Faculty Bibliography

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

BACKGROUND AND OBJECTIVE: Early identification and treatment of severe sepsis and septic shock improves outcomes. We sought to identify and evaluate children with possible sepsis on a pediatric medical/surgical unit through successful implementation of a sepsis identification pathway. METHODS: The sepsis identification pathway, a vital sign screen and subsequent physician evaluation, was implemented in October 2013. Quality improvement interventions were used to improve physician and nursing adherence with the pathway. We reviewed charts of patients with positive screens on a monthly basis to assess for nursing recognition/physician notification, physician evaluation for sepsis, and subsequent physician diagnosis of sepsis and severe sepsis/septic shock. Adherence data were analyzed on a run chart and statistical process control p-chart. RESULTS: Nursing and physician pathway adherence of >80% was achieved over a 6-month period and sustained for the following 6 months. The direction of improvements met standard criteria for special causes. Over a 1-year period, there were 963 admissions to the unit. Positive screens occurred in 161 (16.7%) of these admissions and 38 (23.5%) of these had a physician diagnosis of sepsis, severe sepsis, or septic shock. One patient with neutropenia and septic shock had a negative sepsis screen due to lack of initial fever. CONCLUSIONS: Using quality improvement methodology, we successfully implemented a sepsis identification pathway on our pediatric unit. The pathway provided a standardized process to identify and evaluate children with possible sepsis requiring timely evaluation and treatment.

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Adolescent obesity continues to be a major public health issue with a third of American adolescents being overweight or obese. Excess weight is associated with cardiovascular risk factors and pre-diabetes. High school students identified as carrying excess weight [body mass index (BMI) >/=25 kg/m2, or BMI percentile >/=85 %] were invited to participate in The BODY Project, an intervention that included a medical evaluation and a personalized medical report of the results of that evaluation sent to the parent/guardian at home. The medical evaluation and report was repeated 12 months later. The reports also contained advice on how the individual student could modify their lifestyle to improve the specific medical parameters showing abnormalities. Outcomes were change in BMI, blood pressure, high-density lipoprotein (HDL), low-density lipoprotein (LDL), fasting glucose, and fasting insulin. Students participating in The BODY Project intervention demonstrated modest, yet significant, reductions in BMI (p < 0.001) 1 year later, and also had significant improvements in systolic blood pressure (p < 0.001) and cholesterol profile (HDL p = 0.002; LDL p < 0.001) at follow-up. The BODY Project, by means of a minimal educational program anchored on the principle of teachable moments around the students' increased perception of their own risk for disease from the medical abnormalities uncovered, demonstrates evidence of potential effectiveness in addressing adolescent obesity.

Background. Increased prevalence of type 2 diabetes mellitus (T2DM) makes it important for pediatricians to use effective screening tools for risk assessment of prediabetes/T2DM in children. Methods. Children (n = 149) who had an oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) were studied. American Diabetes Association recommended screening criteria-HbA1c >/=5.7% and fasting plasma glucose (FPG) >/=100 mg/dL-were compared against OGTT. The homeostatic model assessment of insulin resistance (HOMA-IR), a mathematical index derived from fasting insulin and glucose, was compared with OGTT. We studied whether combining screening tests (HbA1c and fasting glucose or HbA1c and HOMA-IR) improved accuracy of prediction of the OGTT. Results. HbA1c of >/=5.7% had a sensitivity of 75% and specificity of 57% when compared with the OGTT. Combining screening tests (HbA1c >/=5.7% and FPG >/=100 mg/dL; HbA1c >/=5.7% and HOMA-IR >/=3.4) resulted in improved sensitivity (95.5% for each), with the HbA1c-FPG doing better than the HbA1c-HOMA-IR combination in terms of ability to rule out prediabetes (likelihood ratio [LR]) negative. 0.07 vs 0.14). Conclusions. HbA1c of >/=5.7% provided fair discrimination of glucose tolerance compared with the OGTT. The combination of HbA1c and FPG is a useful method for identifying children who require an OGTT.

AIM: To establish whether young children watched foreground electronic media or background media that was not aimed at them or was inappropriate for their age. METHODS: We performed a longitudinal analysis of mother-infant dyads participating in a larger parenting study. The primary dependent variable was maternal reports of watching habits from media diaries at 6, 14, 24 and 36 months. Independent variables were child age, programme content and whether the programme was turned on specifically for the child. RESULTS: We analysed 3570 programme exposures in 527 children, mostly from television. Children were significantly more likely to actually watch programmes if they were older, if the content was coded as 'educational young child' or if the parent tuned on the programme specifically so the child could watch it. Children under the age of two were more likely than older children to watch background media that featured age-inappropriate content or had not been turned on for them to watch [30% versus 16% of programmes; AOR = 2.19 (95%CI 1.82-2.65)]. CONCLUSION: Young children under the age of two frequently watch background media that has age-inappropriate content or has not been turned on for them to watch.