Introduction: Childhood malnutrition remains a risk factor for morbidity and mortality. Children admitted to the Pediatric Intensive Care Unit (PICU) are at a higher risk of worsening nutritional status with adverse clinical outcomes. The burden of malnutrition is strongly linked to various well-defined social determinants of health, including race, socioeconomic status, and geography, as these factors influence household food insecurity. This study aimed to analyze the interrelationships of nutritional status, social determinants of health, and health outcomes in critically ill children. Methods: Retrospective cohort study of 6418 critically ill children admitted to PICU from January 2014 to December 2017. Demographic and anthropometric measurements were collected upon admission and outcomes. Based on the patient’s zip code, and median household income, we estimated the percentage of the population living in poverty, and the percentage of the population experiencing food insecurity for 5912 children. Results: The prevalence of underweight, chronic, and acute malnutrition was 13.2%, 17.9%, and 5.6%, respectively. Malnourished children had longer duration of mechanical ventilation and longer PICU and hospital lengths of stay (LOS) compared to nourished children. Underweight and chronic malnutrition were associated with higher mortality. Hispanic children had the highest prevalence of poverty level, while non-Hispanic Black children had the highest food insecurity level and lowest median income. Ethnicity was not associated with mortality. Conclusions: Malnourished critically ill children who were disproportionately non-Hispanic Black, Hispanic, and Asian had worse hospital outcomes, including prolonged hospital and PICU length of stay, increased time on mechanical ventilation, and a higher risk of mortality.

Background: The nutrition support of children with biliary atresia after liver transplant is affected by multiple factors, and a connection between these factors and conditions present before transplant can potentially make the nutrition support more challenging. We aim to assess the adequacy of nutrition support, specifically energy and protein, during the first week of admission to the Pediatric Intensive Care Unit (PICU) in children after liver transplant secondary to biliary atresia. Methods: We performed a retrospective cohort study of 138 patients [13.9 median (9-33.4) IQR months; 62% female] with a diagnosis of biliary atresia admitted to the PICU after liver transplantation at Texas Children's Hospital over a 14-year study period. We obtained nutrition adequacy of enteral and parenteral nutrition support for the first week after transplant during their PICU admission. Results: Goal adequacy was reached at the end of the first week of admission when combined enteral and parenteral nutrition support was provided (median 98% for energy and 101% for protein). Infants achieved significantly higher adequacies than older children during the first week (136% < 1 year vs. 0% > 1 year, p < 0.001 for calories, and 157% < 1 year vs. 0% > 1 year for protein; p < 0.01). Conclusions: These findings highlight the complex nutritional challenges faced by this population, and strategies are needed to meet the unique needs of children after liver transplantation.

Patients admitted to a pediatric intensive care unit (PICU) need individualized nutrition support that is tailored to their particular disease severity, nutritional status, and therapeutic interventions. We aim to evaluate how calories and proteins are provided during the first seven days of hospitalization for children in critical condition with organ dysfunction (OD). A single-center retrospective cohort study of children aged 2–18 years, mechanically ventilated > 48 h, and admitted > 7 days to a PICU from 2016 to 2017 was carried out. Nutrition support included enteral and parenteral nutrition. We calculated scores for the Pediatric Sequential Organ Failure Assessment (pSOFA) on days 1 and 3 of admission, with OD defined as a score > 5. Of 4199 patient admissions, 164 children were included. The prevalence of OD for days 1 and 3 was 79.3% and 78.7%, respectively. On day 3, when pSOFA scores trended upward, decreased, or remained unchanged, median (IQR) caloric intake was 0 (0–15), 9.2 (0–25), and 22 (1–43) kcal/kg/day, respectively (p = 0.0032); when pSOFA scores trended upward, decreased, or remained unchanged, protein intake was 0 (0–0.64), 0.44 (0–1.25), and 0.66 (0.04–1.67) g/kg/day, respectively (p = 0.0023). Organ dysfunction was prevalent through the first 72 h of a PICU stay. When the pSOFA scores trended downward or remained unchanged, caloric and protein intakes were higher than those that trended upward.

Knebusch, Nicole; Hong-Zhu, Paola; Daughtry, Jennifer; Mansour, Marwa; Fogarty, Thomas; Stein, Fernando; Coss-Bu, Jorge Author Information

Background:Nuisance and false alarms distract clinicians from urgent alerts, raising patient safety risks.Local Problem:High alarm rates in a pediatric progressive care unit resulted in experiencing 180-250 alarms per day or 1 alarm every 3 to 4 minutes per clinician.Methods:Through Plan-Do-Study-Act cycles, environmental, policy, and technology changes were implemented to decrease the average alarms/day/bed and percentage of time in alarm.Interventions:Alarm settings tailored to patient needs using features embedded within the patient monitoring system were implemented and monitored with the assistance of alarm champions.Results:The average number of alarms/day/bed decreased from 177.69 to 96.94 over the course of 10 years, a 45.45% reduction. The percentage of time in alarm decreased from 7.52% to 2.83%, a 62.37% reduction.Conclusions:Arming clinicians with technology to analyze real-time clinical data made alarms meaningful and actionable, decreasing false alarms without compromising patient safety.

BACKGROUND:Nuisance and false alarms distract clinicians from urgent alerts, raising patient safety risks. LOCAL PROBLEM:High alarm rates in a pediatric progressive care unit resulted in experiencing 180-250 alarms per day or 1 alarm every 3 to 4 minutes per clinician. METHODS:Through Plan-Do-Study-Act cycles, environmental, policy, and technology changes were implemented to decrease the average alarms/day/bed and percentage of time in alarm. INTERVENTIONS:Alarm settings tailored to patient needs using features embedded within the patient monitoring system were implemented and monitored with the assistance of alarm champions. RESULTS:The average number of alarms/day/bed decreased from 177.69 to 96.94 over the course of 10 years, a 45.45% reduction. The percentage of time in alarm decreased from 7.52% to 2.83%, a 62.37% reduction. CONCLUSIONS:Arming clinicians with technology to analyze real-time clinical data made alarms meaningful and actionable, decreasing false alarms without compromising patient safety.

Because 3% to 4% of children in the United States are foreign-born, it is highly likely that most pediatric providers will encounter these children in their practice, and thus, important for all clinicians to understand best practice guidelines for their care. Immigrant health curricula are not standardized across US pediatric health professional training programs, leading to variable levels of competency in currently practicing providers.After completing this article, readers should be able to: Describe national guidelines for the care of the immigrant child.Use concepts from the national guidelines to implement practical improvements in clinical service delivery for immigrant children, at both the facility and individual levels.Offer solutions for personal and professional obstacles that can arise when caring for immigrant children.There are approximately 2.5 million immigrant children in the United States, (1) defined by the American Academy of Pediatrics (AAP) as “those born outside the United States to non–US citizen parents.” (2) This heterogeneous group includes children from countries all around the world, with the top 4 countries of origin being Mexico (18%), India (8%), China (5%), and the Philippines (3%). (3) Most immigrant children come to the United States with 1 or both parents for 1 or more of a myriad of reasons, including economic opportunity, educational attainment, family reunification, and/or safe haven from violence or persecution. In general, immigrants to the United States tend to be healthier than their US-born counterparts (known as the healthy immigrant paradox), but this advantage tends to decrease over time. (4)(5) Although the exact reasons for this are unknown, the effects of poverty (25% of immigrant children live below the federal poverty level) (3) and lack of health insurance coverage (18%–33% of foreign-born children are uninsured, depending on immigration status) (6) likely play a large role. To mitigate this health decline and provide immigrant children with the highest quality of care possible, the AAP recommends specific core competencies for all pediatric healthcare providers. (2) This paper offers practical advice to achieve these standards for all foreign-born children and concludes with helpful tips for caring for special immigrant subpopulations as well as immigrant child health practitioners themselves.To create a practice environment that is welcoming to all patients, it is helpful to have a visual reflection of diversity. For example, employing staff members and providers who come from the varying communities served by your practice can help a family feel more comfortable. In addition, any people depicted in artwork should represent a variety of different backgrounds, and signage should, when possible, include the most common languages spoken in the local community. Language services, either through a phone/video line or in person, should be available at all visits. Furthermore, offering regular trainings for providers and staff on cultural humility and implicit bias can help everyone work together to create a positive experience for every patient.The gold standard for any pediatric primary care practice is to be a “medical home,” where children and families can receive comprehensive services and care coordination. (7)(8)(9) As such, it is helpful to have a holistic view of health and employ staff who can support patients accordingly. Depending on the population served, recommended resources could be social work, referral coordination, nutrition, and/or financial counseling. For the uninsured population with limited income, having a sliding scale discount or charity care program would also be beneficial. Although these options are most often found at Federally Qualified Health Centers or other low-cost clinics, private practices could help expand access for uninsured children by developing similar programs for a subset of their patients. Complementary services such as behavioral health, dentistry, optometry, and pharmacy should be co-located with primary care providers or, if not available within the clinic, efficient referral pathways should be created to ensure that patients are able to easily access these services at neighborhood organizations.In the same way that health services providers should work together to ensure a holistic approach, pediatric practices should also collaborate with nonmedical community organizations that serve children. Schools, child care centers, community centers, social service organizations, and places of worship can be invaluable partners in the mission to protect children’s health. This partnership should be bidirectional, with medical practices sharing public health information that community organizations can use to educate their beneficiaries and community organizations helping to identify children without a medical home and directing them to medical practices.At the start of the encounter, it is important for the provider to establish which language(s) the caregiver and child are most comfortable speaking (this can differ between the two). If the provider is not fluent in the preferred language of the caregiver and/or child, a certified medical interpreter should be used (ie, not a family member, a friend, or the child). Best practices for working with an interpreter include 1) maintaining eye contact with the caregiver or patient while talking, 2) pausing every 1 to 2 sentences to allow the interpreter to translate, 3) positioning the interpreter next to the provider, and 4) speaking directly to the caregiver or patient (eg, saying to the caregiver, “Your child is growing well” instead of telling the interpreter, “Please tell the caregiver that their child is growing well”). (10)(11)With any new patient, introducing oneself and the involved clinical staff properly is key to establishing rapport. It is also beneficial to describe the flow of the visit so that families know what to expect. This can be particularly important for children new to the United States because many countries around the world do not use a similar preventive care approach (eg, apart from receiving vaccines, children in developing countries might go to a health facility only when they are ill). Normalizing (eg, saying, “These are questions I ask all new patients”) and framing (eg, stating, “I only ask these questions because it helps me understand how to better care for your child”) are 2 techniques that can help the caregiver and patient feel more comfortable. (12)(13) In addition, providers should let families know that the information obtained remains only in the medical record (which is not shared with government authorities), and they can choose not to answer a question at any time without experiencing negative repercussions.Caregivers often possess medical records for the child but might not offer to share them unless asked. Therefore, inquiring whether families brought any past medical paperwork with them (including vaccination records) should be done early in the visit. Children who are new to the United States might have important health information from their home country, countries through which they passed on their journey, predeparture medical visits (eg, through the International Organization for Migration [IOM], US Embassy, or US Department of State), or another health facility in the United States (eg, clinic, urgent care, hospital, immigration facility/shelter, or health department).One of the first questions for all new patients, regardless of background, should be, “Where was the child born?” Whether the child was born outside of the United States will determine whether an immigrant-focused framework should be applied to the visit. If the child was born in the United States, a typical history should be conducted according to AAP and individual practice guidelines. If the child was born outside of the United States, specific questions should be covered in addition to the typical history (Table 1). (14)Through the Bright Futures periodicity schedule, the AAP sets forth guidelines for when to screen children for developmental delay, psychosocial/behavioral concerns, substance use, and depression (https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf). (16) As appropriate for age, screening of immigrant children should be initiated at the first available opportunity. Foreign-born children should also be asked about trauma exposure, if not already part of routine practice, because they experience higher rates of trauma than native-born children. (17) Immigrant adolescents should be screened for depression, anxiety, and posttraumatic stress disorder in addition to a HEADSS (Home, Education, Activities [including employment], Drugs, Suicidality/homicidality, Sex [including questions about menstrual history, consensual sex, sexual abuse, and child marriage]) assessment that covers their experience in previous countries and the United States. Tools to assist with screening for mental health concerns that are recommended for use in the foreign-born population can be found through the National Child Traumatic Stress Network (https://www.nctsn.org/resources/measures-are-appropriate-refugee-children-and-families). (18) All children should also be screened for social determinants of health, including (but not limited to) housing, environmental exposures (eg, cigarette smoke, firearms, and pets), interpersonal violence, food insecurity, and caregiver employment. (19)(20)(21)Vital signs and anthropometric measurements, as well as hearing and vision testing, should be completed as recommended in the AAP Bright Futures guidelines. (16) Furthermore, children younger than 3 years who never received newborn screening—and for whom there is parental or provider concern for hearing loss—should be referred to audiology. For foreign-born children 3 years and older, vision and hearing testing should be conducted at the first opportunity, regardless of whether they are currently the age at which screening is typically conducted in the practice.While the patient is still clothed, it is important to explain to the caregiver and patient what the physical examination entails and how it will proceed. This might be the first time that the child has been fully assessed in the standard manner for US healthcare. Specifically, the caregiver and patient should be informed that the routine health maintenance visit in the United States includes an examination of the external genital area. Many children from developing countries have never had a complete “head to toe” examination by a medical professional because any visits to health facilities might have focused only on the presenting concern. If the caregiver or patient is not comfortable with this full physical review and has no specific concerns about the genital area, this portion of the examination can be deferred until the second visit. However, this should be considered an option only if follow-up can be ensured (due to the potential for missing conditions such as imperforate hymen or undescended testes, among other congenital or acquired conditions).The patient should change into a gown for the physical examination. As the examination is conducted, the provider should talk through every aspect with the patient and caregiver to help them feel as comfortable as possible. The provider should approach the physical examination as he or she would a newborn examination, as if no medical provider has ever fully evaluated the child before. There might be unaddressed or undiagnosed abnormalities found on examination that, with proper intervention or follow-up, can be prevented from causing problems in the future. In addition to the standard physical examination recommendations for all children, special attention should be given to certain areas for immigrant children (Table 2). (14)Children who are born in other countries often do not receive the same laboratory screenings that US-born children receive as neonates and throughout childhood, and neither do their mothers during the prenatal period. If the mothers and/or children were tested, it is unlikely that the results are available or easily attainable. One notable exception is the case of children who enter the United States through the Refugee Resettlement Program. Most receive all the recommended laboratory tests within the first 90 days of arrival in the United States, and the results should be available on request. In addition, a review of their overseas medical examination paperwork might reveal that they were given presumptive treatment for certain conditions immediately before departure and thus do not require additional screening or presumptive treatment (see the Refugees subsection later herein). In the absence of medical records that contain these results, screening laboratory studies should be considered for all asymptomatic foreign-born children, especially those from Africa, the Middle East, Asia, Latin America, and the Caribbean (Table 3).Routine screening tests should be added by age as recommended in the AAP Bright Futures guidelines for all children residing in the United States, (16) as well as targeted testing based on concerns arising during the history and physical examination, such as dietary deficiencies, abnormal physical findings, or risk factors for infectious disease. In addition, providers can consider screening for conditions such as sickle cell trait and glucose-6-dehydrogenase deficiency, depending on family history and region of origin. Further recommendations for screening can be found in the AAP Immigrant Child Health Toolkit (https://www.aap.org/en-us/advocacy-and-xpolicy/aap-health-initiatives/Immigrant-Child-Health-Toolkit/Pages/Immigrant-Child-Health-Toolkit.aspx) and the Centers for Disease Control and Prevention (CDC) Domestic Refugee Guidelines (https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html). (14)(22)Symptomatic children should receive testing and treatment for their presenting condition either before or at the same time as their screening is conducted, whichever is medically appropriate. For children who present with fever within the first 4 months of arrival in the United States from a malaria-endemic area, malaria testing should be performed as part of the evaluation. After 4 months, malaria should remain on the differential diagnosis but testing performed only if indicated by the presence or absence of other symptoms (eg, fever plus headache or fever plus vomiting and diarrhea would be more consistent with malaria, whereas fever plus cough or rhinorrhea is less likely related to malaria).Aside from medicine needed to treat identified concerns, a multivitamin with iron should be considered for all children, especially those between 6 months and 6 years of age. (14) Newly arrived children might not have had access to a wide variety of nutritious foods before coming to the United States and can benefit from supplementation.In addition, presumptive treatment should be given to all children older than 12 months for soil-transmitted helminths (Table 4). This is preferable because stool tests for ova and parasites have poor sensitivity and the medications are generally well tolerated. However, if treatment is contraindicated, stool for ova and parasites should be analyzed with 2 to 3 stool samples from different days. Stool testing is not an effective screen for strongyloidiasis and schistosomiasis, so either serum testing should be performed or presumptive treatment given for these conditions (Table 4).(14)(22) For children who are uninsured or underinsured, discount pricing might be available for medications through prescription assistance programs.Vaccinations given in other countries can be accepted if the dates are written in ink (or typed) on an official immunization form, the timing of administration and vaccine type are acceptable per CDC guidelines, (23)(24) and the record contains the patient’s correct name and date of birth. If the child’s previous immunization record meets all the preceding criteria, they will require only any catch-up vaccinations not already administered (can test for immunity before going directly to administering vaccines, if possible and desired). If the child does not have an attainable immunization record or the record is not acceptable, there are 2 options: 1) serum testing can be performed to assess for immunity (available for hepatitis A, hepatitis B, measles, mumps, rubella, and varicella) and vaccines given only if not immune or for diseases for which serologic evidence of immunity is not possible; or 2) all vaccinations can be administered as if the child has never received any immunizations, per the CDC catch-up schedule. The latter option might be the most practical for situations in which the child is uninsured because the laboratory cost might be prohibitive, the vaccines can be given without charge through the Vaccines for Children program, (25) and the benefits to ensuring coverage for vaccine-preventable illnesses greatly outweigh the minimal risk to the child of receiving vaccinations.Families who are new to the United States would benefit from anticipatory guidance on how the health care system works, including explanations about primary care providers, the concept of a medical home, preventive care, the referral process, and appropriate use of urgent care as well as emergency departments and 9-1-1. They should also be connected to services to meet their comprehensive health needs, either within the same facility or as an external referral. For example, any child 12 months and older should be linked to a dentist. Referrals should also be made for children with behavioral health, optometry, or other subspecialty concerns. Finally, families should be informed of resources for which they are eligible that can alleviate health risks caused by social circumstances. These resources can include federal supports such as the Special Supplemental Nutrition Program for Women, Infants, and Children (aka WIC; open to all children <5 years of age whose families meet income requirements) and the Supplemental Nutrition Assistance Program (aka SNAP; open only to lawful permanent residents, US citizens, and grantees of humanitarian relief whose families meet income requirements) as well as local resources, including food banks, legal organizations, housing support, domestic violence hotlines, utility and rental assistance, recreation/community centers, English-language classes, and job training. Immigrant-specific, nationwide, nongovernmental organizations can also offer resources and/or information for providers and families (Table 5).Immigrant children should be seen on the same routine preventive care schedule as children who were born in the United States, with the exception of the visit immediately after their establishment of care. If the next routine visit would be more than 6 months after the initial visit, a follow-up should be scheduled for 1 to 6 months in the future. This visit is necessary to check on referrals or issues from the first visit, review any medical records that have been received in the interim, do additional laboratory testing and vaccinations (as needed), and identify new concerns.This time should be used to discuss how the child is adjusting to American culture, review how he or she is doing in school (if applicable), reassess the social determinants of health (see the Screening section previously herein), and ask about any new issues. Screening for mental health and trauma should also be repeated because it can capture new concerns or yield previously unrevealed information that the patient is now more comfortable sharing. A second HEADSS assessment should be completed for adolescents as well.A focused physical examination should be conducted to follow up on any abnormalities noted at the first visit or to evaluate new concerns revealed in the history. If the external genital examination was normal at the first visit, there are no current, related complaints, and the child is at least 3 years old, this region does not need to be addressed and can be examined on a once yearly schedule. If, however, all 3 conditions are not met, the genital area should be examined at this follow-up visit. Weight and height/length should also be checked to determine whether the child is growing well. On the other side of the spectrum from undernutrition and failure to thrive, some newly arrived children who initially present with a body mass index within normal limits experience rapid weight gain due to overindulgence in the typical American diet. It is important to identify these children and discuss interventions (eg, how to select healthier foods and beverages, recommendations for exercise, and limiting screen time) with their caregivers before the children develop weight-related health problems.For children up to 6 years of age, a second lead level should be measured 3 to 6 months after the first visit (even if the first level was normal). The reason for repeated testing is to assess the current environmental exposure because the first level can reflect the previous living environment in newly arrived children. If a child of any age was experiencing severe stress, malnutrition, parasitic infection, or untreated human immunodeficiency virus infection at the initial visit, a repeated tuberculosis test should be performed. It is recommended to do an interferon-γ release assay if at all possible, although a tuberculin skin test can be used if the interferon-γ release assay is not feasible. (26)(27)(28) Other tests might be warranted, as well, depending on specific disease processes and new risk factors (eg, testing for sexually transmitted infections might be needed if sexual activity or abuse has occurred or been revealed since the original visit).If presumptive treatment was prescribed for parasites, the provider should ensure that it was taken. In addition, the efficacy of any ongoing medications should be assessed and refills prescribed, as needed. The multivitamin recommended at the first visit can be either continued or stopped after 6 months of treatment, depending on the diet of the child. Catch-up or routine vaccinations should be given per the CDC timetable.If there are no issues identified or continuing vaccination delays that necessitate more frequent follow-up, the child can then be scheduled for his or her next preventive care visit per the routine Bright Futures guidelines. (16)Children who arrive in the United States as refugees are generally with a parent or guardian, although a small subset are “unaccompanied refugee minors” and placed with foster families. Refugees in the United States have been predetermined—through months to years of extensive vetting abroad—to have a well-founded fear of persecution or harm if they were to return to their countries of origin. Before arrival in the United States, refugees receive predeparture medical examinations, usually by the IOM. The US Refugee Resettlement Program is the formal process by which they come to the United States and are resettled into communities by local agencies. (29) Refugee children are typically able to receive Medicaid and have case managers who assist their families with finding health services, among other supports. Furthermore, refugees generally receive their first set of postarrival laboratory screenings and vaccinations at a health department, community health center, or academically affiliated clinic within their first 90 days in the United States. Records from this visit should be requested (if not immediately available) to avoid repeating laboratory tests and vaccinations unnecessarily. In addition, previous records from countries of origin or transit should be reviewed—such as the medical information from the predeparture examination conducted by the IOM—to look for any laboratory and radiology results as well as any presumptive treatment and vaccinations given.Most children without a parent or legal guardian who arrive in the United States and do not have a previously approved form of admittance are transferred to the custody of the Office of Refugee Resettlement (ORR). Although unaccompanied immigrant children (UIC) are not considered refugees, the ORR (under the Department of Health and Human Services) is the branch of the US government tasked with covering the basic needs of these children while the government assesses potential “sponsors” (usually parents or other family members) to assume guardianship. Within the first 24 hours of entry into ORR care in a shelter (where most UICs are placed) or foster home, every child receives a psychological evaluation and, within 48 hours of entry, an initial medical examination. Typically, ORR-affiliated shelters contract with external pediatric-trained practitioners to come into the shelter to provide preventive and acute care, although some hire full-time, in-house providers and others take the UICs to an outside clinic. The initial medical examination consists of a full history and physical examination, vaccinations, and testing for tuberculosis. Adolescents 13 years and older are also tested for human immunodeficiency virus, and children at any age are screened for sexually transmitted infections if they disclose sexual abuse or activity (any disclosure of abuse that occurred in the United States must be reported to child protection authorities, as it is for all children). If there are abnormalities identified through the initial medical examination or known, preexisting conditions, the children are referred to local subspecialists. While in ORR custody, UICs are covered by health insurance, and ORR—as well as shelter staff, by officially designated extension—has medical decision-making authority on their behalf. (30) However, healthcare providers are encouraged to contact the UIC’s parent or other family member, as appropriate, to be sure that an accurate health history is obtained and those who know the minor best are able to contribute to the formulation of their medical plan of action.When UICs are released from ORR care to live with their sponsors, the health insurance coverage they previously received is terminated. In 6 states (Washington, Oregon, California, Illinois, New York, and Massachusetts) and the District of Columbia, children are eligible to receive public health insurance coverage regardless of immigration status. If the child will be living in one of the remaining 44 states, it is likely that he or she will be uninsured (unless the sponsor can provide private insurance coverage). Thus, access to care can be a challenge, and these children typically require financial assistance programs and/or charity care to meet their health needs. If the sponsor and child do not bring the records of vaccinations and laboratory results from ORR to their new health facility after release, they can be requested at the ORR website (https://www.acf.hhs.gov/orr/resource/unaccompanied-childrens-services).Before spring 2021, there was a small but significant minority of children who arrived in the United States with a parent or guardian and were placed in family detention together. There were 3 such facilities in the United States, with a total capacity of approximately 3,700 individuals within family units. (31) Although the medical services varied among facilities, children and adults generally did not receive any screening other than a rapid examination for scabies, lice, and varicella. The families had access to health care on site for acute needs and hospital referral for emergencies only. Occasionally and without a predictable pattern, family detention centers conducted tuberculosis testing or full physical examinations of children but did not typically give vaccinations. (32)Per the Flores Settlement Agreement, children should not be held in detention for more than 20 days. (33) Although this limit was violated at times, most families who were placed in these detention facilities were eventually released, and most of them went on to stay with friends or family in the United States while their asylum claim was processed. Because these children are living in US communities and accessing local health-care, it is important to recognize whether they have a history of detention, to assess for any signs or symptoms of resultant trauma, and to facilitate connections to mental health services, as needed. In addition, note that immigration policies change over time and families could again be held in detention in the future.As a result of the everyday challenges of caring for immigrant children and families, frontline practitioners working with this population are at high risk for burnout. Care must be taken to prevent the compassion fatigue that can result from burnout as well as recognize and intervene when it is beginning to manifest. Although self-care such as yoga and meditation have proved to be beneficial in decreasing stress, interventions that increase resilience and self-efficacy have been shown to be more effective in alleviating burnout. (34) An important avenue through which to build this resilience in practitioners for immigrant children is through advocacy. This can come in the form of contacting elected officials on a particular topic or writing resolutions on immigrant-related issues for state medical societies. (35) Practitioners can also join professional organizations, such as the AAP, in raising awareness about the structural injustices that form the root of health inequities in immigrant children and supporting legislation to reform the system. Although the societal, environmental, and economic challenges facing immigrant populations are staggering, medical professionals can partner in their advocacy with organizations and individuals that address factors across the spectrum of social determinants of health. It is this fortifying, action-oriented collaboration of health professionals, social workers, educators, politicians, faith leaders, service organizations, legal advocates, and immigrant parents, among others, that is the ultimate antidote to burnout and the fuel to keep the fire burning on behalf of immigrant children for as long as they continue to come.

Malignant atrophic papulosis (Degos disease) is an unusual thrombotic microangiopathy of uncertain etiology. The disease characteristically involves the skin and internal organs, with nervous system involvement more common in children. We present a case with diverse neurological manifestations including cranial nerve palsies, gait instability, and urinary incontinence. The patient also developed white papular lesions on her lower extremities and back. Magnetic resonance imaging (MRI) demonstrated progressive intracranial and spinal abnormalities. Despite treatment with numerous biologic agents, the patient had persistent clinical deterioration and expired one month after admission. We highlight the extensive neurologic manifestations of Degos disease correlated with neuroradiological imaging and pathological features. Nervous system involvement in Degos disease requires careful neurologic and dermatologic exam with central nervous system (CNS) magnetic resonance imaging to distinguish it from non-organic etiologies of similar symptoms.

We have seen the horrifying cell phone and surveillance video footage of the murder of George Floyd replay again and again in the last few weeks. The aftermath begs the question why this particular murder of a Black man by a police officer has sparked the international response so few have received.1 Scores of other Black men, women, and children have been killed by police since the 2014 murder of Eric Garner in New York City, in which he suffered an illegal chokehold and uttered the devastating refrain “I can’t breathe,” and countless others have been murdered over generations. These cases represent just the tip of the iceberg because these murders happened to be recorded on bystander cell phone video or police webcam capture. Moreover, it is the tip of another iceberg because these cases represent modern-day lynchings. The lynching of Black people in the United States was routine before the “civil rights era,” when there were major legal advances to change the treatment of Black Americans in this country. However, it was not until February 2020 that federal legislation, the Emmett Till Antilynching Act, was passed by the House of Representatives but is still awaiting Senate approval to make lynching a federal hate crime. The case of George Floyd and other recent cases reveal that we clearly have so much more work to do.When we watched previous videos, including the video of Eric Garner’s death, society let the mistreatment of Black Americans continue unabated and gave in to the excuses and the protections that make it nearly impossible to hold police accountable for their actions. Police unions defended the officers caught on video killing Black Americans, and society went along. Investigators, prosecutors, and juries were unwilling to second guess an officer’s often split-second decisions, even when they were clearly not split second at all, and society went along. Defenders of these actions warned of demoralized police who would be afraid to act quickly to protect the rest of us, and society went along. Local police review boards were incredibly weak and often made recommendations for terminations that were ignored or overthrown, and society went along. The officer who killed George Floyd faced >17 misconduct complaints over the last 20 years, including brutality, but he received only 2 letters of reprimand. The majority of society went along despite strong minority voices calling attention to these crimes. Until now.Now, we all can see the video of a human being, George Floyd (a father, a man of faith, an athlete, a hip-hop artist in the 1990s, a man beloved by people who knew him), begging for his life, calling for help, and a police officer digging his knee into his neck for 8 minutes and 46 seconds while 3 other police officers were holding him or standing by, and finally, we saw his limp, dead body taken away. The nonviolent crime he was accused of was trying to pass a counterfeit $20 bill, alleged but never substantiated, charged, or litigated. He, like so many other African Americans who lost their job as a result of coronavirus disease 2019 (COVID-19), had recently been laid off as a security guard and was struggling to survive. As we watched that video, many in white society finally felt a combination of shame, guilt, and anger and decided not to “go along” with the status quo anymore. Diverse members of society appear to have awakened from passivity and have been moved to act together, not just in Minneapolis, but in cities around the United States and across the world.A year ago, at the Pediatric Academic Societies meeting in Baltimore, the George Armstrong Lecture focused on racism and hatred; the title of the talk was “The Hate U Give: Protecting Children and Families from Racism, Bias, Discrimination, and Hatred.”2 The talk included the statements “Black lives matter” and “we cannot tolerate murdering unarmed men and boys or brutalizing and terrorizing Black citizens.” It did not include a specific path forward for effective change, and that was an error. Many pediatricians embraced the ideas and offered to lend their support to addressing racism and bias and we started an action group called Pediatricians Against Racism and Trauma (PART). This group of >60 pediatric leaders from across the country convened 4 different action groups and planned to present at plenaries and workshops and meet at this year’s Pediatric Academic Societies meeting. This year, we were also armed with an American Academy of Pediatrics policy statement that outlined the impact of racism on child and adolescent health and carried the weight of the largest and one of the oldest pediatric organizations in the world,3 as well as a similar position article from the Society for Adolescent Health and Medicine.4 Alas, COVID-19 cancelled those meetings; since then, we have all been focusing elsewhere, on sick children and adults in the hospital, as well as the needs of poor families and families of color during the COVID-19 pandemic, a pandemic that has laid bare the socioeconomic and racial-ethnic inequities in our society.We are pediatricians, and as such, there are many important problems related to racism that are in our bailiwick, our zone of expertise and comfort: bias in the provision of care to Black children and families; structural racism and bias in medical schools and health care5; the preschool to prison “pipeline”; the mass incarceration of youth of color as well as the parents of children of color; discrimination against Black, Native American, and Latinx families in housing, education, and employment; the microaggressions suffered by individuals of color in the performance of daily life activities; and the criminalization and detention of immigrant families at the border and the harassment of and denial of benefits to these families in our cities and states.6 Although pediatricians must continue to work to address the issues outlined above, each of which is in need of its own set of policy recommendations and actions, we must also recognize that structural racism creates the foundation on which all these injustices are built. As such, these areas of structural racism are closely related to police violence. Moreover, at this time, we must move out of our comfort zone and address this long-standing injustice in policing7 or remain complicit in the continued killing of Black Americans. These killings reverberate throughout the Black communities, causing chronic fear and emotional trauma with terrible implications for children, youth, and families. We must advocate for a suite of evidence-based policy changes specifically related to police violence, most at the local level. Although not typically viewed as a child health issue, we agree with the statement from the American Medical Association that police brutality is a health issue8 and believe that it is indeed a critical issue for the health and well-being of all children and adolescents and their families, yet of course most urgently for Black families. Here are 6 such policies for effective change9:In a recent interview, historian Dr Mary Frances Berry shared that “every generation has to make its own dent in the wall of injustice.”13 So let us all, as pediatricians, follow her example and use our power to stand in solidarity with peaceful protesters around the world and to pursue justice for this generation of children and the next.We acknowledge and thank the members of PART. PART was formed over a year ago to address racism and bias and their impact on children and families. All the authors of this article are members of PART, but many other members have contributed ideas and suggested changes that have greatly enhanced this article. As such, we feel this commentary reflects the whole PART community. Members, in addition to the authors, include the following (in alphabetical order): Rhonda Acholonu, Nusheen Ameenuddin, Judy Aschner, Susan Bostwick, Lisa Chamberlain, Latha Chandran, Tina Cheng, Paul Chung, Chanelle Coble-Sadaphal, Scott Denne, Angela Ellison, Steven Federico, Arthur Fierman, Arvin Garg, Katherine Greenberg, Marsha Griffin, Nia Heard-Garris, Ben Hoffman, Monique Jindal, Jeffrey Kaczorowski, Nancy Kelly, Woodie Kessel, Arthur Lavin, Julie Linton, Camila Mateo, Alan Mendelsohn, Lee Pachter, Eliana Perrin, Ellen Perrin, Katie Plax, Jean Raphael, Joan Reede, Rebecca Rosenberg, Christopher Russell, Steve Selbst, Alan Shapiro, Judith Shaw, Lynn Smitherman, Barry Solomon, Moira Szilagyi, Peter Szilagyi, Leonardo Trasande, Franklin Trimm, Teri Lee Turner, Traci Wolbrink, and Katherine Zuckerman.

The auricle is a key target in pediatric plastic surgery and is considered to develop from a ring- or funnel-like arrangement of six hillocks in the embryo. However, there has been no report showing the morphologies of the auricular muscle and cartilage after midterm in humans.We examined histological sections of 20 near-term human fetuses (29–40 weeks) and those from 7 midterm fetuses (15–16 weeks).At midterm, the auricular cartilage was a single wavy plate with the helicis major muscle (HMM). The superior and posterior auricular muscles (SAM, PAM) were inserted into the middle parts, and the anterior auricular muscle (AAM) was inserted into the lowest part of the cartilage plate, while the tragus and antitragus were not clearly identified. In near-term fetuses, the cartilage plate varied in size and shape between specimens. The scapha and antihelix were separated from the cartilage plate with major or minor involvement of the HMM from the initial mass along the helix. The SAM inserted to the crus helix or the developing scapha, while the insertion sites of the AAM and PAM into the helix were stable. The tragus–antitragus cartilages were well-developed and they sandwiched a deep notch of skin below the helix tail. The antitragicus muscle was more evident than the tragicus muscle. An unnamed muscle was evident along the external acoustic meatus. The other intrinsic muscles, including the transverse and oblique muscles, might develop from the HMM after birth.Development of the auricle was advanced after midterm. However, a single wavy plate-like cartilage was maintained until late-stage. Near term, the antihelix and scapha developed from the plate-like core of the auricle and the tragus and antitragus were added in the antero-inferior side of the cartilage plate. Establishment of muscle arrangements was markedly delayed compared to cartilage development. Altogether, the classical concept of an initial funnel-like arrangement of cartilage anlagen might have been biased by studies of adult morphology.

* Abbreviations: AAP — : American Academy of Pediatrics ECFMG — : Educational Commission for Foreign Medical Graduates IMG — : international medical graduate The American Medical Association Physician Masterfile reveals 26 000 physicians who attended medical school outside the United States and Canada and who are not currently in residency, declaring pediatrics as their specialty. According to the Educational Commission for Foreign Medical Graduates (ECFMG), in 2015, 3 countries (India, Canada, and Pakistan) contributed the highest numbers of non–US-born international medical graduates (IMGs) receiving ECFMG certification. However, there were also a sizable number of certificate holders from Latin America, the Middle East, and Africa (Nigeria).1 Non–US-born pediatricians inherently offer a broad cultural, linguistic, and ethnic diversity; as such, they may contribute to the goal in our pediatric specialty to improve workforce diversity and culturally effective health care.2,3 IMGs (including US-born IMGs) comprise >26% of the entire physician workforce in the United States. Forty-one percent of practicing IMGs are in primary care disciplines as defined by the Association of American Medical Colleges.4 They play a vital role in the care of vulnerable populations in both rural and urban underserved areas.2,5 Non–US-born IMGs also constitute a disproportionate number of subspecialists … Address correspondence to Rana Chakraborty, MD, MSc, FRCPCH, FAAP, FPIDS, PhD, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. E-mail: chakraborty.rana{at}mayo.edu

* Abbreviation: AAP — : American Academy of Pediatrics The mission of the American Academy of Pediatrics (AAP) has always been to attain optimal health and well-being for all children. In recent decades, however, our understanding of the composition of “all children” has changed, and it will continue changing well into the future. By 2020, more than half of all US children will be racial or ethnic minorities; by 2044, no single racial or ethnic group will comprise a majority of the nation’s population.1 There is also a growing understanding of the wide variety of children’s lives and experiences and the needs of those who face social disparities; have special needs; are lesbian, gay, bisexual, transgender, or questioning; or who experience adverse childhood experiences and toxic stress.2 The response to children’s varied life experiences and needs is complicated by the fact that these are perilous times for our nation’s children, who face increasing insecurity and challenges as they strive to develop and grow. Structural drivers of social disparities and income … Address correspondence to Karen Remley, MD, MBA, MPH, FAAP, American Academy of Pediatrics, 345 Park Blvd, Itasca, IL 60143. E-mail: kremley{at}aap.org

Purpose of ReviewTo update the knowledge base and effectiveness of clinical interventions to prevent death from pneumonia.Recent FindingsIntegrated management, early identification of danger signs, appropriate care at the appropriate time, and the use of vaccines against respiratory diseases have proven to reduce mortality drastically.SummaryMost deaths in children less than 5 years of age are from pneumonia in resource-limited environments. Effective strategies such as early detection of signs of danger, access to appropriate care in a timely manner, appropriate antibiotics administered early on, the use of Kangaroo mother care, supplementation of zinc, vaccination and community interventions must to be considered in order to reduce the burden of childhood mortality due to respiratory diseases.

Summary Objective To define the mortality and long‐term outcomes of children undergoing tracheostomy. Design Retrospective chart and Texas Department of Health Bureau of Vital Statistics review of patients admitted to a Pediatric Intensive Care Unit who underwent a tracheostomy between 2001 and 2011. Mortality and decannulation rates were compared based on tracheostomy indication and age. Subjects A total of 426 patients admitted to a Pediatric Intensive Care Unit in a large tertiary children's hospital. Results The median patient age was 1.5 years (3 days–24 years). Primary indications for tracheostomy included (a) airway obstruction, (b) congenital neurologic disease, (c) acquired neurologic disease, (d) congenital respiratory disease, and (e) acquired respiratory disease. Overall, 98 patients (23%) died during the study period, and 75th percentile survival time was 5.9 years (95%CI: 3–8). Patients undergoing a tracheostomy for airway obstruction were the least likely to die; while patients with acquired neurologic disease were most likely to die. A total of 163 patients (38%) were decannulated, and 50% were decannulated at 1.2 years (95%CI: 0.9–1.5). Patients with congenital neurologic disease were the least likely to undergo decannulation. Over half of the patients were discharged from the hospital requiring some form of mechanical respiratory support in addition to their tracheostomy. Conclusions In this largest cohort of long‐term follow‐up to date, we have shown the overall risk of mortality varied according to the indication for the tracheostomy. We were unable to determine exact causes of death. The likelihood of being decannulated also correlates with the underlying indication for the tracheostomy. Pediatr Pulmonol. 2017; 52:946–953. © 2017 Wiley Periodicals, Inc.

In pediatric populations, alarm defaults can be more complex to set, as the normal values for heart rate and respiratory rate vary widely by age range. Therefore we sought to develop more relevant alarm thresholds that were specific to the unique population within our pediatric institution. Complete physiological recordings were collected from 1806 patients in the Progressive Care Unit at Texas Children's Hospital over a five month period in 2014. Patients were grouped by age and centiles plots for Heart Rate, Respiration Rate and SpO2 were calculated and compared to current alarm limits. Comparison of current alarm limits to actual physiologic data shows the mismatch in alarm setting to patient physiology. As an example, the value for the Heart Rate High alarm limit is set such that it falls near the 50% centile, meaning that 50% of the patients will alarm at this value. By re-setting the default settings for Heart Rate, Respiratory Rate and SpO2 limits based on the actual data of a large group of medically complex children, one can reduce non-necessary alarms. However, default alarms need to be set conservatively as complications from complex comorbidities can skew the baseline for the population. Our results demonstrate that age based recommended alarm limits that are derived from healthy cohorts can lead to higher than desired alarm loads in this pediatric population. With data based on the population, more appropriate alarm settings can be derived.

Roy, Kevin; Rauch, Melissa; Stein, Fernando; Williams, Eric; Rafie, Kimia; Gagne, Vincent; Fauss, Emma

In a tumultuous and unpredictable election year, Americans selected Donald Trump as our 45th president. Mr Trump’s approach to policymaking is still unknown, and his positions on certain issues do not follow the typical partisan patterns within American politics. However, Mr Trump has expressed support for family-oriented policies, including paid family leave and child care subsidies. His administration may present an opportunity to continue working on efforts to provide children with the essential elements needed to lead healthy and productive lives. The priorities and policy decisions President Trump takes will have a lasting impact on our nation’s future.To help guide these decisions, in advance of the election, the American Academy of Pediatrics (AAP) laid out a comprehensive plan for the federal government to give children, families, communities, and the nation a solid foundation for the future.The Academy’s plan, Blueprint for Children: How the Next President Can Build a Foundation for a Healthy Future, is grounded in the belief that society’s health depends on its children’s well-being.1 It reflects the AAP’s commitment to programs and policies that improve the lives of children and families so they can achieve their full potential. The Blueprint contains a high-level policy vision as well as many specific administrative and legislative recommendations relevant to 24 federal agencies and departments that can influence the health and well-being of children and families. It was developed in consultation with AAP leaders and reviewed by numerous colleague organizations, 11 of which endorsed it (the Academic Pediatric Association, the American Pediatric Society, America’s Promise Alliance, the Association of Medical School Pediatric Department Chairs, the Children’s Partnership, Family Voices, the National Association of Pediatric Nurse Practitioners, the Pediatric Policy Council, the Society for Adolescent Health and Medicine, the Society for Pediatric Research, and ZERO TO THREE). The Blueprint was presented last September at a panel discussion featuring a range of thought-leaders. The archived event webcast is available at aap.org/blueprint, along with the complete document.1Almost half of children in the United States live in poverty or near poverty.2 Lifting families out of poverty and ameliorating its impact on children is critical for the future of our country. The federal government has existing programs that move millions of children out of poverty, as well as protect them from the negative effects of poverty on their health and well-being.3–5 These programs must be maintained, strengthened, and expanded.Childhood is a critical time of rapid physical, cognitive, emotional, and social development that sets the stage for good health and successful learning and relationships. Early childhood relationships and experiences—positive and negative—significantly affect individual health, educational, and economic outcomes through adolescence and into adulthood.6 Supporting children as they develop, rather than trying to identify and remediate intractable problems later in life, is critical to building healthy adults. Comprehensive and long-term investments in early life experiences that promote resilience and provide a strong start yield significant returns and save money on increased health care expenses and other societal costs.The Blueprint calls for the federal government to invest in, coordinate, and focus on 4 key themes: promoting healthy children, supporting secure families, building strong communities, and ensuring the United States is a leading nation for children.Child health is a strong predictor of adult health. Lack of access to health care threatens the physical, mental, and social well-being of children and their caregivers. The next administration should ensure that all children, regardless of immigration status, have access to high-quality health care, including specialty care. Almost half of US children receive health insturance from Medicaid and the Children's Health Insurance Program (CHIP). Therefore, the next administration must ensure that Medicaid is not subject to payment caps, block grants, or other structural harms, and CHIP is reauthorized and strengthened. Among other recommendations, the Blueprint calls for health plans to offer comprehensive, well-defined, pediatric-specific essential health benefits packages. It also calls for support for programs that promote maternal and reproductive health such as comprehensive prenatal care, the Title X Family Planning program, the Teen Pregnancy Prevention Program, and confidential access to contraception for adolescents.A safe, nurturing environment that includes steady income, stable housing, adequate nutrition, and social-emotional support helps children thrive. The next administration should embrace a multigeneration perspective that values the formation of stable, responsive, and nurturing relationships. The Blueprint recommendations include strengthening several effective federal programs that lift families out of poverty, including minimum wage increases, job training, family-friendly benefits, and tax credits (such as the Earned Income Tax Credit and the Child Tax Credit).7 It also calls for increased support for social programs that provide nutrition, housing, child care, and parenting support to families in need.Communities play a vital role in safeguarding public health, mitigating social disparities, and fostering a resilient society. The next administration should ensure that all children and families are safe in their communities and have equal access to opportunities, regardless of race, ethnicity, or income. The Blueprint recommendations include policies to reduce the dangers of violence, environmental toxins, and preventable infectious diseases; to make sure every child has access to high-quality early learning programs; and to improve the built environment.8The next administration should maintain the United States’ role as a leading nation for children by advancing child health not only within our country but internationally. The Blueprint recommends increased efforts to address climate change, protect civil rights and human rights, and promote maternal and child health globally. It also calls for comprehensive immigration reform, expanded investments in pediatric research to improve child well-being, and the development of innovative therapies for pediatric diseases.This nation has made progress in protecting and nurturing children and expanding opportunities for all. President Trump must preserve these successes, build on them, and create the strongest possible foundation for future generations. Achieving the Blueprint’s goals will require creating new programs, enhancing existing policies, and coordinating federal programs that affect children and families. That is why the Blueprint calls on the next administration, in its first 100 days, to direct all federal agencies to review how their activities can proactively work together to improve children’s lives. Children deserve a bold agenda that prioritizes their needs and places them at the center of our federal policy decisions. The Blueprint offers such a plan, and it is up to us to help our nation’s leaders put it into practice.