A Case Report of Pediatric Paraneoplastic Dysautonomia.

We present the case of a 16-year-old girl who presented with severe refractory orthostatic hypotension secondary to pandysautonomia. Initially, she was treated for Guillain-Barré syndrome given clinical symptoms and increased protein on cerebrospinal fluid, but the severity of symptoms and lack of response to intravenous immunoglobulin prompted further evaluation for an autoimmune etiology. She was ultimately diagnosed with paraneoplastic neuropathy secondary to Hodgkin lymphoma. Paraneoplastic neurologic phenomena are rare, occurring in just 0.01% of cancers, and prompt recognition is crucial for initiating appropriate therapy. Rapid progression of severe disabling symptoms should raise suspicion for an underlying malignancy. The patient had limited response to splanchnic vasoconstrictors in addition to α-agonists, anticholinergics, and mineralocorticoids until initiation of modified Hodgkin lymphoma directed chemotherapy plus rituximab.

Diagnosis and treatment of Mycoplasma pneumoniae in children.

Mycoplasma pneumoniae is a common cause of community-acquired respiratory tract infections and accounts for up to 40% of cases of pneumonia in children over age 5. This article seeks to provide a general overview of the current recommended management of Mycoplasma pneumoniae infection in children.

Elemental mercury poisoning presenting as hypertension in a young child.

Mercury intoxication is an uncommon cause of hypertension in children and can mimic several other diseases, such as pheochromocytoma and vasculitis. Mercury intoxication can present as a diagnostic challenge because levels of catecholamines may be elevated, suggesting that the etiology is a catecholamine-secreting tumor. Once acrodynia is identified as a primary symptom, a 24-hour urine mercury level can confirm the diagnosis. Inclusion of mercury intoxication in the differential diagnosis early on can help avoid unnecessary and invasive diagnostic tests and therapeutic interventions. We discuss a case of mercury intoxication in a 3-year-old girl presenting with hypertension and acrodynia, without a known history of exposure. Chelation therapy successfully treated our patient's mercury intoxication. However, it was also necessary to concurrently treat her hypertension and the pain associated with her acrodynia. Because there were no known risk factors for mercury poisoning in this case, and because ritual use of mercury is common in much of the United States, we recommend high clinical suspicion and subsequent testing in all cases of acrodynia.

Pen Foreign Body Ingestion Mimicking Crohn's Disease in a Pediatric Patient.

Foreign body ingestion is common in pediatrics, particularly in children with psychiatric illness. Foreign bodies present for extended periods of time can trigger a local inflammatory reaction causing weight loss, abdominal pain, and elevated inflammatory markers, mimicking inflammatory bowel disease (IBD). We report a case of intentional pen ingestion in a 13-year-old, whose clinical presentation with elevated inflammatory markers and terminal ileitis suggested on imaging was initially suspicious for Crohn's disease but was found on colonoscopy to be due to foreign body reaction from ingestion of a pen.

Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

The Association of Seasonality With Resource Use in a Large National Cohort of Infants With Bronchiolitis.

OBJECTIVES: Examine the degree of seasonal variation in nonrecommended resource use for bronchiolitis management subsequent to publication of the American Academy of Pediatrics (AAP) 2014 guidelines. METHODS: We performed a multicenter retrospective cohort study using the Pediatric Health Information System database, examining patients aged 1 to 24 months, diagnosed with bronchiolitis between November 2015 and November 2018. Exclusions included presence of a complex chronic condition, admission to the PICU, hospital stay >10 days, or readmission. Primary outcomes were use rates of viral testing, complete blood count, blood culture, chest radiography, antibiotics, albuterol, and systemic steroids. Each hospital's monthly bronchiolitis census was aggregated into hospital bronchiolitis census quartiles. Mixed-effect logistic regression was performed, comparing the primary outcomes between bronchiolitis census quartiles, adjusting for patient age, race, insurance, hospitalization status, bacterial coinfection, time since publication of latest AAP bronchiolitis guidelines, and clustering by site. RESULTS: In total, 196 902 bronchiolitis patient encounters across 50 US hospitals were analyzed. All hospitals followed a similar census pattern, with peaks during winter months and nadirs during summer months. Chest radiography, albuterol, and systemic steroid use were found to significantly increase in lower bronchiolitis census quartiles, whereas rates of viral testing significantly decreased. No significant variation was found for complete blood count testing, blood culture testing, or antibiotic use. Overall adherence with AAP guidelines increased over time. CONCLUSIONS: Resource use for patients with bronchiolitis varied significantly across hospital bronchiolitis census quartiles despite adjusting for potential known confounders. There remains a need for greater standardization of bronchiolitis management.

Racial and ethnic disparities in bronchiolitis management in freestanding children's hospitals.

OBJECTIVE: Variation in bronchiolitis management by race and ethnicity within emergency departments (EDs) has been described in single-center and prospective studies, but large-scale assessments across EDs and inpatient settings are lacking. Our objective is to describe the association between race and ethnicity and bronchiolitis management across 37 U.S. freestanding children's hospitals from 2015 to 2018. METHODS: Using the Pediatric Health Information System, we analyzed ED and inpatient visits from November 2015 to November 2018 of children with bronchiolitis 3 to 24 months old. Rates of use for specific diagnostic tests and therapeutic measures were compared across the following race/ethnicity categories: 1) non-Hispanic White (NHW), 2) non-Hispanic Black (NHB), 3) Hispanic, and 4) other. The subanalyses of ED patients only and children < 1 year old were performed. Mixed-effect logistic regression was performed to compare the adjusted odds of receiving specific test/treatment using NHW children as the reference group. RESULTS: A total of 134,487 patients met inclusion criteria (59% male, 28% NHB, 26% Hispanic). Adjusted analysis showed that NHB children had higher odds of receiving medication associated with asthma (odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.22 to 1.32) and lower odds of receiving diagnostic tests (blood cultures, complete blood counts, viral testing, chest x-rays; OR = 0.78, 95% CI = 0.75 to 0.81) and antibiotics (OR = 0.58, 95% CI = 0.52 to 0.64) than NHW children. Hispanic children had lower odds of receiving diagnostic testing (OR = 0.94, 95% CI = 0.90 to 0.98), asthma-associated medication (OR = 0.92, 95% CI = 0.88 to 0.96), and antibiotics (OR = 0.74, 95% CI = 0.66 to 0.82) compared to NHW children. CONCLUSION: NHB children more often receive corticosteroid and bronchodilator therapies; NHW children more often receive antibiotics and chest radiography. Given that current guidelines generally recommend supportive care with limited diagnostic testing and medical intervention, these findings among NHB and NHW children represent differing patterns of overtreatment. The underlying causes of these patterns require further investigation.

Comparison of eating disorder characteristics and depression comorbidity in adolescent males and females: An observational study.

Depression comorbid with eating disorders is common and can worsen the severity of both disorders. Little is published regarding depression and eating disorders in male adolescents. This retrospective observational study compared eating disorder presentation and depression comorbidity between medically-hospitalized male and female adolescents. Standardized chart abstraction was performed for 148 subjects (n=127 females, =21 males). Male adolescents had significantly greater pre-hospitalization weight loss and longer eating disorder duration, and were 1.6 times more likely to have comorbid depression compared to female patients. These findings suggest increased detection and treatment of both disorders in adolescent males is warranted.

Documentation of Tobacco, Alcohol, and Drug Screening in Hospitalized Adolescents.

OBJECTIVES: To examine the frequency of documented screening for tobacco, alcohol, and drug use in hospitalized adolescents on the pediatric hospitalist service. PATIENTS AND METHODS: This was a retrospective chart review of adolescents aged 14 to 17 years hospitalized at a large urban academic children's hospital in the Northeast from 2013 to 2015. Only patients admitted directly to the hospitalist service and only the first admission (if multiple occurred) were included. Patients presenting for psychiatric illness, ingestions, or impaired neurologic functioning were excluded. Admission history and physical (H&P) notes were reviewed to identify documented screening for tobacco, alcohol, and drug use. χ2 tests and 95% confidence intervals (CIs) were used to compare screenings for each substance and assess for associations of patient and encounter characteristics. RESULTS: A total of 443 charts met criteria for inclusion. The majority of adolescents were girls (n = 286; 64.6%), and mean age was 15.6 years (SD: 1.1). The H&P notes included notation of screening for tobacco use in 75.4% (95% CI: 71.1%-79.3%), alcohol use in 56.4% (95% CI: 51.7%-61.1%), and drug use in 37.9% (95% CI: 33.4%-42.6%) of charts. Girls were 1.4 times more likely to have of documented screening for alcohol use than boys. The admission diagnosis category was significantly associated with documentation of alcohol screening. Tobacco and drug screening frequency did not differ on the basis of sex, age, or diagnosis category. CONCLUSIONS: Documentation of substance use screening was not universal in admission H&P notes. These discrepancies suggest a need for improvements in screening protocols and documentation methods.

An Electronic Sexual Health Module for Hospitalized Adolescent Girls.

OBJECTIVES: To evaluate the acceptability and feasibility of an electronic sexual health module for inpatient adolescent girls and assess the preliminary effect on uptake of sexual health services. METHODS: We recruited girls 14 to 18 years old admitted to the hospitalist service of 1 academic children's hospital from January 2016 to October 2016. Participants completed an electronic sexual health module that included a sexual health assessment, tailored feedback (randomized for half of the participants only), and a questionnaire to request sexual health services. Participation and completion rates, along with effects of tailored feedback, risk perception, age group, and sexual activity on uptake of services, were examined. RESULTS: Seventy-seven percent of eligible participants who were approached enrolled in the study (n = 66 of 86). The completion rate was 100%. Fifty-three percent (n = 35) requested some form of sexual health service; of these, 83% (n = 29) requested to watch a contraception video. There was no statistically significant difference in the frequency of requests for those who received tailored feedback and for those who did not (57% vs 48%; P = .48). Younger teens and those without sexual experience made requests similar to older and sexually experienced girls except regarding sexually transmitted infection testing, which was significantly higher in the latter populations. CONCLUSIONS: This pilot study demonstrated reasonable feasibility and acceptability of a standardized sexual health module for adolescent girls admitted to the general pediatric wards. Videos focused on adolescent health were of particular interest to this population. Further study should examine the impact of such a module on long-term sexual health behaviors.

Are Caregivers Who Respond to the Child HCAHPS Survey Reflective of All Hospitalized Pediatric Patients?

OBJECTIVES: The Child Hospital Consumer Assessment of Healthcare Providers and Systems (C-HCAHPS) survey was developed to measure satisfaction levels of pediatric inpatients' caregivers. Studies in adults have revealed that certain demographic groups (people of color or who are multiracial and people with public insurance) respond to surveys at decreased rates, contributing to nonresponse bias. Our primary goal was to determine if results from the C-HCAHPS survey accurately reflect the intended population or reveal evidence of nonresponse bias. Our secondary goal was to examine whether demographic or clinical factors were associated with increased satisfaction levels. METHODS: This was a retrospective cohort study of responses (n = 421) to the C-HCAHPS survey of patients admitted to a tertiary-care pediatric hospital between March 2016 and March 2017. Respondent demographic information was compared with that of all hospital admissions over the same time frame. Satisfaction was defined as "top-box" scores for questions on overall rating and willingness to recommend the hospital. RESULTS: Caregivers returning surveys were more likely to be white, non-Hispanic, and privately insured (P < .001). Caregivers with the shortest emergency department wait times were more likely to assign top-box scores for global rating (P = .025). We found no differences in satisfaction between race and/or ethnicity, length of stay, insurance payer, or total cost. CONCLUSIONS: Caregivers who identified with underrepresented minority groups and those without private insurance were less likely to return surveys. Among the surveys received, short emergency department wait time and older age were the only factors measured that were associated with higher satisfaction. Efforts to increase patient satisfaction on the basis of satisfaction scores may exacerbate existing disparities in health care.

Documentation of Sexual History in Hospitalized Adolescents on the General Pediatrics Service.

OBJECTIVES: To determine the frequency of sexual history taking and the associated characteristics of hospitalized adolescents in the pediatric hospitalist service. METHODS: A retrospective chart review of adolescents 14 to 18 years old who were admitted to the pediatric hospitalist service at an urban, academic children's hospital in the Northeast from 2013 to 2015 was conducted. Repeat admissions, admissions to specialty services, and charts that noted impairment because of psychosis, cognitive delay, or illness severity were excluded. For charts that met the criteria, the admission history and physical was carefully reviewed for a notation of sexual history. For those with documentation, sexual activity status and a risk level assessment were recorded. Patient demographics and admission characteristics were extracted. χ2 tests and logistic regression were used to examine differences between those with sexual history and those without. RESULTS: A total of 752 charts met the criteria for inclusion. The majority of adolescents were girls (n = 506; 67.3%); the mean age was 15.7 years (SD = 1.2). Girls had 2.99 (95% confidence interval [CI] 2.18-4.11) higher odds of documentation than boys, and older adolescents had 1.41 (95% CI 1.03-1.91) higher odds than younger adolescents. Documentation did not differ significantly on the basis of admission type (medical or psychiatric), admission time, patient race and/or ethnicity, or provider gender. Among those with a documented sexual history, risk-level details were often omitted. CONCLUSIONS: Sexual history taking does not occur universally for hospitalized adolescents. Girls were screened more often than boys despite similar rates of sexual activity. The inpatient admission may be a missed opportunity for harm-reduction counseling and adherence to sexually transmitted infection testing guidelines.

A genital hair tourniquet in a 9-year-old girl.

The hair tourniquet is a well-described phenomenon. Typically, a hair or filament becomes tightly wrapped around an appendage, thereby causing swelling, pain, and, in extreme cases, necrosis. Affected areas include fingers, toes, and the genitalia. A case of a 9-year-old girl with a clitoral hair tourniquet is described, and a review of the literature of genital tourniquets in females is presented, with a discussion about potential etiology. The hair-thread tourniquet syndrome is a disease in which a hair or filament becomes wrapped around an end-perfusion appendage, thereby limiting adequate venous and lymphatic drainage of that tissue. This results in hyperemia, swelling and pain. If uncorrected, edema and interstitial pressures may increase to prevent adequate vascular supply, and the affected area can progress to necrosis. We are classically taught that this syndrome primarily affects the fingers, toes, and infantile penis and is an important consideration in the differential diagnosis of the colicky infant. The author presents a case of a prepubescent girl with a genital hair tourniquet.