Category Archives: Pediatric care
For children, stress can come from sources inside and outside the family. It was recently documented that nearly two out of every three children in the United States have witnessed or been victims of violence in their homes, schools, or communities. That’s a staggering statistic when we consider the well-established link between children’s exposure to stress and their long-term mental and physical health outcomes.
Indeed, we know that early exposure to adverse experiences can change the way that our brains develop and function. We also know that exposure to adversity increases the likelihood that children will develop psychosocial problems, like depression, aggression, and other antisocial behaviors. There is even evidence that exposure to stressors in childhood increases the likelihood of having heart disease and cancer in adulthood!
A leading cause of preventable blindness in premature babies can be successfully identified by trained non-physician evaluators working remotely, according to a study published online by JAMA Ophthalmology. The number of ophthalmologists who conduct screenings for the condition, retinopathy of prematurity (ROP), has declined in the United States, while countries in parts of Latin America, Asia, and Eastern Europe have long-standing ophthalmologist shortages that contribute to high rates of childhood blindness caused by ROP.
“This study provides validation for a telemedicine approach to ROP screening and could help prevent thousands of kids from going blind,” lead investigator Graham E. Quinn, MD, MSCE, said in a news release from the Children’s Hospital of Philadelphia, where he is a pediatric ophthalmologist.
The study involved retinal images taken by neonatal intensive care unit nurses and transmitted to trained image readers at a central location. Ophthalmologists had also examined the infants, and the image readers identified 90 percent of the infants the ophthalmologists had flagged as needing further evaluation.
“Telemedicine potentially gives every hospital access to excellent ROP screening,” said Quinn.
Chris Feudtner, MD, PhD, MPH, is a pediatrician, epidemiologist, historian, and ethicist at The Children’s Hospital of Philadelphia (CHOP) and professor of pediatrics at the University of Pennsylvania. He is an alumnus of the Robert Wood Johnson Foundation Clinical Scholars program.
Living in a situation beyond almost-unbearable imagination: This is the reality that children with life-threatening conditions and their parents confront, and that the rapidly emerging field of pediatric palliative care seeks to address with compassionate and specialized medical and psychosocial expertise.1
A bit of background: just over half of the 45,000 children who die in the United States each year are infants, who often die within hours of their birth. Others die after traumatic injuries, usually quite suddenly. And a substantial proportion of the children die after a prolonged illness trajectory, due to a wide range of chronic conditions, ranging from cancer to congenital anomalies to neurodegenerative diseases. Most of these children spend days or weeks in hospitals, with frequent hospitalizations, and with the likelihood of hospitalization going up as the condition worsens.
To meet the needs of these patients and their families, many children’s hospitals in the United States have created dedicated pediatric palliative care teams. These interdisciplinary teams—composed of physicians, nurses, social workers, child life and art therapists, chaplains, and other specialists—pursue three core tasks on behalf of these patients. First, they manage pain and other symptoms, using both pharmacologic and complementary methods. Second, they support patients and parents in the often overwhelming process of receiving medical information and making treatment decisions. Third, they help coordinate care both across specialty disciplines within the health system, and across different sites of care, from the hospital setting to home or other residential sites, often in partnership with hospice or home nursing. All of this is done in coordination with the patient’s primary medical or surgical team2—palliative care adds and never subtracts.
About 19 in every 100,000 American children under the age of five suffers from an inflammatory illness called Kawasaki Disease (KD) that can cause irreversible damage to the heart. If diagnosed early, it can usually be treated effectively, and children can be returned to health in just a few days. But between 10 and 20 percent of treated patients suffer from a persistent fever, or one that recurs after treatment, and they are at elevated risk of developing coronary artery aneurysms. A new study, led by Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program Scholar Adriana H. Tremoulet, MD, MAS, and published yesterday in The Lancet, offers new hope for patients with KD.
The symptoms of KD include prolonged fever associated with a rash, swollen neck glands, red eyes, swollen red lips, a condition physicians call strawberry tongue, and swollen hands and feet with peeling skin. Current treatment is infusion of intravenous immunoglobulin (IVIG) and aspirin. The IVIG carries the pooled antibodies from the blood plasma of more than 100,000 donors, and in the KD patient, it decreases the inflammation that causes heart damage. The treatment usually works, but some patients’ IVIG-resistance puts them at greater risk and in need of further treatment.
Tremoulet, a pediatric infectious disease specialist at Rady Children’s Hospital in San Diego, conducted a Phase III trial in which a synthetic antibody called infliximab was added to the standard IVIG and aspirin treatment. While the protocol did not affect the patients’ resistance, it had important positive results. “In our study,” Tremoulet said, “we demonstrated that a single dose of infliximab is safe in children with Kawasaki Disease and that this treatment reduced the inflammation in the body overall as well as in the arteries of the heart faster than just using standard treatment with intravenous immunoglobulin.”
Katherine A. Auger, MD, MSc, a pediatrician in the Division of Hospital Medicine, Department of General Pediatrics at Cincinnati Children’s Hospital Medical Center, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program.
A 2006 recommendation from the Centers for Disease Control and Prevention (CDC) that all adolescents receive vaccines for pertussis, also known as whooping cough, is having a positive impact. A new study that I led shows it is associated with lower rates of infant hospitalizations for the respiratory infection than would have been expected had teens not been inoculated.
The study, published in Pediatrics, found that the CDC recommendation led not only to a significant increase in vaccination rates among teens, but also to a reduction in severe pertussis-related hospitalizations among infants, who often catch the disease from family members, including older siblings.
Quick thinking and a lucky coincidence saved a toddler’s life, and the incident is serving as a powerful reminder about the need to train parents and other caregivers about what to do when children choke.
Maja Djukic, PhD, RN, a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar and assistant professor at the New York University College of Nursing, was rollerblading near her home in Connecticut this fall when she heard screaming. Djukic raced to the scene to find a one-year-old boy limp and turning blue. The boy’s father was calling 9-1-1 while him mother tried, unsuccessfully, to clear his air passages. Djukic was able to do so; she had the child breathing by the time an ambulance arrived. He has fully recovered.
In “Keeping Little Breaths Flowing,” Jane E. Brody of the New York Times wrote about the incident, noting that “few parents of newborns are taught how to prevent choking and what to do if it occurs.” Brody’s two-part piece on cardiopulmonary resuscitation (CPR) concludes with “How CPR Can Save a Life,” in which she focuses on resuscitating adult victims of cardiac arrest.
Lisa Ross DeCamp, MD, MSPH, is an alumna of the Robert Wood Johnson Foundation Clinical Scholars program. She is an assistant professor of pediatrics at Johns Hopkins University School of Medicine and a researcher with the Center for Child and Community Health Research.
Good communication is critical for development of an effective partnership between patient and provider. However, for the more than 25 million people in the United States who report speaking English less than very well and are classified as having limited English proficiency (LEP), access to the most basic aspect of communication—a common language with the provider—may be limited.
It is easy to imagine how language barriers may compromise the quality and safety of health care. Research consistently demonstrates that physicians falter in many aspects of communication, compromising health care quality and lowering patient satisfaction even when they speak the same language. Quality and satisfaction gaps stemming from poor communication are only magnified when a language barrier is present. Health care safety requires understanding instructions, again an impossible task if the patient and provider do not share a common language.
Mark I. Neuman, MD, MPH, is director of fellowship research and research education for the division of emergency medicine at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. The following blog, adapted from a commentary he co-authored in Pediatrics, originally appeared on Vector, the science and innovation blog of Boston Children's Hospital.
It’s no secret that the U.S. health care system is in the midst of a financial crisis. As a nation, we spend nearly 18 percent of our Gross Domestic Product on health care, and health care costs remain the largest contributor to the national debt. In 2011 alone, the cost of maintaining the nation’s 5,700 hospitals exceeded $770 billion.
If ever there was a time for a societal mandate to reduce health care costs, that time is now.
It’s widely accepted that one of the first steps to reining in runaway health care costs is reducing variability in the manner in which care is delivered. Well-defined and well-disseminated best practice guidelines can improve the reproducibility and standardization of care. In time, these guidelines may reduce costly and unnecessary tests and hospitalizations, while providing a platform on which to measure and enhance quality. More consistency may also allow providers to be more efficient with their time, space and personnel.
If it’s so costly, why is health care variability so abundant?
Bonnie Zima, MD, MPH, an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1989-1991), published a study this month that appeared in a special supplement of Pediatrics with articles by RWJF Clinical Scholars on child health quality. Pediatrics is the official journal of the American Academy of Pediatrics. Zima is a professor-in-residence in child and adolescent psychiatry at the University of California in Los Angeles (UCLA) and associate director of the UCLA Center for Health Services & Society.
Human Capital Blog: Why did you decide to review the new child mental health quality measures?
Bonnie Zima: This paper was written to stimulate discussion about the need for a paradigm shift for quality measurement for children that more closely aligns research with the accelerated pace of quality measure development.
These are exciting times for those who believe that the quality of child health care can be improved through measurement and public reporting. However, this direction also raises questions about how to improve our methods and data infrastructure to monitor the quality of care received in real-time and to link adherence to quality indicators to clinical outcomes that are meaningful to parents, child advocates, providers, agency leaders and policy-makers.
HCB: Why did you focus on child mental health?
Zima: We focused on child mental health care because quality measurement poses additional challenges that can be used as a stimulus to improve future measure development.
Some of the areas for future research include development of a stronger evidence base to support nationally recommended care processes in community-based populations; models of care coordination across multiple care sectors that often have discrete funding streams, such as specialty mental health, public health, education, child welfare, and juvenile justice; and the development of interventions that more flexibly align service delivery with children’s clinical needs, especially for those with co-morbid mental and physical health conditions.
Lawrence Kleinman, MD, MPH, is vice chair and associate professor of health evidence and policy and associate professor of pediatrics at Mount Sinai Hospital. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1990-1992) and helped guide a special supplement of studies by RWJF Clinical Scholars into publication in Pediatrics this month.
Human Capital Blog: How did this special supplement come to be and what impact do you expect and hope it will have?
Kleinman: Des Runyan, MD, DrPH, director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, called to ask me what I thought about the idea and whether I would be willing to shepherd the issue. Des had observed the historical and seminal role of RWJF Clinical Scholars in the emergence of the field of quality of health care, the work of Bob Brook, MD, ScD, chair in health care services at the RAND Corp., a professor of health policy and management, and of medicine, at the University of California at Los Angeles (UCLA), and an RWJF Clinical Scholar alumnus, and of many others, and also the more recent emergence of Clinical Scholars as leaders in the field of children’s health care.
He also recognized that five of seven centers of excellence funded by the Agency for Healthcare Research and Quality (AHRQ) as part of its flagship Pediatric Quality Measures program (PQMP) were led by alumni of the Clinical Scholars program. I think Des viewed that as a seminal moment that showed that Clinical Scholars alumni had achieved similar leadership in child health that they had achieved in the area of adult health. He recognized the opportunity to celebrate that in a collection of work on children’s health quality by RWJF Clinical Scholars and alumni.
HCB: What are the key messages readers should take away from the series?
Kleinman: This supplement demonstrates the capacity and power of using conceptual models to inform quality and quality improvement research, suggests an approach to developing these kinds of conceptual models, and illustrates that a span of approaches—ranging from evidence synthesis to a highly reductionist analysis of existing data to an extremely generative qualitative analysis to the thoughtful integration of ideas by colleagues—may all inform the field in important ways.
Further, the field of pediatric quality of care is blossoming; it truly needs studies that incorporate and extend its range. Finally RWJF Clinical Scholars are still thought leaders and change agents who as a group demonstrate remarkable versatility in their methods and prove notably capable of provoking progress in children’s health and quality research.