Comparing rates of self-harm during the pandemic to the preceding time

An investigation examines whether self-harm, suicide or suicidal ideation in children and adolescents saw an increase during the pandemic, as anticipated by many clinicians.

Investigating outcomes for extremely preterm infants

Scientific advances have led to more extremely preterm infants surviving delivery. What are the outcomes for these infants?

With increased infectivity of Omicron, the Centers for Control and Prevention (CDC) has updated the guidance on the best mask types to use.

A perspective on the Centers for Medicare & Medicaid Services Innovation Center roundtable on health equity.

Articles

A look at what the Contemporary Pediatrics team covered this week.

In case you missed it: January 17 to 21

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Eating disorders are a difficult behavioral condition to treat and relapse is not rare. Some experiences can make relapse more likely, such as pregnancy when weight gain or loss become a part of the discussion at every doctor’s visit. Understanding the impact of a history of an eating disorder or even an active one on risk of suboptimal outcomes in the offspring is important and a 

 looked into whether eating disorders during pregnancy lead to an increased risk of developing neuropsychiatric diseases.

The investigators used the Swedish Medical Birth Registry for a population-based prospective cohort study. They identified singleton births that had been registered between January 1990 and December 2012. Children who were delivered to mothers with a diagnosis of an eating disorder were matched with children who had mothers with no eating disorder diagnoses. Every child was followed up from his or her first birthday for autism spectrum disorder and from his or her third birthday for attention-deficit/hyperactivity disorder.

A total of 52,878 children were included in the study. The investigators found that maternal eating disorder exposure (n = 8813) was linked to an increased risk of attention-deficit/hyperactivity disorder ADHD (hazard ratio [HR] for anorexia nervosa, 1.42 [95% CI, 1.23-1.63]; HR for bulimia nervosa, 1.91 [95% CI, 1.43-2.54]; and HR for unspecified eating disorder, 2.00 [95% CI, 1.72-2.32]) as well as autism spectrum disorder (HR for anorexia nervosa, 2.04 [95% CI, 1.58-2.63]; HR for bulimia nervosa, 2.70 [95% CI, 1.68-4.32]; and HR for unspecified eating disorder, 1.95 [95% CI, 1.49-2.54]). Following adjustment for parental confounders, they found that the risk of attention-deficit/hyperactivity disorder was still significantly increased, but the risk of autism spectrum disorder in children born to mothers with bulimia nervosa was found to be no longer significant. They also found that ongoing cases of anorexia nervosa was tied to higher risks for attention-deficit/hyperactivity disorder (HR, 2.52 [95% CI, 1.86-3.42]) and autism spectrum disorder (HR, 3.98 [95% CI, 2.49-6.27]) when compared to a history of disease (HRs, 1.26 [95% CI, 1.06-1.48] and 1.81 [95% CI, 1.38-2.38], respectively).

The investigators concluded that the children of mothers with eating disorders and in particular those that experienced an eating disorder during pregnancy are at an increased risk of either attention-deficit/hyperactivity disorder and autism spectrum disorder.

Mantel A, Örtqvist A, Hirschberg A, Stephansson. Analysis of neurodevelopmental disorders in offspring of mothers with eating disorders in Sweden. 

. 2022;5(1):e2143947. doi:10.1001/jamanetworkopen.2021.43947

Eating disorders carry many risks. An investigation looks into whether they can increase the risk of certain neurodevelopmental conditions in the children of mothers with a history of eating disorders.

Examining the effect of eating disorders in pregnancy on neurodevelopmental risk in infants

Frank Ingari is chairman and CEO of Tandigm Health in Conshohocken, Pennsylvania.

 has brought a focus on “health equity,” or fairness in access and quality of care. The appeal to fairness is often made on moral grounds, challenging the nation to live up to its egalitarian ideals.

While I subscribe to this view as a human being, I subscribe to it equally as a businessperson, based on another definition for the word “equity.”

We evaluate corporations by examining balance sheets and income statements. Central to the balance sheet, “equity” represents the value of a company’s assets and serves as one of the best measures to assess the economic health of an enterprise.

The income statement focuses on short-term measurements of profit and loss—on spending versus revenue in the current period. For generations, U.S. health care policy has focused on health care 

in this sense of operating expenses on the income statement. We have measured our success with hoped-for reductions in year-over-year spending.

This short-term focus is exacerbated by our tendency to ricochet between Republican and Democratic administrations every four or eight years. Each party strives to show that its approach can lower spending faster and more effectively, without addressing the difference between short-term “expense” spending and long-term “investment” spending.

During CMS’s December 8 Health Equity Roundtable, we heard from half a dozen passionate advocates for the chronically underserved. Across this diverse group, most from the non-profit and public sectors, there was a consistent call to apply long-term investment thinking to health care reform.

Carrie Cochran-McClain, MPA, chief policy officer at the National Rural Healing Association, said: “It may take years, maybe even a decade, before you really start to see the kind of change you want to see, especially in the cost savings arena…how you’re calculating savings and success of a model may be short-sighted...models really need to have kind of a front-end investment and the need for delayed downside risk.”

Business leaders like myself also realize that the balance sheet and the income statement need to work together to create long-term sustainable success. Not all projects will be profitable in the near term, and important innovations take time at the expense level to generate value at the asset level.

In this area, health systems should take a cue from the business sector. Karthik Sivashanker, MD, MPH, vice president of equitable health systems & innovation at the American Medical Association, put it this way: “Look further out than a year because it may take many years to actually assess the savings.”

From experience, I know many businesses also understand that not every project can be staffed identically. A major health care corporation may invest in resources to become efficient in a new payment model in three years. For the same project, a non-profit organization may need more resources and time. However, they will often offer unique access to communities that represent the best opportunities for large-scale critical improvement over the long term.

Veronica Mallet, MD, president and CEO of MMC Ventures, Inc. put it this way: “There are several obstacles to safety net providers entering into the value-based pay space... primary is the capital needed to respond to the increased staffing, training and data required to respond to the needs of most of the programs.”

When applied to national health care strategy, I often see the message of these leaders ignored at our peril—as reflected in the unmistakable facts of our national life. How much suicide, substance abuse, mental illness, gun violence, anti-scientific misinformation, and intergenerational transfer of poverty must we witness before we realize that our national balance sheet is crumbling at the base? We cannot simply buy our way out of this problem with more spending. Instead, we must begin to evaluate the second meaning of the word “equity.”

This means applying a balance sheet mentality to health care policy. The well-documented impact of good pediatric care 20 years hence should not merely be a feel-good argument—it should be part of a rigorous, long-term portfolio analysis aiming to build the strongest national balance sheet to pass on to these children.

One powerful opportunity lies in using prospective health status assessment, a clinical strategy supported financially by the risk adjustment of clinician compensation. Future-focused patient examinations—wellness visits—can identify chronic disease risks, thereby resulting in great patient outcomes and great societal savings. But these savings often take several years to materialize.

CMS should promote adopting such risk assessments in Medicare and Medicaid. It should also incentivize mitigation of the health risks identified—recognizing some of the future value today for savings that will be realized later. This would require CMS to identify the risk factors that present the best opportunity for mitigation, to incentivize those evidence-based interventions, and even to recognize non-traditional resources as part of such interventions. For example, a community PCP could be rewarded for referring a morbidly obese teen to a novel behavioral health program that might not have traditionally been funded.

As a side benefit, adopting such risk adjustment in traditional Medicare, supported by audits that ensure doctors are treating the high-risk factors they are coding, would also help punish those who do HCC coding simply for revenue rather than to help patients.

 in health care along a wide spectrum, from those who say, “privatize and deregulate” to those who want health care “government-run.” But in my opinion, the overwhelming majority of Americans want some form of public-private infrastructure. Surely few would oppose the application of core business principles to the management of our most important industry.

The U.S. is the only advanced nation in which the national health care debate centers on whether universal access to care is a right or a privilege, and whether health care spending is a net cost to society or a net investment.

An increasingly healthy population is the most important asset we can pass on to the next generation—a population that is more productive, optimistic, committed to its own health, and to the future of its children. As Dr. Mallett said: “CMS should recognize the fact that the safety net providers are an investment. And do just that: invest.”

Taking it a step further, I believe we need to recognize future health as a kind of financial equity to ensure the fair access that is usually meant when we say, “health equity.”

This article was originally published by sister publication Medical Economics.

What does health equity mean?

With science leading to better outcomes for preterm infants, even in those who were born extremely preterm, it’s become increasingly important to understand how extreme prematurity impacts mortality, in-hospital morbidity, and 2-year neurodevelopmental outcomes. An

 of extremely preterm infants born between 2013 and 2018 provides some much-needed data.

Investigators ran an observational study that used a prospective registry of infants born at 22-28 weeks’ gestational age in 19 US academic medical centers. They looked at survival as well as 12 different in-hospital morbidities, which including necrotizing enterocolitis, infection, intracranial hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia. At 22-26 months’ corrected age the infants were given an assessment for health and functional outcomes, including neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices.

A total of 10,877 infants were included, 49.0% female and 51.0% male. In this cohort, 78.3% survived to be discharged from the hospital, which was an increase from the 76.0% (adjusted difference, 2.0%; 95% CI, 1.0%-2.9%) seen in 2008-2012. Survival to discharge was 10.9% for infants at 22 weeks and 94.0% for infants at 28 weeks. Among actively treated infants, survival was 30.0% among those born at 22 weeks and 55.8% at 23 weeks. The investigators found that all in-hospital morbidities were more likely to occur in infants who born at an earlier gestation age. The percentages of in-hospital morbidities were 8.9% (890/9956) of infants had necrotizing enterocolitis; 2.4% (238/9957) had early-onset infection; 19.9% (1911/9610) had late-onset infection; 14.3% (1386/9705) had severe intracranial hemorrhage; 12.8% (1099/8585) had severe retinopathy of prematurity; and 8.0% (666/8305) had severe bronchopulmonary dysplasia. A total of 2566 infants were seen for follow-up. By the time of a 2-year follow-up, 8.4% (214/2555) of children had moderate to severe cerebral palsy; 1.5% (38/2555) had bilateral blindness; 2.5% (64/2527) required hearing aids or cochlear implants; 49.9% (1277/2561) had been rehospitalized; and 15.4% (393/2560) required mobility aids or other supportive devices. In the group of 2458 fully evaluated infants, the investigators determined 48.7% had no or mild neurodevelopmental impairment at follow-up; 29.3% had moderate neurodevelopmental impairment; and 21.2% had severe neurodevelopmental impairment.

The investigators concluded that for 2013-2018 the survival to discharge in extremely preterm infants had improved from the levels seem in 2008-2012. However, they also noted that among infants who were born at less than 27 weeks’ gestational age both neurodevelopmental impairment and rehospitalization were common when they were aged 2 years.

Bell E, Hintz S, Hansen N, et al. Mortality, In-hospital morbidity, care practices, and 2-year outcomes for extremely preterm infants in the US, 2013-2018. 

. 2022;327(3):248-263. doi:10.1001/jama.2021.23580

N95 and KN95 masks are the most effective in preventing the spread of COVID-19, according to 

 from the Centers for Disease Control and Prevention (CDC). At the same time, the agency continues to urge Americans to consistently use the most protective type of masking available so long as it’s comfortable and will be worn consistently.

In its latest guidance, posted on its website on January 14, the CDC ranks different types of 

 according to the level of protection they provide. “Loosely woven cloth products provide the least protection, layered finely woven products offer more protection, well-fitting disposable surgical masks and KN95s offer even more protection, and well-fitting NIOSH [National Institute for Occupational Safety and Health]-approved respirators (including N95s) offer the highest level of protection,” the guidance states.

But regardless of the type of mask chosen, the CDC adds, it should fit closely on the face and be comfortable enough when worn correctly (covering the nose and mouth) that it can be used when needed.

The updated guidance also explains the difference between masks and respirators. Masks are designed primarily to contain droplets that the wearer sneezes, breathes or coughs out, while also offering some protection from viruses spread by others.

Respirators are meant to provide protection by filtering the air and fitting closely on the face to filter out particles, but they also have some ability to contain droplets the wearer emits. “A respirator has better filtration, and if worn properly the whole time it is in use, can provide a higher level of protection than a cloth or procedural mask,” according to the guidance.

Given the greater protection respirators afford, the CDC says they “may be considered in certain situations and by certain people when greater protection may be needed or desired.” These include:

When caring for someone who is sick with COVID-19

If a person is at increased risk for severe illness, such as those who are immunocompromised, are over 65, or have certain underlying medical conditions

Working in a job that requires interacting with large numbers of the public particularly when not everyone is 

When using public transportation, such as buses, planes and trains

In crowded settings where physical distancing isn’t possible

Not being up-to-date on COVID-19 vaccinations

In a statement announcing the updates the CDC said they “reflect the science on masking, including what we have learned in the past two years, and will provide people the information they need to improve how well their 

them. We will continue to share the science of masking as it becomes available.”

This article was originally published by Medical Economics.

CDC updates mask guidance 

Advance payments for the Child Tax Credit became available in the summer of 2021 to address food insufficiency in families, which had been exacerbated by the pandemic. An investigation examines the efficacy of the intervention.

Early utilization of cochlear implants in children with bilateral severe to profound sensorineural hearing loss can lead to better long-term language outcomes. However, some children have delays in receiving their implants. A report looks into what may be causing these delays and where there are initiatives that could reduce the risk of delay.

A look at what to expect from Contemporary Pediatrics this week

What's new on Contemporary Pediatrics: January 17 to 21

Over the past decade, concerns about the mental health of teenagers has grown as rates of suicidality and self-harm have risen. With the pandemic came a heightened worry that mental health issues in this population would significantly increase as a result of isolation and anxiety about COVID-19. A

 compares the risk of self-harm or overdose among teenagers and young adults living in the Ontario province in Canada during the pandemic with the 2 years preceding it.

Investigators ran a population-based cohort study that included all teenagers and young adults who were born in Ontario between 1990 and 2006. They compared April 1, 2020 to June 30, 2021, to March 1, 2018 to February 28, 2020. The main outcomes were emergency department encounters and hospitalizations for either self-harm or overdose. Secondary measures included self-harm, overdose, or all-cause mortality.

There were a total of 1,690,733 teenagers and young adults included in the cohort. There were slightly more girls in the cohort and the median age was 17.7 years at the start of follow-up, which was either March 1, 2018 or the participants 14th birthday. Following 4,110,903 person-years of follow-up, investigators found that 6224 participants had experienced a primary outcome of self-harm or overdose during the pandemic (39.7 per 10 000 person-years) vs 12 970 (51.0 per 10 000 person-years) prepandemic, with an hazard ratio (HR) of 0.78 (95% CI, 0.75-0.80). Furthermore, they found that the risk of self-harm, overdose, or death was lower during the pandemic than in the preceding period (HR, 0.78; 95% CI, 0.76-0.81). This was not true of all-cause of mortality (HR, 0.95; 95% CI, 0.86-1.05).

The investigators concluded that contrary to what many predicted, that in the first 15 months of the pandemic, there was a decline in hospital care for either self-harm of overdose in teenagers and adolescents. They noted that this is in line with other research that indicated either little change in mental health care utilization in hospitals or declines in such care.

Ray J, Austin P, Aflaki K, Guttmann A, Park A. Comparison of self-harm or overdose among adolescents and young adults before vs during the COVID-19 pandemic in Ontario. 

. 2022;5(1):e2143144. doi:10.1001/jamanetworkopen.2021.43144

A sobering look at children and gun violence in the United States

Gun violence is an ongoing epidemic in the United States. A recent investigation examines the impact of living in a county with high levels of poverty on gun violence.

What hyperoxia means for critically ill children

Supplemental oxygen is a major element of critical care, but is there such a thing as too much of good thing? A meta-analysis examines the impact of hyperoxia on mortality in critically ill children.

Finding the positive in distance learning

The move to distance learning as a result of the pandemic led to may negative impacts on the lives of children, but a new report indicates that there may have been at least one positive: better sleep duration for teenagers.

How social media may be getting around measures to restrict depictions of unhealthy food and drinks

Regulations ensure that the advertising of unhealthy foods is limited to children in traditional media. An investigations looks into how celebrity social media may be showing children and adolescents a variety of unhealthy foods and drinks.

It was a very busy week for the Contemporary Pediatrics team.

In case you missed it: January 10 to 14

 used in the U.S. lose some of their ability to prevent breakthrough infections over time, but they remain highly effective at preventing hospitalizations and deaths, a new study finds.

The study, a collaboration between the University of North Carolina-Chapel Hill and the North Carolina Department of Health and Human Services, sought to determine whether COVID-19 breakthrough infections are the result of waning immunity provided by vaccines or the greater transmissibility of the disease’s variants.

To find out, researchers looked at vaccination histories and health outcomes of 10.6 million North Carolina residents who received either the Pfizer, Moderna or Johnson & Johnson vaccine between December 2020 and September 2021. The data did not include outcomes from the omicron variant, which emerged after the study concluded. Results were published in the 

The researchers found that the mRNA Pfizer and Moderna vaccines, both of which require two doses, were 95% effective at lowering the risk of COVID-19 two months after the first dose. After seven months the Moderna vaccine dropped to 80% effectiveness, while the Pfizer vaccine was 67% effective. The effectiveness of both vaccines dropped significantly during June and July, when the COVID-19 Delta variant was at its height in the state.

The Johnson & Johnson adenovirus vaccine, which requires a single dose, was 75% effective after one month and 60% effective after five months. Based on these findings, the authors conclude that the reduced protection against COVID-19 infection was due to both declining immunity and the emergence of the delta variant.

However, all three vaccines have been more effective at preventing hospitalizations due to severe COVID-19. 

 reached peak effectiveness of 96% at two months and was about 90% after seven months.

Effectiveness of the Moderna vaccine was 97% and 94%, respectively, at the same points. The Johnson & Johnson vaccine peaked at 86% effectiveness at two months and was higher than 80% through six months. All three vaccines were more effective against death than hospitalization.

“The primary takeaway message from our study is that unvaccinated people should get vaccinated right away,” Danyu Lin, PhD, professor of biostatistics at the UNC Gillings School of Global Public Health said in an accompanying news release. “The results of our study also underscore the importance of booster shots, especially for older adults.”

What is driving breakthrough infections?

With the COVID-19 pandemic reaching an unprecedented crescendo and pediatric cases continuing to become more prominent with each new variant of the disease, an understanding of how many pediatric cases that initially present and receive testing in an emergency department experience a severe outcome or death is more important than ever. A 

 aims to find the proportion of pediatric patients who experience such outcomes within 14 days.

Investigators performed a prospective cohort study with 14-day follow-up that enrolled participants between March 2020 and June 2021. They included children and adolescents aged younger than 18 years who were tested for COVID-19 infection at an emergency department in 10 countries: Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Infection was confirmed via a polymerase chain reaction test. Severe outcomes were either the occurrence of a complication such as encephalitis or cardiac arrest or the performance of an intervention linked to a severe occurrence such as chest drainage or positive pressure ventilation, as well as death.

There were 3221 patients included in the study, with 2007 coming from the United States and 484 self-reporting a chronic illness. The median age of the cohort was 3 years. Following 14 days of follow-up, 735 children required hospitalization; 107 recorded severe outcomes; and 4 children had died. Investigators noted that there were several characteristic that were linked to severe outcomes, including being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). In a subcohort of patients who were sent home from the emergency department after being tested and completed the 14 days of follow-up, 50 were subsequently hospitalized and 12 had severe outcomes.

The investigators concluded that about 3% of pediatric patients who tested positive for COVID-19 in the emergency department had severe outcomes within 2 weeks of their initial visit. The risk was much less for children who were sent home from the emergency department than among those who were kept in the hospital. The risk factors noted such as age and underlying chronic illness could be useful when determining a patient’s clinical care.

Funk A, Florin T, Kupperman N, et al. Outcomes of SARS-CoV-2–positive youths tested in emergency departments: the global PERN–COVID-19 study. 

. 2022;5(1):e2142322. doi:10.1001/jamanetworkopen.2021.42322

A global study examines how often severe outcomes occur within 14 days of a positive COVID-19 test occurring in an emergency department (ED).

What's new on Contemporary Pediatrics: January 17 to 21

Comparing rates of self-harm during the pandemic to the preceding time

In case you missed it: January 10 to 14

What is driving breakthrough infections?

Looking into the rate of severe COVID-19 outcomes for kids tested in the ED