A new AAP-endorsed
document provides overarching guidance for clinicians, administrators and
policymakers on the safe
and effective practice of pediatric telehealth.
Published by the American Telemedicine
Association (ATA), the guidance is the result of a three-year, unprecedented collaborative effort by multiple clinical, administrative and industry leaders in pediatric
telehealth, including representatives from
the AAP Section on Telehealth Care.
A link to Operating Procedures for Pediatric Telehealth is published in the August
issue of Pediatrics. Access the document at
The core issues addressed in the operating procedures
• telehealth within the context of the patient-cen-
tered medical home (PCMH);
• communication with primary care and referring
• appropriate patient follow-up;
• parent or legal guardian presence during an encounter;
• patient privacy and confidentiality;
• appropriate examination and testing prior to the
prescription of treatment;
• legal and regulatory considerations; and
• technical and security considerations.
Importantly, the document does not provide clinical
guidance on telehealth applications for specific conditions or diagnoses. The operating procedures were
designed to create a framework of broadly applicable
recommendations, which serve as a foundation on which
to base the development of pediatric telehealth practices,
regulations, legislation and specific clinical guidance.
Pediatric telehealth includes a vast array of practices and
applications such as 24/7 remote consultation to rural
emergency departments by pediatric critical care specialists, school-based telehealth services and remote monitoring in the home for children with chronic conditions.
While these practices are generally viewed as beneficial adjuncts to health care, certain telehealth applications are of particular concern to community
pediatricians, due to their potential negative impact
on continuity and coordination of care. One such
application is the provision of on-demand primary
and urgent care services, commonly referred to as di-rect-to-consumer (DTC) telehealth.
These applications are most often delivered via a pa-
tient’s home computer or mobile device, or at walk-up
kiosks in retail pharmacies and stores, and focus on ad-
dressing minor, acute illnesses. There is wide variability
in DTC practice. Many providers of this service offer
high-quality care that integrates with the PCMH. In
fact, community pediatricians and academic medical
centers are increasingly providing DTC telehealth ser-
vices to their own patients, allowing for enhanced off-
hours coverage, increased convenience for patients
and an additional revenue stream for the practice.
However, other providers of DTC telehealth services are taking a more entrepreneurial approach,
attempting to capitalize on the convenience of telehealth for patients and parents while potentially sacrificing quality. Such services may fall short on issues
such as coordination or communication with the
PCMH, availability for follow-up and appropriate
examination prior to the prescription of antibiotics.
These issues are not unique to telehealth, as other
health care delivery models, such as retail-based
clinics and stand-alone urgent care centers, have
demonstrated similar potential shortfalls. However, the new operating procedures include language
to address these issues and encourage the provision
of higher quality, more efficient telehealth services
Continued collaboration on pediatric operating procedures, clinical guidelines and research
will pave the way for the ongoing development
of safe and effective pediatric telehealth practices, and
will allow patient- and provider-focused organizations
to solidify their leadership role in that development.
Dr. McSwain, a member of the AAP Section on Telehealth Care Executive Committee, chaired the Pediatric Telehealth
Work Group, which produced the ATA
guidance. He also chairs the ATA’s Pediatric Special Interest Group Section on Best
Practices and Guidelines.
by Trisha Korioth • Staff Writer
Optimal nutrition of critically ill pediatric patients
is the focus of new guidelines that provide a starting
point for identifying malnourished patients.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient
aims to improve outcomes with a blend of expert opinion and clinical practicality. The work is based on an
extensive review of data involving critically ill patients
ages 1 month to 17 years.
“Malnutrition, including obesity, is associated with
adverse clinical outcomes, including longer periods of
ventilation, higher risk of hospital-acquired infection,
longer PICU and hospital stay, and increased mortality,” according to the report available at http://bit.
The American Society for Parenteral and Enteral Nu-
trition released the report with the Society for Critical
Care Medicine after forming a task force of experts in
clinical nutrition to develop the guidelines.
A research team looked at more than 2,000 cita-
tions related to pediatric nutritional support, partic-
ularly data from critically ill pediatric patients whose
pediatric intensive care unit stay was longer than two
to three days. They found:
• There was a significant gap in proper nutritional
interventions among malnourished patients, put-
ting them at risk for adverse clinical outcomes.
• There are potential benefits when patients receive
detailed nutritional assessment within 48 hours of
• Timing and method of nutrient delivery matters.
Tips for optimizing tube feeding and benefits of
delayed approach to intravenous feeding are discussed.
• The pediatric intensive care unit would benefit
from a dedicated dietitian who can facilitate nu-
tritional assessment, delivery and adjustment as the
patient’s needs change.
• At least weekly monitoring for unintended under-and overfeeding is critical.
• Determining how much nutrition is essential. The
guidelines offer recommendations on minimum
protein intake, and note that Recommended Daily
Allowance values underestimate protein needs of
children with critical illness.
While many of the recommendations and suggestions were driven by low-grade evidence and consensus
among the task force members, the authors noted that
it provides a starting point for developing the next level
of evidence-based nutrition therapy.
“Overall, the pediatric critical care population is heterogeneous,” the authors wrote. “A nuanced approach
to individualize nutrition support with the aim of improving clinical outcomes is necessary.”
New guidelines focus on nutrition support for critically ill patients
AAP, others endorse operating procedures for pediatric telehealth
Courtesy of Sarah Pack, University of South Carolina
Communication with primary care and referring providers is among
issues addressed in new pediatric telehealth guidance, which also
covers technical and security considerations, patient follow-up, and
legal and regulatory concerns.
• “Pediatric Telehealth: Making It a Part of Your Medical
Home (S1113)” will be held from 2-3: 30 p.m. Sept. 16
at the AAP National Conference & Exhibition in Chicago.
• AAP Section on Telehealth Care, http://bit.ly/1P3zpfS
• American Telemedicine Association, http://www.amer