Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS. METHODS: In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors. RESULTS: Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively. CONCLUSIONS: We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.

Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care.

BACKGROUND AND OBJECTIVES: Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC). METHODS: A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports. RESULTS: The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs. CONCLUSIONS: The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.

Identification of Multisystem Inflammatory Syndrome in Children Classes and Development of Hyperinflammation Score in Pediatric COVID-19.

The aim of this study is to describe characteristics and hospital course of children admitted with COVID-19 to a tertiary care pediatric center in Southeastern United States, and to present the frequency of three classes of multisystem inflammatory syndrome in children (MIS-C) and develop pediatric COVID-19 associated hyperinflammation score (PcHIS). A retrospective cohort study of 68 children was performed. Critical illness was defined as any child requiring respiratory or cardiovascular support or renal replacement therapy. PcHIS was developed by using six variables: fever, hematological dysfunction, coagulopathy, hepatic injury, macrophage activation, and cytokinemia. Centers for Disease Control and Prevention criteria were used to identify MIS-C, and three classes of MIS-C were identified based on the findings of recently published latent class analysis (Class 1: MIS-C without Kawasaki like disease, Class 2: MIS-C with respiratory disease, and Class 3: MIS-C with Kawasaki like disease). The median age was 6.4 years. Fever, respiratory, and gastrointestinal were common presenting symptoms. MIS-C was present in 32 (47%), critical COVID-19 illness in 11 (16%), and 17 (25%) were admitted to the PICU. Children with critical illness were adolescents with elevated body mass index and premorbid conditions. PcHIS score of 3 had a sensitivity of 100% and a specificity of 77% for predicting critical COVID-19 illness. Among MIS-C patients, 15 (47%) were in Class 1, 8 (25%) were in Class 2, and 9 (28%) were in Class 3. We conclude that most children with COVID-19 have mild-to-moderate illness. Critical COVID-19 is mainly seen in obese adolescents with premorbid conditions. Three Classes of MIS-C are identifiable based on clinical features. Validation and clinical implication of inflammation score in pediatric COVID-19 need further investigation.

A Case-Control Study Evaluating Risk Factors and Outcomes of Hospitalized Children With ESBL-UTI.

Urinary tract infections (UTIs) are among the most common causes of hospitalization in children, with a rising prevalence of extended-spectrum beta-lactamase-producing organisms (ESBL). The purpose of this study was to identify risk factors and treatment outcomes of children with ESBL-UTI. A retrospective case-control study of hospitalized children was performed from July 2014 till December 2017. Medical records from patients with a positive urine culture were reviewed and included in the study if they met criteria for UTI. Cases were defined as ESBL-UTI, while controls were defined as non-ESBL-UTI patients. This study confirmed that there are certain risk factors, such as previous UTI, recent antibiotic use, urinary tract abnormalities, recent hospital admission, and nonrenal comorbidities, that are associated with ESBL-UTI. Most of the patients with ESBL-UTI responded to discordant antibiotics. Other significant outcomes in patients with ESBL-UTI included a longer length of stay and longer intravenous antibiotic therapy.

Risk of Serious Bacterial Infections in Young Febrile Infants With COVID-19.

OBJECTIVES: The purposes of this study were to describe the clinical characteristics of febrile infants younger than 90 days with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, to investigate the prevalence of serious bacterial infections (SBIs) in these infants, and to compare the risk of SBI in SARS-CoV-2-positive febrile infants with sex- and age-matched SARS-CoV- 2-negative febrile infants. METHODS: This was a retrospective cohort study conducted from March to November 2020 in a tertiary children's hospital. Patients were identified by International Classification of Diseases, 10th Revision codes and included if age was younger than 90 days, a SARS-CoV-2 test was performed, and at least 1 bacterial culture was collected. Positive cases of SARS-CoV-2 were age- and sex-matched to negative controls for analysis. Serious bacterial infection was defined as a urinary tract infection, bacterial enteritis, bacteremia, and/or bacterial meningitis. RESULTS: Fifty-three SARS-CoV-2-positive infants were identified with a higher rate of respiratory symptoms and lower white blood cell and C-reactive protein values than their SARS-CoV-2 matched controls. The rate of SBI in the SARS-CoV-2-positive infants was 8% compared with 34% in the controls; the most common infections were urinary tract infections (6% vs 23%). There were no cases of bacteremia or bacterial meningitis in the COVID-19 (coronavirus disease 2019) infants and 2 (4%) cases of bacteremia in the controls. The relative risk of any SBI between the 2 groups was 0.22 (95% confidence interval, 0.1-0.6; P ≤ 0.001). CONCLUSIONS: These results suggest that febrile infants younger than 90 days with COVID-19 have lower rates of SBI than their matched SARS-CoV-2-negative controls. These data are consistent with previous studies describing lower risks of SBI in febrile infants with concomitant viral respiratory tract infections.

Impact of the Choosing Wisely® Campaign Recommendations for Hospitalized Children on Clinical Practice: Trends from 2008 to 2017.

BACKGROUND: The Choosing Wisely® Campaign (CWC) was launched in 2012. Five recommendations to reduce the use of "low-value" services in hospitalized children were published in 2013. OBJECTIVES: The aim of this study was to estimate the frequency and trends of utilization of these services in tertiary children's hospitals five years before and after the publication of the recommendations. METHODS: We conducted a retrospective, longitudinal analysis of hospitalizations to 36 children's hospitals from 2008 to 2017. The "low-value" services included (1) chest radiograph (CXR) for asthma, (2) CXR for bronchiolitis, (3) relievers for bronchiolitis, (4) systemic steroids for lower respiratory tract infection (LRTI), and (5) acid suppressor therapy for uncomplicated gastroesophageal reflux (GER). We estimated the annual percentages of the use of these services after risk adjustment, followed by an interrupted time series (ITS) analysis to compare trends before and after the publication of the recommendations. RESULTS: The absolute decreases in utilization were 36.6% in relievers and 31.5% in CXR for bronchiolitis, 24.1% in acid suppressors for GER, 20.8% in CXR for asthma, and 2.9% in steroids for LRTI. Trend analysis showed that one "low-value" service declined significantly immediately (use of CXR for asthma), and another decreased significantly over time (relievers for bronchiolitis) after the CWC. CONCLUSIONS: There was some decrease in the utilization of "low-value" services from 2008 to 2017. Limited changes in trends occurred after the publication of the recommendations. These findings suggest a limited impact of the CWC on clinical practice in these areas. Additional interventions are required for a more effective dissemination of the CWC recommendations for hospitalized children.

Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Children's Hospitals.

OBJECTIVES: In 2013, the Society of Hospital Medicine (SHM) released 5 pediatric recommendations for the Choosing Wisely Campaign (CWC). Our goals were to develop a report card on the basis of those recommendations, calculate achievable benchmarks of care (ABCs), and analyze performance among hospitals participating in the Pediatric Health Information System. METHODS: Children hospitalized between January 2013 and September 2015 from 32 Pediatric Health Information System hospitals were studied. The quality metrics in the report card included the use of chest radiograph (CXR) in asthma and bronchiolitis, bronchodilators in bronchiolitis, systemic corticosteroids in lower respiratory tract infections (LRTI), and acid suppression therapy in gastroesophageal reflux (GER). ABCs were calculated for each metric. RESULTS: Calculated ABCs were 22.3% of patients with asthma and 19.8% of patients with bronchiolitis having a CXR, 17.9% of patients with bronchiolitis receiving bronchodilators, 5.5% of patients with LRTIs treated with systemic corticosteroids, and 32.2% of patients with GER treated with acid suppressors. We found variation among hospitals in the use of CXR in asthma (median: 34.7%, interquartile range [IQR]: 28.5%-45.9%), CXR in bronchiolitis (median: 34.4%, IQR: 27.9%-49%), bronchodilators in bronchiolitis (median: 55.4%, IQR: 32.3%-64.9%), and acid suppressors in GER (median: 59.4%, IQR: 49.9%-71.2%). Less variation was noted in the use of systemic corticosteroids in LRTIs (median: 13.5%, IQR: 11.1%-17.9%). CONCLUSIONS: A novel report card was developed on the basis of the SHM-CWC pediatric recommendations, including ABCs. We found variance in practices among institutions and gaps between hospital performances and ABCs. These findings represent a roadmap for improvement.

Sensorineural hearing loss in Kawasaki disease.

Kawasaki disease is a common nonspecific vasculitis seen in childhood. The most significant long-term sequela is coronary artery aneurysm. However, the spectrum of complications involves not only the heart, but also other organs such as the eyes, skin, kidneys, gallbladder, liver, and central nervous system. Sensorineural hearing loss (SNHL) is a relatively unrecognized complication of the disease. Although most of the complications (except coronary artery aneurysm) are self-limiting, SNHL can be persistent. It is, especially important in infants and young children who might not be able to report the hearing deficits and are most likely to have cognitive and speech delays if this hearing loss is not addressed in a timely manner. We report a child with Kawasaki disease who had SNHL during the 2(nd) week of the illness. The aim of this article is to briefly review the pathophysiology behind this hearing loss and strongly emphasize the importance of universal hearing evaluation in all children diagnosed with Kawasaki disease. This screening in children with Kawasaki disease may provide some timely intervention if needed. Since most Kawasaki disease patients will be seen by cardiologists, we hope to create more awareness about this complication to the cardiology community as well.