Failure to Thrive, Metabolic Acidosis, and Diarrhea in a 7-Week-Old Infant.

A 7-week-old infant presented to the emergency department with fussiness, decreased oral intake, loose stool, and respiratory distress for 2 days. The patient was born full-term with an uncomplicated birth history but had a history of slow weight gain. He was alert, but toxic-appearing at presentation, hypothermic with signs of dehydration, and with respiratory failure. He was found to have severe anion gap metabolic acidosis, hypokalemia, elevated lactate, and hyperammonemia. He responded well to initial resuscitation and was admitted to the ICU for intravenous electrolyte replacement, bowel rest, and respiratory support. A workup was pursued for failure to thrive with severe malnutrition, hyperammonemia, hyperlactatemia, anemia, vitamin D deficiency, and electrolyte abnormalities. After stabilization, he was restarted on enteral feeds and had a recurrence of loose stool and severe electrolyte abnormalities, which were refractory to enteral supplementations and required readmission to the ICU. His hospital course extended several weeks, included several subspecialty consultations, and ended with a surprising diagnosis of exclusion based on his clinical response to therapy.

Treating Children and Adolescents with Aggressive Behaviors in the Inpatient Setting.

The mental health crisis in children and adolescents presents a unique challenge for pediatric providers in the inpatient setting. Patients are presenting to the emergency department in acute psychiatric crises, but the increased need for behavioral health services is met with an already limited supply of behavioral health services and facilities. As such, these patients are hospitalized on acute care floors, which can serve to exacerbate symptoms of aggression regardless of cause and complicates treatment and harm prevention strategies. We present a comprehensive management approach to the acutely agitated pediatric patient with aggressive behaviors, including prevention of symptoms in patients with risk factors; nonpharmacological approaches to de-escalation, including the use of restraint; and common oral and parenteral psychopharmacological agents. Such strategies are considered from a medical, ethical, and legal standpoint with the goal of maintaining safety and minimizing harm to patients, families, and staff. [Pediatr Ann. 2024;53(8):e293-e298.].

The Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study.

BACKGROUND AND OBJECTIVES: With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams. METHODS: In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis. RESULTS: Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows. CONCLUSIONS: This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.

The Kids Are Alright: a New Generation of Educators.

Generational theory states that as a result of experiencing the same life-altering, world-wide events at key developmental ages, individuals of a given generation share unique perspectives, values, and traits compared to other generations as reported by Johnson and Romanello (Nurse Educ. 30(5):212-216, 2005) and Howe and Strauss 2000. Thus, while individual variation still exists, generational theory can be used as a tool to predict individual behavior and capitalize on shared traits in the workplace or educational setting. The millennial generation, born between 1981 and 1996, has previously been negatively perceived; however, application of generational theory can allow for a reshaping of public perception. For example, there now exists ample research, both within and outside of medical education, on how to take advantage of typical traits of the millennial student to maximize their learning, such as Twenge (Med Educ. 43(5):398-405, 2009), Eckleberry-Hunt and Tucciarone (J Grad Med Educ. 3(4):458-461, 2011), and Nicholas (Int J Learn Annu Rev. 15(6):27-34, 2008). As the cohort ages, the focus has shifted to helping millennials reach their full potential as employees. However, due to intensive and lengthy training required, medicine is only now seeing the first cohort of millennials entering the workforce as faculty physicians. As such, academic medicine is seeing millennials move from the learner role into that of the teacher. Thus far, the influence of the shared generational characteristics on their success and challenges as clinician educators and educational leaders is novel and has not been explored in the literature. By overlaying generational theory on Srinivasan et al.'s (Acad Med. 86(10):1211-1220, 2011) proposed six competencies for medical educators, we predict the strengths and challenges of millennial medical educators and hypothesize on the impact this generation may have on academic medicine.

From Telemedicine to the ICU-Fever and Rash in a 9-Year-Old Girl.

A 9-year-old girl presented to her primary care pediatrician via telemedicine during the initial months of the coronavirus disease 2019 pandemic because of 4 days of warmth perceived by her mother, decreased energy, and a new rash on her upper extremities. After 10 additional days of documented fever >38°C, worsening fatigue, and 1 day of nausea, vomiting, and diarrhea, she was allowed to schedule an in-person visit with her pediatrician after testing negative for severe acute respiratory syndrome coronavirus 2. She appeared ill on arrival to clinic, and her pediatrician recommended evaluation in an emergency department. Her initial laboratory testing revealed nonspecific elevation in several inflammatory markers and leukopenia, and she responded well to intravenous hydration. Over the next 2 weeks, her fever persisted, constitutional symptoms worsened, and she developed progressively painful cervical lymphadenopathy and pancytopenia. She was evaluated in clinic by several specialists and eventually was urged to present to the emergency department again, at which time she was admitted to the PICU. After consulting additional specialists and waiting for laboratory results, the team reached a definitive diagnosis and initiated therapy; however, she experienced rapid clinical decline shortly thereafter. The specialists who assisted with identification of the underlying etiology of her symptoms were able to work together to manage the subsequent complications.

How Perceived Burnout Alters Frontline Educators' Assessments in the Clinical Learning Environment.

OBJECTIVE: This study explores frontline educators' experience with learner burnout in the clinical learning environment (CLE) and how perceived burnout may impact assessment. METHODS: A survey was sent to 105 Pediatric Hospital Medicine faculty and fellows at 7 sites across the United States representing diverse CLEs. They were invited to participate in an 11-question web-based survey that was developed, edited, and revised in step-wise fashion. It consisted of 5-point Likert scale, forced-choice, and dichotomous questions. Data from the web-based survey were compiled for descriptive purposes and analyzed for trends. RESULTS: The response rate was 53%. Most respondents (83%) perceive learner burnout at least once per year, but median comfort in identifying burnout was 3 (scale 1-5, 3 = neutral). Factors associated with comfort were education as primary niche (P = .01) and having wellness training (P = .045). In terms of the impact of perceived learner burnout impacts on assessment, 88% report impact on feedback sessions and 60% reported impact on summative assessment; most are more lenient. Stated belief in whether perceived burnout should or should not impact assessment had 60% sensitivity and 84% specificity in predicting whether it does. CONCLUSIONS: Frontline educators routinely perceive learner burnout in the CLE and it often impacts educators' assessment of a learner. The discrepancy between the expected and actual impact may suggest amplification of known barriers to accurate assessment in the CLE. Comfort associated with wellness training suggests that interventions targeting frontline educators in the CLE may improve their ability to simultaneously support and assess learners.

Salpingitis in an Adolescent Female With Constipation and Abdominal Pain.

Abdominal pain is one of the most common presenting complaints in the emergency room for pediatric patients. While constipation is one of the most common causes for abdominal pain in pediatrics, serious intra-abdominal pathology must always be excluded. We report a pre-coital post-menarchal adolescent female who presented with severe abdominal pain and constipation and had radiographic findings of salpingitis. It was suspected that uterine and adnexal changes seen on imaging resulted from the fecal mass compressing the genitourinary tract leading to fluid collection manifesting as radiographic evidence of salpingitis. This mechanism is similar to bladder outlet obstruction resulting from compression by intestinal stool burden, leading to urinary stasis, bacteriuria, and ascending urinary tract infection. This case demonstrates how a common pediatric problem, constipation, can lead to a condition rarely found in the pre-coital adolescent population.

Comparison of a Teaching and Nonteaching Service at a Children's Hospital in the Community.

OBJECTIVE: The impact of trainees on inpatient patient care is incompletely understood. This study sought to discern the impact of trainees on patient outcomes and costs at a children's hospital in the community. We hypothesized that there would be no differences in patient outcomes and costs on an inpatient teaching service compared to a nonteaching service. As a secondary goal, we analyzed trainee evaluations. METHODS: The authors conducted a cohort study of patients hospitalized from October 1, 2016 to September 30, 2017 on an acute care unit in a children's hospital in the community. Using t test or Fisher exact test, the authors compared patient outcomes between teaching and nonteaching services including, length of stay, discharge times, readmission rates, rapid response team (RRT) calls, pediatric intensive care unit (PICU) transfers, hospital transfers, and costs. RESULTS: During the study period, there were 1066 patients admitted and discharged from the teaching service and 1038 from the nonteaching service. There were no statistically significant differences in patient demographics or patient complexity. Similarly, there were no differences in length of stay, discharge times, readmission rates, RRT calls, PICU transfers, hospital transfers or patient costs between services. Trainee evaluations of the inpatient experience were overwhelmingly positive. CONCLUSIONS: In a children's hospital in the community, there were no significant differences in patient outcomes and costs on a teaching service compared to a nonteaching service. Furthermore, trainee evaluations suggested a favorable learning experience, illustrating the feasibility of incorporating trainees into inpatient care in a nontraditional learner setting.

Stridor Due to Cranial Nerve X Palsy Progressing to Polyneuropathy in a Teenager With COVID-19.

The neurologic manifestations of coronavirus disease 2019 (COVID-19) are wide-ranging, including various cranial neuropathies, beyond anosmia and dysgeusia, the exact neuropathological mechanism of which are yet unknown. Acute cranial nerve (CN) X neuritis with vocal cord paralysis has not been reported in COVID-19 and is a rare presentation of neuropathy in general. A girl aged 14 years was admitted with stridor. She was diagnosed with symptomatic COVID-19 8 days before. By presentation, fever had resolved, but she had developed stridor; sore throat with dysphagia; chest, shoulder, and back pain; and generalized weakness. Neurologic examination and laryngoscopy were consistent with isolated left CN X palsy. Steroids were started, but neurologic disease progressed with subjective pain, right lower face numbness, and eye fatigability. Respiratory distress increased, and she was intubated for airway protection. MRI revealed abnormal enhancement of CNs III, V, XII, and X. Cerebrospinal fluid studies were normal. Nasopharyngeal severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test result was positive. She was treated with intravenous immunoglobulin, a total of 2 g/kg, and steroids were continued. She made a full neurologic recovery and was discharged after 9 days of hospitalization. This is a case of a teenager who presented with an acute, life-threatening CN X palsy and development of a progressive polyneuropathy in the setting of COVID-19. Although there was concern for Guillain-Barre syndrome, a definitive diagnosis could not be made, and the unusual features of this case, including presentation with stridor and predominate CN involvement seem to indicate a separate symptomatic COVID-19-associated polyneuritis.

Murine Typhus in 5 Children Hospitalized for Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children (MIS-C) is an emerging disease described in children in association with infection or epidemiological link to severe acute respiratory syndrome coronavirus 2. Signs and symptoms include fever, rash, and cardiac dysfunction; US Centers for Disease Control and Prevention have put forth broad criteria for diagnosis. The illness is serious and can progress rapidly to heart failure and death. However, findings in MIS-C are nonspecific, and there is significant overlap with other systemic illnesses, including Kawasaki disease and several viral and bacterial infections. We present 5 children admitted to a teaching hospital within an 11-day period in May 2020 for MIS-C evaluation who were later diagnosed with murine typhus. Typhus is a rickettsial infection that presents with fever and rash, and, although usually self-limited, responds well to treatment with doxycycline to shorten the course of illness. Clinical and laboratory characteristics of these children are presented to illustrate similarities to MIS-C, which can also be shared with viral, bacterial, or other regional endemic infections, as well as noninfectious inflammatory diseases. This case series serves to remind pediatric hospitalists to be vigilant to avoid premature closure on MIS-C for children admitted with fever and systemic inflammation. Maintaining a wide differential diagnosis in approaching such patients is of utmost importance as community exposure to severe acute respiratory syndrome coronavirus 2 is likely and evidence of past infection becomes commonplace.

A 16-Year-Old Boy With Cough and Fever in the Era of COVID-19.

A 16-year-old white boy with a history of chronic lung disease of prematurity, cough-variant asthma, and incidental lung nodules presented to the emergency center in spring 2020 with acute onset dry cough, shortness of breath, and fever. An initial history, gathered from his mother because of the patient's respiratory distress, revealed no recent travel. However, his mother is a health care worker at a hospital, and sick contacts included ongoing contact with a friend with cold-like symptoms. He had a variety of animals at home, including a dog, cats, fish, rodents, and reptiles. He had a history of vaping tobacco products >6 months ago. Fever and respiratory symptoms were associated with fatigue, chest tightness, abdominal pain, and myalgias. On examination, he was ill appearing and had tachycardia, tachypnea, borderline hypoxia with an oxygen saturation of 91% on room air, diminished breath sounds at the lung bases, and unremarkable abdominal examination results. A chest radiograph was consistent with the lung examination, revealing bilateral lower lobe hazy infiltrates. He showed initial improvement for 48 hours with antibiotics, intravenous fluid resuscitation, oxygen via nasal cannula, albuterol, and prednisone. Subsequently, he worsened with persistent high fever, increasing respiratory distress with pulmonary findings, and severe persistent epigastric pain, which added a layer of diagnostic complexity. As this patient's clinical course evolved and further history became available, pulmonary medicine and infectious diseases services were consulted to guide diagnostic evaluation and treatment of this patient early in the era of coronavirus disease 2019.

Barriers to Tobacco Cessation for Caregivers of Hospitalized Children: Perspectives of Pediatric Hospitalists.

OBJECTIVES: Secondhand smoke exposure is associated with adverse health outcomes in children, yet tobacco cessation efforts for caregivers of hospitalized children are lacking. We sought to explore pediatric hospitalists' attitudes and barriers to providing tobacco cessation for caregivers of hospitalized children. METHODS: We conducted a cross-sectional survey of pediatric hospitalists and fellows at 7 hospitals from November 1, 2018, to November 30, 2019. A 70-question anonymous survey was used to assess participants' perceptions of current practices, attitudes, and barriers to providing tobacco cessation support for caregivers of hospitalized children. We used descriptive statistics to summarize the data. RESULTS: Of 207 eligible participants, 100 responded (48%). A majority (79%) agreed that offering tobacco cessation counseling for caregivers is an important part of their role in caring for hospitalized children, but 79% never received tobacco cessation training. Only half of the participants were comfortable providing brief advice and few were comfortable prescribing nicotine replacement therapy. Identified barriers included lack of time (74%), perceived lack of interest from patients' caregivers (71%), and other medical conditions of the patient taking priority (70%). The majority of participants were interested in further training in tobacco cessation support. CONCLUSIONS: In this survey of 100 pediatric hospitalists, we found overall agreement that tobacco cessation support for caregivers of hospitalized children is important. However, most participants did not feel comfortable with provision of evidence-based counseling or pharmacotherapy because of identified barriers. Future work should target actionable barriers to improve provision of tobacco cessation support in this clinical setting.

Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness.

OBJECTIVE: This study aims to assess whether secondhand smoke (SHS) exposure has an impact on health-related quality of life (HRQOL) in children with acute respiratory illness (ARI). METHODS: This study was nested within a multicenter, prospective cohort study of children (two weeks to 16 years) with ARI (emergency department visits for croup and hospitalizations for croup, asthma, bronchiolitis, and pneumonia) between July 1, 2014 and June 30, 2016. Subjects were surveyed upon enrollment for sociodemographics, healthcare utilization, home SHS exposure (0 or ≥1 smoker in the home), and child HRQOL (Pediatric Quality of Life Physical Functioning Scale) for both baseline health (preceding illness) and acute illness (on admission). Data on insurance status and medical complexity were collected from the Pediatric Hospital Information System database. Multivariable linear mixed regression models examined associations between SHS exposure and HRQOL. RESULTS: Home SHS exposure was reported in 728 (32%) of the 2,309 included children. Compared with nonexposed children, SHS-exposed children had significantly lower HRQOL scores for baseline health (mean difference -3.04 [95% CI -4.34, -1.74]) and acute illness (-2.16 [-4.22, -0.10]). Associations were strongest among children living with two or more smokers. HRQOL scores were lower among SHS-exposed children for all four conditions but only significant at baseline for bronchiolitis (-2.94 [-5.0, -0.89]) and pneumonia (-4.13 [-6.82, -1.44]) and on admission for croup (-5.71 [-10.67, -0.75]). CONCLUSIONS: Our study demonstrates an association between regular SHS exposure and decreased HRQOL with a dose-dependent response for children with ARI, providing further evidence of the negative impact of SHS.