2 Minute Medicine Rewind January 23, 2023

Impact of COVID-19 on pediatric asthma-related healthcare utilization in New York City: a community based study

1. Children with asthma with private insurance disproportionately affected by the COVID-19 pandemic in terms of indoor asthma triggers, reduced income and housing insecurity

2. Families with public insurance also more likely to test positive for SARS-CoV-2

Evidence Rating Level: 2 (Good)

The COVID-19 pandemic has had an impact on healthcare utilization patterns as well as total number of emergency department visits in the USA. Emergency room visits in New York City (NYC) for asthma, one of the most common chronic conditions in children, decreased by 92% in the 12 weeks following NYC’s stay at home orders compared to the same time from in the prior year. Those in low-income neighborhoods such as East Harlem, NYC are disproportionately affected by asthma morbidity and were also severely affected by the high burden of COVID-19. This cross-sectional survey included families from two sites that care for children who have asthma that were geographically close but from distinct neighborhoods. These sites were East Harlem and Upper East Side. East Harlem is a high-poverty neighborhood, with 23% of residents living in poverty, whereas the Upper East Side is a low-poverty neighborhood, with only 7% of residents living in poverty. A phone survey was conducted by families who had children treated for asthma between 5-18 years of age and a primary address within the two neighborhoods. Participants were also stratified into whether their health insurance was private or public (Medicaid). The study found that those with public health insurance had significantly higher reports of indoor asthma triggers (cockroach 76% vs 23%; mold 40% vs 12%), reduced income (72% vs 27%), and housing insecurity (32% vs 0%), and were also more likely to experience conditions less suitable to social distancing. The families with public insurance were also more likely to test positive for COVID-19, but less likely to get tested (48% vs 15% and 76% vs 100% respectively). Those with public insurance had greater challenges in accessing medical care and telehealth but not at statistically significant levels. Limitations to this study include sample size as well as recall bias. However, this study does highlight that insurance type is associated with disparities in healthcare for those with asthma due to the COVID-19 pandemic. Further studies investigating barriers to care as well as ways to support those who experience these barriers are needed to help support the health and well-being of children with asthma.

Concordance of Diagnosis of Autism Spectrum Disorder Made by Pediatricians vs a Multidisciplinary Specialist Team

1. High accuracy of concordance of autism spectrum disorder (ASD) diagnosis between general pediatricians and expert multidisciplinary teams when pediatricians felt confident about autism assessment

2.  Lower accuracy was seen when ruling out ASD

Evidence Rating Level: 2 (Good)

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by challenges in social communication and interaction, and the presence of restrictive and repetitive behaviors, interests, and activities. Currently, many guidelines recommend that multidisciplinary teams (MDTs) be involved in all ASD diagnostic assessments, however with increased demand and wait times, this may delay therapies for ASD. It is known that timely ASD diagnosis facilitates access to support sooner, positively impacting development and improving outcomes and allowing general pediatricians to diagnose ASD may help with facilitating time to therapy. This prospective study aimed to identify agreement between general pediatricians and subspecialist MDT ASD assessment. Patients were allocated into two groups, one who had their MDT visits before pediatrician assessment and one who had their MDT visits after pedestrian assessments to reduce in bias in parental reports of symptoms. Both general pediatricians and MDT completed a decision on whether they believed the child met diagnostic criteria for ASD, as well as a Likert scale indicating level of certainty of diagnosis. Sensitivity and specificity of pediatrician assessments versus MDT were 0.75 (95% CI, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively. The positive predictive value pediatrician assessments was 0.89 and the negative predictive value was 0.60. Higher pediatrician certainty was associated with increased diagnostic accuracy. This study shows that general pediatricians have a high likelihood of correctly diagnosing ASD, especially in conditions in which they feel certain. Limitations to this study include that pediatricians were self-selected, thus likely more interested in ASD and not representative of all general pediatricians. Future studies involving more general pediatricians and development of guidelines for the diagnosis of ASD within general practices may help those with ASD reach earlier diagnoses and seek earlier treatment.

Rates of and factors associated with exclusive and any breastfeeding at six months in Canada: an analysis of population-based cross-sectional data

1. In a population-based cross-sectional study in Canada, rates of exclusive breastfeeding for six-months found to be 35.6%, lower than the target of 50% by 2025

2. Factors associated with exclusive breastfeeding include bachelor’s degree (or higher degree), normal body mass index, being married and daily co-sleeping

Evidence Rating Level: 2 (Good)

Breastfeeding is known to have many health, economic, and environmental benefits. The World Health Organization (WHO) and Health Canada recommended exclusive breastfeeding for the first six months of life, with no other liquid or solid foods with the exception of nutritional supplements and medications. Females in Canada do not meet these recommendations, in a 2006-2007 survey, it was found that only 14.4% of females exclusively breastfed for at least six-months and 25% of those who initiated breastfeeding added liquids other than breastmilk within two weeks of delivery. The aim of this study was to examine rates of exclusive breastfeeding and factors associated with breast feeding duration. A survey was conducted including 5392 females aged 15-55 who had given birth in the five years preceding the survey. Exclusive breastfeeding for at least six months was the main outcomes, with other questions including any breastfeeding duration, and maternal characteristics. The study found that 35.6% of participants breastfed exclusively for six-months and 62.2% did any breastfeeding. Within the first month there was the largest decline in breastfeeding, and insufficient milk supply was given as the most common reason for breastfeeding cessation regardless of time of cessation. Factors associated with six-month exclusive breastfeeding included bachelor’s degree (or higher degree), normal body mass index, being married and daily co-sleeping. Although the rates of exclusive breastfeeding in Canada are below the target of 50% by 2025 and 70% by 2030, there has been an increase compared to the previous rates of 14.4% in 2006/7 and 26% in 2011/12. Continuing to identify factors that influence breastfeeding and tailoring interventions towards these factors may help Canadians reach the recommended targets in the future.

Evaluation of Faculty Parental Leave Policies at Medical Schools Ranked by US News & World Report in 2020

1. In a study of 87 medical schools in the United States, many medical schools have limited to no paid leave for parental leaves

2. Lack of paid parental leave associated with higher rates of physician burnout and work-life integration dissatisfaction

Evidence Rating Level: 2 (Good)

Physicians are more likely to experience infertility, often delay childbearing, and experience stigmatization and discrimination as parents. Many physicians are also likely to consider adoption and foster care. Unfortunately, physicians who are interested in parenting are often affected by institutional leave policies, increasing the risk of female physicians reducing work hours and leaving clinical practice which further perpetuates the gender gap within the field of medicine. This cross-sectional study investigated the parental leave policies of 87 medical schools in the United States. 72.4% of schools had some paid leave for birth mothers, while only 14.9% offered 12 weeks of fully paid leave. In terms of nonbirth parents, 12.6% offered 12 weeks of fully paid leave, while 43.7% offered no paid leave. 40.2% had no paid leave for adoptive parents, and 74.7% had no paid leaves for foster parents. About one-third of schools relied on vacation and sick leave polices to provide birth mothers with leave. Limitations to this study include vaguely written leave policies, as well as physicians taking less than promised leave due to unwritten pressures within the medical community. There are clear benefits to paid leave for parents and newborns and lack of adequate leave policies contributed to burnout and difficulties integrating work life balance. Future studies and guidelines are needed to support the implementation of paid leave for physicians.

Risk of Sudden Infant Death Syndrome Among Siblings of Children Who Died of Sudden Infant Death Syndrome in Denmark

1. In a nationwide cohort study in Denmark, a higher rate of sudden infant death syndrome (SIDS) observed among siblings of children who died of SIDS

2. Genetic and environmental factors should be investigated in those who have siblings that died of SIDS

Evidence Rating Level: 2 (Good)

Sudden infant death syndrome (SIDS) is a leading cause of death in the first year of life, however the mechanisms are unclear, making prevention a challenge. Although previous studies have described a positive family history, they were on select populations. This nationwide study involved a population of 266 834 consecutive births during a 39-year study period. Of this group. 1540 infants died of SIDS and 2384 younger siblings were identified to these cases. The main outcome was standardized incidence ratios (SIRs) of SIDS. Other characteristics including maternal educational status and household income were also assessed. It was found that most cases of SIDS (90%) occurred within the first six months of life. Between SIDS index cases and the general population, there were no significant differences in sex of child and mother’s age at childbirth. It was found that siblings of SIDS index cases were more likely to live in low-income households (50% vs 30%) and have mothers with only an elementary school education (54% vs 26%) compared to the general population. After adjusting for sex, age and calendar year, a higher rate of SIDS was seen in siblings compared to the general population with a SIRS of 4.27 (95% CI, 2.13-8.53). With further adjustment for mother’s age and education, a SIRS of 3.50 was seen. This study shows that shared genetic and environmental factors may play a role in SIDS. This study is limited in the fact that the results were not statistically significant. Future studies involving larger population sizes as well as those investigating more specific genetic and environmental factors are needed to identify any modifiable risk factors contributing to SIDS.

Image: PD

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