Tiny patients, huge impact: a call to action.

The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.

The transition to Pediatric Hospital Medicine fellowship: A national survey-based needs assessment.

BACKGROUND: Each year, the number of fellows entering Pediatric Hospital Medicine (PHM) fellowship is increasing. Residency curricula do not always prepare trainees for all aspects of PHM as a specialty and gaps often exist in the transition to fellowship. OBJECTIVE: To explore the preparedness of PHM fellows for clinical, teaching, and scholarship tasks at the start of fellowship and to identify opportunities for residency and fellowship program development. DESIGN: Quantitative survey. SETTING AND PARTICIPANTS: Current and recently graduated PHM fellows (matriculation years 2019-2022). METHODS: We conducted a national cross-sectional survey from July 2022 to February 2023. We designed survey questions based on PHM fellowship core competencies. MAIN OUTCOME AND MEASURES: We asked participants to rate preparedness for tasks on a 5-point Likert scale (1 = very unprepared, 5 = very prepared). We analyzed numerical data using descriptive and comparative statistics and free-response data using inductive content analysis. RESULTS: We received 223 responses to our survey (response rate 74%). Of the respondents, 25% reported no PHM-specific orientation at their program (n = 55). Respondents reported lower median preparedness for research (3, interquartile range [IQR] [2,4]) and teaching tasks (4, IQR [4,4]) compared to clinical tasks (4, IQR [4,5]) at the start of fellowship (p < 0.01, p < 0.01). Content analysis revealed most fellows wished they had received more training around scholarship at the start of fellowship. CONCLUSIONS: Many PHM fellows enter fellowship feeling inadequately prepared, particularly in scholarship and teaching. Our findings suggest that residency and fellowship programs need to develop more robust curricula to better prepare trainees for successful PHM fellowship. This national survey-based needs assessment should serve as a guide for further program development.

De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative.

Bronchiolitis is the most common cause for hospitalization in the first year of life, with hypoxemia and acute respiratory failure as major determinants leading to hospitalization. In addition, the lack of existing guidelines for weaning and discontinuing supplemental oxygen, including high-flow nasal cannula, may contribute to prolonged hospitalization and increased resource utilization. Methods: This single-center quality improvement initiative assessed the effect of implementing a standardized care process for weaning and discontinuing high-flow oxygen for patients hospitalized with bronchiolitis. Patients aged 1-24 months with bronchiolitis admitted to the general wards or ICU step-down unit from February 1, 2018, and January 31, 2020 were included in the study. Primary outcomes included length of stay and time on supplemental oxygen, with time on high-flow oxygen and length of time in ICU step-down unit as secondary outcomes. Balancing measures included transfer rate to Pediatric Intensive Care Unit, intubation rate, 7- and 30-day readmission rates, and 7- and 30-day ED visits after discharge. Results: Following the standardized care process implementation, the mean length of stay decreased from 60.7 hours to 46.7 hours (P < 0.01). In addition, the mean time on any supplemental oxygen decreased by 47% (P < 0.01), the mean time on high-flow oxygen decreased by 45% (P < 0.01), and the mean time in the ICU step-down unit decreased by 27% (P =< 0.01). Balancing measures remained unchanged with no statistically significant differences. Conclusion: Implementing a standardized care process for weaning and discontinuing high-flow oxygen may reduce the length of stay and resource utilization for patients hospitalized with bronchiolitis.

Acute Kidney Injury Among Children Admitted With Viral Rhabdomyolysis.

BACKGROUND: Infectious etiologies cause a large portion of pediatric rhabdomyolysis. Among pediatric patients with rhabdomyolysis, it is unknown who will develop acute kidney injury (AKI). We sought to test the hypothesis that a viral etiology would be associated with less AKI in children admitted with rhabdomyolysis than a nonviral etiology. METHODS: In this single-center retrospective cohort study, patients <21 years of age admitted with acute rhabdomyolysis from May 1, 2010, through December 31, 2018, were studied. The primary outcome was development of AKI, defined by using the Kidney Disease: Improving Global Outcomes guidelines. The primary predictor was identification of viral infection by laboratory testing or clinical diagnosis. Covariates included age, sex, race, insurance provider, presence of proteinuria and myoglobinuria, and initial creatinine kinase and serum urea nitrogen. Routine statistics and multivariable logistic modeling were performed via SAS 9.4 (SAS Institute, Inc, Cary, NC). RESULTS: In total, 319 pediatric patients with rhabdomyolysis were studied. The median age was 13 years. Patients were predominately male (69.9%), non-Hispanic Black (55.2%), and publicly insured (45.1%). We found no difference in the rates of AKI in those with a viral diagnosis versus those without a viral diagnosis (30 of 77 [39.0%] vs 111 of 234 [47.4%]; P = .19). Multivariable analysis revealed that viral diagnosis was not associated with the development of AKI. Patients ≥13 years of age, male patients, and those with proteinuria and elevated serum urea nitrogen on admission had increased odds of developing AKI. CONCLUSIONS: In our study, viral rhabdomyolysis did not have lower rates of AKI compared with nonviral etiologies of AKI; therefore, providers should consider continued caution in these patients.