OBJECTIVES During infancy, the American Academy of Pediatrics Bright Futures fourth edition health supervision guidelines recommend frequent well-child visits (WCVs) in which providers are expected to screen for and address maternal depression, intimate partner violence (IPV), and health-related social needs (HRSN). We spread an evidence-based approach that implements these recommendations (Developmental Understanding and Legal Collaboration for Everyone; DULCE) with 3 aims for 6-month-old infants and their families: 75% receive all WCVs on time, 95% are screened for 7 HRSNs, and 90% of families with concrete supports needs and 75% of families with maternal depression or IPV receive support. METHODS Between January 2017 and July 2018, five DULCE teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, pediatric and behavioral health clinicians) from 3 communities in 2 states participated in a learning collaborative. Teams adapted DULCE using Plan-Do-Study-Act cycles, reported data, and shared learning monthly. Run charts were used to study measures. The main outcome was the percent of infants that received all WCVs on time. RESULTS The percentage of families who completed all WCVs on time increased from 46% to 65%. More than 95% of families were screened for HRSNs, 70% had ≥1 positive screen, and 86% and 71% of those received resource information for concrete supports and maternal depression and IPV, respectively. CONCLUSIONS Quality improvement–supported DULCE expansion increased by 50% the proportion of infants receiving all WCVs on time and reliably identified and addressed families’ HRSNs, via integration of existing resources.
OBJECTIVE: We examined factors associated with in-hospital death among children with tuberculosis (TB). We hypothesized that a negative response to tuberculin skin testing (TST) would predict decreased survival. METHODS: This retrospective cohort comprised 2392 children ages 0 to 14 years hospitalized with TB at a Peruvian referral hospital over the 25-year study period. Detailed chart abstraction captured clinical history including TB contacts, physical examination findings, diagnostic data, treatment regimen, and hospitalization outcome. We used Cox proportional hazards regression analyses to determine risk factors for mortality. RESULTS: Of 2392 children, 2 (0.1%) were known to be HIV-positive, 5 (0.2%) had documented multidrug-resistant TB, and 266 (11%) died. The median time from hospitalization to death was 16 days (interquartile range: 4–44 days). Reaction of <5 mm induration on TST predicted death in a multivariable analysis (hazard ratio [HR]: 3.01; 95% confidence interval [CI]: 2.15–4.21; P < .0001). Younger age, period of admission, alteration of mental status (HR: 3.25; 95% CI: 2.48–4.27; P < .0001), respiratory distress (HR: 1.40; 95% CI: 1.07–1.83; P = .01), peripheral edema (HR: 1.97; 95% CI: 1.42–2.73; P < .0001), and hemoptysis (HR: 0.57; 95% CI: 0.32–1.00; P = .05) were associated with mortality. Treatment regimens that contained rifampicin (HR: 0.47; 95% CI: 0.33–0.68; P < .0001) were associated with improved survival. CONCLUSIONS: Negative reaction to TST is highly predictive of death among children with active TB. In children with clinical and radiographic findings suggestive of TB, a negative TST should not preclude or delay anti-TB therapy.