Child health research funding and policy: imperatives and investments for a healthier world

Barriers to and facilitators of paediatric medical device innovation: a scoping review protocol

INTRODUCTION

The development of paediatric medical devices continues to lag adult medical devices and contributes to issues of inequity, safety, quality and patient outcomes. New legislation and funding mechanisms have been introduced over the past two decades, but the gap remains. Clinical trials have been identified as a pain point, but components of effective clinical research infrastructure are poorly understood. As part of a multimodal research strategy, the Pediatric Device Consortia (PDC) will conduct a scoping review to better understand infrastructural barriers to and facilitators of paediatric medical device clinical research identified in the health sciences literature.

METHODS AND ANALYSIS

The following databases will be included for this review: Medline, Embase, Cochrane CENTRAL, Web of Science and IEEE Xplore. Additional grey literature will be sought out through Google Scholar and reviewing the citations of included studies. Included studies will discuss medical devices according to the U.S. Food and Drug Administration classification, focus on the paediatric population (ages 0-21 years) and involve human premarket or postmarket research. All study types that were published in 2007-present in English, Spanish, French or Italian will be included. Using Covidence web-based software, two independent reviewers will screen the resulting titles, abstracts and the full text of potential studies. Conflicts will be resolved by the primary investigator during both phases. REDCap will be used for quantitative and qualitative data charting, generating data tables and narrative synthesis.

ETHICS AND DISSEMINATION

This research did not require research ethics board consideration as it does not involve human participants and all data will be collected from published literature. We will share our findings through peer-reviewed manuscripts, clinical and research conference presentations and professional networks available to the PDC.

STUDY REGISTRATION

Open Science Framework (https://osf.io/k72bn).

Making the case for pediatric research: a life-cycle approach and the return on investment

There is unmistakable evidence of increased NIH funding for pediatric and perinatal research, but there is much work to be done. To further promote NIH-funded pediatric and perinatal research, we advocate for a life-cycle approach in which the return on the investment continues over the lifespan. Although elected policymakers have short-time horizons, pediatric and perinatal researchers must provide novel evidence and theoretical arguments demonstrating the long-term health benefits for the adults of tomorrow by improving the health of our current pediatric populations. Child health researchers must communicate the role of early developmental events on childhood and adult disease, including those that are prenatal and gestational so that its importance is understood by the public and policymakers.

Modified e-Delphi Process for the Selection of Patient-Reported Outcome Measures for Children and Families With Type 1 Diabetes Using Continuous Glucose Monitors: Delphi Study

BACKGROUND

Type 1 diabetes (T1D) management is complex and associated with significant psychosocial burden. Continuous glucose monitors (CGM) can improve disease management and outcomes and introduce new or exacerbate existing psychosocial concerns. Patient-reported outcome measures (PROMs) can be used to capture this information, but there is no consensus on which PROMs should be used in pediatric CGM research.

OBJECTIVE

Here we describe the process to (1) identify PROMs that could be used to assess the impact of CGMs on pediatric patients with T1D, (2) implement a modified electronic Delphi (e-Delphi) methodology to arrive at an expert consensus on which PROMs are most suitable for clinical and research applications, and (3) establish a periodicity table for the administration of PROMs over time in a real-world evidence study.

METHODS

To identify appropriate PROMs for pediatric patients and families with T1D and CGMs, we conducted an asynchronous, e-Delphi process with a multidisciplinary group of experts from around the country. We identified candidate instruments through a literature review. The 3-round e-Delphi process was conducted via a study website, email, and web-based forms. Participants provided opinions on the usefulness of instruments, age validation, feasibility, time, and frequency of administration.

RESULTS

In total, 16 experts participated in the e-Delphi process; 4 of whom consistently participated in all 3 rounds. We identified 62 candidate instruments, which were narrowed down to 12 final PROMs across 5 domains: diabetes distress and burden (n=4), autonomy (n=2), quality of life (n=1), psychosocial (n=3), and technology acceptance (n=2). A quarterly administration schedule was developed to reduce burden on participants.

CONCLUSIONS

PROMs can provide critical insights into the psychosocial well-being of patients. The specific measures identified in the paper are particularly well suited for pediatric patients with T1D using CGMs. Clinical implementation could help health care providers, patients, and families to engage in more comprehensive disease management.

The impact of COVID-19 on disease epidemiology, family dynamics, and social justice in Minnesota: All that you cannot see

Objective

The COVID-19 pandemic presented a challenge to established seed grant funding mechanisms aimed at fostering collaboration in child health research between investigators at the University of Minnesota (UMN) and Children's Hospitals and Clinics of Minnesota (Children's MN). We created a "rapid response," small grant program to catalyze collaborations in child health COVID-19 research. In this paper, we describe the projects funded by this mechanism and metrics of their success.

Methods

Using seed funds from the UMN Clinical and Translational Science Institute, the UMN Medical School Department of Pediatrics, and the Children's Minnesota Research Institute, a rapid response request for applications (RFAs) was issued based on the stipulations that the proposal had to: 1) consist of a clear, synergistic partnership between co-PIs from the academic and community settings; and 2) that the proposal addressed an area of knowledge deficit relevant to child health engendered by the COVID-19 pandemic.

Results

Grant applications submitted in response to this RFA segregated into three categories: family fragility and disruption exacerbated by COVID-19; knowledge gaps about COVID-19 disease in children; and optimizing pediatric care in the setting of COVID-19 pandemic restrictions. A series of virtual workshops presented research results to the pediatric community. Several manuscripts and extramural funding awards underscored the success of the program.

Conclusions

A "rapid response" seed funding mechanism enabled nascent academic-community research partnerships during the COVID-19 pandemic. In the context of the rapidly evolving landscape of COVID-19, flexible seed grant programs can be useful in addressing unmet needs in pediatric health.

Reconsidering reviews: the role of scoping reviews in digital medicine and pediatrics

Digital health is a rapidly developing field which is positioned to transform the manner in which healthcare is delivered, especially amongst adolescents and young adults. In order to assess the efficacy of novel medical devices, clinicians and researchers often turn to the literature for guidance. Randomized control trials and the systematic reviews and meta-analyses that they inform are considered to be at the top of the evidence hierarchy. While they are excellent tools to identify and to summarize the best available evidence to answer a specific research question, they are poorly equipped to provide a more expansive understanding of the body of relevant literature in a timely manner. In this letter we discuss the utility of the scoping review, an underutilized style of academic writing designed to map key concepts in a body of literature. This method is ideal when reporting on the fast-paced field of digital medicine, as it allows for rapid synthesis of the available literature.

PedAM: a database for Pediatric Disease Annotation and Medicine

There is a significant number of children around the world suffering from the consequence of the misdiagnosis and ineffective treatment for various diseases. To facilitate the precision medicine in pediatrics, a database namely the Pediatric Disease Annotations & Medicines (PedAM) has been built to standardize and classify pediatric diseases. The PedAM integrates both biomedical resources and clinical data from Electronic Medical Records to support the development of computational tools, by which enables robust data analysis and integration. It also uses disease-manifestation (D-M) integrated from existing biomedical ontologies as prior knowledge to automatically recognize text-mined, D-M-specific syntactic patterns from 774 514 full-text articles and 8 848 796 abstracts in MEDLINE. Additionally, disease connections based on phenotypes or genes can be visualized on the web page of PedAM. Currently, the PedAM contains standardized 8528 pediatric disease terms (4542 unique disease concepts and 3986 synonyms) with eight annotation fields for each disease, including definition synonyms, gene, symptom, cross-reference (Xref), human phenotypes and its corresponding phenotypes in the mouse. The database PedAM is freely accessible at http://www.unimd.org/pedam/.

Road to the Future: Priorities for Child Health Services Research

BACKGROUND

Prior health services research (HSR) agendas for children have been published, but major ones are now over 15 years old and do not reflect augmented understanding of the drivers and determinants of children's health; recent changes in the organization, financing, and delivery of health care; a growing emphasis on population health; and major demographic shifts in the population. A policy-relevant research agenda that integrates knowledge gained over the past 2 decades is essential to guide future child HSR (CHSR). We sought to develop and disseminate a robust, domestically focused, policy-oriented CHSR agenda.

METHODS

The new CHSR agenda was developed through a series of consultations with leaders in CHSR and related fields. After each round of consultation, the authors synthesized the previous experts' guidance to help inform subsequent discussions. The multistep process in generation of the agenda included identification of major policy-relevant research domains and specification of high-value research questions for each domain. Stakeholders represented in the discussions included those with expertise in child and family advocacy, adult health, population health, community development, racial and ethnic disparities, women's health, health economics, and government research funders and programs.

RESULTS

In total, 180 individuals were consulted in developing the research agenda. Six priority domains were identified for future research, including both enduring and emerging emphases: 1) framing children's health issues so that they are compelling to policy-makers; 2) addressing poverty and other social determinants of child health and wellbeing; 3) promoting equity in population health and health care; 4) preventing, diagnosing, and treating high priority health conditions in children; 5) strengthening performance of the health care system; and 6) enhancing the CHSR enterprise. Within these 6 domains, 40 specific topics were identified as the most pertinent for future research. Three overarching and crosscutting themes that affect research across the domains were also noted: the need for syntheses to build on the current, and sometimes extensive, evidence base to avoid duplication; the interrelated nature of the domains, which could lead to synergies in research; and the need for multidisciplinary collaborations in conducting research because research studies will look beyond the health sector.

CONCLUSIONS

The priorities presented in the agenda are policy-oriented and include a greater emphasis on how findings are framed and communicated to support action. We expect that the agenda will be useful for immediate uptake by investigators and research funders.

Musculoskeletal Pain in Children and Adolescents: A Way Forward

There are substantial gaps in our understanding of musculoskeletal pain in children and adolescents. While there are challenges to performing research in this space, the prevalence, burden, and lack of available evidence to inform clinical practice mean that overcoming these challenges is important. The editors see the collection of work in this special issue as a step in the right direction. J Orthop Sports Phys Ther 2017;47(10):702-704. doi:10.2519/jospt.2017.0109.

Premature Discontinuation of Pediatric Randomized Controlled Trials: A Retrospective Cohort Study

OBJECTIVES

To determine the proportion of pediatric randomized controlled trials (RCTs) that are prematurely discontinued, examine the reasons for discontinuation, and compare the risk for recruitment failure in pediatric and adult RCTs.

STUDY DESIGN

A retrospective cohort study of RCTs approved by 1 of 6 Research Ethics Committees (RECs) in Switzerland, Germany, and Canada between 2000 and 2003. We recorded trial characteristics, trial discontinuation, and reasons for discontinuation from protocols, corresponding publications, REC files, and a survey of trialists.

RESULTS

We included 894 RCTs, of which 86 enrolled children and 808 enrolled adults. Forty percent of the pediatric RCTs and 29% of the adult RCTs were discontinued. Slow recruitment accounted for 56% of pediatric RCT discontinuations and 43% of adult RCT discontinuations. Multivariable logistic regression analyses suggested that pediatric RCT was not an independent risk factor for recruitment failure after adjustment for other potential risk factors (aOR, 1.22; 95% CI, 0.57-2.63). Independent risk factors were acute care setting (aOR, 4.00; 95% CI, 1.72-9.31), nonindustry sponsorship (aOR, 4.45; 95% CI, 2.59-7.65), and smaller planned sample size (aOR, 1.05; 95% CI 1.01-1.09, in decrements of 100 participants).

CONCLUSION

Forty percent of pediatric RCTs were discontinued prematurely, owing predominately to slow recruitment. Enrollment of children was not an independent risk factor for recruitment failure.

Blueprint for Action: Visioning Summit on the Future of the Workforce in Pediatrics

The Federation of Pediatric Organizations engaged members of the pediatric community in an 18-month process to envision the future of the workforce in pediatrics, culminating in a Visioning Summit on the Future of the Workforce in Pediatrics. This article documents the planning process and methods used. Four working groups were based on the 4 domains that are likely to affect the future workforce: Child Health Research and Training, Diversity and Inclusion, Gender and Generations, and Pediatric Training Along the Continuum. These groups identified the issues and trends and prioritized their recommendations. Before the summit, 5 key megatrends cutting across all domains were identified:1. Aligning Education to the Emerging Health Needs of Children and Families 2. Promoting Future Support for Research Training and for Child Health Research 3. Striving Toward Mastery Within the Profession 4. Aligning and Optimizing Pediatric Practice in a Changing Health Care Delivery System 5. Taking Advantage of the Changing Demographics and Expertise of the Pediatric Workforce At the Visioning Summit, we assembled members of each of the working groups, the Federation of Pediatric Organizations Board of Directors, and several invited guests to discuss the 5 megatrends and develop the vision, solutions, and actions for each megatrend. Based on this discussion, we offer 10 recommendations for the field of pediatrics and its leading organizations to consider taking action.

A healthy nation: strengthening child health research in the UK

Despite a general acknowledgment that research in children is necessary and ethical, the evidence base for child-specific treatments is still sparse. We investigated children's biomedical and health services research in the UK in relation to training, infrastructure and activity, research evidence, and visibility. We show that excellent opportunities for career researchers exist through a competitive, national integrated academic training programme, but that the number of academic paediatricians has decreased by 18% between 2000 and 2011, falling from 11·3% to 5·9% of the consultant workforce. The potential for rapid delivery of studies in children through the National Health Service (NHS) is not being realised: clinical trainees are poorly equipped with core research skills; most newly appointed consultant paediatricians have little or no research experience; less than 5% of contracted consultant time supports research; less than 2·5% of the 2 million children seen in the NHS every year are recruited to studies; and ten of the 20 UK children's hospitals do not have a clinical research facility. Support through National Institute for Health Research networks is good for studies into drugs, but inconsistent for non-drug research; less than 5% of registered studies involve children and only one children's biomedical research centre has been allocated funding from 2012. Of the UK annual public and charitable biomedical research expenditure of roughly £2·2 billion, about 5% is directed at child health research. The scant evidence base is impeding the development of clinical guidance and policy-less than 20% of the outputs of the National Institute for Health and Clinical Excellence are applicable to children. Paediatric representation on major research boards is weak. Parent and young people's advocacy is fragmented, and their views are insufficiently heeded by regulatory bodies. The strong UK Government commitment to biomedical research has not been translated fully to research for children. The power of research in children to turn the tide of the growing burden of non-communicable, chronic, adult diseases that have their origins in early life, to benefit the health of an ageing population and future generations, and to reduce health-care costs is inadequately recognised. On the basis of our findings, we make several recommendations to improve early-years research, including the formation of multidisciplinary, cross-institutional groups of clinical and non-clinical child health researchers and their access to diagnostic and laboratory facilities suitable for children; a unified Children's Research Network for drug studies and non-drug studies; regulatory assessment of research that is proportionate and based on consistent national criteria; an expansion of research posts; support for parents' and young people's advocacy; collaboration between children's research charities; improved research training for paediatric trainees; and closer integration of child health research with core NHS activities.

Tracking the impact of the National Institutes of Health Clinical and Translational Science Awards on child health research: developing and evaluating a measurement strategy

Since 2006, the National Institutes of Health has provided institutional infrastructure grants, called Clinical and Translational Science Awards (CTSAs), to support adult and pediatric clinical and translational research in United States institutions. A CTSA Consortium Child Health Oversight Committee workgroup developed metrics to measure the impact of CTSAs on child health (CH) research. A cross-sectional survey to collect metric data was distributed to the 46 institutions that received CTSAs during 2006-09. Thirty-seven (80%) institutions responded to the survey. Data regarding 7 metrics were reported by >70% of responding institutions: the proportion of overall funding (median, interquartile range; 0.12, 0.06–0.19) and pilot grants (0.15, 0.11–0.21) supporting CH research; the proportion of active clinical research center studies involving children (0.23, 0.15–0.35); the proportion of IRB-approved (0.24, 0.16–0.30) and funded (0.22, 0.18–0.30) studies involving children; the proportion of mentored research training awards to CH investigators (0.18, 0.11–0.28); and, the proportion of CTSA leadership positions held by pediatricians (0.18, 0.12–0.28). CTSAs provide substantial support for CH research, although additional investment in CH research is needed to improve the health of children. These metrics provide an initial means to track the impact of CTSAs on CH research.

Pediatric drug-trial recruitment: enticement without coercion

Despite federal initiatives to increase research and expand data about the effectiveness and safety of medications in children, data are still limited for this population. One of the most salient barriers to conducting pediatric clinical trials involves participant recruitment. In this article, we summarize recruitment challenges including a lack of research infrastructure, the need to properly define appropriate use of incentives and payments, and inconsistencies in the current use of payments and incentives. We also searched the Centerwatch.com and ClinicalTrials.gov databases for updated data on current practices in pediatric participant compensation/payment. We provide recommendations for tackling current barriers to recruiting and retaining children and families in clinical trials.