Category Archives: Pediatric care
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.
Antoinette L. Laskey, MD, MPH, FAAP, is an associate professor of pediatrics and division chief and medical director at the Center for Safe and Healthy Families at the Primary Children’s Medical Center at the University of Utah in Salt Lake City. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2001-2003).
During medical school at the University of Missouri-Columbia, I had my first exposure to child abuse pediatrics. As a third-year student on my pediatrics clerkship, I had the opportunity to participate in the care of a child whom I suspected had been beaten. From that point forward I knew this was where I wanted to spend my career.
I started looking into fellowship opportunities even before I had started my residency. Early in my intern year in 1998, I reached out to Des Runyan, MD, DrPH, a pioneer in child abuse pediatrics and an alumnus of the RWJF Clinical Scholars program (1979-1981) who was then at University of North Carolina at Chapel Hill and who is now national program director of the RWJF Clinical Scholars program. We arranged a visit so that I could learn more about the field through his expert eyes.
Before child abuse pediatrics was recognized as an official subspecialty of pediatrics, there were two different paths to enter practice: a one-year “apprenticeship” or a two-year clinical and research fellowship. In my short visit to Chapel Hill, it became apparent to me that an RWJF Clinical Scholars position was the way I needed to go to not only practice in the field of child abuse pediatrics but to also gain the knowledge base necessary to move the field forward.
Andrea Gottsegen Asnes, MD, MSW, is an assistant professor of pediatrics at the Yale School of Medicine and a Robert Wood Johnson Foundation (RWJF) Clinical Scholars program alumnus (2001-2003).
Human Capital Blog: What kind of work do you do in the area of child abuse pediatrics?
Andrea Gottsegen Asnes: I am a child abuse pediatrician. Nearly eight years ago, I joined former Robert Wood Johnson Foundation (RWJF) Clinical Scholar and fellow child abuse pediatrician John Leventhal, MD, as a member of the faculty of the Yale School of Medicine. In 2009, we both became board certified in the new pediatric sub-board of child abuse pediatrics. At Yale, I am the associate director of the Yale Child Abuse and the Yale Child Abuse Prevention programs.
Most often, I am asked to evaluate suspected cases of child abuse by other medical colleagues, by my state’s child protective services agency, or by local police departments. I am frequently asked to testify in court as a medical expert in cases of suspected child maltreatment. I also participate in several multidisciplinary, community-based teams that are designed to improve both criminal prosecutions of those who abuse children as well as the care that abused children receive.
I have a particular interest in optimizing recognition of subtle signs of physical abuse by frontline pediatric providers, and I teach on this subject regularly. I also have a special interest in linking abused children and their non-offending caregivers to mental health treatment. In 2006, I started the Bridging Program, which provides immediate, evidence-based mental health care to sexually abused children and their non-offending family members. My hope for the future is to devote increasingly more time to work in child abuse treatment and prevention.
Brendan T. Campbell, MD, MPH, is an assistant professor of surgery and pediatrics at the University of Connecticut School of Medicine and an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2000-2002).
Human Capital Blog: What kind of work do you do in the area of child abuse pediatrics?
Brendan Campbell: I am a pediatric general and thoracic surgeon and the medical director of the pediatric trauma program at Connecticut Children’s Medical Center in Hartford. Connecticut Children’s is a Level I pediatric trauma center, which means we see patients with relatively minor and severe multisystem injuries. Caring for abused children is one of the most important services we provide. When children with non-accidental trauma are initially identified, they are admitted to the pediatric surgical service to rule out life-threatening injuries. During their admission we work closely and collaboratively with the suspected child abuse and neglect team (SCAN) to make sure children with inflicted injuries are identified, have their injuries treated, and are kept out of harm’s way.
HCB: Why did you decide to focus on this area?
Campbell: It can be challenging to get a pediatric surgeon interested in child abuse because caring for vulnerable children who are intentionally harmed is not easy, and most of these kids don’t have life-threatening injuries that require an operation. What draws me to the care of injured children is that they are the patients who need me the most. If we don’t identify the risks they are up against at home, no one else will. They need someone to advocate for them.
The other thing that draws me to child abuse pediatrics is that there is an enormous need to develop better ways to screen for and to prevent abuse. Over the last 30 years we’ve made enormous strides in lowering the number of children injured in car crashes by enacting seat belt laws, toughening drunk-driving laws, and improving graduated driver licensing systems. Child abuse in the United States, however, remains a significant public health problem that needs more effective screening initiatives and prevention programs.