Digital Approaches to Remote Pediatric Health Care Delivery During the COVID-19 Pandemic: Existing Evidence and a Call for Further Research

A Global Overview of COVID-19 Research in the Pediatric Field: Bibliometric Review

BACKGROUND

Since the beginning of the COVID-19 pandemic, a great number of papers have been published in the pediatric field.

OBJECTIVE

We aimed to assess research around the globe on COVID-19 in the pediatric field by bibliometric analysis, identifying publication trends and topic dissemination and showing the relevance of publishing authors, institutions, and countries.

METHODS

The Scopus database was comprehensively searched for all indexed documents published between January 1, 2020, and June 11, 2020, dealing with COVID-19 in the pediatric population (0-18 years). A machine learning bibliometric methodology was applied to evaluate the total number of papers and citations, journal and publication types, the top productive institutions and countries and their scientific collaboration, and core keywords.

RESULTS

A total of 2301 papers were retrieved, with an average of 4.8 citations per article. Of this, 1078 (46.9%) were research articles, 436 (18.9%) were reviews, 363 (15.8%) were letters, 186 (8.1%) were editorials, 7 (0.3%) were conference papers, and 231 (10%) were categorized as others. The studies were published in 969 different journals, headed by The Lancet. The retrieved papers were published by a total of 12,657 authors from 114 countries. The most productive countries were the United States, China, and Italy. The four main clusters of keywords were pathogenesis and clinical characteristics (keyword occurrences: n=2240), public health issues (n=352), mental health (n=82), and therapeutic aspects (n=70).

CONCLUSIONS

In the pediatric field, a large number of articles were published within a limited period on COVID-19, testifying to the rush to spread new findings on the topic in a timely manner. The leading authors, countries, and institutions evidently belonged to the most impacted geographical areas. A focus on the pediatric population was often included in general articles, and pediatric research about COVID-19 mainly focused on the clinical features, public health issues, and psychological impact of the disease.

Effects of a novel mobile health intervention compared to a multi-component behaviour changing program on body mass index, physical capacities and stress parameters in adolescents with obesity: a randomized controlled trial

Background

Less than 2% of overweight children and adolescents in Switzerland can participate in multi-component behaviour changing interventions (BCI), due to costs and lack of time. Stress often hinders positive health outcomes in youth with obesity. Digital health interventions, with fewer on-site visits, promise health care access in remote regions; however, evidence for their effectiveness is scarce.

Methods

This randomized controlled not blinded trial (1:1) was conducted in a childhood obesity center in Switzerland. Forty-one youth aged 10–18 years with body mass index (BMI) > P.90 with risk factors or co-morbidities or BMI > P.97 were recruited. During 5.5 months, the PathMate2 group (PM) received daily conversational agent counselling via mobile app, combined with standardized counselling (4 on-site visits). Controls (CON) participated in a BCI (7 on-site visits). We compared the outcomes of both groups after 5.5 (T1) and 12 (T2) months. Primary outcome was reduction in BMI-SDS (BMI standard deviation score: BMI adjusted for age and sex). Secondary outcomes were changes in body fat and muscle mass (bioelectrical impedance analysis), waist-to-height ratio, physical capacities (modified Dordel-Koch-Test), blood pressure and pulse. Additionally, we hypothesized that less stressed children would lose more weight. Thus, children performed biofeedback relaxation exercises while stress parameters (plasma cortisol, stress questionnaires) were evaluated.

Results

At intervention start median BMI-SDS of all patients (18 PM, 13 CON) was 2.61 (obesity > + 2SD). BMI-SDS decreased significantly in CON at T1, but not at T2, and did not decrease in PM during the study. Muscle mass, strength and agility improved significantly in both groups at T2; only PM reduced significantly their body fat at T1 and T2. Average daily PM app usage rate was 71.5%. Cortisol serum levels decreased significantly after biofeedback but with no association between stress parameters and BMI-SDS. No side effects were observed.

Conclusions

Equally to BCI, PathMate2 intervention resulted in significant and lasting improvements of physical capacities and body composition, but not in sustained BMI-SDS decrease. This youth-appealing mobile health intervention provides an interesting approach for youth with obesity who have limited access to health care. Biofeedback reduces acute stress and could be an innovative adjunct to usual care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02781-2.

Telemedicine in Malignant and Nonmalignant Hematology: Systematic Review of Pediatric and Adult Studies

BACKGROUND

Telemedicine, including video-, web-, and telephone-based interventions, is used in adult and pediatric populations to deliver health care and communicate with patients. In the realm of hematology, telemedicine has recently been used to safely and efficiently monitor treatment side-effects, perform consultations, and broaden the reach of subspecialty care.

OBJECTIVE

We aimed to synthesize and analyze information regarding the feasibility, acceptability, and potential benefits of telemedicine interventions in malignant and nonmalignant hematology, as well as assess the recognized limitations of these interventions.

METHODS

Studies were identified through a comprehensive Medical Subject Headings (MeSH) search on the PubMed MEDLINE, Controlled Register of Clinical Trials (Cochrane CENTRAL from Wiley), Embase, and CINAHL (EBSCO) databases on February 7, 2018. A second search, utilizing the same search strategy, was performed on October 1, 2020. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the reporting of included evidence. Included studies were original articles researching the feasibility, acceptability, and clinical outcomes of telemedicine or telehealth interventions in pediatric or adult populations with malignant or nonmalignant hematological conditions. Data items in the extraction form included first author name, publication year, country, malignant or nonmalignant hematological condition or disease focus of the study, participant age, participant age subgroup (pediatric or adult), study design and setting, telemedicine intervention type and description, study purpose, and main study outcomes.

RESULTS

A total of 32 articles met the preset criteria and were included in this study. Most (25/32) studies were conducted in adults, and the remaining (7/32) were conducted in the pediatric population. Of the 32 studies, 12 studied malignant hematological conditions, 18 studied nonmalignant conditions, and two studied both malignant and nonmalignant conditions. Study types included pilot study (11/32), retrospective study (9/32), randomized controlled trial (6/32), cross-sectional study (2/32), case study (1/32), pre-post study (1/32), noncomparative prospective study (1/32), and prospective cohort study (1/32). The three main types of telemedicine interventions utilized across all studies were video-based (9/32), telephone-based (9/32), and web-based interventions (14/32). Study results showed comparable outcomes between telemedicine and traditional patient encounter groups across both pediatric and adult populations for malignant and nonmalignant hematological conditions.

CONCLUSIONS

Evidence from this review suggests that telemedicine use in nonmalignant and malignant hematology provides similar or improved health care compared to face-to-face encounters in both pediatric and adult populations. Telemedicine interventions utilized in the included studies were well received in both pediatric and adult settings. However, more research is needed to determine the efficacy of implementing more widespread use of telemedicine for hematological conditions.

User Perspectives on a Resilience-Building App (JoyPop): Qualitative Study

BACKGROUND

Resilience is the capability, resources, and processes that are available to a person or system to adapt successfully in the face of stress or adversity. Given that resilience can be enhanced, using advances in technology to deliver and evaluate the impact of resilience interventions is warranted. Evidence supports the effectiveness of the resilience-building JoyPop app in improving resilience-related outcomes after use; however, experiential data from users is also needed to provide a more comprehensive account of its utility.

OBJECTIVE

The aim of this study was to explore users' experiences with the JoyPop app and their perspectives on its utility.

METHODS

This qualitative description study involved a combination of group and one-on-one semistructured interviews with a subset of first-year undergraduate students who participated in a larger evaluation of the JoyPop app. Participants used the app for a 4-week period and were subsequently asked about their frequency of app use, most and least used features (and associated reasons), most and least helpful features (and associated reasons), barriers to use, facilitators of use and continuation, and recommendations for improvement. Data were coded and categorized through inductive content analysis.

RESULTS

The sample of 30 participants included 24 females and 6 males, with a mean age of 18.77 years (SD 2.30). App use ranged from 1 to 5 times daily (mean 2.11, SD 0.74), with the majority indicating that they used the app at least twice daily. The Rate My Mood, Journal, and SquareMoves features were reported to be used most often, while the Rate My Mood, Journal, and Breathing Exercises features were identified as the most helpful. A number of themes and subthemes pertaining to facilitators of app use (prompts, creating routine, self-monitoring opportunities, expressive opportunities), barriers to app use (editing, lack of variety, student lifestyle), outcomes of app use (increased awareness, checking in with oneself, helpful distraction, emotional control), and recommendations for app improvement (adding more features, enhancing existing features, enhancing tracking abilities, providing personalization) were identified.

CONCLUSIONS

This study provides insight into the aspects of the JoyPop app that motivated and benefitted users, as well as measures that can be taken to improve user experiences and promote longer-term uptake. Users were willing to engage with the app and incorporate it into their routine, and they valued the ability to self-monitor, express emotion, and engage in distraction.

Virtual Handover of Patients in the Pediatric Intensive Care Unit During the Covid-19 Crisis

OBJECTIVE

A key measure to mitigate coronavirus disease 2019 (COVID-19) has been social distancing. Incorporating video-conferencing applications in the patient handover process between healthcare workers can enhance social distancing while maintaining handover elements. This study describes pediatric intensive care unit (PICU) physicians' experience using an online video-conferencing application for handover during the COVID-19 pandemic.

DESIGN

Qualitative content analysis.

SETTING

PICU at a university hospital in Riyadh, Saudi Arabia.

SUBJECTS

PICU Physicians.

INTERVENTIONS

Due to the pandemic, the hospital's PICU used Zoom® as a remote conferencing application instead of a face-to-face handover. Following institutional review board approval, data were collected over two weeks (1 Jul 2020 to 14 Jul 2020).

MEASUREMENTS

An online survey was conducted using open-ended questions to capture demographic data and the perceived efficacy of remote handovers. Thematic framework analysis process included open coding, creating categories, and abstraction.

MAIN RESULTS

All 37 PICU physicians who participated in the handover completed the survey. The participants comprised six attendings, nine specialists, and 22 residents. While 20 (54.1%) physicians reported attending 1-5 Zoom handovers by the time of the study, some (n. 6, 16.2%) had more than ten virtual handovers. They had variable previous teleconferencing experiences. Most physicians (78.4%) were comfortable conducting a remote handover. Most found that Situation-Background-Assessment-Recommendation handover elements were properly achieved through this remote handover process. The perceived advantages of online handover included fewer interruptions, time efficiency, and facilitation of social distancing. The perceived disadvantages were the paucity of nonverbal communication and teaching during virtual meetings.

CONCLUSION

Video-conferencing applications for online handovers could supplement traditional face-to-face intensive care unit patient handover during outbreaks of infectious diseases. The use of video streaming and more emphasis on teaching should be encouraged to optimize the users' experience.

Rapid Implementation of Telerehabilitation for Pediatric Patients During Covid-19

The COVID-19 pandemic necessitated a sudden limitation of in-person outpatient occupational and physical therapy services for most patients at a large, multisite pediatric hospital located in the Midwest, United States. To ensure patient and staff safety, the hospital rapidly shifted to deliver most of these services via telerehabilitation. The purposes of this study were to (1) describe the rapid implementation of telerehabilitation during the COVID-19 pandemic, (2) describe the demographic characteristics of patients who continued in-person services and those who received telerehabilitation, and (3) evaluate the therapists' perceptions of telerehabilitation for physical and occupational therapy. Most of the children (83.4% of n=1352) received telerehabilitation services. A family was more likely to choose to continue in-person visits if their child was <1-year-old, had a diagnosis of torticollis, received serial casting, or was post-surgical. Occupational and physical therapy therapists (n=9) completed surveys to discern their perceptions of the acceptability of telerehabilitation, with most reporting that telerehabilitation was as effective as in-person care.

Digital Solutions to Alleviate the Burden on Health Systems During a Public Health Care Crisis: COVID-19 as an Opportunity

The COVID-19 pandemic has generated unprecedented and sustained health management challenges worldwide. Health care systems continue to struggle to support the needs of the majority of infected individuals that are either asymptomatic or have mild symptoms. In addition, long-term effects in the form of long-lasting COVID-19 symptoms or widespread mental health issues aggravated by the pandemic pose a burden on health care systems worldwide. This viewpoint article considers aspects of digital health care solutions and how they can play an ongoing role in safely addressing gaps in the health care support available from initially and repeatedly overwhelmed providers and systems. Digital solutions can be readily designed to address this need and can be flexible enough to adapt to the evolving management requirements of various stakeholders to reduce COVID-19 infection rates, acute hospitalizations, and mortality. Multiplatform solutions provide a hybrid model of care, which can include mobile and online platforms accompanied by direct clinician input and feedback. Desirable components to be included are discussed, including symptom tracking, patient education, well-being support, and bidirectional communication between patients and clinicians. Customizable and scalable digital health platforms not only can be readily adapted to further meet the needs of employers and public health stakeholders during the ongoing pandemic, but also hold relevance for flexibly meeting broader care management needs into the future.

"The Stay at Home Order is Causing Things to Get Heated Up": Family Conflict Dynamics During COVID-19 From The Perspectives of Youth Calling a National Child Abuse Hotline

The purpose of this study was to identify changes in family conflict and abuse dynamics during COVID-19 stay-at-home orders from the perspectives of youth calling a national child abuse hotline. We analyzed text and chat transcripts from Childhelp's National Child Abuse Hotline from May-June 2020 that were flagged as coming from a child with a COVID-19-related concern (N = 105). Thematic analysis was used to identify COVID-19 related influences of family conflict as well as how COVID-19 constraints influenced coping and survival for youth reporting distress or maltreatment to the hotline. Family conflict most commonly disclosed stemmed from parental or child mental health concerns, often manifesting in escalated child risk taking behaviors, parental substance use, and violence in the home. Conflict was also mentioned surrounding caregiver issues with child productivity while sheltering-in-place, commonly related to school or chores. Youth often voiced feeling unable to find relief from family conflict, exacerbated from physical distance from alternative social supports, technological isolation, and limited contact with typical safe places or supportive adults. To cope and survive, youth and crisis counselors found creative home-based coping skills and alternative reporting mechanisms. Understanding the unique impact of COVID-19 on youth in homes with family conflict and abuse can point to areas for intervention to ensure we are protecting the most vulnerable as many continue to shelter-in-place. In particular, this study revealed the importance of online hotlines and reporting mechanisms to allow more youth to seek out the help and professional support they need.

The Effects of Caregiver Social Support and Depressive Symptoms on Child Medication Adherence and Asthma Control

The purpose of this study was to examine relationships among caregiver social support, caregiver depressive symptoms, medication adherence, and asthma control in a sample of low-income, urban, Black children aged 3–12 years with uncontrolled asthma and their caregivers. Using longitudinal data from a randomized controlled trial (RCT) assessing the efficacy of an environmental control educational intervention, we used generalized estimating equations and ordered logistic regression models to evaluate the relationship between caregiver social support (Medical Outcomes Study Social Support Survey), depressive symptoms (Center for Epidemiologic Studies Depression scale), and two child asthma outcomes: (a) medication adherence (Asthma Medication Ratio) and (b) asthma control. At baseline, 45.7% of the 208 children had very poorly controlled asthma. Nearly a third of caregivers (97% female) had clinically significant depressive symptoms at each data collection point. Social support was not associated with either asthma outcome nor did it moderate the relationship between depressive symptoms and child asthma outcomes. Higher caregiver depressive symptoms predicted decreased medication adherence (b=−0.003, SE 0.002). Moderate asthma at baseline (OR: 0.305, SE: 0.251), severe asthma at baseline (OR: 0.142, SE: 0.299), household income < $20,000 per year (OR: 0.505, SE: 0.333), and fall season (OR: 0.643, SE: 0.215) were associated with poorer asthma control. Attending to the social context of low-income, urban, Black children with asthma is critical to reduce asthma morbidity. Maternal depressive symptoms are modifiable and should be targeted in interventions to improve child asthma outcomes in this vulnerable population. The RCT was registered with ClinicalTrials.gov (NCT01981564) in October 2013.

Barriers and Facilitators to Telemedicine: Can You Hear Me Now?

In its most direct interpretation, telemedicine is medical care provided at a distance. Although telemedicine's use had been steadily increasing, the COVID-19 pandemic prompted an unprecedented interest and urgency among patients, health care professionals, and policymakers to facilitate health care devoid of the need for in-person contact. The growth in personal access to telecommunications technology meant an unprecedented number of people in the United States and around the world had access to the equipment and technology that would make virtual care possible from the home. As the mass implementation of telemedicine unfolded, it became quickly apparent that scaling up the use of telemedicine presented considerable new challenges, some of which worsened disparities. This article describes those challenges by examining the history of telemedicine, its role in both supporting access and creating new barriers to access in trying to get everyone connected, frameworks for thinking about those barriers, and facilitators that may help overcome them, with a particular focus on older adults and patients with cancer in rural communities.

Building MedVenture - A mobile health application to improve adolescent medication adherence - Using a multidisciplinary approach and academic-industry collaboration

Objective

Mobile health (mHealth) tools are increasingly used to support medication adherence yet few have been designed specifically for the pediatric population. This paper describes the development of a medication adherence application (MedVenture) using the integration of patient and healthcare provider input, health behavior theory, and user engagement strategies for adolescents with chronic gastrointestinal disease.

Methods

MedVenture was created by a multidisciplinary research team consisting of a gastroenterologist, a social health psychologist, software developers, and digital health researchers. Healthcare providers and adolescent patients were interviewed to identify barriers to medication adherence, explore ways that technologies could best support medication adherence for both patients and providers, and determine user requirements and core design features for a digital health tool. Intervention mapping was used to match themes from qualitative content analysis to known efficacious adherence strategies, according to a conceptual framework based on self-determination theory. Iterative design with review by the research team and two rounds of user testing informed the final prototype.

Results

Three themes were identified from content analysis: 1) lack of routine contributes to nonadherence, 2) adolescents sometimes purposefully forgo medications, and 3) healthcare providers would prefer a tool that promotes patient self-management rather than one that involves patient-provider interaction. These findings, combined with evidence-based adherence and user engagement strategies, resulted in the development of MedVenture – a game-based application to improve planning and habit formation.

Conclusions

Academic-industry collaboration incorporating stakeholders can facilitate the development of mobile health tools designed specifically for adolescents with chronic disease.

A cross-sectional online survey on patients' satisfaction using store-and-forward voice and text messaging teleconsultation service during the COVID‑19 pandemic

AIM

This study aimed to evaluate the patients' satisfaction with using store-and-forward voice and text messaging teleconsultation service to provide primary health care to patients during the COVID-19 pandemic.

METHOD

A cross-sectional survey was conducted between October 1 and December 1, 2020, in Iran. The study population consisted of patients who used the service. Three hundred-ninety-six patients were enrolled in the study by convenience sampling. Data were collected by a researcher-made questionnaire. The face, comprehensibility, and content validity of the questionnaire were tested and met. The reliability of this questionnaire was confirmed (r = 0.9). Descriptive statistics and multinomial logistic regression were conducted. Data were analyzed using STATA 14.0 software.

RESULTS

In total, 396 patients responded to the online questionnaire. The mean age of patients was 37 ± 10.31 years. More than half of them had an academic degree (65.40 %). Teleconsultation was considered satisfactory by 172 patients (43.43 %), while more than half of the patients (56.57 %) were unsatisfied with teleconsultation. In terms of "quality of care provided" and "patient information privacy" components, around 41 % of patients were satisfied. However, the number of patients who feel satisfied with teleconsultation's similarity to a face-to-face encounter was lower (37.88 %). The results showed no significant relationship between age, gender, education, and overall satisfaction (p > 0.05). The association between overall satisfaction and health status was (AOR = 1.51, 95 % CI = 1.16-1.96).

CONCLUSION

More than half of patients from our study did not have a good experience with teleconsultation. This is also partially due to the use of existing communication platform, instead of custom-made solution. It is necessary to improve the services' quality and meet patients' needs to optimize patients' experience, particularly during a health crisis, resulting in better health outcomes and end-user satisfaction.

mHealth: Potentials and Risks for Addressing Mental Health and Well-Being Issues Among Nepali Adolescents

Adolescents are slowly being recognized as a generation, worldwide, that may require different policy approaches to improve staggering statistics on their failing well-being, including mental health. By providing the support to allow the next generation to achieve better mental health outcomes, they are going to be more economically successful and the future economic growth of nations can be better assured. Adoption of mobile-based health interventions (e.g., mHealth) has garnered a lot of attention toward this end. While mHealth interventions are growing in popularity, many researchers/policy-makers appear to have neglected assessing potential (indirect) costs/negative consequences from their use. Evidence from the developed world shows strong associations between extensive cell phone use and negative mental health outcomes, but similar research is minimal in developing world contexts. Additionally, the bulk of work on the outcomes of mobile phone use is studied using a unidirectional approach with blinders to front-end motivations. Using primary data from a large-scale, school-based survey of older adolescents in southwestern Nepal (N = 539), this work investigates such a tension between mobile/smartphone usage as a true mobile health (mHealth) opportunity in Nepal or as a potential problem, introducing additional deleterious well-being effects from over-use. Founded in Basic Psychological Needs Theory (BPNT), robust results of analyses using full structural modeling approaches (and traditional regression-based sensitivity analyses) indicate support for the BPNT framework in explaining statistically significant positive associations between bullying and anxiety, as well as, negative associations between bullying and grit, including evidence to support the mediating role of problematic mobile phone use in these relationships. More than 56% of the sample showed indicators of mild to moderate anxiety and over 10% claim experiences of bullying, coupled with over 75% of the sample scoring above the midline of a problematic mobile phone use scale, all of which motivates the relevance of our findings. Potential policy implications of these findings, and mention of other intriguing avenues for future work are further discussed.

Going virtual: youth attitudes toward and experiences of virtual mental health and substance use services during the COVID-19 pandemic

Background

During the COVID-19 pandemic, youth mental health and substance use services rapidly moved to virtual modalities to meet social distancing requirements. It is important to understand youth attitudes toward and experience of virtual services.

Objective

This study examined the attitudes toward and experiences of virtual mental health and substance use services among youth drawn from clinical and non-clinical samples.

Method

Four hundred nine youth completed a survey including questions about their attitudes toward and experience of virtual services. The survey included quantitative and open-ended questions on virtual care, as well as a mental health and substance use screener.

Results

The majority of youth with mental health or substance use challenges would be willing to consider individual virtual services, but fewer would consider group virtual services. However, many have not received virtual services. Youth are interested in accessing a wide variety of virtual services and other supportive wellness services. Advantages and disadvantages of virtual services are discussed, including accessibility benefits and technological barriers.

Discussion

As youth mental health and substance use services have rapidly gone virtual during the COVID-19 pandemic, it is essential that we hear the perspectives of youth to promote service utilization among those in need. Diverse, accessible, technologically stable virtual services are required to meet the needs of different youth, possibly with in-person options for some youth. Future research, engaging youth in the research process, is needed to evaluate the efficacy of virtual services to plan for the sustainability of some virtual service gains beyond the pandemic period.

The Potential of mHealth as a Game Changer for the Management of Sickle Cell Disease in India

Sickle cell disease (SCD) is a chronic genetic disease that requires lifelong therapy and monitoring. Low drug adherence and poor monitoring may lead to an increase in morbidities and low quality of life. In the era of digital technology, various mobile health (mHealth) apps are being tested for their potential in increasing drug adherence in patients with SCD. We herewith discuss the applicability and feasibility of these mHealth apps for the management of SCD in India.

Strategies for Improving Inhalation Technique in Children: A Narrative Review

Inhaled medicines are commonly utilized by children for various respiratory conditions and must be used effectively for the medication to reach the airways. Poor inhaler technique contributes to poorly controlled asthma with significant associated morbidity. Given the significant consequences of improper inhaler use in children, the goal of this review is to comprehensively describe existing and potential solutions to improve inhaler technique. Because children move through various settings, including clinical practices, schools, pharmacies, and homes, in their daily routine, there is great opportunity to teach and reinforce proper inhaler technique across settings. Within each setting, in-person and technology-based interventions have shown promise to improve technique. These solutions need to be more broadly adopted to deliver tailored education with support for provider training, team-based care, communication structures, and reimbursement. Such solutions hold the potential to improve inhaler use among children, with potential for decreasing morbidity and costs.

Interventions to Ameliorate the Psychosocial Effects of the COVID-19 Pandemic on Children-A Systematic Review

The aim of this study was to identify interventions targeting children and their caregivers to reduce psychosocial problems in the course of the COVID-19 pandemic and comparable outbreaks. The review was performed using systematic literature searches in MEDLINE, Embase, PsycINFO and COVID-19-specific databases, including the CDC COVID-19 Research Database, the World Health Organisation (WHO) Global Database on COVID-19 Research and the Cochrane COVID-19 Study Register, ClinicalTrials.gov, the EU Clinical Trials Register and the German Clinical Trials Register (DRKS) up to 25th September 2020. The search yielded 6657 unique citations. After title/abstract and full text screening, 11 study protocols reporting on trials planned in China, the US, Canada, the UK, and Hungary during the COVID-19 pandemic were included. Four interventions targeted children ≥10 years directly, seven system-based interventions targeted the parents and caregivers of younger children and adolescents. Outcome measures encompassed mainly anxiety and depressive symptoms, different dimensions of stress or psychosocial well-being, and quality of supportive relationships. In conclusion, this systematic review revealed a paucity of studies on psychosocial interventions for children during the COVID-19 pandemic. Further research should be encouraged in light of the expected demand for child mental health management.

Telemedicine in Pediatrics: Systematic Review of Randomized Controlled Trials

BACKGROUND

Telemedicine modalities, such as videoconferencing, are used by health care providers to remotely deliver health care to patients. Telemedicine use in pediatrics has increased in recent years. This has resulted in improved health care access, optimized disease management, progress in the monitoring of health conditions, and fewer exposures to patients with illnesses during pandemics (eg, the COVID-19 pandemic).

OBJECTIVE

We aimed to systematically evaluate the most recent evidence on the feasibility and accessibility of telemedicine services, patients' and care providers' satisfaction with these services, and treatment outcomes related to telemedicine service use among pediatric populations with different health conditions.

METHODS

Studies were obtained from the PubMed database on May 10, 2020. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In this review, we included randomized controlled trials from the last 10 years that used a telemedicine approach as a study intervention or assessed telemedicine as a subspecialty of pediatric care. Titles and abstracts were independently screened based on the eligibility criteria. Afterward, full texts were retrieved and independently screened based on the eligibility criteria. A standardized form was used to extract the following data: publication title, first author's name, publication year, participants' characteristics, study design, the technology-based approach that was used, intervention characteristics, study goals, and study findings.

RESULTS

In total, 11 articles met the inclusion criteria and were included in this review. All studies were categorized as randomized controlled trials (8/11, 73%) or cluster randomized trials (3/11, 27%). The number of participants in each study ranged from 22 to 400. The health conditions that were assessed included obesity (3/11, 27%), asthma (2/11, 18%), mental health conditions (1/11, 9%), otitis media (1/11, 9%), skin conditions (1/11, 9%), type 1 diabetes (1/11, 9%), attention deficit hyperactivity disorder (1/11, 9%), and cystic fibrosis-related pancreatic insufficiency (1/11). The telemedicine approaches that were used included patient and doctor videoconferencing visits (5/11, 45%), smartphone-based interventions (3/11, 27%), telephone counseling (2/11, 18%), and telemedicine-based screening visits (1/11, 9%). The telemedicine interventions in all included studies resulted in outcomes that were comparable to or better than the outcomes of control groups. These outcomes were related to symptom management, quality of life, satisfaction, medication adherence, visit completion rates, and disease progression.

CONCLUSIONS

Although more research is needed, the evidence from this review suggests that telemedicine services for the general public and pediatric care are comparable to or better than in-person services. Patients, health care professionals, and caregivers may benefit from using both telemedicine services and traditional, in-person health care services. To maximize the potential of telemedicine, future research should focus on improving patients' access to care, increasing the cost-effectiveness of telemedicine services, and eliminating barriers to telemedicine use.

Access to Technology and Preferences for an mHealth Intervention to Promote Medication Adherence in Pediatric Acute Lymphoblastic Leukemia: Approach Leveraging Behavior Change Techniques

Background

Suboptimal adherence to 6-mercaptopurine (6-MP) is prevalent in pediatric acute lymphoblastic leukemia (ALL) and associated with increased risk of relapse. Rapid uptake of personal technology makes mobile health (mHealth) an attractive platform to promote adherence.

Objective

Study objectives were to examine access to mobile technology and preferences for an mHealth intervention to improve medication adherence in pediatric ALL.

Methods

A cross-sectional survey was administered in oncology clinic to parents of children with ALL as well as adolescents and young adults (AYAs) with ALL receiving maintenance chemotherapy.

Results

A total of 49 parents (median age [IQR] 39 [33-42] years; female 76% [37/49]) and 15 patients (median age [IQR] 17 [16-19]; male 80% [12/15]) participated. All parents and AYAs owned electronic tablets, smartphones, or both. Parents’ most endorsed mHealth app features included a list of medications (71%, 35/49), information about 6-MP (71%, 35/49), refill reminders (71%, 35/49), and reminders to take 6-MP (71%, 35/49). AYAs' most endorsed features included refill reminders (73%, 11/15), reminders to take 6-MP (73%, 11/15), and tracking 6-MP (73%, 11/15).

Conclusions

Parents and AYAs reported ubiquitous access to mobile technology and strong interest in multiple adherence-specific mHealth app features. Parents and AYAs provided valuable insight into preferred features for a multifunctional behavioral intervention (mHealth app) to promote medication adherence in pediatric ALL.

Paediatric and adolescent asthma: A narrative review of telemedicine and emerging technologies for the post-COVID-19 era

Children and young people with asthma need regular monitoring to maintain good asthma control, prevent asthma attacks and manage comorbidities. The COVID‐19 pandemic has resulted in healthcare professionals making fundamental changes to the way healthcare is delivered and for patients and families adapting to these changes. Comprehensive remotely delivered, technology‐based healthcare, closer to the patients home (reducing hospital footfall and possibly reducing carbon footprint) is likely to be one of the important collateral effects of the pandemic. Telemedicine is anticipated to impact everyone involved in healthcare ‐ providers and patients alike. It is going to bring changes to organization, work areas and work culture in healthcare. Healthcare providers, policymakers and those accessing healthcare services will experience the impact of technology‐based healthcare delivery. Telemedicine can play an exciting role in the management of childhood asthma by delivering high‐quality care closer to the child's home. However, unlike adults, children still need to be accompanied by their carers for virtual care. Policymakers will need to take into account potential additional costs as well as the legal, ethical and cultural implications of large scale use of telemedicine. In this narrative review, we review evidence regarding the role of telemedicine and related emerging technologies in paediatric and adolescent asthma. Although there are gaps in the current knowledge, there is evidence demonstrating the important role of telemedicine in management of childhood and adolescent asthma. However, there is an urgent need for healthcare researchers and policymakers to focus on improving the technologies and address the disparities in accessing novel technology‐based management strategies to improve asthma care.

Parents' and Students' Perceptions of Telepractice Services for Speech-Language Therapy During the COVID-19 Pandemic: Survey Study

BACKGROUND

The ongoing COVID-19 pandemic has resulted in the suspension of face-to-face classes and a considerable increase in the use of telepractice services in speech-language pathology. However, little is known about parents' and students' satisfaction with telepractice services and their preferences for different service delivery modes. These factors may affect therapy effectiveness and the future adoption of telepractice.

OBJECTIVE

We evaluated students' and parents' perceptions of telepractice efficacy and their preferences for different service delivery modes (ie, on-site practice vs telepractice). We also identified factors that affect parents' and students' preferences for different service delivery modes during the COVID-19 pandemic.

METHODS

A 19-question survey on telepractice satisfaction and preferences was administered to 41 Hong Kong Chinese students and 85 parents who received telepractice services from school-based speech-language pathologists during the COVID-19 class suspension period. In addition to providing demographic information and data on the implementation of telepractice services, all participants were asked to rate their perceptions of the efficacy of telepractice services and compare on-site practices to telepractice on a 5-point Likert scale (ie, 1=strongly disagree/prefer the use of on-site speech-language therapy services and 5=strongly agree/prefer the use of telepractice services).

RESULTS

Despite the fact that telepractice efficacy was highly rated by parents (95% CI 3.30-3.66) and students (95% CI 3.21-3.76), both groups believed that telepractice was less effective than on-site practices (parents: 95% CI 2.14-2.52; students: 95% CI 2.08-2.65). Moreover, parents preferred on-site practices over telepractice (95% CI 2.04-2.43), whereas students did not prefer one mode of practice over the other (95% CI 2.74-3.41). A significant association between telepractice efficacy and a preference for telepractice services was found only among the students (τ=.43, P<.001), not the parents (τ=.07; P=.44).

CONCLUSIONS

Although telepractice is an acceptable alternative service delivery option for providing speech and language therapy services to school-aged individuals, speech-language therapists and parents must play a more proactive role in telepractice services to facilitate effective communication between clinicians and parents.

Willingness to Adopt mHealth Among Chinese Parents During the COVID-19 Outbreak: Cross-sectional Questionnaire Study

Background

Parental involvement in mobile health (mHealth) to consult with medical professionals appears to be prevalent in China with the rapid development of the internet. More parents with busy jobs have chosen to use mHealth. During the ongoing COVID-19 outbreak, mHealth can assist with health promotion, directions for medication use, and disease diagnosis via online chat and video consultation without contacting others. To our knowledge, no studies have been performed to explore the role of mHealth in parents’ attitudes toward child health care at home during the COVID-19 outbreak.

Objective

This study aims to identify the associated factors of willingness to adopt mHealth among Chinese parents during the COVID-19 outbreak and to explore the correlation between the frequency of adopting mHealth and parents’ attitudes toward child health care at home.

Methods

Chinese parents were asked to complete an online survey from January 25 to February 15, 2020. The questionnaire comprised of two parts with a total of 16 items, including parents’ demographic variables and attitudes toward child health care at home. By multivariate logistic regression, we explored factors associated with parents’ willingness to adopt mHealth during the COVID-19 outbreak. Pearson chi-square tests were used to reveal the correlation between the frequency of adopting mHealth and parents’ attitudes toward child health care at home.

Results

A total of 254 parents enrolled, and 202 (79.5%) parents were willing to adopt mHealth during the COVID-19 outbreak. Parents’ age (26-35 years: adjusted odds ratio [AOR] 8.114, 95% CI 1.471-44.764), parents’ interest in the COVID-19 pandemic (moderate: AOR 8.753, 95% CI 2.009-38.127; high: AOR 22.194, 95% CI 5.509-89.411), the source that recommended mHealth (medical health providers: AOR 4.257, 95% CI 1.439-12.596), the presence of chronic disease in their children (yes: AOR 20.844, 95% CI 4.600-94.443), parents’ duration of daily internet use (4-6 hours: AOR 6.487, 95% CI 1.870-22.495; >6 hours: AOR 8.766, 95% CI 1.883-40.804), and adoption of mHealth before the COVID-19 outbreak (yes: AOR 3.413, 95% CI 1.234-9.444) were significantly correlated with the parents’ willingness to adopt mHealth during the COVID-19 outbreak. The frequency of mHealth use among parents was correlated with their behaviors in regard to handwashing (χ²₆=18.967, P=.004), mask wearing (χ²₆=45.364, P<.001), frequency of leaving the home (χ²₆=16.767, P=.01), room disinfection and ventilation (χ²₆=19.515, P=.003), temperature checking (χ²₆=17.47, P=.007), and mental health care of children (χ²₆=63.810, P<.001) during the COVID-19 pandemic.

Conclusions

We found various objective factors that were associated with parents’ willingness to adopt mHealth during the COVID-19 outbreak. Overall, parents’ willingness to adopt mHealth was high. The frequency of mHealth use among parents was correlated with their attitudes toward child health care at home. The option of mHealth to patients at home during the COVID-19 outbreak would be beneficial for education and improvement in self-management of child health care at home.

Children and Telehealth in Mental Healthcare: What We Have Learned From COVID-19 and 40,000+ Sessions

Objective

Of the many impacts of COVID-19 on contemporary healthcare is the rapid and overwhelming shift to remote telehealth (TH) service. The precise effect of TH on treatment is yet unknown, and the possible child/adult differences are an essential point of clarification for the utility of TH services and efforts to improve upon them.

Methods

The current study considers data reflecting pre-, during-, and post-COVID-19 lockdown over the first six months of 2020. Data comprise records of N = 43,294 services delivered to N = 2520 unique clients across multiple outpatient mental health sites at a Certified Community Based Mental Health Clinic (CCBHC) in Rockland County, NY, an area hard hit by COVID-19.

Results

Results demonstrate significant differences between child and adult sessions with a relative decrease in the number of child mental health services with the switch to TH in March 2020 (onset of lockdown) and a relatively rapid shift back to face-to-face among child services when in-person services resumed in May and June 2020. Results further highlight significant differences between child age and service type, with psychiatry less affected by TH than psychotherapy.

Conclusions

Implicit in the data is the ability to offer remotely, a high volume of ongoing behavioral intervention. Findings support TH as less preferred for children than adults while indicating that child TH is favored for psychiatry and support services, less so for psychotherapy. Implications for enhancing child TH delivery and directions for continued research include relational factors, platform (phone/video) and screen salience.

Adverse Childhood Experiences and Building Resilience With the JoyPop App: Evaluation Study

BACKGROUND

The effects of adverse childhood experiences (ACEs) on mental health, self-regulatory capacities, and overall resilience are well-known. Given such effects, ACEs may play a role in how individuals adjust to challenges later in life. Of interest in this study is the transition to university, a time of heightened stress when adapting to circumstances is required and when those with ACEs may need additional in-the-moment support to exercise resilience. A smartphone app may provide a worthwhile and readily accessible medium for a resilience intervention, provided behavioral outcomes are adequately evaluated.

OBJECTIVE

This study evaluates the impact of an innovative, smartphone app-based resilience intervention. The JoyPop app was designed to promote resilience through the use of self-regulatory skills such as emotion regulation and executive functioning. Among a sample of first-year undergraduate students, we explored whether use of the app would be associated with positive changes in resilience and related outcomes, and whether these benefits were influenced by level of childhood adversity.

METHODS

Participants (N=156) were requested to use the JoyPop app for 4 weeks, at least twice daily. Changes in resilience, emotion regulation, executive functioning, and depression were assessed after 2 and 4 weeks of app usage using multilevel modeling.

RESULTS

The sample of 156 participants included 123 females and 33 males, with a mean age of 19.02 years (SD 2.90). On average participants used the app on 20.43 of the possible 28 days (SD 7.14). App usage was associated with improvements in emotion regulation (χ²₁=44.46; P<.001), such that it improved by 0.25 points on the 18-point scale for each additional day of app usage, and symptoms of depression (χ²₁=25.12; P<.001), such that depression symptoms were reduced by .08 points on the 9-point scale with each additional day of app usage. An interaction between ACEs and days of app usage existed for emotion regulation, such that participants with more adversity evidenced a faster rate of change in emotion regulation (P=.02).

CONCLUSIONS

Results highlight that daily incorporation of an app-based resilience intervention can help youth who have experienced adversity to improve emotion regulation skills and experience reductions in depression. The JoyPop app represents an important step forward in the integration of resilience intervention research with a technology-based medium that provides in-the-moment support.

Pediatric Telehealth Expansion in Response to COVID-19

Introduction: Telehealth utilization has been steadily increasing for the past two decades and has been recognized for its ability to access rural and underserved populations. The advent of COVID-19 in March 2020 limited the feasibility of in-person healthcare visits which in turn increased telehealth demand and use. However, the long-term impacts of COVID-19 on the telehealth sector of the healthcare industry, and particularly on pediatric healthcare volume demand and subsequent expansion, are yet to be determined. Objective and Methods: To understand the impact of COVID-19 on telehealth utilization, volume demand, and expansion in one large pediatric healthcare system serving greater Dallas-Fort Worth, Texas, data on telehealth clinic visits by month, pre-COVID and post/current-COVID were compared. A quasi-experimental pretest-posttest design analysis compared telehealth visit counts from 54 ambulatory pediatric health specialties. Pre-post new patient counts were also analyzed via chi square. Results: Total telehealth visit counts significantly increased between March-October 2019 (2,033 visits) compared to March-October 2020 (54,276 visits). Mean monthly telehealth visits increased by 6,530 visits, or 2,569.75% over the same time period (p < 0.0001). In October 2020, total telehealth visits were still 1,194.78% above 2019 levels (345 visits in 2019 vs. 4467 visits in 2020). Discussion: Results here show a substantial volume increase in telehealth-delivered pediatric healthcare and resource utilization as a response to COVID-19. This provides a template for permanent adoption of pediatric telehealth delivery post pandemic. Further investigation is needed to determine impacts upon resource allocation, processes, and general models and standard of care to assist facilities and programs to better address the needs of the pediatric populations they serve in the post-COVID era.

Perceptions and Attitudes Toward Telemedicine by Clinicians and Patients in Japan During the COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide. In Japan, the spread of COVID-19 was recognized and a state of emergency declared in April 2020. In response, public health interventions, such as discouraging people from leaving their homes unnecessarily, were enacted across the country. Under these circumstances, telemedicine has received a great deal of social attention, and it has become necessary to identify the perceptions of and attitudes toward telemedicine by clinicians and patients and to clarify the problems and advantages. Materials and Methods: Ten clinicians and 10 family members (if the patient was pediatric or elderly, a caregiver was included) were invited to participate in individual private interviews in 2020. All interviews were conducted from October to December 2020 using a semistructured interview guide. All transcripts were coded using thematic content analysis. Results: Four categories from clinicians and five from patients were identified as perceptions of and attitudes toward telemedicine. Both evaluated the usefulness and convenience of telemedicine in the same manner, but there was a large gap in the content under the safety and problem categories. Discussion: It is necessary to disseminate information about the communication techniques unique to telemedicine to doctors and to improve the "operation and introduction" and "communication environment and device settings" when starting or using telemedicine for all patients. Conclusions: The perceptions and attitudes identified in this study will be useful for establishing and developing a telemedicine system in Japan.

COVID-19 pandemic experiences of parents caring for children with oesophageal atresia/tracheo-oesophageal fistula

PURPOSE

The COVID-19 pandemic has resulted in a global health crisis of unparalleled magnitude. The direct risk to the health of children is low. However, disease-containment measures have society-wide impacts. This study explored the pandemic experiences of parents of children with oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) in the UK.

DESIGN

A phenomenological approach underpinned use of an asynchronous online forum method, in collaboration with a patient support group. Data were evaluated using thematic analysis.

RESULTS

The online forum ran between 7 November and 18 December 2020 with 109 participants.Pandemic experiences were divided into themes relating to healthcare and disease containment. Participants described positive experiences with remote healthcare but identified limitations. Delays and cancellations led to escalation of care to an emergency level, slower developmental progress and feelings of being abandoned by services. Inpatient care was perceived as safe but caring alone was emotionally and practically challenging. Disease containment themes revealed anxiety regarding health risks, 'collateral' damage to well-being because of isolation, and an impact on finances and employment. Parents described a transition from worry about direct health risks to concern about the impact of isolation on socialisation and development. A process of risk-benefit analysis led some to transition to a more 'normal life', while others continued to isolate. Benefits to their child's health from isolation were reported.

CONCLUSIONS

Parents' experiences of caring for a child with OA/TOF during the pandemic were varied. Rapid adoption of telehealth has demonstrated the enormous potential of remote healthcare delivery but requires refinement to meet the needs of the individual. Future pandemic planning should aim to retain community healthcare services to avoid escalation of care to an emergency, manage chronic and developmental concerns, and support parental well-being. Accurate and consistent disease-specific information is highly valued by parents. Third sector organisations are ideally positioned to support this.

The Impact of COVID-19 Pandemic in Children With Cancer: A Report From Saudi Arabia

In January 2020, the WHO declared the novel coronavirus (2019-nCoV) outbreak as a public health emergency of international concern. Due to the rapid spread of 2019-nCoV, all countries started preventive and precautionary measures to prevent COVID-19 infection spread. These measures limited the population mobility and services provided, which subsequently Impact of on children with cancer and cancer care delivery in the many health centers in Saudi Arabia. We did a cross-sectional study to assess the impact of this outbreak on children with cancer concerning all aspects of life including medical services provided, the specific precautions to prevent spread in cancer patients, mental, psychological effects, and its effect on the quality of life. We collected 204 responses during a survey that assessed the impact on the treatment of cancer children at a tertiary institution during the COVID-19 pandemic. The majority of patients were receiving ongoing chemotherapy for leukemia/lymphoma. The majority of these patients (60.5%) reported a delay in treatment received due to hospital cancellation of appointments due to the pandemic. Although the majority of patients in our cohort complained of delayed treatment, fortunately, none of the delays led to fatalities. In the context of global lockdowns and physical distancing to help flatten the COVID-19 curve, telemedicine has proved fundamental to keeping patients and their healthcare providers connected and safe. Children also faced multiple other difficulties such as psychosocial issues during the COVID-19 pandemic. Our long-term goals are to develop new programs that will enable children with cancer to emerge successfully during a pandemic.

COVID-19 Mobile Apps: A Systematic Review of the Literature

Background

A vast amount of mobile apps have been developed during the past few months in an attempt to “flatten the curve” of the increasing number of COVID-19 cases.

Objective

This systematic review aims to shed light into studies found in the scientific literature that have used and evaluated mobile apps for the prevention, management, treatment, or follow-up of COVID-19.

Methods

We searched the bibliographic databases Global Literature on Coronavirus Disease, PubMed, and Scopus to identify papers focusing on mobile apps for COVID-19 that show evidence of their real-life use and have been developed involving clinical professionals in their design or validation.

Results

Mobile apps have been implemented for training, information sharing, risk assessment, self-management of symptoms, contact tracing, home monitoring, and decision making, rapidly offering effective and usable tools for managing the COVID-19 pandemic.

Conclusions

Mobile apps are considered to be a valuable tool for citizens, health professionals, and decision makers in facing critical challenges imposed by the pandemic, such as reducing the burden on hospitals, providing access to credible information, tracking the symptoms and mental health of individuals, and discovering new predictors.

Feasibility and Acceptability of Clinical Pediatric Telerehabilitation Services

Objective

Telerehabilitation has long been recognized as a promising means of providing pediatric services; however, significant barriers such as cost, payor reimbursement, and access prevented widespread use. The advent of the COVID-19 pandemic necessitated rapid adoption of telerehabilitation into clinical practice to provide access to care while maintaining social distancing. The purpose of this study is to present clinical data on the feasibility and acceptability of speech-language pathology, developmental occupational and physical therapies, and sports and orthopedic therapies telerehabilitation delivered in a pediatric hospital setting.

Methods

Telerehabilitation services were rapidly implemented in three stages: building the foundation, implementing, and refining this service delivery model. Paper patient satisfaction surveys were administered as part of ongoing quality improvement efforts throughout 2019 and were adapted for online administration in 2020 for telerehabilitation patients. Outpatient visit counts by type (in-person, phone, and video) were extracted from the electronic medical record using data warehousing techniques.

Results

Historical patient satisfaction rates from 2019 indicated high patient satisfaction (98.97% positive responses); these results were maintained for telerehabilitation visits (97.73%), indicating that families found telerehabilitation services acceptable. Patient volume returned to 73.5% of pre-pandemic volume after the implementation of telerehabilitation services.

Conclusions

Pediatric telerehabilitation is feasible to provide in clinical settings, and the services are acceptable to patient families. Future work is needed to evaluate the impact of telerehabilitation services on patient care and applications for ongoing use of this delivery model.

The Needle in the Haystack: Identifying Credible Mobile Health Apps for Pediatric Populations during a Pandemic and beyond

Background

The COVID-19 pandemic has ignited wider clinical adoption of digital health tools, including mobile health apps (mHealth apps), to address mental and behavioral health concerns at a distance. While mHealth apps offer many compelling benefits, identifying effective apps in the crowded and largely unregulated marketplace is laborious. Consumer demand and industry productivity are increasing, although research is slower, making it challenging for providers to determine the most credible and safe apps for patients in need.

Objectives/Methods

This commentary offers a practical, empirically guided framework and associated resources for selecting appropriate mHealth apps for pediatric populations during the pandemic and beyond.

Results

In the first stage, Narrow the target problem, end user, and contender apps. Beginning the search with continuously updated websites that contain expert app ratings can help expedite this process (e.g., Psyberguide). Second, Explore each contender app’s: (a) scientific and theoretical support (e.g., are app components consistent with health behavior change theories?), (b) privacy policies, and (c) user experience (e.g., through crowdsourcing feedback about app usability and appeal via social media). Third, use clinical expertise and stakeholder feedback to Contextualize whether the selected app is a good fit for a particular patient and/or caregiver (e.g., by considering age, race/ethnicity, ability, gender, sexual orientation, technology access), including conducting a brief self-pilot of the app.

Conclusion

Youth are increasingly turning to technology for support, especially during the pandemic, and pediatric psychologists must be primed to recommend the most credible tools. We offer additional recommendations for rapidly disseminating evidence-based apps to the public.

Designing Futuristic Telemedicine Using Artificial Intelligence and Robotics in the COVID-19 Era

Technological innovations such as artificial intelligence and robotics may be of potential use in telemedicine and in building capacity to respond to future pandemics beyond the current COVID-19 era. Our international consortium of interdisciplinary experts in clinical medicine, health policy, and telemedicine have identified gaps in uptake and implementation of telemedicine or telehealth across geographics and medical specialties. This paper discusses various artificial intelligence and robotics-assisted telemedicine or telehealth applications during COVID-19 and presents an alternative artificial intelligence assisted telemedicine framework to accelerate the rapid deployment of telemedicine and improve access to quality and cost-effective healthcare. We postulate that the artificial intelligence assisted telemedicine framework would be indispensable in creating futuristic and resilient health systems that can support communities amidst pandemics.

A Paradigm Shift in the Delivery of Physical Therapy Services for Children With Disabilities in the Time of the COVID-19 Pandemic

With the COVID pandemic, the delivery of rehabilitation services has been greatly affected across lifespan, especially towards children with disabilities. The significant physical and mental health stressors of prolonged home confinement coupled with discontinuation of rehabilitation services can lead to several long-term concerns among children with disabilities. In light of the current events, our approach towards rehabilitation needs to be re-evaluated and revamped. The point of view highlights the potential ways in which we could continue to provide physical therapy services for children with disabilities. Use of family-centered and home-based models of care can be considered to reach out to children with disabilities using telerehabilitation and digital physical therapy by adopting a modified framework of care. The implications of the point of view may help aid clinician’s world-over to continue providing rehabilitation services to children with disabilities.

Psychosocial Challenges and Opportunities for Youth With Chronic Health Conditions During the COVID-19 Pandemic

School closures, altered access to health services, and economic stress during the COVID-19 pandemic have likely had an impact on the mental and physical well-being of youth worldwide, particularly among those with chronic health conditions (CHCs). A number of challenges and opportunities have emerged during the COVID-19 pandemic for youth with CHCs. Challenges include heightened anxiety, disrupted routines, academic and social stresses associated with school closure, increased risk of domestic violence and abuse, and reduced access to physical and psychosocial support. On the other hand, opportunities include reduced academic and social stress, increased time with families, reduced access to substances, easier access to health care using technology, and opportunities to build resilience. This viewpoint paper highlights both challenges and opportunities for youth with CHCs during the pandemic and offers recommendations for further research and clinical care.

Child Abuse in Times of Crises: Lessons Learned

The COVID-19 pandemic has created conditions which heighten risk for child abuse. As key players in times of crisis, pediatric emergency medicine providers must be equipped with the tools to recognize, respond to, and mitigate risk of child abuse. An exploration of the scientific literature, stakeholder organization reports and lay press was undertaken to understand the impact of large-scale U.S. crises, including infectious disease, financial downturn, natural disaster, and violence, on child abuse risk and inform prevention strategies. Review of the literature suggests a relationship between crises and child abuse risk, though gaps in the research remain. We outline the role of pediatric emergency medicine providers in partnering with communities in organizing and advocating for systems that better protect children and strengthen families.

Pediatric Mental and Behavioral Health in the Period of Quarantine and Social Distancing With COVID-19

The coronavirus disease (COVID-19) pandemic has spread rapidly throughout the world and has had a long-term impact. The pandemic has caused great harm to society and caused serious psychological trauma to many people. Children are a vulnerable group in this global public health emergency, as their nervous systems, endocrine systems, and hypothalamic-pituitary-adrenal axes are not well developed. Psychological crises often cause children to produce feelings of abandonment, despair, incapacity, and exhaustion, and even raise the risk of suicide. Children with mental illnesses are especially vulnerable during the quarantine and social distancing period. The inclusion of psychosocial support for children and their families are part of the health responses to disaster and disaster recovery. Based on the biopsychosocial model, some children may have catastrophic thoughts and be prone to experience despair, numbness, flashbacks, and other serious emotional and behavioral reactions. In severe cases, there may be symptoms of psychosis or posttraumatic stress disorder. Timely and appropriate protections are needed to prevent the occurrence of psychological and behavioral problems. The emerging digital applications and health services such as telehealth, social media, mobile health, and remote interactive online education are able to bridge the social distance and support mental and behavioral health for children. Based on the psychological development characteristics of children, this study also illustrates interventions on the psychological impact from the COVID-19 pandemic. Even though the world has been struggling to curb the influences of the pandemic, the quarantine and social distancing policies will have long-term impacts on children. Innovative digital solutions and informatics tools are needed more than ever to mitigate the negative consequences on children. Health care delivery and services should envision and implement innovative paradigms to meet broad well-being needs and child health as the quarantine and social distancing over a longer term becomes a new reality. Future research on children's mental and behavioral health should pay more attention to novel solutions that incorporate cutting edge interactive technologies and digital approaches, leveraging considerable advances in pervasive and ubiquitous computing, human-computer interaction, and health informatics among many others. Digital approaches, health technologies, and informatics are supposed to be designed and implemented to support public health surveillance and critical responses to children's growth and development. For instance, human-computer interactions, augmented reality, and virtual reality could be incorporated to remote psychological supporting service for children's health; mobile technologies could be used to monitor children's mental and behavioral health while protecting their individual privacy; big data and artificial intelligence could be used to support decision making on whether children should go out for physical activities and whether schools should be reopened. Implications to clinical practices, psychological therapeutic practices, and future research directions to address current effort gaps are highlighted in this study.

Digital Approaches to Remote Pediatric Health Care Delivery During the COVID-19 Pandemic: Existing Evidence and a Call for Further Research

The global spread of the coronavirus disease (COVID-19) outbreak poses a public health threat and has affected people worldwide in various unprecedented ways, both personally and professionally. There is no question that the current global COVID-19 crisis, now more than ever, is underscoring the importance of leveraging digital approaches to optimize pediatric health care delivery in the era of this pandemic. In this perspective piece, we highlight some of the available digital approaches that have been and can continue to be used to streamline remote pediatric patient care in the era of the COVID-19 pandemic, including but not limited to telemedicine. JMIR Pediatrics and Parenting is currently publishing a COVID-19 special theme issue in which investigators can share their interim and final research data related to digital approaches to remote pediatric health care delivery in different settings. The COVID-19 pandemic has rapidly transformed health care systems worldwide, with significant variations and innovations in adaptation. There has been rapid expansion of the leveraging and optimization of digital approaches to health care delivery, particularly integrated telemedicine and virtual health. Digital approaches have played and will play major roles as invaluable and reliable resources to overcome restrictions and challenges imposed during the COVID-19 pandemic and to increase access to effective, accessible, and consumer-friendly care for more patients and families. However, a number of challenges remain to be addressed, and further research is needed. Optimizing digital approaches to health care delivery and integrating them into the public health response will be an ongoing process during the current COVID-19 outbreak and during other possible future pandemics. Regulatory changes are essential to support the safe and wide adoption of these approaches. Involving all relevant stakeholders in addressing current and future challenges as well as logistical, technological, and financial barriers will be key for success. Future studies should consider evaluating the following research areas related to telemedicine and other digital approaches: cost-effectiveness and return on investment; impact on quality of care; balance in use and number of visits needed for the management of both acute illness and chronic health conditions; system readiness for further adoption in other settings, such as inpatient services, subspecialist consultations, and rural areas; ongoing user-centered evaluations, with feedback from patients, families, and health care providers; strategies to optimize health equity and address disparities in access to care related to race and ethnicity, socioeconomic status, immigration status, and rural communities; privacy and security concerns for protected health information with Health Insurance Portability and Accountability Act (HIPAA)-secured programs; confidentiality issues for some specific populations, especially adolescents and those in need of mental health services; early detection of exposure to violence and child neglect; and integration of training into undergraduate and graduate medical education and subspecialty fellowships. Addressing these research areas is essential to understanding the benefits, sustainability, safety, and optimization strategies of telemedicine and other digital approaches as key parts of modern health care delivery. These efforts will inform long-term adoption of these approaches with expanded dissemination and implementation efforts.

Metal substitutions incarbonic anhydrase: a halide ion probe study

Monitoring of the mental health status of the population and assessment of its determinants are 2 of the most relevant pillars of public mental health, and data from population health surveys could be instrumental to support them. Although these surveys could be an important and suitable resource for these purposes, due to different limitations and challenges, they are often relegated to the background behind other data sources, such as electronic health records. These limitations and challenges include those related to measurement properties and cross-cultural validity of the tools used for the assessment of mental disorders, their degree of representativeness, and possible difficulties in the linkage with other data sources. Successfully addressing these limitations could significantly increase the potential of health surveys in the monitoring of mental disorders and ultimately maximize the impact of the relevant policies to reduce their burden at the population level. The widespread use of data from population health surveys, ideally linked to electronic health records data, would enhance the quality of the information available for research, public mental health decision-making, and ultimately addressing the growing burden of mental disorders.