Predicting Serious Bacterial Infections Among Hypothermic Infants in the Emergency Department.

BACKGROUND: There is insufficient evidence to guide the initial evaluation of hypothermic infants. We aimed to evaluate risk factors for serious bacterial infections (SBI) among hypothermic infants presenting to the emergency department (ED). METHODS: We conducted a multicenter case-control study among hypothermic (rectal temperature <36.5°C) infants ≤90 days presenting to the ED who had a blood culture collected. Our outcome was SBI (bacteremia, bacterial meningitis, and/or urinary tract infection). We performed 1:2 matching. Historical, physical examination and laboratory covariables were determined based on the literature review from febrile and hypothermic infants and used logistic regression to identify candidate risk factors. RESULTS: Among 934 included infants, 57 (6.1%) had an SBI. In univariable analyses, the following were associated with SBI: age > 21 days, fever at home or in the ED, leukocytosis, elevated absolute neutrophil count, thrombocytosis, and abnormal urinalysis. Prematurity, respiratory distress, and hypothermia at home were negatively associated with SBI. The full multivariable model exhibited a c-index of 0.91 (95% confidence interval: 0.88-0.94). One variable (abnormal urinalysis) was selected for a reduced model, which had a c-index of 0.82 (95% confidence interval: 0.75-0.89). In a sensitivity analysis among hypothermic infants without fever (n = 22 with SBI among 116 infants), leukocytosis, absolute neutrophil count, and abnormal urinalysis were associated with SBI. CONCLUSIONS: Historical, examination, and laboratory data show potential as variables for risk stratification of hypothermic infants with concern for SBI. Larger studies are needed to definitively risk stratify this cohort, particularly for invasive bacterial infections.

Incidence and Transmission of SARS-CoV-2 in US Child Care Centers After COVID-19 Vaccines.

Importance: SARS-CoV-2 surveillance studies in US child care centers (CCCs) in the post-COVID-19 vaccine era are needed to provide information on incidence and transmission in this setting. Objective: To characterize SARS-CoV-2 incidence and transmission in children attending CCCs (students) and their child care providers (CCPs) and household contacts. Design, Setting, and Participants: This prospective surveillance cohort study was conducted from April 22, 2021, through March 31, 2022, and included 11 CCCs in 2 cities. A subset (surveillance group) of CCPs and students participated in active surveillance (weekly reverse transcription-polymerase chain reaction [RT-PCR] swabs, symptom diaries, and optional baseline and end-of-study SARS-CoV-2 serologic testing), as well as all household contacts of surveillance students. Child care center directors reported weekly deidentified self-reported COVID-19 cases from all CCPs and students (self-report group). Exposure: SARS-CoV-2 infection in CCC students. Main Outcomes and Measures: SARS-CoV-2 incidence, secondary attack rates, and transmission patterns were determined from diary entries, self-reports to CCC directors, and case logs. Incidence rate ratios were measured using Poisson regression clustering on centers with a random intercept and unstructured matrix. Results: From a total population of 1154 students and 402 CCPs who self-reported cases to center directors, 83 students (7.2%; mean [SD] age, 3.86 [1.64] years; 55 male [66%]), their 134 household contacts (118 adults [mean (SD) age, 38.39 (5.07) years; 62 female (53%)], 16 children [mean (SD) age, 4.73 (3.37) years; 8 female (50%)]), and 21 CCPs (5.2%; mean [SD] age, 38.5 [12.9] years; 18 female [86%]) participated in weekly active surveillance. There were 154 student cases (13%) and 87 CCP cases (22%), as defined by positive SARS-CoV-2 RT-PCR or home antigen results. Surveillance students had a higher incidence rate than self-report students (incidence rate ratio, 1.9; 95% CI, 1.1-3.3; P = .01). Students were more likely than CCPs to have asymptomatic infection (34% vs 8%, P < .001). The CCC secondary attack rate was 2.7% to 3.0%, with the upper range representing possible but not definite secondary cases. Whether the index case was a student or CCP, transmission within the CCC was not significantly different. Household cumulative incidence was 20.5%, with no significant difference in incidence rate ratio between adults and children. Household secondary attack rates were 50% for children and 67% for adults. Of 30 household cases, only 5 (17%) represented secondary infections caused by 3 students who acquired SARS-CoV-2 from their CCC. Pre- and poststudy seroprevalence rates were 3% and 22%, respectively, with 90% concordance with antigen or RT-PCR results. Conclusions and Relevance: In this study of SARS-CoV-2 incidence and transmission in CCCs and students' households, transmission within CCCs and from children infected at CCCs into households was low. These findings suggest that current testing and exclusion recommendations for SARS-CoV-2 in CCCs should be aligned with those for other respiratory viruses with similar morbidity and greater transmission to households.

Disaster and Emergency Preparedness and the Impact of the COVID-19 Pandemic on Child Care Programs in Michigan: A Mixed-Methods Analysis.

BACKGROUND: Historically, the child care industry has been unprepared for emergencies. A previous study identified gaps in Michigan's child care programs' emergency plans. Study objectives were to reassess programs' preparedness plans after introduction of state-mandated emergency plans and to examine the effect of the coronavirus disease 2019 (COVID-19) pandemic on programs' operations. METHODS: A 29-question survey was sent to ∼500 child care programs across Michigan in 2020 to assess emergency plans and response to COVID-19. Data were analyzed using descriptive statistics and qualitative methods. RESULTS: A total of 346 programs (70%) responded. Most (92%) reported having a written plan, but one-third reported having no infectious outbreak plan pre-pandemic. One-third of programs lacked plans for special needs children (vs 40% in 2014); 62% lacked plans for child reunification (vs 60% in 2014); 46% reported staff received no preparedness training. COVID-19 impacted programs substantially: 59% closed, 20% decreased capacity, 27% changed disinfecting protocols. Several themes related to the pandemic's effect on programs were identified: (1) changes in learning, (2) changes in socialization, (3) increased family burden, (4) financial challenges, (5) lack of guidance. CONCLUSIONS: Significant preparedness gaps remain among Michigan's child care programs, suggesting the need for increased support and addition of emergency preparedness to programs' quality ratings.

Hearing Loss in Children: Critical Medical Education Delivered as Massive Open Online Course (MOOC).

Purpose: Although early identification of pediatric hearing loss is crucial, a formal online training course has not been freely accessible to a global audience. In response, we created a novel course for health professionals worldwide. Method: Course development occurred from February 2019 to May 2020. Seventeen multidisciplinary experts provided video lectures and demonstrations, including a tour of ear anatomy, operating footage of cochlear implant insertion, and demonstrations of children undergoing hearing testing. Content also included steps for interpreting audiograms, an overview of early screening programs, interviews with Deaf/Hard of Hearing children, and an introduction to public health/educational infrastructure. The course was hosted on Coursera and launched on May 4, 2020. Results: The course was approved for 11.5 Continuing Medical Education (CME) and American Board of Pediatrics Maintenance of Certification (MOC)-Part 2 credits and spanned five modules comprised of 50 video learning segments: 1) Ear Anatomy, 2) Hearing Loss and Assessments, 3) Hearing Loss Diagnosis and Impact on Speech and Language Development, 4) Interventions for Hearing Loss, 5) Pediatric Vestibular System and Balance. Since its launch, 6,556 learners have enrolled and 1,540 have fully completed the course; Fifty percent were 25-34 years old, 62% were female, and 43% were from Asia. Average rating was 4.9/5 (n=180 reviews). Conclusions: We created a freely accessible course for a global audience that provides a broad overview of pediatric hearing loss. Our multidisciplinary approach addresses an educational gap and can serve as a model for developing other online courses.

Variability in emergency department management of hypothermic infants ≤90 days of age.

OBJECTIVES: Hypothermic infants are at risk for serious bacterial and herpes simplex virus infections, but there are no evidence-based guidelines for managing these patients. We sought to characterize variations and trends in care for these infants in the emergency department (ED). METHODS: We conducted a retrospective cross-sectional study of infants under 90 days old presenting to 32 pediatric EDs from 2009 through 2019 with an International Classification of Diseases diagnosis code for hypothermia. We characterized variation in diagnostic testing, antimicrobial treatment, and disposition of children in three age groups (≤30 days, 31-60 days, and 61-90 days old) and analyzed care trends. RESULTS: Of 7828 ED encounters meeting inclusion criteria, most (81%) were ≤ 30 days of age. Infants in the 0-30 days old age group, compared to 61-90 days old age group, had a higher proportion of blood (75% vs. 68%), urine (72% vs. 64%), and cerebrospinal fluid (CSF; 35% vs. 22%) cultures obtained (p < 0.01) and greater antimicrobial use (81% vs. 68%; p < 0.01) in the ED. From 2009 to 2019, C-reactive protein (CRP), and procalcitonin usage steadily increased, from 25% to 40% and 0% to 30% respectively, while antibiotic use (83% to 77%), CSF testing (53% to 44%), and chest radiography (47% to 34%) decreased. Considerable interhospital variation was noted in testing and treatment, including CSF testing (14-70%), inflammatory markers (CRP and procalcitonin; 8-88%), and antibiotics (56-92%). CONCLUSION: Substantial hospital-level variation exists for managing hypothermic infants in the ED. Long-term trends are notable for changing practice over time, particularly with increased use of inflammatory markers. Prospective studies are needed to risk stratify and optimize care for this population.

Using the MCRISP Network for Surveillance of Pediatric Exanthema in Child Care Centers.

BACKGROUND: Systematic monitoring of exanthema is largely absent from public health surveillance despite emerging diseases and threats of bioterrorism. Michigan Child Care Related Infections Surveillance Program (MCRISP) is the first online program in child care centers to report pediatric exanthema. METHODS: MCRISP aggregated daily counts of children sick, absent, or reported ill by parents. We extracted all MCRISP exanthema cases from October 1, 2014 through June 30, 2019. Cases were assessed with descriptive statistics and counts were used to construct epidemic curves. RESULTS: 360 exanthema cases were reported from 12,233 illnesses over 4.5 seasons. Children ages 13-35 months had the highest rash occurrence (45%, n = 162), followed by 36-59 months (41.7%, n = 150), 0-12 months (12.5%, n = 45), and kindergarten (0.8%, n = 3). Centers reported rashes of hand-foot-mouth disease (50%, n = 180), nonspecific rash without fever (15.3%, n = 55), hives (8.1%, n = 29), fever with nonspecific rash (6.9%, n = 25), roseola (3.3%, n = 12), scabies (2.5%, n = 9), scarlet fever (2.5%, n = 9), impetigo (2.2%, n = 8), abscess (1.95, n = 7), viral exanthema without fever (1.7%, n = 6), varicella (1.7%, n = 6), pinworms (0.8%, n = 3), molluscum (0.6%, n = 2), cellulitis (0.6%, n = 2), ringworm (0.6%, n = 2), and shingles (0.2%, n = 1). CONCLUSION: Child care surveillance networks have the potential to act as sentinel public health tools for surveillance of pediatric exanthema outbreaks.

Creating a 'choose your topic' massive open online course: an innovative and flexible approach to delivering injury prevention education.

BACKGROUND: A pediatric injury prevention course has not been available as a massive open online course (MOOC). Creating a comprehensive topic course is particularly challenging because the traditional, week-by-week linear curriculum design is often a barrier to learners interested in only specific topics. We created a novel, flexible course as both a 'choose your topic' MOOC for the public learner and a Small Private Online Course (SPOC) for medical students. METHODS: We describe creating 'Injury Prevention for Children and Teens', a course of 59 video learning segments within eight modules taught by a multidisciplinary panel of 25 nationally-recognized experts. Completion tracking and course evaluations were collected. RESULTS: In 2.5 years, 4,822 learners from 148 countries have enrolled. Two-thirds of learners were female. Median age of learners was 31 years. For engagement, 19.3% (n = 932) of learners attempted quizzes, and 5.2% (n = 252) participated in online forum discussions. Medical professionals (n = 162) claimed an average of 13 credit hours per learner. Over 200 senior medical students have taken the SPOC. CONCLUSION: 'Injury Prevention for Children and Teens' is a novel approach to injury prevention education that is broad, science-based, accessible, and not cost-prohibitive for a diverse group of global learners.

The Statewide Economic Impact of Child Care-Associated Viral Acute Gastroenteritis Infections.

INTRODUCTION: More than 65% of children aged ≤5 years in the United States require out-of-home child care. Child care attendance has been associated with an elevated risk of respiratory illness and acute gastroenteritis (AGE). While child care-associated respiratory disease cases are more numerous, AGE is associated with more severe symptoms and more than double the number of absences from child care. In addition, viral pathogens such as norovirus, rotavirus, and adenovirus are highly infectious and may be spread to parents and other household members. As a result, child care-associated viral AGE may incur substantial economic costs due to healthcare service usage and lost productivity. METHODS: We used surveillance data from a network of child care centers in Washtenaw County, Michigan, as well as a household transmission model to estimate the annual cost of child care-associated viral AGE in the state of Michigan. RESULTS: We estimated that child care-associated viral AGE in Michigan costs between $15 million and $31 million annually, primarily due to lost productivity. CONCLUSIONS: The economic burden of child care-associated infections is considerable. Effective targeted interventions are needed to mitigate this impact.

Expanding Surveillance Toward Sharing Data with the Community: Qualitative Insights from a Childcare Center Illness Surveillance Program.

Childcare attendance is a recognized independent risk factor for pediatric infectious diseases due to the pathogen-sharing behaviors of young children and the crowded environments of childcare programs. The Michigan Child Care Related Infections Surveillance Program (MCRISP) is a novel online illness surveillance network used by community childcare centers to track disease incidence. It has been used to warn local public health departments about emerging outbreaks. The flow of data from MCRISP, however, remains largely unidirectional-from data reporter to public health researchers. With the intent to ultimately improve the system for users, we wanted to better understand how community illness data collected by MCRISP might best benefit childcare stakeholders themselves. Using a ground-up design approach, we conducted a series of focus groups among childcare directors participating in MCRISP. All primary data reporters from each of the 30 MCRISP-affiliated childcare centers were eligible to participate in the focus groups. A thematic assessment from the focus groups revealed that participants wanted surveillance system improvements that would (1) support subjective experiences with objective data, (2) assist with program decision making, (3) provide educational resources, and (4) prioritize the user's experience. Our findings support a framework by which community disease surveillance networks can move toward greater transparency and 2-way data flow. Ultimately, a more mutually beneficial surveillance system improves stakeholder engagement, provides opportunities for rapid mitigation strategies, and can help allocate timely resources in responding to emerging outbreaks and pandemics.

Participation of Children and Adolescents in Live Crisis Drills and Exercises.

Children and adolescents should be included in exercises and drills to the extent that their involvement advances readiness to meet their unique needs in the event of a crisis and/or furthers their own preparedness or resiliency. However, there is also a need to be cautious about the potential psychological risks and other unintended consequences of directly involving children in live exercises and drills. These risks and consequences are especially a concern when children are deceived and led to believe there is an actual attack and not a drill and/or for high-intensity active shooter drills. High-intensity active shooter drills may involve the use of real weapons, gunfire or blanks, theatrical makeup to give a realistic image of blood or gunshot wounds, predatory and aggressive acting by the individual posing to be the shooter, or other means to simulate an actual attack, even when participants are aware that it is a drill. This policy statement outlines some of the considerations regarding the prevalent practice of live active shooter drills in schools, including the recommendations to eliminate children's involvement in high-intensity drills and exercises (with the possible exception of adolescent volunteers), prohibit deception in drills and exercises, and ensure appropriate accommodations during drills and exercises based on children's unique vulnerabilities.

Pilot of an Asynchronous Web-Based Video Curriculum to Improve Firearm Safety Counseling by Pediatric Residents.

Pediatric residents report lack of confidence in providing firearm safety anticipatory guidance. A self-paced online curriculum, including video demonstration of firearms, safe storage options, and counseling methods for families improved resident self-efficacy, confidence, and knowledge surrounding firearm injury prevention counseling.

Circumferential Partial-Thickness Burn Caused by Mobile Telephone Charger: A Case Report.

Many children and adolescents have access to portable electronic devices. Although not always the case, these devices are often charged at nighttime, especially while being used in bed. There are increasing media reports of electric current injury from the portable electronic devices' charging cables, particularly with equipment that is available for lower cost from generic manufacturers. A 19-year-old woman presented to the pediatric emergency department after a burn from her generic iPhone charger. She was lying in bed wearing a chain necklace, with the charger underneath her pillow and plugged into an electrical outlet, when she felt a sudden burning sensation and severe pain around her neck. She was found to have a circumferential partial-thickness burn. She underwent computed tomographic angiogram, whose result was unremarkable. The wound was debrided, and she was then discharged home. She likely sustained an electrical injury from the charger as it came in contact with her necklace, causing a burn. Several companies have investigated the difference in quality and safety of generic versus Apple-brand chargers and have found that the majority of the generic chargers fail basic safety testing, making them a higher risk for electrical injury. As a result of this case, patients and families should be educated about safe use of these devices, especially while they are charging.

Camp Leadership Perspectives on Food Allergy-Related Anaphylaxis Events and Training for Camp Staff: A National Survey of Summer Camps.

BACKGROUND: Training of camp staff to recognize and treat anaphylaxis is recommended because food allergies are prevalent among summer campers. The frequency of food allergy anaphylaxis events and the extent of anaphylaxis training for camp staff are unknown. OBJECTIVE: To estimate the frequency of food-allergic reactions in camps across the United States and to assess the state of food allergy anaphylaxis training for camp staff. METHODS: We partnered with CampDoc.com to send a 20-question survey in February 2016 to camp leadership representing 528 camps. Questions addressed demographic characteristics, food allergy policies, training, medication availability, anaphylaxis events, and confidence in staff to recognize and treat anaphylaxis. RESULTS: A total of 559 responses were received, representing 258 camps. The majority surveyed (n = 529 [94.6%]) reported food-allergic children attending their camps. Only 47.6% (n = 266) respondents reported requiring individualized emergency action plans as required for camper attendance. Anaphylaxis treated with epinephrine was reported by 24% (n = 134) of leadership within the previous 2 years at their camp. These respondents were more likely to have a training session for staff (odds ratio, 2.46; 95% CI, 1.4-4.3). A total of 63.3% (n = 354) reported training session presence. However, 15.6% (n = 87) of leadership were unsatisfied with training materials and one-third were not confident in staff to manage anaphylaxis. CONCLUSIONS: Appropriate policies to manage food anaphylaxis events and anaphylaxis management training were missing in a substantial proportion of camps. Camp-tailored food allergy training is needed given the number of camps reporting food allergy reactions requiring epinephrine.

Communicable Disease Outbreaks in Michigan Child Care Centers Compared With State and Regional Epidemics, 2014-2017.

The Michigan Child Care Related Infections Surveillance Program (MCRISP) is a novel, online illness surveillance system used by a collection of southeast Michigan child care centers. Recently established, MCRISP has not been assessed epidemiologically. We created MCRISP epidemic curves for both respiratory and gastrointestinal disease over three seasons, comparing these to data from an established statewide surveillance system. Results suggest that online child care center-based disease surveillance is timely, functional, and has potential as an early sentinel system for community epidemics.

Variation in surface decontamination practices among Michigan child care centers compared to state and national guidelines.

BACKGROUND: Environmental decontamination is one of the most effective methods to prevent transmission of infectious pathogens in child care centers (CCCs). Alongside state recommendations, national organizations-including the American Academy of Pediatrics (AAP)-offer best-practice policies. In Michigan, these sets of guidelines differ, and the extent to which CCC practices agree with either set of protocols is unknown. METHODS: A survey of environmental decontamination practices was administered at a professional meeting of CCC directors (N = 24) in a single Michigan county. CCC practices (eg, products, locations, frequencies) were compared to state and AAP guidelines. Bivariate analyses investigated CCC characteristics as predictors of decontamination policy agreement. RESULTS: CCC agreement with established policy was slightly higher for national AAP guidelines (66%) than Michigan standards (59%). The use of an outside child care health consultant was strongly associated with a significantly higher level of agreement with state decontamination policy (P = .01). CONCLUSION: We noted substantial disagreement between county CCC practices and state/national guidelines, regardless of CCC size or director experience. Results highlight opportunities to improve CCC director familiarity with current state and nationally advised protocols, to consolidate state licensing and AAP guidelines, and to promote the use of child care health consultants.

Disaster Preparedness Among Michigan's Licensed Child Care Programs.

OBJECTIVE: This study aimed to assess if Michigan child care directors have created disaster management plans, and if local resources were used to develop and implement plans. METHODS: From December 2013 to March 2014, the Early Childhood Investment Corporation conducted a survey of licensed child care programs in Michigan. An online survey regarding disaster preparedness and training resources was distributed to the directors of a convenience sample of registered child care centers among the Early Childhood Investment Corporation's statewide network of 11 resource centers. RESULTS: A total of 210 child care programs responded. Most (91%) of respondents had a disaster plan, but 40% did not include accommodations for special needs children, 51% did not have a family/child identification or reunification plan, and 67% did not have car safety devices and a predetermined route for evacuation. Fewer than 9% made disaster plans available online. Few collaborated with local fire (22%), police (27%), or pediatric or emergency medicine organizations (11%). Online modules were the most desirable training format. CONCLUSIONS: In a state without mandated child care guidelines for disaster preparedness, a substantial proportion of child care programs were missing critical components of disaster planning. Future interventions must focus on increasing partnerships with local organizations and developing guidelines and training to include plans for special needs children, family/child identification and reunification, and evacuation/relocation.