Does participation in the community outreach for asthma care and healthy lifestyles (COACH) program alter subsequent use of hospital services for children discharged with asthma?

Introduction: Transition from hospital to home is a challenging time for children with asthma and their caregivers because of the high risk for reutilization of acute hospital services. Detecting effective quality improvement initiatives to reduce utilization of urgent services in children discharged with asthma is an important clinical and public health question. This study was designed to identify the role of a multimodal, nurse-driven, inpatient initiated Community Outreach for Asthma Care and Healthy lifestyles (COACH) program on subsequent use of hospital services for pediatric patients with asthma.Methods: We utilized comparative effectiveness design to identify the difference in recurrent emergency department (ED) visits and/or admissions within 12-months after discharge between patients with asthma who engaged in the COACH program (Intervention group) and those who did not (Comparison group). We used administrative databases of hospitals included in the Meridian Health system to identify the number of and time to asthma-related readmissions and ED re-attendances.Results: We found no difference in the rate or number of recurrent hospital-based services used within 12 months, but found a reduction in ED re-visitation and/or readmission within 30 days for COACH program participants prior to and after adjustment for age, race/ethnicity, insurance status, and clinical presentation (Odd Ratio 0.44, 95% Confidence Interval 0.20, 0.93).Conclusion: Participation in the COACH program decreases the likelihood for subsequent use of hospital services within a month of discharge for children with asthma. Enhanced post-discharge interactions with families may reduce long-term reuse of hospital-based services for COACH program participants.

Acute Kidney Injury in Rhabdomyolysis: A 5-Year Children's Hospital Network Study.

Rhabdomyolysis is a skeletal muscle injury that can cause myoglobinuria and acute kidney injury (AKI). Risk factors for AKI in children are not clearly understood with no standardized treatment guidelines for rhabdomyolysis. Our study explores factors associated with AKI and management of pediatric patients with rhabdomyolysis. Medical records from a children's hospital network over a 5-year period were retrospectively reviewed. The results are described with respect to the presence or absence of AKI. Of the 112 patients who met the inclusion criteria, AKI incidence was 7.1% (n = 8), with all affected patients having exertional etiology. The overall mean age was 13.5 years; patients without AKI were younger than patients with AKI (13.3 versus 17; p < 0.001). Using regression models for hypothesis generation, we found that patients with AKI were more likely to be older (OR = 1.44, 95%CI [1.11-2.19]; p = 0.03), have myoglobinuria (OR = 22.98, 95%CI [2.05-432.48]; p = 0.02), and have received intravenous bicarbonate (OR = 16.02, 95%CI [1.44-228.69]; p = 0.03). In our study, AKI was uncommon and associated with older age, myoglobinuria and bicarbonate treatment. Larger, prospective studies are needed to further understand AKI risk factors and optimal management of pediatric rhabdomyolysis.

Gastrointestinal Perforation with Blunt Abdominal Trauma in Children.

Gastrointestinal tract perforation is uncommon in children, accounting for <10% of cases of blunt abdominal trauma. Diagnosis of bowel perforation in children can be challenging due to poor diagnostic imaging accuracy. Intra-abdominal free air is found only in half of the children with bowel perforation. Ultrasound findings are nonspecific and suspicious for perforation in only two-thirds of cases. A computer tomography (CT) scan has a sensitivity and specificity of 50% and 95%, respectively. Surgical decisions should be made based on clinical examination despite normal CT results. Management of bowel perforation in children includes primary repair in 50-70% and resection with anastomosis in 20-40% of cases.

Cocaine-induced dystonic reaction: an unlikely presentation of child neglect.

Child neglect can be difficult to recognize. Parental substance abuse may place a child at increased risk of neglect. This report reviews 2 cases of dystonic reaction in children after accidental exposure to cocaine in their home environments. The reports are followed by a review of proposed physiologic mechanisms for cocaine-induced dystonia and a discussion on neurological symptoms that may develop after cocaine exposure. Pediatric emergency physicians should consider cocaine exposure when a child of any age presents with abnormal movements. Dystonic reaction is an uncommon, but reported, complication of cocaine exposure in the absence of other risk factors and may be the first presentation of child neglect.

Role of viral pathogen(s) detection in hospital-based management of 29-90-day-old infants with unexplained fever.

BACKGROUND: The risk for invasive bacterial infection (IBI) in young infants with fever increases the use of invasive and therapeutic interventions, such as lumbar puncture (LP) and antimicrobials which may be unnecessary. In the present study, we analyzed whether viral pathogen(s) detection using a respiratory pathogen panel (RPP) alters the use of LP and antibiotics in 29-90-day-old infants presenting with fever to a regional pediatric hospital. METHODS: We collected medical history, clinical presentation, diagnostic tests and results, treatment, disposition, and length of stay (LOS) for selected patients. Data were compared between RPP positive (+) and RPP negative (-) infants. Use of LP and antibiotics were controlled for using regression analysis. P values <0.05 were considered significant. RESULTS: Among 172 RPP-tested infants, 45.4% had a virus(es). LP and antibiotics were used in 14.2% and 19.5% of infants in RPP(+) and in 17.0% and 28.7% in RPP(-) groups (P=0.60, 0.16), respectively. Nearly half of the infants in both groups were admitted and had comparable LOS. Hospitalization and at least one abnormal laboratory result were associated with a 2-3 times higher chance of LP and antibiotic utilization, irrespective to age and temperature level. No studied infant had been diagnosed with IBI, and 14.5% of infants in the RPP(-) group had bacteriuria. CONCLUSIONS: Detection of viral pathogen(s) did not significantly reduce the use of LP or antimicrobials in young infants with unexplained fever.

The clinical value of procalcitonin cut-off levels for pediatric patients in the hospital setting.

BACKGROUND: Utilization of procalcitonin (PCT) is challenging for hospital pediatricians because of uncertainty in clinical interpretation. We used a PCT decision cut-off value (<0.15 ng/mL) to identify if PCT can differentiate bacterial infections from viral and other conditions in pediatric patients who presented for hospital-based care. METHODS: This retrospective study included PCT tested patients who presented to our children's hospital from 2017 to 2020. We analyzed relevant demographic, laboratory, treatment, and clinical data, including discharge diagnoses consolidated into bacterial infections, viral syndromes, and other conditions by the highest PCT defined as ≤0.15 ng/mL (Group A) or >0.15 ng/mL (Group B). We used regression models to identify factors associated with PCT above decision limits and the role of PCT levels in the duration of antibiotic therapy. RESULTS: Of 238 patients, 32.8% constituted Group A. Bacterial infections represent 25.6% of diagnoses for patients in Group A and 55% for Group B (P<0.001), however, the distribution of bacterial infection types, including bacteremia, was comparable. Number of PCT tests performed and C-reactive protein (CRP) ≥5 mg/L, but no other factors were significantly associated with PCT >0.15 ng/mL. PCT levels did not predict the length of antibiotic therapy, which depended on duration of hospitalization and increased CRP. CONCLUSIONS: PCT as a single measurement above or below a decision cut-off value of 0.15 ng/mL does not specify bacterial infections or predict the duration of antibiotic therapy in hospitalized pediatric patients.

Risk Factors and Outcomes Associated With Antibiotic Therapy in Children Hospitalized With Asthma Exacerbation.

OBJECTIVE: Despite lack of benefit, antibiotics are overused in management of asthma exacerbation in children. In this study, data from a single children's hospital were analyzed to identify factors and outcomes associated with antibiotic use in children hospitalized with asthma. METHODS: The study population was identified by using administrative data from 2012 to 2015, with subsequent verification of asthma. We analyzed factors associated with antibiotic use (demographic, seasonal, clinical) and outcome (length of stay [LOS]) with respect to: 1) disposition to pediatric floor (PF) or pediatric intensive care unit (PICU); and 2) evidence of coexisting bacterial infection and/or fever. Statistical analysis included univariate and controlled regression models. Data are presented as median and IQR for continuous variables and OR and regression coefficient (ß) with 95% CIs for regression analyses. RESULTS: Of 600 patients, 28.8% were admitted to PICU, 14.8% had verified bacterial infection, and 53.8% received antibiotic, mainly azithromycin. Nearly all PICU patients were treated with antibiotic, irrespective of coexisting bacterial infection or fever. Among PF patients, nearly 30% without bacterial infection or fever and 40% with fever alone received antimicrobials. Overall risk for antibiotic treatment was associated with older age, female sex, desaturation events, oxygen supplementation, and PICU admission. Additionally, antibiotic treatment was associated with 13- to 19-hour increased LOS for PF patients without bacterial infection and/or fever. CONCLUSIONS: Almost half of pediatric patients admitted with asthma exacerbation received antibiotic therapy with no clear indication, which was associated with prolonged LOS.

Combined Effect of Race/Ethnicity and Type of Insurance on Reuse of Urgent Hospital-Based Services in Children Discharged with Asthma.

Asthma is a leading cause of health disparity in children. This study explores the joint effect of race/ethnicity and insurance type on risk for reuse of urgent services within a year of hospitalization. Data were collected from 604 children hospitalized with asthma between 2012 and 2015 and stratified with respect to combination of patients' insurance status (public vs. private) and race/ethnicity (white vs. nonwhite). Highest rates for at least one emergency department (ED) revisit (49.5%, 95% CI 42.5, 56.5) and for average revisits (1.03, 95% CI 0.83, 1.22) were recorded in nonwhite children with public insurance. Adjusted models revealed higher chance for ED reuse in white as well as nonwhite children covered by public insurance. Hospitalization rate was not dependent on the combination of social determinants, but on the number of post-discharge ED revisits. The combined effect of race/ethnicity and health insurance are associated with post-discharge utilization of ED services, but not with hospital readmission.

Evaluation and analysis of the Modified Finnegan Scoring System for assessment of neonatal abstinence syndrome.

OBJECTIVE: The Finnegan Neonatal Abstinence Scoring System (FNASS) is the most commonly used scoring system for neonatal abstinence syndrome (NAS) both in its original and modified versions, despite challenges related to tool length and observer bias. The purpose of this study was to determine the most frequent symptoms of NAS that led to score elevation and prompted initiation of drug therapy on the Modified Finnegan (MF). We also sought to identify vital sign changes associated with score elevation. DESIGN: We conducted a retrospective study of neonates diagnosed with NAS, based on ICD-9 codes and charge data for methadone administration. SETTING: The study setting was in a Level III Neonatal Intensive Care Unit. PATIENTS, PARTICIPANTS: Ninety patients with a total of 286 MF scores recorded from 2011 to 2015 met inclusion criteria. MAIN OUTCOME MEASURE(S): The primary outcome was overall occurrence for each specific component of the MF scoring tool during symptomatic periods. Secondary outcomes were vital sign changes. RESULTS: Among the MF elements, there were 13 components that were scored more often than others in symptomatic infants. Respiratory rate (RR) was elevated in infants with NAS, but other vital signs did not differ from age-specific norms. CONCLUSIONS: Of the various signs of NAS used to score the MF, few are frequently observed. Our study reinforces literature that proposes a shortened MF assessment tool. Experimental research will be needed to determine the efficacy of a shortened MF tool for diagnosing NAS.

Detection of Acute Gastroenteritis Etiology in Hospitalized Young Children: Associated Factors and Outcomes.

BACKGROUND: The decision to test for the etiology of diarrhea is a challenging question for practicing pediatricians. METHODS: The main goal of this retrospective cohort study was to identify factors associated with testing for and diagnosis of rotavirus, Clostridium difficile, or other bacterial infections, as well as the length of stay (LOS) for children with acute gastroenteritis who were hospitalized at a single institution. Patients aged 6 to 60 months with acute diarrhea (<14 days) and no underlying gastrointestinal conditions were included. Data were analyzed by using multivariate logistic and linear regression models. RESULTS: Stool testing was performed in 73.1% of the 331 patients studied. The majority were tested for multiple pathogens, including rotavirus (65.9%), C difficile (30.8%), and other bacteria (63.4%), with recovery rates of 33.0%, 9.8%, and 6.7%, respectively. Rotavirus was more often identified in older patients with dehydration and vomiting. Although testing for C difficile was more likely with prolonged diarrhea, no vomiting, and recent antibiotic use, no factors were associated with C difficile recovery. Patients who were diagnosed with C difficile were more likely to receive probiotics than those who received negative test results. LOS was not associated with stool testing or recovery of any tested pathogens. CONCLUSIONS: Although children with acute gastroenteritis underwent frequent stool testing for diarrheal etiology, detection of a pathogen was uncommon and not associated with a change in LOS. Experimental research will be needed to make additional conclusions about the efficacy of testing for diarrheal etiology in the inpatient practice of acute pediatric diarrhea.

Lactobacillus acidophilus Mixture in Treatment of Children Hospitalized With Acute Diarrhea.

Despite unproven effectiveness, Lactobacillus acidophilus is a widely used probiotic in the treatment of pediatric diarrhea. In this report, we evaluated the association between length of stay (LOS) for 290 young children hospitalized with acute diarrhea and adjuvant therapy with a probiotic mixture containing 80% L acidophilus that was included in treatment for 22.4% of them. Overall, no association between LOS and use of L acidophilus was recorded after controlling for age, length of diarrhea symptoms, duration of intravenous fluids, and prior exposure to antibiotic. However, LOS was directly associated with use of L acidophilus in children with negative stool studies, and no such association was recorded in children with positive stool for rotavirus or other infections. We concluded that adjuvant therapy with L acidophilus mixture is not beneficial for young children hospitalized with acute diarrhea.

Duration of Hospitalization in Association with Type of Inhalation Therapy Used in the Management of Children with Nonsevere, Acute Bronchiolitis.

BACKGROUND: Acute bronchiolitis is one of the main respiratory emergencies in young children. Although supportive therapy is recommended, substantial inconsistency in the clinical usage of inhaled treatments has been reported. In the present study, we evaluated the association between different types of nebulized therapies in clinical practice and the length of stay (LOS) of young children hospitalized with nonsevere bronchiolitis. METHODS: Medical records of 195 patients with bronchiolitis, without evidence of pneumonia or congenital/chronic respiratory conditions, were stratified with respect to the type of inhalation therapy received: nebulized albuterol (Group 1, n = 53), nebulized albuterol with 3% saline (Group 2, n = 38), nebulized 3% saline alone (Group 3, n = 33), or no inhaled treatment (Group 4, n = 71). Duration of hospital stay was reported with respect to the type of inhalation therapy received after controlling for variability in patient age (months), oxygen saturation, respiratory score, and use of other treatments (antibiotics, oxygen supplementation, and/or corticosteroids). LOS is presented in terms of mean and 95% confidence interval (95% CI). RESULTS: The groups were similar except for differences in the mean level of oxygen saturation, respiratory score, and corticosteroid use. Children in Group 4 had the lowest mean respiratory score due to a lesser prevalence of wheezing and/or retractions than in other groups. The LOS for children in Groups 1 and 4 was shorter (43.2 hours, 95% CI 34.9-51.3, and 44.1 hours, 95% CI 37.3-51.0, respectively) than in Groups 2 and 3 (72 hours, 95% CI 62.1-81.6, and 65.1 hours, 95% CI 54.7-75.6, respectively) (p < 0.02). The mean LOS in each group did not change significantly after adjustment for covariants. CONCLUSION: Prolonged hospitalization of children younger than 2 years with acute, nonsevere bronchiolitis is associated with administration of nebulized 3% saline, independent of age, clinical presentation of disease, or inclusion of other treatments in their management.

Comparative effectiveness of implementation of a nursing-driven protocol in reducing bronchodilator utilization for hospitalized children with bronchiolitis.

OBJECTIVE: The goal of our study was to determine whether the administration of bronchodilators is affected by implementation of a nursing-driven protocol in the care of children hospitalized with bronchiolitis. METHODS: We included children less than 2 years old, hospitalized with bronchiolitis, but without chronic lung problems, immunodeficiencies or congenital heart disease in the 1-year periods before, during and after implementation of a nursing-driven bronchiolitis protocol. The protocol is based on nursing assessments of respiratory status prior to initiation and continuation of bronchodilator therapy. Utilization rates of bronchodilators were compared with respect to implementation of the nursing-driven protocol using Chi-square, analysis of variance, and regression analysis that is presented as adjusted odds ratio (OR) and 95% confidence interval (95% CI) of the OR. RESULTS: Among the 80 children who were hospitalized before, 63 during and 89 after the implementation of the nursing-driven bronchiolitis protocol, 70.0, 60.3, and 29.2%, respectively, received treatment with bronchodilators (P < 0.0001). Reduction in the use of bronchodilators in association with the implementation of the nursing-driven bronchiolitis protocol was also observed after controlling for the child's age and evidence of pneumonia (OR 0.68, 95% CI 0.61-0.79). The mean number of bronchodilator doses administered among patients in the three groups who received at least one treatment was comparable. CONCLUSIONS: Implementation of a nursing-driven bronchiolitis protocol was associated with significant reduction in initiation of bronchodilator treatments, which suggests a benefit from nursing involvement in the promotion of evidence-based recommendations in the management of children hospitalized with bronchiolitis.

Pediatric residents' perceptions of family-centered rounds as part of postgraduate training.

PURPOSE: Although family-centered rounds (FCRs) are recommended as standard practice, limited data address pediatric residents' opinions of FCRs. In the present study, we assessed residents' perceptions with respect to rounding experience and postgraduate year (PGY). METHODS: An anonymous online questionnaire was distributed to pediatric residents from nine accredited programs in New Jersey. RESULTS: Of 95 residents who completed questionnaires, 69.5% participated in FCRs and traditional rounds, 17.9% in FCRs, and 12.6% in traditional rounds. Irrespective of rounding experience and PGY, the majority believed that FCRs benefit families and pediatric training, felt that an attending's style greatly affects their experience, report discomfort sharing sensitive information and answering questions, and did not support the superiority of FCRs for efficiency and professional satisfaction. CONCLUSIONS: Concerns regarding discomfort, attending approach and efficiency are potential barriers to residents' full acceptance of FCRs that should be addressed to improve the efficacy of postgraduate pediatric training.