This technical report provides the evidence base for the accompanying tobacco clinical report and policy statement. It builds on, strengthens, and expands AAP recommendations from the previous version in 2015. Tobacco use remains the leading preventable cause of disease and death for adults in the United States. The tobacco epidemic takes a substantial toll on children's and adolescent's health, including harms because of prenatal exposure during pregnancy, secondhand and thirdhand exposure during infancy and childhood, and/or direct use during adolescence. Tobacco and nicotine use almost always starts in childhood or adolescence. Almost 40% of children aged 3 to 11 years are regularly exposed to secondhand tobacco smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade.

Tobacco use remains the leading preventable cause of disease and death for adults in the United States. Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. However, rates of e-cigarette and similar device use among youth are high, and rates of other tobacco product use, such as cigars and hookahs, have not declined. Public policy actions to protect children and adolescents from tobacco and nicotine use, as well as tobacco smoke and aerosol exposure, have proven effective in reducing harm. Effective public health approaches need to be both extended to include e-cigarettes, similar devices, and other and emerging tobacco products and expanded to reduce the toll that the tobacco epidemic takes on children and adolescents.

Significant strides have been made in reducing rates of cigarette smoking among adolescents in the United States. However, rates of e-cigarette and similar device use among youth are high, and rates of other tobacco product use, such as cigars and hookahs, have not declined. In addition, almost 40% of children 3 to 11 years of age are regularly exposed to secondhand tobacco smoke, and rates of secondhand exposure to e-cigarette aerosol have increased over the last decade. Pediatricians are uniquely positioned to help children, adolescents, and their families live tobacco-free lives. Actions by pediatricians can help reduce children's risk of developing tobacco and nicotine use disorder and reduce children's tobacco smoke and/or aerosol exposure.

BACKGROUND: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion.

OBJECTIVE: To assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates.

METHODS: The system was evaluated at one large pediatric practice through a single-arm pilot study from June-November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: 1) the parent remembered the motivational message, 2) the pediatrician reinforced the message, and 3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text-message counseling). We described survey response rates overall and with 95% confidence intervals (CI).

RESULTS: During the entire study period, 8488 parents completed use of the CDS: 9.3% (n=786) reported smoking, and 48.2% (n=379) accepted at least one treatment. One hundred and two parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25-34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported the pediatrician reinforced the motivational message.

CONCLUSION: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.

BACKGROUND: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion.

OBJECTIVE: To assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates.

METHODS: The system was evaluated at one large pediatric practice through a single-arm pilot study from June-November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: 1) the parent remembered the motivational message, 2) the pediatrician reinforced the message, and 3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text-message counseling). We described survey response rates overall and with 95% confidence intervals (CI).

RESULTS: During the entire study period, 8488 parents completed use of the CDS: 9.3% (n=786) reported smoking, and 48.2% (n=379) accepted at least one treatment. One hundred and two parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25-34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported the pediatrician reinforced the motivational message.

CONCLUSION: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.

INTRODUCTION: Pediatric obesity rates increased during the COVID-19 pandemic. This study examined the associations of neighborhood greenspace with changes in pediatric obesity during the pandemic.

METHODS: Electronic health record data from a large pediatric primary care network were extracted to create a retrospective cohort of patients aged 2-17 years with a visit in each of 2 periods: June 2019-December 2019 (before pandemic) and June 2020-December 2020 (pandemic). Multivariable longitudinal generalized estimating equations Poisson regression estimated the associations of census tract‒level Normalized Difference Vegetation Index with (1) changes in obesity risk during the pandemic and (2) risk of new-onset obesity among children who were not obese prepandemic. Analyses were conducted between November 2021 and May 2022.

RESULTS: Among 81,418 children (mean age: 8.4 years, 18% Black), the percentage of children who were obese increased by 3.2% during the pandemic. Children in Normalized Difference Vegetation Index Quartiles 2-4 had smaller increases in obesity risk during the pandemic than those in Quartile 1 (risk ratio=0.96, 95% CI=0.93, 0.99; Quartile 3 risk ratio=0.95; 95% CI=0.91, 0.98; Quartile 4 risk ratio=0.95, 95% CI=0.92, 0.99). Among the subset who were not obese before the pandemic, children in Normalized Difference Vegetation Index quartiles 3-4 had a lower risk of new-onset obesity during the pandemic (Quartile 3 risk ratio=0.82, 95% CI=0.71, 0.95; Quartile 4 risk ratio=0.73, 95% CI=0.62, 0.85). Higher Normalized Difference Vegetation Index was associated with smaller increases in obesity risk and lower risk of new-onset obesity among children in urban and suburban areas, but results were in the opposite direction for children in rural areas.

CONCLUSIONS: Children living in greener neighborhoods experienced smaller increases in obesity during the pandemic than children in less green neighborhoods, although findings differed by urbanicity.

OBJECTIVE: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022.

METHODS: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice.

RESULTS: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the pre-pandemic period (RD: 3.8%; 95% CI: 2.9, 4.8; RD: 2.8%, 95% CI: 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD: 0.7% 95% CI: -0.4, 1.7; RD: 1.8% 95% CI: 0.9%, 2.7%).

CONCLUSIONS: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to pre-pandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

OBJECTIVE: To assess the impact of the COVID-19 pandemic on screening for autism spectrum disorder (ASD) and screening equity among eligible children presenting for well-child care in a large primary care pediatric network, we compared rates of ASD screening completion and positivity during the pandemic to the year prior, stratified by sociodemographic factors.

METHODS: Patients who presented for in-person well-child care at 16 to 26 months between March 1, 2020 and February 28, 2021 (COVID-19 cohort, n = 24,549) were compared to those who presented between March 1, 2019 and February 29, 2020 (pre-COVID-19 cohort, n = 26,779). Demographics and rates of completion and positivity of the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT/F) were calculated from the electronic health record and compared by cohort using logistic regression models.

RESULTS: Total eligible visits decreased by 8.3% between cohorts, with a greater decline in Black and publicly insured children. In the pre-COVID-19 cohort, 89.0% of eligible children were screened at least once, compared to 86.4% during the pandemic (P < 0.001). Significant declines in screening completion were observed across all sociodemographic groups except among Asian children, with the sharpest declines among non-Hispanic White children. Sociodemographic differences were not observed in screen-positive rates by cohort.

CONCLUSIONS: Well-child visits and ASD screenings declined across groups, but with different patterns by race and ethnicity during the COVID-19 pandemic. Findings regarding screen-completion rates should not be interpreted as a decline in screening disparities, given differences in who presented for care. Strategies for catch-up screening for all children should be considered.

<p><strong>OBJECTIVE: </strong>To assess the impact of the COVID-19 pandemic on screening for autism spectrum disorder (ASD) and screening equity among eligible children presenting for well-child care in a large primary care pediatric network, we compared rates of ASD screening completion and positivity during the pandemic to the year prior, stratified by socio-demographic factors.</p>

<p><strong>METHODS: </strong>Patients who presented for in-person well-child care at 16-26 months between 3/1/2020 and 2/28/2021 (COVID-19 cohort, n=24,549) were compared to those who presented between 3/1/2019 and 2/29/2020 (pre-COVID-19 cohort, n= 26,779). Demographics and rates of completion and positivity of the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT/F) were calculated from the electronic health record (EHR) and compared by cohort using logistic regression models.</p>

<p><strong>RESULTS: </strong>Total eligible visits decreased by 8.3% between cohorts, with a greater decline in Black and publicly insured children. In the pre-COVID-19 cohort, 89.0% of eligible children were screened at least once, compared to 86.4% during the pandemic (p&lt;0.001). Significant declines in screening completion were observed across all socio-demographic groups except among Asian children, with the sharpest declines among non-Hispanic White children. Socio-demographic differences were not observed in screen-positive rates by cohort.</p>

<p><strong>CONCLUSIONS: </strong>Well-child visits and ASD screenings declined across groups, but with different patterns by race and ethnicity during the COVID-19 pandemic. Findings regarding screen-completion rates should not be interpreted as a decline in screening disparities, given differences in who presented for care. Strategies for catch-up screening for all children should be considered.</p>

<p>Commercial electronic health records (EHRs) were first developed to automate business processes. As EHRs developed, design principles focused on transferring existing paper-based documentation to comparable electronic forms. In addition, a strong industry focus on adult healthcare settings and quality measures has limited attention and resources for high priority EHR functionality needed for the unique health care of children. The objective of this paper is to provide a review of innovation in the EHR, that includes a variety of established and emerging technologies that may help realize a more effective EHR in child health settings. A more effective EHR would serve as an electronic hub. Existing EHR infrastructure could provide the foundation upon which new technologies and approaches branch and extend, enabling more rapid and customizable innovation to better meet shifting stakeholder and end-user needs. Among many areas for improvement, key goals of innovation could include technology that relieves ambulatory primary care clinician documentation burden, identifies needs, and supports improved care coordination and outcomes, focused on the following key areas: identification of child and family care needs, decision support, documentation, care coordination, and family communication.</p>