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

Miranda Hester

The first 1000 days of a child’s life has become increasingly seen as a crucial time to shape lifelong health outcomes and habits. This may be particularly true with regards to nutrition, as the period sets dietary habits and cover key points in brain development. An 

 was used to see how it would impact the prevalence of an overweight infant as well as the mother’s postpartum weight retention and care.

The investigators examined the effects of the First 1000 Days program among 995 term, low-income infants as well as their mothers who received care at 2 intervention community health centers. There were 650 infant/mother pairs at 2 comparison health centers for control purposes. The pairs in the control arm received usual care. At the intervention centers, there was staff training, health, and behavioral screening, patient navigating, educational materials, health coaching, growth tracking, and text messaging. Infants were assessed at 6 and 12 months of age. 

The average birth weight was 3.34 kg. Two-thirds of the infant/mother pairs were publicly insured. At 6 months, the infants in intervention group had lower weight-for length 

 scores (β: −.27; 95% CI: −.39 to −.15) as well as lower odds of overweight (adjusted odds ratio [OR]: 0.46; 95% CI: 0.28 to 0.76) than the infants who were seen at the comparison sites. These differences were maintained through the 12 month assessment (z score β: −.18; 95% CI: −.30 to −.07; adjusted OR for overweight: 0.60; 95% CI: 0.39 to 0.92). Mothers who were part of the intervention program were found to have lower weight retention, noted as nonsignificant, when they were seen 6 weeks’ postpartum (β: −.51 kg; 95% CI: −1.15 to .13). Furthermore, the mothers had higher odds of having a postpartum visit than the mothers in the control sites.

The investigators concluded that the intervention, when used in combination with coaching appeared to be linked to improvements in both maternal postpartum care as well as infant weight status.

1. Taveras E, Perkins M, Boudreau A, et al. Twelve-Month outcomes of the first 1000 days program on infant weight status. 

. July 29, 2021. Epub ahead of print. doi:10.1542/peds.2020-046706

Articles

The first months of life set the course of a child’s health. How effective is an intervention at improving weight outcomes in the infant and use of postpartum care by the mother?

“First 1000 day” intervention improves newborn weight status

For children with systemic juvenile idiopathic arthritis, steroids have long been one of the only available treatments, despite the fact that they can increase the risk of infection and impede growth. The introduction of biologic therapies over the past few years has offered a new way to treat the condition without those adverse effects. A 

 examined how early initiation of biologic therapy impacted the use of glucocorticoids.

The investigators performed an emulated pragmatic trial that used observational data from children who had been hospitalized with new-onset systemic juvenile idiopathic arthritis. The Pediatric Health Information System was used to determine diagnostic and billing records. Glucocorticoid exposure during the index hospitalization was found through an inpatient billing code for oral or intravenous dexamethasone, hydrocortisone, methylprednisolone, prednisolone, or prednisone. Biologic therapy included anakinra, rilonacept, canakinumab, or tocilizumab.

A total of 468 children met the eligibility criteria for the study. Among this cohort, 19% of the patients had a billing code for biologic therapy without either preceding or concurrent initiation of immunomodulatory medications. The proportion saw significant increase over the study period from 2008 to 2019, reaching 40% of all patients discharged between 2017 and 2019. Median time to initiate a biologic therapy from admission was 4 days. For glucocorticoids, it was 5 days. Overall 51.3% of patients were given glucocorticoids, including 22.5% who were administered at least 1 dose of pulse dose glucocorticoids. Once glucocorticoids were started in patients, nearly all of them continued receiving them until they were discharged. Additionally, exposure to methotrexate was more common in patients who did not initiate biologics versus those who initiated them (8.6% vs 2.8%, 

= 0.09). The most common biologic therapy used was anakinra, which was initiated in 69 patients. Canakinumab was used in 1 patient and tocilizumab was used another patient.

The investigators concluded that not only has the use of biologic therapy with new-onset systemic juvenile idiopathic arthritis increased meaningfully over the past decade, but this shift in treatment appeared to be linked to less exposure to glucocorticoids. They believe that this increase in biologics could lead to clinically relevant reductions in adverse effects tied to the use of glucocorticoids.

1. Peterson R, Xiao R, Katcoff H, Fisher B, Weiss P. Effect of first-line biologic initiation on glucocorticoid exposure in children hospitalized with new-onset systemic juvenile idiopathic arthritis: emulation of a pragmatic trial using observational data. 

. 2021;19(1)109. doi:10.1186/s12969-021-00597-z

Treatment for systemic juvenile idiopathic arthritis (sJIA) has long included steroids, but biologics now offer new ways to treat. Does early initiation of biologic therapy lead to a lessening in steroid use?

 Reducing steroid use with sJIA

Patient portals in electronic health records are a helpful way for patients and families to have beneficial information about diagnoses and prescriptions. The portal is also a helpful tool for clinicians and families to communicate with one another. A 

 looked at whether using the portal to remind parents about influenza vaccines had a positive impact on vaccination rates.

The investigators performed an intention-to-treat randomized clinical trial in children aged 6 months to <18 years who were seen in 1 of 53 primary care practices. Patients or their parent/proxy who were considered active portal users were randomly assigned to 1 of 2 groups: receive reminder messages that were framed as gains or losses or receive no messages. The participants were also separately randomized to receive a precommitment message before the start of the influenza season. The administration of ≥1 seasonal influenza vaccinations were considered primary outcomes. Among patients aged 6 months to < 3 years who needed a second influenza vaccine dose, participants were randomized to either receive a message reminding the parent about the second dose or receiving no reminder.

There were 22,046 children included in the study. In the main control group, the vaccination rate was 56.9%. Within the intervention groups, the rate was 58.0% in the loss-frame reminders group (

 = .07), and 58.0% in the gain-frame group (

 = .47). When looking at the precommitment messaging, the investigators found that the rate was 58.3% in the precommitment group versus 57.0% in the control group (P = .11). Furthermore, the adjusted risk ratio for precommitment messaging was 1.02 (95% CI: 1.00–1.04) versus the control and 1.01 (95% CI: 0.98–1.05) for gain-frame reminders as well as 1.02 (95% confidence interval [CI]: 1.00–1.04) for loss-frame reminders. For the subset of children who required a second dose, the second-dose vaccination rates were 55.0% in the intervention group and 44.1% in the control group and had an adjusted risk ratio of 1.25 (95% CI: 1.07–1.45).

The investigators concluded that using patient portal reminders for influenza vaccines had no impact on first-dose influenza vaccination rates. However, the use of reminders was found to be an effective way to get young children back into the office for their second dose of the influenza vaccine.

1. Lerner C, Albertin C, Casillas A, et al. Patient portal reminders for pediatric influenza vaccinations: a randomized clinical trial. 

. July 28, 2021. Epub ahead of print. doi:10.1542/peds.2020-048413

Patient portals can be a powerful communication tool for both clinician and family, but can they also be used to improve uptake of the annual influenza vaccine?

Using patient portals to improve flu shot rates

In a hospital setting, awareness of medical conditions that are most prevalent, have the highest costs, or greatest variations in costs can be helpful in determining which could most benefit from research funding. A 

Investigators performed a retrospective cohort study of children who had hospital encounters at 45 tertiary care US children’s hospitals. The Pediatric Clinical Classification System was used to classify the primary diagnosis discharge code. The Cost Master Index was used to determine the standard cost of hospital goods and services used for care, in order to eliminate the high variation in those costs across hospitals.

There were 2,882,490 inpatient hospital encounters included in the report. From a list of 50 most prevalent and 50 most costly conditions, there were 74 total conditions, of which 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 costly conditions made up $12.4 billon of $33.4 billon total costs and 33.8% of all of the conditions. The highest cost per encounter was seen with extreme immaturity conditions (ie, birth weight 500-749 g) at $382,910 (95% CI, $368,084-$397,736). The highest degree of interhospital variability in cost was seen with major depressive disorder, type 1 diabetes with complications, diabetic ketoacidosis, and acute appendicitis without peritonitis. Conditions that had high prevalence, variation in cost, and overall cost were major depressive disorder (cost rank, 19; prevalence rank, 10), scoliosis (cost rank, 6; prevalence rank, 38), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11), asthma (cost rank, 10; prevalence rank, 2), and dehydration (cost rank, 24; prevalence rank, 8).

Those in charge of determining where to allocate research funding for improved care and outcomes should keep in mind the conditions that were found to be most common and costly.

1. Gill P, Anwar M, Thavam T, et al. Identifying conditions with high prevalence, cost, and variation in cost in US children’s hospitals. 

. 2021;4(7):e2117816. doi:10.1001/jamanetworkopen.2021.17816

Knowing what conditions are the most prevalent and costly in hospitals can help determine the focus of future research, which can ensure better care. A report sheds some light.

Miranda Hester

Articles

“First 1000 day” intervention improves newborn weight status

Reducing steroid use with sJIA

Using patient portals to improve flu shot rates

What are the common but costly conditions treated at hospitals?