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In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting.METHODS:
A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention.RESULTS:
The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged.CONCLUSIONS:
Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children’s hospital without impacting other outcome measures.
In Lyme disease endemic areas, initial management of children with arthritis can be challenging because diagnostic tests take several days to return results, leading to potentially unnecessary invasive procedures. Our objective was to examine the role of the C6 peptide enzyme immunoassay (EIA) test to guide initial management.METHODS:
We enrolled children with acute arthritis undergoing evaluation for Lyme disease presenting to a participating Pedi Lyme Net emergency department (2015–2019) and performed a C6 EIA test. We defined Lyme arthritis with a positive or equivocal C6 EIA test result followed by a positive supplemental immunoblot result and defined septic arthritis as a positive synovial fluid culture result or a positive blood culture result with synovial fluid pleocytosis. Otherwise, children were considered to have inflammatory arthritis. We report the sensitivity and specificity of the C6 EIA for the diagnosis of Lyme arthritis.RESULTS:
Of the 911 study patients, 211 children (23.2%) had Lyme arthritis, 11 (1.2%) had septic arthritis, and 689 (75.6%) had other inflammatory arthritis. A positive or equivocal C6 EIA result had a sensitivity of 100% (211 out of 211; 95% confidence interval [CI]: 98.2%–100%) and specificity of 94.2% (661 out of 700; 95% CI: 92.5%–95.9%) for Lyme arthritis. None of the 250 children with a positive or equivocal C6 EIA result had septic arthritis (0%; 95% CI: 0%–1.5%), although 75 children underwent diagnostic arthrocentesis and 27 underwent operative joint washout.CONCLUSIONS:
In Lyme disease endemic areas, a C6 EIA result could be used to guide initial clinical decision-making, without misclassifying children with septic arthritis.
In this study, we aim to evaluate the current trends in pediatric fractures related to trampolines.METHODS:
The National Electronic Injury Surveillance System was queried for fractures occurring between 2008 and 2017 in individuals aged 0 to 17 years. Sex, anatomic region, locale of injury, admission status, and year of injury were recorded. Incidence rates were calculated by using national census data. Poisson regression analysis was used to test for changes in fracture incidence across the time period. Logistic regression analyses were used to test temporal trends in the odds of a fracture occurring at a place of recreation or sport and a patient with a fracture being admitted.RESULTS:
Between 2008 and 2017, there was a 3.85% (95% confidence interval [CI]: 0.51–7.30) increase in the incidence of trampoline-related pediatric fractures per person-year. The incidence of pediatric trampoline-related fractures increased from 35.3 per 100 000 person-years in 2008 to 53.0 per 100 000 person-years in 2017. There was no change in the odds of a trampoline fracture requiring hospitalization (odds ratio per 1 year: 1.02; 95% CI: 0 6–1.07; P = .5431). There was a significant increase in the odds of a fracture occurring at a place of recreation or sport (odds ratio per year: 1.32; 95% CI: 1.21–1.43; P < .0001).CONCLUSIONS:
Between 2008 and 2017, there was a significant increase in the national incidence of trampoline-related fractures. We identified a significant increase in the proportion of trampoline fractures that occurred at a place of recreation or sport. Advocacy campaigns should consider these sites in their prevention efforts.
We aimed to describe the national epidemiology of burnout in pediatric residents.METHODS:
We conducted surveys of residents at 34 programs in 2016, 43 programs in 2017, and 49 programs in 2018. Survey items included the Maslach Burnout Inventory, demographics, program characteristics, personal qualities, experiences, and satisfaction with support, work-life balance, and learning environment. Analyses included cross-sectional comparisons and cross-sectional and longitudinal regression.RESULTS:
More than 60% of eligible residents participated; burnout rates were >50% in all years and not consistently associated with any demographic or residency characteristics. Cross-sectional associations were significant between burnout and stress, sleepiness, quality of life, mindfulness, self-compassion, empathy, confidence in providing compassionate care (CCC), being on a high-acuity rotation, recent major medical error, recent time off, satisfaction with support and career choice, and attitudes about residency. In cross-sectional logistic regression analyses, 4 factors were associated with an increased risk of burnout: stress, sleepiness, dissatisfaction with work-life balance, and recent medical error; 4 factors were associated with lower risk: empathy, self-compassion, quality of life, and CCC. Longitudinally, after controlling for 2017 burnout and 2018 risk factors (eg, recent error, sleepiness, rotation, and time off), 2017 quality of life was associated with 2018 burnout; 2017 self-compassion was associated with lower 2018 stress; and 2017 mindfulness, empathy, and satisfaction with learning environment and career choice were associated with 2018 CCC.CONCLUSIONS:
A majority of residents met burnout criteria. Several identified factors (eg, stress, sleepiness, medical errors, empathy, CCC, and self-compassion) suggest targets for interventions to reduce burnout in future studies.
Nadolol is a β-adrenergic antagonist that has been shown to be efficacious in the treatment of infantile hemangioma. It has been suggested that this drug may have fewer side effects compared with the gold standard therapy, propranolol, because it does not exhibit membrane-stabilizing effects and has little ability to cross the blood-brain barrier. However, the pharmacokinetics and safety of nadolol in infants are not well understood, potentially making this therapy dangerous. β-adrenergic antagonist toxicity causes bradycardia, hypotension, hypoglycemia, and even death. We report a case of a 10-week-old girl who was started on nadolol for infantile hemangioma, died 7 weeks later, and was found to have an elevated postmortem cardiac blood nadolol level of 0.94 mg/L. The infant had no bowel movements for 10 days before her death, which we hypothesize contributed to nadolol toxicity. Pharmacokinetics studies show a large fraction of oral nadolol either remains in the feces unchanged or is excreted into feces via the biliary system, allowing continued absorption over time in infants who stool infrequently. Propranolol may be a safer therapy overall. Not only does it have a shorter half-life, but propranolol is hepatically metabolized and renally eliminated, allowing for less drug accumulation in healthy infants with variable stooling patterns. We suggest that if nadolol is selected for therapy, pediatricians should instruct parents to monitor their infants’ bowel movements closely and encourage early intervention in the event of decreased stooling. This intervention may greatly improve the safety of nadolol in this vulnerable patient population.
Despite being unable to purchase firearms directly, many adolescents have access to guns, leading to increased risk of injury and death. We sought to determine if the National Instant Criminal Background Check System (NICS) changed adolescents’ gun-carrying behavior.METHODS:
We performed a repeated cross-sectional study using National Youth Risk Behavior Survey data from years 1993 to 2017. We used a survey-weighted multivariable logistic regression model to determine if the NICS had an effect on adolescent gun carrying, controlling for state respondent characteristics, state laws, state characteristics, the interaction between the NICS and state gun laws, and time.RESULTS:
On average, 5.8% of the cohort reported carrying a gun. Approximately 17% of respondents who carried guns were from states with a universal background check (U/BC) provision at the point of sale, whereas 83% were from states that did not have such laws (P < .001). The model indicated that the NICS together with U/BCs significantly reduced gun carrying by 25% (adjusted relative risk = 0.75 [95% confidence interval: 0.566–0.995]; P = .046), whereas the NICS independently did not (P = .516).CONCLUSIONS:
Adolescents in states that require U/BCs on all prospective gun buyers are less likely to carry guns compared with those in states that only require background checks on sales through federally licensed firearms dealers. The NICS was only effective in reducing adolescent gun carrying in the presence of state laws requiring U/BCs on all prospective gun buyers. However, state U/BC laws had no effect on adolescent gun carrying until after the NICS was implemented.
Invasive pneumococcal disease (IPD) and pneumonia are a leading cause of morbidity and mortality throughout the world, and asthma is the most common chronic disease of childhood.OBJECTIVE:
To evaluate the risk of IPD or pneumonia among children with asthma after the introduction of pneumococcal conjugate vaccines (PCVs).DATA SOURCES:
Four electronic databases were searched.STUDY SELECTION:
We selected all cohorts or case-control studies of IPD and pneumonia in populations who already received PCV (largely 7-valent pneumococcal conjugate vaccine), but not 23-valent pneumococcal polysaccharide, in which authors reported data for children with asthma and in which healthy controls were included, without language restriction.DATA EXTRACTION:
Two reviewers independently reviewed all studies. Primary outcomes were occurrence of IPD and pneumonia. Secondary outcomes included mortality, hospital admissions, hospital length of stay, ICU admission, respiratory support, costs, and additional medication use.RESULTS:
Five studies met inclusion criteria; of those, 3 retrospective cohorts (~26 million person-years) and 1 case-control study (N = 3294 children) qualified for the meta-analysis. Children with asthma had 90% higher odds of IPD than healthy controls (odds ratio = 1.90; 95% confidence interval = 1.63–2.11; I2 = 1.7%). Pneumonia was also more frequent among children with asthma than among controls, and 1 study reported that pneumonia-associated costs increased by asthma severity.LIMITATIONS:
None of the identified studies had information of asthma therapy or compliance.CONCLUSIONS:
Despite PCV vaccination, children with asthma continue to have a higher risk of IPD than children without asthma. Further research is needed to assess the need for supplemental 23-valent pneumococcal polysaccharide vaccination in children with asthma, regardless of their use of oral steroids.
2019 American Heart Association Focused Update on Pediatric Basic Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation’s continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.
2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post–cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.
2019 American Heart Association Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (<35 weeks of gestation). This article summarizes those evidence reviews and presents recommendations. The recommendations for neonatal resuscitation are as follows: In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen and to base subsequent oxygen titration on oxygen saturation targets. These guidelines require no change in the Neonatal Resuscitation Algorithm–2015 Update.
Latino children in immigrant families experience health care disparities. Text messaging interventions for this population may address disparities. The objective of this study was to evaluate the impact of a Spanish-language text messaging intervention on infant emergency department use and well care and vaccine adherence.METHODS:
The Salud al Día intervention, an educational video and interactive text messages throughout the child’s first year of life, was evaluated via randomized controlled trial conducted in an urban, academic pediatric primary care practice from February 2016 to December 2017. Inclusion criteria were publicly insured singleton infant <2 months of age; parent age >18, with Spanish as the preferred health care language; and at least 1 household cellular phone. Primary outcomes were abstracted from the electronic medical record at age 15 months. Intention-to-treat analyses were used.RESULTS:
A total of 157 parent-child dyads were randomly assigned to Salud al Día (n = 79) or control groups (n = 78). Among all participants, mean parent age was 29.3 years (SD: 6.2 years), mean years in the United States was 7.3 (SD: 5.3 years), and 87% of parents had limited or marginal health literacy. The incidence rate ratio for emergency department use for the control versus intervention group was 1.48 (95% confidence interval: 1.04–2.12). A greater proportion of intervention infants received 2 flu vaccine doses compared with controls (81% vs 67%; P = .04).CONCLUSIONS:
This Spanish-language text messaging intervention reduced emergency department use and increased flu vaccine receipt among a population at high risk for health care disparities. Tailored text message interventions are a promising method for addressing disparities.
Leftover prescription opioids pose risks to children and adolescents, yet many parents keep these medications in the home. Our objective in this study was to determine if providing a behavioral disposal method (ie, Nudge) with or without a Scenario-Tailored Opioid Messaging Program (STOMP) (risk-enhancement education) improves parents’ opioid-disposal behavior after their children’s use.METHODS:
Parents whose children were prescribed a short course of opioids were recruited and randomly assigned to the Nudge or control groups with or without STOMP. Parents completed surveys at baseline and 7 and 14 days. Main outcomes were (1) prompt disposal (ie, immediate disposal of leftovers after use) and (2) planned retention (intention to keep leftovers).RESULTS:
There were 517 parents who took part, and 93% had leftovers after use. Prompt disposal behavior was higher for parents who received both the STOMP and Nudge interventions (38.5%), Nudge alone (33.3%), or STOMP alone (31%) compared with controls (19.2%; P ≤ .02). Furthermore, the STOMP intervention independently decreased planned retention rates (5.6% vs 12.5% no STOMP; adjusted odds ratio [aOR] 0.40 [95% confidence interval (CI) 0.19–0.85]). Higher risk perception lowered the odds of planned retention (aOR 0.87 [95% CI 0.79–0.96]), whereas parental past opioid misuse increased those odds (aOR 4.44 [95% CI 1.67–11.79]).CONCLUSIONS:
Providing a disposal method nudged parents to dispose of their children’s leftover opioids promptly after use, whereas STOMP boosted prompt disposal and reduced planned retention. Such strategies can reduce the presence of risky leftover medications in the home and decrease the risks posed to children and adolescents.
Mental health disorders in adolescents present some of the most challenging of all ethical dilemmas. This is particularly true when they lead to self-injurious behavior that can only be prevented by either limiting the freedom of the adolescent or forcing treatments on them that they do not want. Intentional and repeated foreign-body ingestion (FBI) in youth is a poorly understood self-injurious behavior that can be life-threatening. It poses unique clinical and ethical challenges. Ingestion of sharp or magnetic objects increases the need for endoscopic retrieval or surgical intervention with associated risks, including perforation and anesthesia-related adverse events. When behavior modification efforts fail to prevent recurrent FBI, the cumulative risk of medical intervention mounts. Sometimes, as a last resort, doctors consider surgical procedures that limit jaw movement and may physically prevent recurrent FBI. In this Ethics Rounds article, we present a case in which doctors consider whether it is in the best interest of a teenager with this behavior to undergo orthodontic jaw wiring as a next step in treatment of repeated FBI. Doctor commentary on the ethical decision-making process is provided.
Pediatricians aspire to optimize overall health and development, but there are no comprehensive measures of well-being to guide pediatric primary care redesign. The objective of this article is to describe the Cincinnati Kids Thrive at 5 outcome measure, along with a set of more proximal outcome and process measures, designed to drive system improvement over several years. In this article, we describe a composite measure of "thriving" at age 66 months, using primary care data from the electronic health record. Thriving is defined as immunizations up-to-date, healthy BMI, free of dental pain, normal or corrected vision, normal or corrected hearing, and on track for communication, literacy, and social-emotional milestones. We discuss key considerations and tradeoffs in developing the measure. We then summarize insights from applying this measure to 9544 patients over 3 years. Baseline rates of thriving were 13% when including all patients and 31% when including only patients with complete data available. Interpretation of results was complicated by missing data in 50% of patients and nonindependent success rates among bundle components. There was considerable enthusiasm among other practices and sectors to learn with us and to measure system performance using time-linked trajectories. We learned to present our data in ways that balanced aspirational long-term or multidisciplinary goal-setting with more easily attainable short-term aims. On the basis of our experience with the Thrive at 5 measure, we discuss future directions and place a broader call to action for pediatricians, researchers, policy makers, and communities.
Young children have increasing access to interactive applications (apps) at home and at school. Existing research is clear on the potential dangers of overuse of screens, but there is less clarity around the extent to which interactive apps may be helpful in supporting early learning.OBJECTIVE:
In this systematic review, we present a narrative synthesis of studies examining whether children <6 years can learn from interactive apps.DATA SOURCES:
The PsycInfo, PubMed, ACM Digital Library, and ERIC databases were searched.STUDY SELECTION:
Studies were included if the study design was randomized or nonrandomized controlled (quasi-experimental), the sample mean age was <6 years, the intervention involved children playing with an interactive app, and academic, cognitive, or social-emotional skill outcomes were measured.DATA EXTRACTION:
Of 1447 studies, 35 were included.RESULTS:
Evidence of a learning benefit of interactive app use for early academic skills was found across multiple studies, particularly for early mathematics learning in typically developing children. Researchers did not find evidence of an intervention effect for apps aiming to improve social communication skills in children with autism spectrum disorder.LIMITATIONS:
Risk of bias was unclear for many studies because of inadequate reporting. Studies were highly heterogenous in interventions, outcomes, and study design, making comparisons of results across studies difficult.CONCLUSIONS:
There is emerging evidence to suggest that interactive apps may be useful and accessible tools for supporting early academic development. More research is needed to evaluate both the potential of educational apps to support early learning, and their limitations.
Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children.OBJECTIVE:
To explore the effectiveness of IND for procedural distress in children.DATA SOURCES:
We performed electronic searches of Medline (1946–2019), Embase (1980–2019), Google Scholar (2019), Cumulative Index to Nursing and Allied Health Literature (1981–2019), and Cochrane Central Register.STUDY SELECTION:
We included randomized trials of IND for procedures in children.DATA EXTRACTION:
Methodologic quality of evidence was evaluated by using the Cochrane Collaboration’s risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. The primary outcome was the proportion of participants with adequate sedation.RESULTS:
Among 19 trials (N = 2137), IND was superior to oral chloral hydrate (3 trials), oral midazolam (1 trial), intranasal midazolam (1 trial), and oral dexmedetomidine (1 trial). IND was equivalent to oral chloral hydrate (2 trials), intranasal midazolam (2 trials), and intranasal ketamine (3 trials). IND was inferior to oral ketamine and a combination of IND plus oral ketamine (1 trial). Higher doses of IND were superior to lower doses (4 trials). Adverse effects were reported in 67 of 727 (9.2%) participants in the IND versus 98 of 591 (16.6%) in the comparator group. There were no reports of adverse events requiring resuscitative measures.LIMITATIONS:
The adequacy of sedation was subjective, which possibly led to biased outcome reporting.CONCLUSIONS:
Given the methodologic limitations of included trials, IND is likely more effective at sedating children compared to oral chloral hydrate and oral midazolam. However, this must be weighed against the potential for adverse cardiovascular effects.
Adenovirus infection is common in childhood and is generally associated with self-limited disease. Cidofovir, a viral DNA polymerase inhibitor, is used to treat adenovirus infection in select populations but is not often recommended for immunocompetent patients because of limited antiviral activity and nephrotoxicity. Here, we report a case of fulminant adenovirus infection associated with lymphopenia and multiple organ failure requiring extracorporeal membrane oxygenation support in a previously healthy child. After 1 week of supportive therapy, the patient had persistent organ failure and continued to have adenoviremia of >560 000 copies per mL. Weekly doses of cidofovir with concurrent probenecid for renal protection was initiated. Adenovirus blood load declined after the first cidofovir dose, becoming undetectable after 3 doses. The patient was successfully decannulated from extracorporeal membrane oxygenation, extubated, and eventually discharged at his functional baseline without need for ongoing respiratory support. Lymphopenia improved after viremia resolved, and a subsequent immunologic workup revealed no evidence of primary immunodeficiency. The viral isolate was genotyped as adenovirus type 7. This case reveals the successful use of cidofovir for management of severe adenovirus infection in a previously healthy child. To date, there are no universally accepted recommendations for the use of cidofovir in this population. Further study is warranted to determine the potential role of cidofovir in treating severe adenovirus infections in immunocompetent children.