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

Miranda Hester

A trip to the grocery store will clearly illustrate the increasing number of processed foods available with new types of cookies, crackers, and other snacks seeming to pop up every week. These foods are specifically engineered to be as tempting as possible, but consuming a lot of them has been linked to adverse physical outcomes in children. A 

Journal of the Academy of Nutrition and Dietetics

 looked at children’s school lunches and snacks to see how much of it is processed as well as whether an intervention could reduce the amount of processed foods a child takes to school.1

The investigators looked at children in 3rd and 4th grade in public elementary schools in Massachusetts. The Great Taste Less Waste program is a 22-lesson classroom curriculum that also includes homework activities, school-wide announcements, food demonstrations, and a poster contest for the children. For parents, the program includes a monthly parent newsletter as well as a food shopping and packing guide. Photos of food were used to estimate the calorie content of the foods children brought to school. The food was also assigned to a processing level: less processed or unprocessed, moderately processed, or highly processed.

A majority of the food that children brought to school was considered highly processed and accounted for 70% of the food energy. Snack foods and desserts provided the greatest percentage of total energy in the highly processed category at both baseline and follow-up (72% and 69%, respectively). When compared to food meant for lunchtime such as sandwiches, items that were brought in for snacks were more highly processed. The intervention appeared to have no significant differences between consumption before the intervention and after it with the percentage of energy that was from processed foods in adjusted models (β: −1.1, standard error: 2.2, 

Investigators concluded that processed food was very prevalent in food brought to school, particularly with snack food choices; this continued even after an intervention. They urged further research into identifying strategies that can improve the healthfulness quality of foods brought for lunch and snack. Until those strategies are determined, clinicians can discuss good nutrition habits at well-child visits and why processed foods should not be a common part of a child’s diet.

Blondin S, AlSukait R, Bleiweiss-Sande R, Economos C, Tanskey L, Goldberg J. Processed and packed: how refined are the foods that children bring to school for snack and lunch?. 

. 2021;121(5):883-894. doi:10.1016/j.jand.2020.07.017

Articles

Processed foods have continued to be a big part of the everyday diet, even with research showing how unhealthy they are. A study examines how much processed food ends up in a child’s lunch and school snacks.

How processed are children's lunches?

Last week the International Society for Vaccines hosted it’s fifth COVID-19 vaccine update in its Virtual Congress. The latest update looked at vaccines being produced in China by 3 companies: CanSino Biological, Sinopharm CNBG, and Sinovac Biotech, Co., Ltd.

The CanSino vaccine is a recombinant adenovirus 5 vector based COVID-19 vaccine. The data was in participants aged 18 years and older and 28 days after the vaccination was received. Efficacy was 65.28 for symptomatic cases and 90.07 for severe cases. Adverse reactions seen include lethargy, fever, headache, nausea, diarrhea, vomiting, myalgia, pain, swelling, and redness. The average duration of the reaction 2 days, except for fever, which was 1 day. No serious adverse events were found. No statistically difference in the incidence of medically attended adverse event was seen between the vaccine and placebo groups. The vaccine appears to be quite effective against variants, although more research needs to be done with the South African variant. The company is currently running a trial in children and adolescents.

The Sinopharm CNBG is an inactivated vaccine. The active component is inactivated severe acute respiratory syndrome coronavirus 2 virus and the adjuvant used is aluminum hydroxide. Its dose is 6.5U/dose and it comes packaged in a prefilled syringe that should be stored at 2 to 8 degrees Celsius with an efficacy of around 72 in adults aged 18 and older. The majority of adverse events were grade 1 and the placebo group had higher incidence of grade 1 adverse events. Some adverse events were erythema, pain, and swelling at the injection site; fever; and fatigue. Pain at the injection site was the most common event after dose 1. Serum samples indicate that the vaccine has good cross-neutralization abilities for fighting variants. A trial has been completed in children aged 3 to 17 years and will start the approval process soon.

The Sinovac Biotech, Co., Ltd. vaccine called CoronaVac is also an inactivated COVID-19 vaccine. Its research and development started in early 2020 and Phase III trials started in Brazil on July 21, 2020. Other countries for the Phase III trial included Turkey, Indonesia, and Chile. Participant were either general population, medical staff, or a mix of both. The efficacy of the vaccine was found to be 50.65% in Brazil, 83.5% in Turkey, and 65.3% in Indonesia. Efficacy for hospitalized cases was 100%. The most common adverse events were pain at injection site, headache, fatigue, and myalgia. The vaccine has been approved for emergency use by 40 authorities and 180 million doses have been given globally. Vaccine trials for CoronaVac will be starting soon in children.

1. International Society for Vaccines. 5th COVID-19 Vaccine Update; April 27, 2021; virtual. Accessed May 4, 2021.

The International Society for Vaccines (ISV) presented its fifth update on COVID-19 vaccines around the world. This update focused on vaccines produced in China.

ISV COVID-19 vaccine update highlights Chinese vaccines

A quality improvement initiative of 2 interventions showed that documenting the use of sleep hygiene for sleep disturbances in children with neurodevelopmental disorders (NDD) improves adherence to evidence-based sleep hygiene strategies. Parents were given a screening questionnaire related to the child’s sleep and embedding prompts in the electronic medical record (EMR) to guide assessment.

In the first intervention, 144 parents completed the BEARS sleep screening tool (bedtime issues, excessive daytime sleepiness, night awakenings, regularity and durations of sleep, and snoring), which was adapted for this population to help identify patients with sleep disturbance. Sleep hygiene was considered documented if the provider used the term or documented behaviors or environmental conditions pertaining to sleep. In the second intervention, 2 evidence-based SmartPhrases were embedded within the EMR system. The first SmartPhrase was used during history collection in response to positive answers on the BEARS screening tool and contained evidence-based prompts to guide the assessment. The second intervention inserted individualized, evidence-based strategies for sleep hygiene into the patient instruction section of the discharge summary.

Investigators compared EMR data after implementation of the practice change with the same data obtained before implementation 13 weeks earlier. In the 6 months before implementation, 44 patients had received diagnoses of sleep disturbance, insomnia, or behavioral insomnia in the EMR. Sleep hygiene was documented in 27% of the identified charts. After the interventions, the number increased, with 53 patients’ having received 1 of the 3 diagnoses. Sleep hygiene documentation in the EMR of identified patients nearly doubled. The postimplementation query also found a 55% increase in documentation of sleep hygiene when melatonin was initiated. Of those patients prescribed melatonin for the first time, 100% had documentation for sleep hygiene.

As much as I appreciate melatonin, which has been a boon for many parents of children with NDD, we should not necessarily jump to it as the first approach. This study is a reminder to look at traditional sleep hygiene techniques (eg, bedtime routine with a wind-down, turning off electronic devices) before advising medication.

1. Hosley S, Fortney C, Harrison T, Steward D. Documentation of sleep hygiene with melatonin use in management of sleep disturbance in children with neurodevelopmental disorders: a quality improvement project. 

. February 3, 2021. Epub ahead of print. doi:10.1016/j.pedhc.2020.11.011

A study examines the efficacy of using documentation to improve sleep treatment.

Documentation improves sleep issue treatment in children with NDD

Discharging a child from the emergency department can be a complex process and having a standardized discharge process can prevent harm to the child. A sentinel event at Boston’s Children Hospital in Massachusetts prompted a team at the hospital to create a quality improvement program with the goal eliminating serious preventable adverse events linked to discharge by February 2019. At the virtual 2021 Pediatric Academic Societies meeting, Niloufar Paydar-Darian, MD, attending physician at Boston Children’s Hospital, presented the results of the program.

The improvement program occurred at Boston Children’s Hospital, a 400-bed academic children’s hospital that has approximately 60,000 emergency department visits every year, which results in 80% of emergency department patients being discharged. The team used data from the data warehouse, safety event reporting system, and Press Ganey patient survey results. The program had 4 key drivers:

Ensure that parents felt equipped to provide care for the child at home

Promote communication between care team members

Completely reconcile all components or testing and treatment

Foster awareness of the value of high-quality discharge to the outpatient setting

To help parents be prepared to care for their child, the program created a “5 things to know before you go” handout that had 5 questions that parents should have the answer to: (1) what is the diagnosis; (2) what medications or treatments does the child need; (3) who should the child receive follow-up care from and when should this occur; (4) what reasons may require the child return to the emergency department; and (5) does the parent have any other questions. For fostering awareness, the program emailed out data and success stories from the program twice during the program as well as an initial marketing push.

To assist with care team communication, the program created a discharge checklist that was nicknamed ‘the golden ticket’ and has 3 sections: a doctor to-do list, a nurse to-do list, and a huddle meeting between doctor and nurse. The doctor to-do list includes writing any prescriptions, reviewing the discharge plan with the patient and the family, and printing discharge instructions. The nurse to-do includes removing medical equipment, asking if the patient or family has any questions, and reviewing medication administration. During the huddle, both should check for outstanding orders and vital signs within an hour of discharge and ensure that the patient name matches all instructions and prescriptions.

Over the course of the program, the discharge checklist was completed roughly 87% of the time, with initiation of the marketing and data sharing leading to spikes in completion. Before the program, the vital signs were assessed within 60 minutes of discharge 61% of the time. After the initiative, they were assessed 83% of the time. Although there was no change in how parents perceived discharge information as well as length of stay or 72 hour return visits to the emergency department, there have been no serious preventable safety events since April 2018.

1. Paydar-Darian N. Improving discharge safety in a pediatric emergency department. Pediatric Academic Societies Meeting 2021; May 4, 2021; virtual. Accessed May 4, 2021.

At the virtual 2021 Pediatric Academic Societies meeting, Niloufar Paydar-Darian, MD, attending physician at Boston Children’s Hospital, presented the results of a quality improvement program with the aim of eliminating serious preventable adverse events linked to discharge.

Miranda Hester

Articles

How processed are children's lunches?

ISV COVID-19 vaccine update highlights Chinese vaccines

Documentation improves sleep issue treatment in children with NDD

Improve discharge safety with a checklist