Electrocardiogram Abnormalities in Children With Lyme Arthritis.

BACKGROUND: Classically, Lyme disease follows a staged illness pattern with carditis occurring in early disseminated disease and arthritis in late-stage disease. A more comprehensive understanding of Lyme suggests that clinical stages may intersect. Little is known regarding the overlap of electrocardiogram (ECG) abnormalities in children with Lyme arthritis. This study aimed to estimate the prevalence of ECG changes in pediatric patients presenting with Lyme arthritis. METHODS: In this retrospective, cross-sectional study was conducted at a tertiary care children's hospital in a Lyme endemic area; patients were identified based on Lyme testing performed from January 2012 to August 2022. Children diagnosed with Lyme arthritis by 2-tiered serology with ECGs obtained within 2 days of antibiotic initiation were included. A study cardiologist reviewed all ECGs for evidence of carditis defined as atrioventricular block, ST-T wave changes, QTc interval prolongation, accelerated junctional rhythm or right bundle branch block. RESULTS: Two hundred thirty-three patients were diagnosed with Lyme arthritis; 90 (38.6%) had ECGs completed. Five patients (5.6%) had ECG abnormalities: 3 were diagnosed with first-degree atrioventricular block, 1 with QTc prolongation, and 1 with ST-T wave changes. No clinical or laboratory features in patients with Lyme arthritis were associated with an increased likelihood of having an abnormal ECG. All patients with ECG abnormalities were treated with oral antibiotics, and none had clinically significant cardiac disease. CONCLUSIONS: ECG abnormalities in children with Lyme arthritis rarely occur and, when present, are not reflective of clinically significant cardiac disease. These results do not support routine screening ECGs on asymptomatic pediatric patients with Lyme arthritis.

Variability in Occult Injury Screening Among Siblings/Household Contacts of Physical Abuse Victims.

OBJECTIVE: The objective of this study is to examine radiologic occult injury screening performance/yield among contacts presenting for precautionary medical assessments and assess factors associated with deferred screening. METHODS: Data were collected retrospectively from charts of contacts younger than 8 years presenting for precautionary evaluation to a level 1 pediatric emergency department January 1, 2018 to March 31, 2023. Demographics, radiologic performance/yield, physical examination, social work-based psychosocial assessment, reasons for deferred imaging, and diagnostic codes were abstracted. Descriptive statistics and χ 2 analysis are reported. RESULTS: Three hundred ninety contacts were identified; 364 (93.3%) were biological siblings. Most (276, 70.8%) were 2 to 8 years old. Statistically significant relationships were identified with age, insurance, and hospital social work assessment and screening. Thirty-four infants (54%) underwent neuroimaging; no studies were abnormal. Of 114 contacts, <2 years old, 97 (85%) underwent skeletal survey (SS); 9 (9%) SS were abnormal. Twenty-seven (24%) returned for follow-up SS; 4 (14.8%) were abnormal. For 2 contacts, an abnormal initial SS was refuted by follow-up imaging. Physical examinations were abnormal for 11% of contacts. Reasons for deferred imaging included contact well appearance, caregiver concerns, and clinician disagreement with indications. Encounter International Classification of Diseases codes varied, commonly reflecting nonspecific screening assessments. CONCLUSIONS: Despite national clinical practice guidelines, studies of abusive injury prevalence and radiologic yield among at-risk contacts exposed to unsafe environments are few. Screening evaluations inclusive of physical examination and radiologic studies identify abuse concerns among at-risk contacts. Further study of factors impacting radiologic screening decisions is needed. Considerations to advance epidemiologic research include standardized diagnostic coding and prospective assessment of radiologic yield.

Factors Impacting Maltreatment Evaluation and Reports to Child Protective Services in Pediatric Substance Exposures.

OBJECTIVES: The objective of this study was to assess demographic, clinical, and psychosocial factors associated with pediatric substance exposures, describe the medical evaluation, and identify factors associated with social work (SW) and hospital-based child protection team (CPT) safety assessments and reports to child protective services (CPS). METHODS: We retrospectively reviewed charts of electronic medical records for children ages 0 to 72 months presenting for accidental ingestion evaluated May 1, 2015 to May 1, 2021 at a level 1 pediatric trauma center. Cases of environmental exposures, iatrogenic medication errors, dosing errors, and allergies/adverse reactions were excluded. Data were analyzed using descriptive statistics; χ 2 and multivariable logistic regression analysis assessed factors associated with two primary outcomes of interest, SW/CPT assessment and CPS report. RESULTS: Among 773 total cases of substance exposures during the studied time frame, 27% were referred to SW/CPT for further safety assessments and 15.4% were reported to CPS. Being admitted to the hospital, prescription medication or recreational/illegal/illicit substance exposures, and increasing psychosocial risk factors were found to be significantly associated with referrals. Age, race, and insurance status were not found to be associated. Toxicology screening was performed in only 24.7% of cases. Of those eligible for further imaging per hospital protocol, skeletal surveys were obtained in 5.5% of cases and head imaging was obtained in 9% of cases. CONCLUSIONS: There is significant variability in pediatric substance exposure assessment practices. Disparities based on demographic characteristics are uncommon. Perceived severity of condition, exposures involving recreational/illegal/illicit substances, and greater prevalence of family psychosocial adversities are associated with higher rates of SW/CPT assessment and CPS reports.

A Summer of Fevers and Fussiness: Eighteen Infants Admitted With Parechovirus Meningitis.

OBJECTIVE: To define the presentation, spectrum of illness, and outcomes in infants with parechovirus (PeV) meningitis admitted to our inpatient general pediatrics service during a spike in incidence of admissions in summer 2022. PATIENTS AND METHODS: This study is a retrospective case series of all patients aged 3 months and younger discharged from our institution with a CSF BioFire (BioFire Diagnostics, Salt Lake City, UT) FilmArray Polymerase Chain Reaction Meningitis/Encephalitis Panel result positive for PeV between January 1 and September 19, 2022. We collected and analyzed clinical and demographic data. RESULTS: Eighteen infants with PeV meningitis were admitted within our time frame, with 8 (44%) of the admissions occurring in July. Patients' mean age was 28.7 days and mean length of stay was 50.5 hours. Although all had a history of fever, only 72% were febrile on presentation. Laboratory findings showed a procalcitonin of less than 0.5 ng/mL in 86% of the 14 patients who had it drawn and no cerebrospinal fluid (CSF) pleocytosis in 83% of the patients who had CSF cell counts sent. Neutropenia was present in 17%. Although 89% of infants were given initial antibiotics, antibiotics were discontinued in 63% once their CSF panel returned positive for PeV, and in all by 48 hours. CONCLUSIONS: Infants hospitalized with PeV meningitis were febrile and fussy, but experienced uncomplicated hospital stays without neurological deficits. Parechovirus meningitis must be considered as a common cause of acute viral meningitis in young infants even without CSF pleocytosis. This study, although limited in scope and follow-up, can potentially assist in the diagnosis and treatment of PeV meningitis at other institutions.

Sensitivity of Two-Tiered Lyme Disease Serology in Children With an Erythema Migrans Lesion.

In our prospective cohort of 192 children with a physician-diagnosed erythema migrans (EM) lesion, two-tier Lyme disease serology had higher sensitivity in children with multiple EM lesions (76.8% multiple lesions vs. 38.1% single EM; difference 38.7%, 95% confidence interval 24.8%-50.4%). The diagnosis of cutaneous Lyme disease should be based on careful physical examination rather than laboratory testing.

COVID-19 Screening in the Pediatric Emergency Department.

BACKGROUND: Screening for COVID-19 infection in pediatrics is challenging as its clinical presentation may be asymptomatic or mimic other common childhood infections. We examined the use of a COVID-19 screening protocol (CSP) in the pediatric emergency department (PED) to determine the incidence of positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) tests in patients who are CSP+ and CSP-. METHODS: We conducted a retrospective cohort study of pediatric patients with SARS-CoV-2 testing completed in an urban tertiary care PED from November 1 to December 31, 2020. Demographics, CSP designation, test results, and disposition were compared. Statistical significance was determined using chi-square or a comparison of means. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) with 95% confidence intervals (CI) were calculated. RESULTS: A total of 1,613 patients had SARS-CoV-2 tests completed with 9.1% (N=147) having positive test results. Of 1,014 (62.9%) patients who were CSP+, 12.9% tested positive. Comparatively, 599 (37.1%) patients were CSP- with only 2.7% positive tests, p<0.0001. The sensitivity, specificity, NPV, and PPV of the CSP in all tested patients were 89.1%, 39.8%, 97.3%, and 12.9%, respectively. Of tested patients, 887 (55.0%) were admitted to the hospital and were more likely to be positive if CSP+, p≤0.001. Within the admitted group, 16.8% were admitted to the operating room, of whom 83.9% were CSP- with 4.0% testing positive for SARS-CoV-2. CONCLUSIONS: COVID-19 screening in the pediatric population is a useful modality to risk stratify most patients presenting to the PED for the purpose of selective testing and guiding personal protective equipment use. This may be particularly useful in low-resource settings.

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents.

BACKGROUND: Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion. METHODS: We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models. RESULTS: Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P < .01). Vomiting was significantly associated with torsion for all patients (P < .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion. CONCLUSIONS: Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together. LEVEL OF EVIDENCE: Study of Diagnostic Test, Level II.

Preoperative Hospitalist Telehealth Visits for Medically Complex Children During the COVID-19 Pandemic.

BACKGROUND: During the coronavirus disease 2019 pandemic, telehealth has emerged as an alternative to in-person visits. Our children's hospital's preoperative program includes a pediatric hospitalist evaluation of medically complex patients undergoing elective orthopedic surgery. Starting in March 2020, patients were offered either in-person or telehealth preoperative visits. Few data exist regarding preoperative telehealth for medically complex children. We sought to assess this program's practicality and compare clinical characteristics, demographic data, and visit outcome data of patients seen via telehealth versus those seen in person. METHODS: We retrospectively collected demographic or clinical data, visit characteristics, and visit outcome data of medically complex children scheduled for orthopedic surgery seen April-October 2020. We reviewed the data to compare characteristics of patients seen in person to those seen via telehealth. RESULTS: We reviewed 68 visits: 34 (50%) telehealth and 34 (50%) in-person. There was no statistically significant difference in telehealth use by primary language, insurance type, underlying medical condition, gross motor function classification system score, or technology dependence. There was no significant difference between the median number of hospitalist recommendations (4 telehealth vs 3 in-person, P = .553) or progression to surgery (32 vs 32, odds ratio 1.000, confidence interval 0.133-7.540) on the basis of visit type. CONCLUSIONS: A preoperative telehealth program is practical for medically complex children. We found no significant difference in telehealth use between technology-dependent patients and those who are not. Further study of preoperative telehealth visits will hopefully be broader in scope.

Hospital Costs, Revenue, and Abuse Detection Associated With Occult Injury Screening.

OBJECTIVE: Performance of occult injury screening including skeletal surveys and neuroimaging is recommended to comprehensively evaluate suspected child physical abuse. Screening performance-associated hospital costs and net revenue for care of index abuse victims and siblings/household contacts are largely unknown. We aimed to describe 1) costs and net revenue associated with radiologic occult injury screening at an urban level 1 pediatric trauma center, 2) areas of perceived high resource intensity (time spent in abuse victim-related care), and 3) detection yield among children undergoing occult injury screening and physical assessment. METHODS: Using time-driven activity-based cost analysis, hospital, per physician, staff, and radiology costs associated with occult injury screening performance were mapped for 199 children <2 years old. Hospital costs and resource times were approximated and compared with net revenue for each healthcare encounter. Abstracted variables included index/sibling status, injury classification, and length of stay (LOS). RESULTS: Of 199 children with variable LOS (0-45 days), total hospital costs (facility, physician, staff, radiology) ranged $297.83 to $81,474; net revenue was positive. Total ED time per abuse case varied 32 to 1823 minutes; social work (SW) time ranged 44 to 720 minutes; prolonged ED/SW time represented resource-intense areas. Of siblings, 27% were diagnosed with unanticipated findings based on occult injury screening and examination. CONCLUSIONS: At a single center, occult injury screening was associated with cost variability, resource intensity, and enhanced victim identification when external examination findings or clinical symptoms were absent. While further study is needed, cost and resource concerns associated with screening may be offset by societal benefit and minimal hospital-based financial losses.

Impact of Plans of Safe Care on Prenatally Substance Exposed Infants.

OBJECTIVE: To assess the impact of recent federal statute changes mandating child welfare-based Plan of Safe Care (POSC) supportive programming and community-based linkages to treatment providers, resources, and services for families of infants affected by prenatal substance exposure (IPSE). STUDY DESIGN: Retrospective review of Delaware's statewide child welfare case registry data for IPSE birth notifications and subsequent hotline reports for serious physical injury/fatality concerns from November 1, 2018-October 31, 2020. Abstracted variables included IPSE sex, substance exposure type, family characteristics (maternal personal child welfare history or mental health diagnosis, treatment engagement), and POSC referrals. RESULTS: Of 1436 IPSE, 1347 (93.8%) had POSC support. Most IPSE (67.2%) had exposure to single substance types prenatally. Nearly 90% avoided out-of-home placement. Nearly one-fourth of mothers delivered a prior IPSE; 40% of mothers had personal histories of childhood protective services involvement. Also, 43.5% of mothers and 9.1% of fathers were referred to community-based resources, including substance use, mental health treatment, parenting classes, and home visiting nursing. Nearly 58% of IPSE were referred for pediatric/developmental assessment. Notably, 0.82% (11 out of 1347) of IPSE with POSC sustained serious physical or fatal injury. CONCLUSIONS: POSC promote supportive, potentially protective linkages to community-based programming for IPSE and their families.