June 2014 Journal Watch

Allergy/Immunology

Sedaghat et al. Prevalence of and Association with Allergic Rhinitis in Children with Chronic Rhinosinusitis. International Journal of Pediatric Otorhinolaryngology. 2014;78: 343-347.

Chronic rhinosinusitis (CRS) is defined as “90 days or more of persistent purulent rhinorrhea and nasal congestion.” The objective of this retrospective cohort study was to evaluate the epidemiologic relationship between allergic rhinitis (AR) and CRS as well as CRS and atopic disease, CF, immunologic disorders, and primary ciliary dyskinesia (PCD). 4,044 children were diagnosed with CRS over a 10 year period; the median age was 8.9 years. Four percent with CRS also had CF, 12.3% had an immune system disorder, and 0.2% had PCD. The prevalence of allergic rhinitis in children with CRS was 26.9%. Interestingly, 18.1% of children with CRS also had a diagnosis of asthma; there was a higher prevalence of asthma in the population with both CRS and AR compared to children without AR. A diagnosis with CF was negatively associated with AR, but there was a positive association with AR and asthma (P<0.001). In a multivariate analysis, children with uncomplicated CRS had a positive association with a diagnosis of AR, younger age, and asthma. I find it helpful in building a “clinical script” to learn about associations or the prevalence amongst certain disease. Recognizing that children with chronic rhinosinusitis have a higher prevalence of allergic rhinitis may lead to allergen testing. Results of testing could help me treat or prevent exacerbations of the patient’s rhinitis. Likewise, knowing that there is a positive association between AR and asthma may lead to the early recognition of asthma symptoms in those with CRS or AR.

Submitted by: Meg Oberle

Caserta: This is very interesting and timely since we are in a peak allergy season currently. It is important to recognize associations and trends while evaluating a patient and this kind of information is very helpful.

Child Abuse/Advocacy

Chien AT, Song Z, et al. Two-year Impact of the Alternative Quality Contract on Pediatric Health Care Quality and Spending. Pediatrics. 2014;133: 96-104.

This study compared quality and spending trends in children before and after the implementation of the Alternative Quality Contract (AQC). The AQC is a program which provides incentives to reduce spending while improving quality. They compared these trends in children with special health care needs to those without special health care needs. This study found that pediatric care quality that was tied to pay-for-performance increased in both groups of children while quality measures not tied to pay-for-performance did not increase. Average annual spending was five times greater for children with special health care needs than those without and there was no change in spending among either group after AQC implementation. Insurance companies are more frequently using contracts which combine pay-for-performance and global budgets. For reimbursement purposes, it will become more important for pediatricians to maximize the quality of care provided to their patients and, ideally, reduce spending. Despite the possibility of rewards for decreased spending, spending did not change with the implementation of the AQC. This could point to efforts already in place to minimize spending among pediatric patients, but since children with special health care needs contribute a significantly higher amount toward average annual spending, these children might be an area of focus for future spending reduction. It is important for pediatricians to be cognizant of these issues as they are increasingly being forced to reduce their spending while simultaneously improving their quality of care.

Submitted by: Amanda Lansell

Caserta: It is encouraging that the quality of care was not impacted by the AQC initiative. The authors do point out that targeted efforts to reduce spending for children with special health care needs may need to be the focus in the future.

Mabli, J & Worthington, J. Supplemental Nutrition Assistance Program Participation and Child Food Security. Pediatrics. 2014;Volume 133: 610-619.

Over the past few years, government budgeting been a heavily debated topic at the national level. One of these government programs discussed has been the allocation for Supplemental Nutrition Assistance Program (SNAP) benefits. Most recently in January the House of Representatives have passed a five year farm bill that also cuts 1 billion dollars of funding to SNAP program per year. According to the most recent data released by the Food and Nutrition Service, more than 1.8 million people in Ohio receive assistance through SNAP, and about forty percent are children. The authors wanted to analyze the association of SNAP enrollment and children’s food security. Using a questionnaire to assess food insecurity and very low food insecurity, they compared household newly entering SNAP with those that had been in SNAP for 6-7 months. They found that those children whose households were in SNAP for 6-7 months were 36% less likely to be food insecure. Additionally, they found that those children in SNAP for 6 months were 52% less likely to be experiencing very low food insecurity. These authors also investigated a longitudinal study looking at the same children over a period of 6 months and found that after 6 months of SNAP enrollment, children were 38% less likely to be food insecure. For me I need to be aware of signs of food insecurity among the patients I serve at RAP clinic and connect these families to the resources needed.

Other resources used:
http://www.fns.usda.gov/pd/29snapcurrpp.htm
http://www.fns.usda.gov/pd/snapmain.htm

Submitted by: Casey Lwo

Azok: This article highlights the huge impact that the Supplemental Nutrition Assistance Program (SNAP) has on improving food insecurity for children. Unfortunately, huge cuts have been made in this program, which will have a profound effect, especially in our patient population.

General Pediatrics

Journal Citation: Macy ML, Cunningham RM, Resnicow K and Freed GL. Disparities in Age-Appropriate Child Passenger Restraint Use among Children Aged 1 to 12 Years. Pediatrics. 2014;133(2): 262-271.

There are many topics that the AAP recommends pediatricians to educate their patients about at each visit. It is, at times, difficult to determine which topics are should touch on as it is not feasible to mention all of them in a visit. This article pushes the idea that age appropriate child safety seat use is one of the topics that we should address. With proper use, injury risk is reduced by 50-75%. These authors investigated whether or not appropriate restraint use was correlated with ethnicity. This study, a 2 site cross-sectional study performed in Michigan, was able to recruit 601 parent self-reported surveys of child passenger safety practices. Using bivariate and multivariate analysis, they determined that white parents reported increased proper car seat use in children aged 1-3 years old and booster seats for children 4-7 years old compared to non-white parents (85% vs. 61% and 86% vs. 69% respectively with p<0.001 for both comparisons). There were also more premature transitions from car seats to booster seats in non-white parents. They felt that these racial disparities were complex and not fully explained by socioeconomic variables. The authors also pointed out that parents who remember getting car safety tips at their office visits were more likely to have proper seat options. As discussing car safety with parents increases their safe practices, I feel that it is important to mention car safety to parents in our RAP clinic. In addition, if we promote safe car practices now, then when these children become teenagers they may be more likely to become safe drivers themselves.

Submitted by: Diana Yan

Caserta : I could not agree more! This is one issue that must be addressed at every WCC visit. This data regarding racial differences is quite interesting, and may point to a need for targeted public health education as well as vigilance in the PMD office.

Schmidt ME et. al. Systematic Review of Effective Strategies for Reducing Screen Time among Young Children. Obesity. 2012;20: 1338-1354.

The AAP recommends <2hours of television or screen time per day for children, but the average child receives around 7 hours of screen time in a day. This study reviewed 47 randomized control trials of interventions to reduce screen time in children <12 years of age. The study found 3 effective, statistically significant strategies. The first was TV time monitors, which would alarm when the screen time limit was achieved. The second was contingent feedback systems, which was a system of making screen time allowances based on the amount of physical activity performed. The third was clinic-based counseling. Limitations of this study included diverse measurement techniques across the different studies and variable sources of information (ie parent vs. child). This study was useful in providing information about effective strategies to reduce television time. Based on the strategies studied in this review, I now have more suggestions when I counsel parents about reducing television time. I will be more likely to recommend using a timer or using limited television time as a reward for healthy behaviors.

Submitted by: Divya Parikh

Caserta: The idea of a timer on the TV is great. It can be difficult for parents to recognize how much time their children are in front of the TV, and this seems like a good way to control the behavior.

Infectious Disease

Vaz LE, Kleinman KP, Raebel MA, et al. Recent Trends in Outpatient Antibiotic Use in Children. Pediatrics. 2014;133(3): 375-85.

This was a retrospective cohort study that looked at population data for children in 3 commercial health plans located in “geographically distinct” areas between September 1, 2000, and August 31, 2010. The study linked dispensed antibiotics to age and diagnosis documented at clinic visits (if able). The study showed a decline in antibiotic prescription between 2000-2001 and 2009-2010. The study also demonstrated a “2-slope model” which showed that the trends changed over the 10 year study period, which differed among age groups (youngest pt’s showing the slowest decline). Overall, however the rates were more rapid in the beginning of the decade when compared to later in the decade, with wide variation across the three national sites used. Otitis media was the largest contributor to decline in antibiotic prescribing overall. This was driven by a decline in diagnosis rather than changes in management guidelines. When the study teased out prescribing habits in terms of antibiotic class, relatively broad spectrum (macrolides/3rd gen cephalosporins) they found less decline. They identified this as an area that continued efforts to curb inappropriate antibiotic use would be effective, despite overall decline in prescribing. Antibiotic stewardship is still relevant in an era of continued antibiotic prescription decline. I will practice adherence to guidelines in conjunction with clinical judgment. I will also utilize the narrowest spectrum agent that is useful.

Submitted by: PJ Tate

Azok: There has been improvement in antibiotic prescribing over the decade. However, the most improvement in prescribing practices was seen at the beginning of the decade. While there have been declines in overall prescribing, we still need to make strides in prescribing as narrow of antibiotic as clinically appropriate in order to reduce antibiotic resistance.

Nephrology

Sureshkumar P, et al. Predictors of Remission and Relapse in Idiopathic Nephrotic Syndrome: A Prospective Cohort Study. Pediatric Nephrology. 2014 Jun;29(6): 1039-46.

The incidence of idiopathic nephrotic syndrome (INS) is 2-7 cases/100,000 children below 16 years of age. Although most children respond to corticosteroid therapy and achieve remission, 80-90% will experience one or more relapse. There have been retrospective studies assessing predictors of remission and relapse, but this paper is a prospective study of children presenting with their first episode. 145 children met criteria for INS, 129 had follow-up questionnaires completed by their physicians. Questions include age of onset, gender, ethnicity, clinical characteristics (BP, hematuria, creatinine). Socio-economic status was also collected. At 12 months, outcome of interest were remission, relapse, and frequently relapsing or steroid-dependent nephrotic syndrome. At 12-month follow-up, 83% achieved remission and 22% had steroid-resistant nephrotic syndrome. Analysis showed that response to treatment differs between boys and girls. For remission, male gender is the only predictor. For first relapse, male gender and longer time to first remission are independent risk factors. The risk for frequently relapsing course was increased with shorter time from remission to first relapse. The strengths of this study are the prospective design and good follow-up rate. Limitations include the short study period of one year. In the discussion, this paper also recognizes that there is variability between this study and other retrospective studies. This study identified predictors for remission and relapse and this can be used to counsel families about future course of INS. This could also potentially allow reduced exposure to corticosteroids if the child has been identified to have low risk to relapse.

Submitted by: Chia-Lei Vivian Lin

Azok: This is an interesting article looking at predictors of remission and relapse for idiopathic nephrotic syndrome. This can be used to both better counsel families about prognosis and also better tailor treatment to individual patients.

PICU

Stickney CA, Ziniel SI, Brett MS. Family Participation during Intensive Care Unit Rounds: Attitudes and Experiences of Parents and Healthcare Providers in a Tertiary Pediatric Intensive Care Unit. J Pediatr. 2014;164: 402-6.

In recent years there has been a large movement towards patient centered care and increased involvement of family members in care. With this rising involvement there has been significant concern on the part of healthcare providers at the ability of parents to understand the information being communicated to them. This study was a cross-sectional survey of 100 parents of patients admitted for at least 2 days in the PICU from 2/2011-5/2011. The survey assessed perceptions of understanding of rounds and perceptions of parental involvement. Demographic information on patients/parents was also collected. Healthcare providers including physicians, nurses, and residents/fellows also completed the survey. The results demonstrated that parent participants were mostly Caucasian (80%), educated (52% with college or greater), and a mix of healthy children and children with chronic medical conditions. Parents were significantly more likely than physicians to believe they understood rounds, were comfortable with teaching during rounds, and that physicians should return to discuss the plan after rounds. Additionally providers were more likely than parents to believe that morning rounds make parents anxious, confused, and that it is sometimes inappropriate for parents to participate in rounds. On subgroup analysis nurses were more likely than physicians to agree with parents regarding parental understanding, teaching during rounds, and that parental involvement did not slow rounding times. This article demonstrates that physician perceptions of parental involvement might be overly pessimistic in terms of parental understanding of the process of rounding/teaching. I will continue to advocate for involvement of parents during rounds.

Submitted by: Nathan Beins

Caserta: There have been previous studies showing higher parent satisfaction when family centered rounds are instituted. Even if parents do not understand 100% of what is discussed during rounds, they usually are the experts regarding their child and often have insight that could help the healthcare team.

Pulmonology

Harutyunyan A, Movsisyan N. Reducing Children's Exposure to Secondhand Smoke at Home: A Randomized Trial. Pediatrics. 2013;132; 1071-1080.

250 families in Yerevan, Armenia- a country with an above average rate of smoking, especially among the male population- were randomized to receive educational pamphlets versus an intensive second-hand smoking educational program that emphasized limit-setting for in-home smoking using the motivational interviewing technique with 2 phone call follow-ups. Mothers and one daily smoker from the family were included in the education with subsequent assessment of in-home exposure and pediatric nicotine exposure, as measured in levels detected from hair follicles of children living in the smoking environment. After the intervention, nicotine levels measured in children’s hair were significantly decreased in the intensive intervention arm as compared to the standard education protocol. These findings suggest that directed education aimed at parents of children with significant second hand smoke exposure in the home can successful alter behaviors; this offers support and additional evidence for my ongoing efforts to counsel families about risk-minimization and ultimate smoking cessation during outpatient clinic visits.

Submitted by: Anya Kleinman

Azok. This is an exciting article which shows the effectiveness of education to limit second-hand smoke exposure to children. This study supports efforts to counsel families about the risk of second-hand smoke.

Sports Medicine

Schatz, P, Sandel, N. Sensitivity and Specificity of the Online Version of ImPACT in High School and Collegiate Athletes. Am J Sports Med. 2013;41; 322-326.

Concussions are commonly seen in athletes and the frequency of concussions has been on the rise. Many states have now passed legislation to require that athletes with suspected concussions be evaluated before returning to play by a licensed health care professional. Recently, many have supported a serial assessment model that allows athletes to serve as their own controls by comparing baseline to post injury performance to help eliminate underreporting of symptoms. One available computerized tool is the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). This study looked at ImPACT results in two groups of athletes with concussion – those reporting symptoms and those reporting no symptoms after a suspected injury – and compared them to non concussed athletes matched on the basis of sex, age, handedness, sport, and history of concussion. A discriminant analysis on the subscale scores for the symptomatic group versus normal controls correctly classified 91.4% of participants in the concussed group (sensitivity) and 69.1% of participants in the non concussed group (specificity). The same analysis for the “asymptomatic” group versus normal controls correctly classified 94.6% of participants in the concussed group (sensitivity) and 97.3% of participants in the non concussed group (specificity). Those suspected of hiding symptoms displayed more variability in testing thus discriminating them from normal controls. This study supports the use of ImPACT in diagnosing concussion in the acute phase. ImPACT is a good tool to use for diagnosing concussion and potentially for following post concussive symptoms after an injury.

Submitted by: Elise Bream

Azok: There has been a lot of research and information in the media recently about the risks of concussions to the developing adolescent brain. It is crucial to have an easy way to identify athletes with concussions. This study supports using a computerized tool, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) to identify those patients with concussions to determine who needs to be removed from activity. This tool was also valid in athletes who were trying to hide their symptoms.

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