Overmedicalization in Children with Medical Complexity

Children with medical complexity (CMC) are a unique pediatric patient population with increased exposure and interactions with the health care system and reliance on family caregivers. These attributes place CMC at high risk of overmedicalization (OM). This article reviews the risk factors for OM in CMC and presents an algorithm that primary providers can use to recognize and address this issue. Involvement of a broad multidisciplinary team, including child advocacy when needed, is recommended. The article also focuses on challenges and additional considerations that arise when medical child abuse as the cause of OM is suspected in this population. [Pediatr Ann. 2020;49(11):e478-e485.].

Written Versus Verbal Food Insecurity Screening in One Primary Care Clinic

OBJECTIVE

Clinics are increasingly interested in identifying food insecurity (FI), but there are 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 1 pediatric primary care clinic in which we screened 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 to 10/2018 for children age 0 to 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 7996 well-child visits, 1141 patients (14.3%) 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 < .001). In interrupted time series, changing to the written questionnaire was associated with a significant increase in FI disclosure rates (β = .04, 95% confidence interval: 0.01, 0.07; P = .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.

Human Papilloma Virus Vaccination After Pediatric Sexual Abuse Evaluations in the Outpatient Child Sexual Abuse Subspecialty Clinic: A Quality Improvement Project

The nonavalent human papilloma virus (HPV) vaccination prophylactically contributes to the prevention of nine types of HPV-associated oral and genital cancers. HPV vaccination rates remain lower than the national Healthy People 2020 goal of 80%. Victims of pediatric sexual abuse are at a higher risk for acquiring and developing HPV-related outcomes. Current research supports vaccination after sexual abuse as soon as eligible and suggests utilizing multiple types of medical encounters to increase vaccination rates.An institutional-review-board-approved quality improvement project was developed to determine the impact of promoting and providing HPV vaccination during the medical encounter after pediatric sexual abuse in a child protection team (CPT) clinic. Twenty percent of the 111 total clinic patients evaluated in the preintervention period and 21% of the 99 patients evaluated in the postintervention period were HPV vaccine eligible, illustrating a significant opportunity for impact. During the intervention period, 62% of patients who were vaccine eligible and presented for their CPT clinic visit received HPV vaccine. Barriers to vaccination in the outpatient CPT clinic setting included high appointment no-show rates, high social and medical visit complexity, and absence of an appropriate consenting caretaker. Implications for forensic nursing practice are discussed.

Prematurity and neonatal comorbidities as risk factors for nonaccidental trauma

BACKGROUND

Parental, familial, and demographic risk factors for nonaccidental trauma (NAT) have been well-studied, but neonatal factors, such as comorbidities and prematurity have not. We assess the correlation of these factors with NAT.

METHODS

A total of 234 cases of NAT and 287 cases of accidental trauma (AT) among children <1 year were identified in a trauma registry. Known risk factors for NAT, gestational age, and neonatal comorbidities were abstracted from medical records. Chi-square analysis and logistic regression evaluated the association of prematurity and comorbidities with NAT compared to AT with and without controlling for confounders.

RESULTS

Children treated for NAT were younger than those treated for AT and were more likely to have younger parents with substance abuse issues. Prematurity, major comorbidities, and minor comorbidities were more common in those treated after NAT than after AT (24.8% vs 12.7%, p=0.0004; 25.6% vs 7.2%, p<0.0001, and 42.6% vs 29.3%, p=0.0014, respectively). After model adjustments for other risk factors, major comorbidity remained a significant risk factor for NAT compared to AT, with an adjusted odds ratio of 4.37 (p<0.0001).

CONCLUSIONS

Among other risk factors, neonatal factors predict a child's risk for abuse. We have an opportunity for targeted preventive interventions among this at-risk population.

Invisible children

A series of severe child abuse cases in the state, all involving children who were reportedly homeschooled, are cause for concern. We review 4 such cases and the regulations regarding homeschooling in the state of North Carolina, exploring potential deficits in the system and suggesting ways of addressing them.