A 15-month-old African American male patient presented to the pediatric clinic to establish care. The patient had been seen and treated by a previous pediatrician who had diagnosed him with failure to thrive, anemia, and hepatosplenomegaly, according to the patient\'s parents. Upon physical examination, the patient was determined to be less than the first percentile for height and in the eighth percentile for weight. Frontal bossing was also observed. The patient\'s hemoglobin level was measured in the office to help confirm the previous anemia diagnosis and was determined to be 6.3 g/dL (normal: 10.5-13.0 g/dL). At this point, the patient was sent to a pediatric emergency department for continued treatment and workup. At the emergency department, the patient received an extensive laboratory workup for the evaluation of anemia, revealing iron deficiency anemia (hemoglobin: 5.6 g/dL (normal: 10.5-13 g/dL), mean corpuscular volume: 51.4 fl (normal: 70-84 fl), iron: 18 mcg/dL (normal: 30-70 mcg/dL), total iron binding capacity: 598 mcg/dL (normal: 100-400 mcg/dL), and hematocrit: 23.7% (normal: 33-38%)) and decreased levels of vitamin D (<6 ng/mL, normal: >30 ng/mL), ionized calcium (1.17 mg/dL, normal: 4.4-5.2 mg/dL), and phosphorus (2.4 mg/dL, normal: 2.9-5.9 mg/dL). These studies, paired with X-ray images of the patient\'s shoulders and wrists, further confirmed the diagnosis of rickets. Rickets is a disease in pediatric patients defined as a condition in which the mineralization of epiphyseal plates is defective. A nutritional deficiency in vitamin D, calcium, or phosphate causes acquired rickets. This condition is most commonly found in developing countries; some predisposing factors include poor sun exposure, high altitude, and breastfeeding. The patient was seen in the outpatient pediatric setting after the hospitalization, in which he received a blood transfusion, where he was managed on supplementation of calcium carbonate suspension, polysaccharide iron complex/novaferrum drops, and cholecalciferol drops with referral to endocrinology, hematology, and dietetics. This case serves as an example of how the diagnosis of nutritional deficiencies, such as rickets, can also be found in developed countries like the United States. Other conditions considered in the differential diagnosis were cystic fibrosis, necrotizing enterocolitis, metabolic disorders, inadequate absorption, and mechanical feeding difficulties, each of which must be ruled out to ensure that even an unlikely finding was not missed.

OBJECTIVE: To evaluate a fast-track triage model in an integrated community specialty clinic to reduce the age of diagnosis for patients with autism spectrum disorder (ASD).
METHODS: A retrospective chart review was performed for patients seen in an integrated community specialty pediatric practice using a fast-track screening and triage model. The percentage of ASD diagnoses, age at diagnosis, and time from referral to diagnosis were evaluated. The fast-track triage model was compared with national and statewide estimates of median age of first evaluation and diagnosis.
RESULTS: From January 1, 2020, through December 31, 2021, 189 children with a mean (SD) age of 32.2 (12.4) months were screened in the integrated community specialty. Of these, 82 (43.4%) children were referred through the fast-track triage for further evaluation in the developmental and behavioral pediatrics (DBP) department, where 62 (75.6%) were given a primary diagnosis of ASD. Average wait time from referral to diagnosis using the fast-track triage model was 6 months. Mean (SD) age at diagnosis was 37.7 (13.5) months. The median age of diagnosis by the fast-track triage model was 33 months compared with the national and state median ages of diagnosis at 49 and 59 months, respectively.
CONCLUSIONS: With the known workforce shortage in fellowship-trained developmental behavioral pediatricians, the fast-track triage model is feasible and maintains quality of care while resulting in more timely diagnosis, and reducing burden on DBP by screening out cases who did not require further multidisciplinary DBP evaluation as they were appropriately managed by other areas.

Objective: Evidence for pharmacogenomic (PGx) guided treatment in child and adolescent psychiatry is growing. This study evaluated the impact of PGx testing on psychotropic medication prescribing in an ambulatory child and adolescent psychiatry and a developmental pediatrics clinic. Methods: This was a single-center, retrospective, descriptive analysis of patients who underwent PGx testing between January 2015 and October 2022 at a child and adolescent psychiatry clinic or developmental pediatrics clinic. The primary outcome was the proportion of patients with at least one psychotropic medication modification made 6-month posttesting that could be attributed to CYP2C19, CYP2D6, HLA-B*15:02, or HLA-A*31:01. Secondary outcomes included reason for testing, types of therapeutic modifications made, and whether the therapeutic modifications concorded with PGx guidelines. Results: A total of 193 patients were analyzed. The average age was 10 ± 4 years old, 60% were male, 78% were Caucasian. Sixty-eight percent had a primary diagnosis of a neurodevelopmental disorder, namely autism spectrum disorder (51%), and attention-deficit/hyperactivity disorder (14%). The reasons for PGx testing included medication inefficacy (34%), medication intolerance (20%), and family request (19%). At the time of PGx testing, 37% of patients were taking ≥1 psychotropic medication with PGx annotation. Overall, 35 PGx-related therapeutic modifications were made in 32 (17%) patients. These included continuing current PGx medication (6.2%) and starting PGx medication (5.2%). These modifications mainly involved antidepressants. Out of these 35 PGx-related therapeutic modifications, 94% were concordant with PGx guidelines. Among 29 patients who were prescribed at least one CYP2D6 inhibitor, 25 (86%) underwent CYP2D6 phenoconversion. Conclusions: It is critical to apply pediatric age-specific considerations when utilizing PGx testing in child and adolescent psychiatry. PGx testing stewardship could provide a framework to guide the clinical utility of PGx in a pediatric population with mental health conditions, including neurodevelopmental disorders.

This article was migrated. The article was marked as recommended. Introduction: Postgraduate medical training worldwide has recently experienced a transition to Competency-Based Medical Education (CBME). This provides a timely opportunity to critically evaluate the postgraduate medical curriculum, particularly from a trainee perspective. Studies reveal that Canadian residents and recent graduates in pediatrics and family medicine are uncomfortable with their proficiency in child development. However, little is known about residents\' perceptions of their training, nor where specific needs lie. We therefore sought to identify gaps in developmental pediatrics training, with the goal of informing the development of a new CBME curriculum. Methods: An online cross sectional needs assessment survey was administered to current pediatrics and family medicine residents at our institution. A total of 63 residents participated, 43 pediatrics and 20 family medicine. Results: Four key themes emerged from analysis of survey results: 1. Residents agree that developmental pediatrics is relevant to future practice and competency; 2. Residents feel they lack competency in the assessment and management of patients with developmental issues; 3. Residents\' feelings of insufficient and inadequate training increase over time; 4. Residents recommend changes to developmental pediatrics training. Conclusion: As we prepare to transition to CBME, curriculum should be purposefully developed to meet resident identified need and reflect appropriate competencies required for clinical practice.

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Children and adolescents with autism spectrum disorder (ASD) and/or Intellectual/Developmental Disability (IDD) are at greater risk of developing comorbid medical conditions, mental health diagnoses, behavioral challenges, and having overall poorer physical and mental health outcomes. Hospital environments present unique stressors and challenges for children and adolescents with ASD/IDD including a change in familiar environment, unpredictable routines, and exposure to sensory stimuli that may be overwhelming. While many school boards have specialized multi-disciplinary special needs support teams and services made up of professionals with expertise in supporting students with ASD/IDD, most hospitals do not have a formal multi-disciplinary ASD/IDD support team in place to support patients, families, and health care staff across the hospital. There is an emerging recognition of the need for specialized multi-disciplinary developmental-behavioral and mental health expertise in hospital inpatient settings. This paper describes the framework for the development of an innovative multi-disciplinary program to better support children and adolescents with ASD/IDD within a tertiary children\'s hospital setting.

BACKGROUND: The COVID-19 outbreak has taken a heavy toll on the mental well-being of healthcare workers, even those who have not been directly involved in the care of acutely ill patients. The aims of this study were to identify the overall burden and mental health status of healthcare workers in pediatric developmental services under the influence of the COVID-19 pandemic, and to identify the risk and protective factors associated with mental health.
METHODS: This cross-sectional web-based study was part of a large multicenter VOICE study conducted among employees ((neuro-)pediatricians, psychologists, speech therapists, occupational therapists, etc.) from various pediatric developmental services between June and July 2020. A total of 1291 questionnaires regarding overall burden, mental health status (depression, generalized anxiety disorder and emotional exhaustion) and risk and protective factors for mental health (working conditions, potential problems during the COVID-19 pandemic and psychological resources) were analyzed. Descriptive statistics and multiple linear regression were used for data analysis.
RESULTS: A total of 44.5% (574/1291) participants felt a high or very high overall burden during the COVID-19 pandemic. Of all the participants, 14.6% (171/1173) reported clinically significant levels of depressive symptoms, 17.0% (199/1173) reported generalized anxiety disorder symptoms and 44.6% (532/1192) reported emotional exhaustion. Multiple linear regression analyses identified several common risk and protective factors for mental health status variables. The burden of an increase in the quantity of work, fear of work and fear of becoming infected showed the strongest negative associations, whereas psychological resources and sufficient relaxation in leisure time exhibited the strongest positive associations.
CONCLUSIONS: Employees who were not directly involved in the care of acutely ill patients were also exposed to considerable stress, some of which was not different from that experienced by professionals who were directly affected. These employees should not be lost sight of and must be offered appropriate support.

Developmental-behavioral issues are among the most frequent and disabling conditions of children and adolescents seen in ambulatory settings. Guidelines of the Israeli Pediatric Association and the Israeli Society for Developmental Pediatrics specify the role of the primary-care pediatrician in screening and early identification of mild developmental behavioral conditions and define the criteria for referral to child development institutes. The aims of this study were to examine and describe how directors of these institutes perceive the role and involvement of community pediatricians in child development.
Qualitative interviews of the directors of 22 child development institutes from the ministry of health and the four health plans.
According to the interviewees, there is little involvement of community pediatricians in detecting developmental delays, and it is mainly nurses and preschool teachers who detect such delays. They report that the key barriers that deter community pediatricians from greater involvement in child development diagnosis and treatment are lack of time, lack of compensation, and insufficient clinical knowledge. The interviewees would like to see community pediatricians conducting the primary medical evaluation, providing parental guidance, referring to therapists in mild cases, exercising discretion before referring children to child development institutes and providing relevant information to the institutes in the referral process. The mechanisms that they proposed for increasing the involvement of community pediatricians were expansion of pediatricians\' training, increased pediatricians\' use of teleconsultation with child development specialists and incentives for thorough performance of developmental assessments.
Due to the importance of the Issue, we strongly recommend that policymakers require child development principles, evaluation, and providing appropriate parental guidance in the curriculum of the Israeli pediatric residency program. In addition, health plans should compensate pediatricians who need to conduct longer visits for children with developmental delays. The health plans should also develop teleconsultation channels for pediatricians with child development specialists to reduce unnecessary referrals to child development institutes.

A typical presentation of a foreign body aspiration (FBA) in a child includes witnessed choking, respiratory distress, cyanosis, coughing, wheezing, diminished breath sounds, and/or altered mental status. Following an extensive literature review, we found pneumothorax occurring secondary to FBA is a rare occurrence and should elicit prompt treatment. This 17-month-old female was admitted for respiratory syncytial virus (RSV) bronchiolitis and developed a subsequent pneumothorax during her hospital stay, consequent to aspiration of a cashew fragment two weeks before presentation. In light of the National Institute of Allergy and Infectious Diseases (NIAID)-sponsored expert panel\'s addended guidelines, published and endorsed by the American Academy of Pediatrics (AAP) in 2017, we highlight a potential complication of increasing encouragement of peanut consumption in children as young as four months.

Current evidence-based research suggests that early evaluation, comprehensive care plans, and appropriate referrals for childhood and adolescent behavioral and development needs is critical for successful family-centered outcomes. The overall purpose of this study was to conduct an assessment of a state public health program that offers diagnostic evaluation and coordination for children with behavioral and developmental disorders in the state of Virginia (Child Development Center programs, or CDC). A secondary purpose was to provide translational policy and advocacy targets based on key findings.
The evaluation of the scope of services of the CDC programs was done using qualitative interviews with a focus group interview (n = 23), interviews from representatives from individual centers ( n = 5 centers), and descriptive quantitative data elements for the fiscal year 2015.
After conducting the state public health evaluation, several translational health policy priorities emerged, including: (a) the need for integrated data standards, (b) Lack of developmental pediatric workforce, particularly in rural sectors of the state, and (c) Need for enhanced program support for care coordination.
Academic nurse and public health partnerships can aid in translation from research to policy among vulnerable populations and assist in communication to key stakeholders and legislators for iterative action and reassessment.