: Academic Pediatrics Author(s): Mersine A Bryan, Yolanda Evans, Carlie Morishita, Nikita Midamba, Megan Moreno Abstract Objective 1) To evaluate differences in how parents use the internet and social media for health information by child age 2) To examine parental perceptions of health information on social media Methods We conducted a cross-sectional survey of parents of children 0-18 years seen in clinics and an inpatient medical unit. Survey questions focused on: patterns of internet and social media use, for what topics, and parental ratings of the accuracy, reliability and appeal of information from social media. Parents’ responses were categorized by age of their youngest child in years (0-4, 5-11, 12-18). Results 258 parents completed the survey. The mean age was 39.8 years, 83% were female, 59% were white. The most common topics parents read about online were: sleep, mental health and car safety. Nearly all parents (96%) used social media, with 68% using social media for health information. There were no significant differences in the proportion of parents who reported using social media for health information by child age. Only half of parents discussed information from social media with their physician. Parents of children age≥5 years rated health information on social media as significantly more accurate than parents of younger children. There were no significant differences in ratings of reliability and appeal by child age. Conclusions Parents of children of all ages use social media for a variety of important topics related to child health. As many parents do not discuss it with their physician, there are missed opportunities for pediatricians to provide high quality information.

Diagnostic Testing during Pediatric Hospitalizations: the Role of Attending In-house Coverage and Daytime Exposure Publication date: Available online 21 October 2019 Source: Academic Pediatrics Author(s): Kira L. Ryskina, Linda Dynan, Rebecca Stein, Evan Fieldston, Deepak Palakshappa Abstract Objective Overuse of diagnostic tests is of particular concern for pediatric academic medical centers. Our objective was to measure variation in testing based on proportion of hospitalization during the day versus night and the association between attending in-house coverage on the teaching service and test utilization for hospitalized pediatric patients. Methods Electronic health record data from 11,567 hospitalizations to a large, Northeastern, academic pediatric hospital were collected between January 2007 and December 2010. The patient-level dataset included orders for laboratory and imaging tests, information about who placed the order, and the timing of the order. Using a cross-sectional effect modification analysis, we estimated the difference in test utilization attributable to attending in-house coverage. Results We found that admission to the teaching service was independently associated with higher utilization of laboratory and imaging tests. However, the number of orders was 0.76 lower (95% CI -1.31 to -0.21, p=0.006) per 10% increase in the proportion in the share of the hospitalization that occurred during daytime hours on the teaching services, which is attributable to direct attending supervision. Conclusions Direct attending care of hospitalized pediatric patients at night was associated with slightly lower diagnostic test utilization.

Written versus Verbal Food Insecurity Screening in one Primary Care Clinic Publication date: Available online 17 October 2019 Source: Academic Pediatrics Author(s): Deepak Palakshappa, Meggan Goodpasture, Laurie Albertini, Callie L. Brown, Kimberly Montez, Joseph A. Skelton Abstract Objective Clinics are increasingly interested in identifying food insecurity (FI), but there is limited data on how to implement FI screening. Our objective was to determine the difference in FI disclosure rates by parents/guardians screened by a written questionnaire compared to verbally. Methods The study occurred in one pediatric primary care clinic in which we screen for FI using the 2-item Hunger Vital Sign™. We used interrupted time series to evaluate the effect of changing from the clinician verbal screening to a written questionnaire. Screening results were extracted for all well-child visits from 4/2017-10/2018 for children age 0-18 years. The outcome was the proportion who screened positive for FI 9 months before and 9 months after the implementation of the written questionnaire. We estimated the difference in the level and trend of positive screens using ordinary least squares regression using Newey-West standard errors and adjusting for autocorrelation. Results In 7,996 well-child visits, 1,141 (14.3%) patients screened positive. In bivariate analysis, there was a significant difference in the FI disclosure rates between patients screened by written questionnaire compared to verbally (16.3% vs 10.4%, p<0.001). In interrupted time series, changing to the written questionnaire was associated with a significant increase in FI disclosure rates (β=0.04, 95% CI: 0.01, 0.07; p=0.02). There was no significant change in the trend in disclosure rates. Discussion Multiple barriers exist to effectively implementing FI screening in clinical care. Changing from a verbal to a written questionnaire resulted in an immediate and significant increase in the number of parents/guardians who reported FI.

Cluster Randomized Trial of a Pre/Interconception Health Intervention for Mothers In Pediatric Visits Publication date: Available online 17 October 2019 Source: Academic Pediatrics Author(s): Krishna K. Upadhya, Kevin J. Psoter, Katherine A. Connor, Kamila B. Mistry, Daniel J. Levy, Tina L. Cheng Abstract Objective Recognizing that pediatric primary care focuses on family health and is an important location of contact for women of childbearing age, this project assessed the effectiveness of a pre/interconception women's health intervention delivered during pediatric primary care using a cluster randomized trial. Methods Pediatric clinicians were randomized to a screening and brief educational intervention group or usual care comparison group. Intervention group clinicians received training on pre/interconception care, including recommended counseling and referral resources for needs identified. Women presenting to primary care with their child ≤12 months were enrolled and assigned to the group corresponding to the assignment of their child's clinician. Mothers seen by clinicians in the intervention group completed a pre/interconception health screening tool and discussed results with their child's clinician during the visit. These mothers were compared to mothers seen by comparison group clinicians who did not receive the screening tool or clinician discussion. All enrolled mothers (Intervention and Comparison) received written preconception health information and a 90 day supply of multivitamins. Primary outcomes at 6 and 12 months post enrollment included contraception use, pregnancy, and access to and use of preventive health care. Secondary outcomes included daily folic acid supplementation, smoking and substance use. Results 415 women were enrolled and those who had at least one follow-up assessment were included in the analysis (n= 383). There was no significant effect of the intervention on contraceptive use, pregnancy incidence, or use of preventive care. Assignment to the intervention increased the odds of daily folic acid use [OR 1.82, 95% CI 1.25, 2.63] during follow-up. Intervention mothers were less likely to smoke at 6, but not 12 months. Conclusions Pediatric visits are an opportune location for addressing maternal health and this intervention demonstrated feasibility and improved outcomes for some but not all outcomes Attention to maternal health needs across pediatric visits during infancy may be important for maintaining positive pre/interconception health behaviors.

The development of an instrument for faculty to assess resident-led large group teaching Publication date: Available online 17 October 2019 Source: Academic Pediatrics Author(s): Ariel S. Frey-Vogel, Kristina Dzara, Kimberly A. Gifford, Erica Y. Chung Abstract Objective The Accreditation Council on Graduate Medical Education requires residents to teach and many residency programs assess resident teaching competency. While much formal resident-led teaching is for large groups, no corresponding published assessment instrument with validity evidence exists. We developed an instrument for faculty to assess pediatric resident-led large group teaching and gathered preliminary validity evidence. Methods Literature review and our experience leading resident-as-teacher curricula informed initial instrument content. Resident focus groups from three northeastern pediatric residency programs provided stakeholder input. A modified Delphi panel of international experts provided iterative feedback. Three investigators piloted the instrument in 2018; each assessed eight video-recordings of resident-led teaching. We calculated Cronbach's alpha for internal consistency and intraclass correlation (ICC) for interrater reliability. Results The instrument has six elements: learning climate, goals/objectives, content, promotion of understanding/retention, session management, and closure. Each element contains behavioral sub-elements. Cronbach's alpha was 0.844. ICC was excellent for 6 sub-elements, good for 1, fair for 1, and poor for 3. Conclusions We developed an instrument for faculty assessment of resident-led large group teaching. Pilot data showed assessed behaviors had good internal consistency, but inconsistent interrater reliability. With further development, this instrument has potential to assess resident teaching competency.

Parents’ Perceptions of Infant Crying: A Possible Path to Preventing Abusive Head Trauma Publication date: Available online 16 October 2019 Source: Academic Pediatrics Author(s): Melora Wiley, Alysse Schultheis, Brianna Francis, Gunjan Tiyyagura, John M Leventhal, Helena JV Rutherford, Linda C Mayes, Kirsten Bechtel Abstract Objective Infant crying can lead to parental frustration and is the most common trigger for abusive head trauma (AHT). We used qualitative methodology with an activating stimulus (an audiotape of an infant crying) to prime the participants to engage in open dialogue for the purpose of understanding their perceptions of infant crying and its association with AHT, with the aim that information from these interviews and the impact of hearing the activating stimulus could be used to inform interventions to prevent AHT that would resonate with parents. Methods We conducted 25 initial qualitative interviews and 16 subsequent interviews with mothers and fathers of newborns. Before the initial interview, parents listened to a 1-minute audio clip of a crying infant, followed by a preventive message regarding AHT. The transcribed data were analyzed, and themes were developed using the constant comparative method of grounded theory. Data collection and analysis continued past the point of thematic saturation. Results Four themes emerged from the initial interviews: (1) previous experience is helpful to manage infant crying; (2) babies cry for a reason; (3) shaking an infant is incomprehensible to parents; and (4) the role of safety planning to manage frustration with crying. Analysis of the subsequent interviews revealed two additional themes: (1) use of supports for infant crying (e.g., technology and physician advice) and (2) effects of the audio clip on caregiving practices. Conclusion Previous experiences and beliefs about crying affect parents’ perceptions of infant crying and AHT. After discharge, parents reported using technology for information and support and thinking about the audio clip when caring for their infant. These experiences, beliefs and practices may aid in shaping effective prevention strategies to prevent AHT.

Pediatric Resident Training in the Community Hospital Setting: a Survey of Program Directors Publication date: Available online 16 October 2019 Source: Academic Pediatrics Author(s): Steven C. Marek, Sandra Cuzzi, Priti Bhansali Abstract Background and Objectives The role of a hospitalist differs in a community hospital (CH) compared to a university/children's hospital. Residents are required to practice in a variety of relevant clinical settings, but little is known about current trends regarding pediatric resident training in different hospital settings. This study explores CH rotations including their value for resident training, characteristics, benefits, and drawbacks. This study also seeks to define “community hospital.” Methods Authors conducted an online cross-sectional survey of pediatric residency program directors distributed by the Association of Pediatric Program Directors. The survey was developed and revised based on review of the literature and iterative input from experts in pediatric resident training and CH medicine. It assessed residency program demographics, availability of CH rotations, value of CH rotations, and their characteristics including benefits and drawbacks. Results Response rate was 56%. CH rotations were required at 24% of residency programs, available as an elective at 46% of programs, and unavailable at 48% of programs. Residency program directors viewed these rotations as valuable for resident training. CH rotations were found to have multiple benefits and drawbacks. Definitions of “community hospital” varied and can be categorized according to positive or negative characteristics. Conclusions Resident rotations at a CH provide valuable learning opportunities with multiple potential benefits that should be weighed against drawbacks in the context of a residency program's curriculum. There are many characteristics that potentially distinguish CH from university/children's hospitals.

Feasibility and Effectiveness of Telelactation among Rural Breastfeeding Women Publication date: Available online 16 October 2019 Source: Academic Pediatrics Author(s): Lori Uscher-Pines, Bonnie Ghosh-Dastidar, Debra L. Bogen, Kristin N. Ray, Jill R. Demirci, Ateev Mehrotra, Kandice A. Kapinos Abstract Objective To evaluate the feasibility and impact of telelactation via personal electronic devices on breastfeeding duration and exclusivity among rural women. Methods The Tele-MILC trial, a pragmatic, parallel design trial, recruited 203 women during their postpartum hospitalization in a critical access hospital in Pennsylvania and randomized them to receive telelactation (n=102) or usual care (n=101). We used intent-to-treat (ITT) and instrumental variable (IV) approaches to analyze study data for the 187 participants who completed follow-up. The primary outcomes were any breastfeeding and exclusive breastfeeding at 12 weeks postpartum. Results Among participants in the telelactation arm, 50% (47/94) reported participating in video calls. At 12 weeks, 71% of participants in the telelactation arm vs. 68% of control participants were breastfeeding in the ITT model (3% difference, p=0.73), whereas 73% of participants in the telelactation arm vs. 68% of control participants were breastfeeding in the IV model (5% difference, p=0.74). Among participants who were still breastfeeding at 12 weeks, 51% participants in the telelactation arm were breastfeeding exclusively vs. 46% of control participants in the ITT model (5% difference, p=0.47), whereas 56% of participants in the telelactation arm were breastfeeding exclusively vs. 45% of control participants in the IV model (11% difference, p=0.48). In all models, participants in the telelactation arm were breastfeeding at higher rates; however, differences were not statistically significant. Conclusions This trial demonstrated that telelactation can be implemented with a rural underserved population. Though this trial was not powered to detect differences in breastfeeding duration and exclusivity, and none were observed, telelactation remains a promising approach for further investigation. ClinicalTrials.gov Identifier: NCT02870413

CORNET CARD STUDY #1: DO YOU SEE WHAT I SEE? Provider Confidence in Caring for Children with Special Health Care Needs Publication date: Available online 15 October 2019 Source: Academic Pediatrics Author(s): Sandra F. Braganza, Hollyce Tyrrell, Carolyn Rosen, Leora Mogilner, Ann Phillips, Sara Slovin, Iman Sharif ABSTRACT Objective Understanding differences between trainee and faculty experience with and confidence caring for children with special health care needs (CSHCN) can inform pediatric resident education. Methods Residents and faculty across the Continuity Research Network (CORNET) reported on a consecutive series of 5 primary care encounters. Respondents answered questions about visit characteristics, patient demographics, and applied the CSHCN Screener. Respondents also reported on how confident they felt addressing the patient's healthcare needs over time. We dichotomized confidence at “very confident” vs. all other values. We used logistic regression to describe the correlates of provider confidence managing the patient's care. Results We collected data on 381 (74%) resident-patient and 137 (26%) attending-patient encounters. A higher proportion of attending encounters compared to resident encounters were with CSHCN (49% vs. 39%, p<0.05), including children with complex needs (17% vs. 10%, p<0.05). The odds of feeling “very confident” [AOR(95%CI)] was lower with increasing CSHCN score [0.61(0.51-0.72)] and was lower for resident vs. attending encounters [0.39(0.16-0.95)]. Confidence was higher if the provider had previously seen that patient [2.07 (1.15-3.72)], and for well [2.50(1.35-4.64)] or sick visits [3.18(1.46-6.94)] (vs. follow-up). Differences between residents and attending pediatricians regarding the relationship between confidence and visit characteristics for subsets of CSHCN are reported. Conclusion All providers felt less confident caring for CSHCN; however for certain needs, resident confidence did not increase with level of training. The data suggest potential educational/programmatic opportunities.