Standardized In-harness Ultrasound Protocol Improves Success Rate of Brace Treatment for Dislocated Hips.

OBJECTIVE: Infant hip dislocations benefit from early detection and treatment for optimal outcomes. Prior studies have identified that there remains wide variability in the success rate of bracing between institutions. Although there are standardized methods to screen infants for hip dysplasia, there are no clear guidelines regarding how to image a child being treated for a hip dislocation with a Pavlik harness. As a result, there is substantial variability in how treatment success or failure is monitored between and within institutions. The goal of our study is to determine whether a standardized in-harness imaging protocol improves outcomes and the likelihood of successful treatment for dislocated hips being treated with the Pavlik harness. METHODS: All patients with hip dislocations and pretreatment ultrasound (US) were included from July 2018 to July 2022. A new institutional US protocol was implemented in July 2020, during which standardized in-harness imaging was obtained for patients with hip dislocations. Patients treated before the implementation of standardized in-harness imaging were categorized as nonstandardized and after implementation as a standardized group. Outcomes were compared between standardized and nonstandardized groups. P <0.05 determined the statistical significance. RESULTS: One hundred twenty-eight hips met the inclusion criteria (n = 97 patients). The mean age at diagnosis was 41.6 ± 23.4 days and was predominantly female (85.6%). There was no significant difference between the patients' demographics and baseline clinical characteristics between the standardized and nonstandardized groups. Pavlik harness success rate was significantly higher in the standardized group (85% vs 60%, P = 0.0024). Twenty-eight hips in the nonstandardized group remained dislocated and were indicated for surgical treatment, whereas only 8 hips remained dislocated in the standardized group and necessitated closed or open reduction. CONCLUSIONS: Standardization of in-harness imaging for patients undergoing treatment for developmental hip dislocations can significantly improve the Pavlik harness success rate. These findings emphasize the importance of obtaining images with the hip in flexion and abduction to prevent inadvertent stress during US evaluation for hips that have not yet stabilized, which may lead to premature cessation of the Pavlik harness. LEVEL OF EVIDENCE: Level III.

Real-world economic evaluation of prospective rapid whole-genome sequencing compared to a matched retrospective cohort of critically ill pediatric patients in the United States.

There is an increasing demand for supporting the adoption of rapid whole-genome sequencing (rWGS) by demonstrating its real-world value. We aimed to assess the cost-effectiveness of rWGS in critically ill pediatric patients with diseases of unknown cause. Data were collected prospectively of patients admitted to the Nicklaus Children's Hospital's intensive care units from March 2018 to September 2020, with rWGS (N = 65). Comparative data were collected in a matched retrospective cohort with standard diagnostic genetic testing. We determined total costs, diagnostic yield (DY), and incremental cost-effectiveness ratio (ICER) adjusted for selection bias and right censoring. Sensitivity analyses explored the robustness of ICER through bootstrapping. rWGS resulted in a diagnosis in 39.8% while standard testing in 13.5% (p = 0.026). rWGS resulted in a mean saving per person of $100,440 (SE = 26,497, p < 0.001) and a total of $6.53 M for 65 patients. rWGS in critically ill pediatric patients is cost-effective, cost-saving, shortens diagnostic odyssey, and triples the DY of traditional approaches.

A Randomized Pilot Trial Assessing the Role of Human Fibrinogen Concentrate in Decreasing Cryoprecipitate Use and Blood Loss in Infants Undergoing Cardiopulmonary Bypass.

The objective of this study was to determine whether treatment with human fibrinogen concentrate decreases the need for component blood therapy and blood loss in neonate and infant patients undergoing cardiopulmonary bypass. Pediatric patients (N = 30) undergoing elective cardiac surgery were randomized to receive human fibrinogen concentrate or placebo following cardiopulmonary bypass termination. The primary endpoint was the amount of cryoprecipitate administered. Secondary endpoints included estimated blood loss during the 24 h post-surgery; perioperative blood product transfusion; effects of fibrinogen infusion on global hemostasis, measured by laboratory testing and rotational thromboelastometry; and adverse events. No clinically significant differences were identified in baseline characteristics between groups. A significantly lower volume of cryoprecipitate was administered to the treatment group during the perioperative period [median (interquartile range) 0.0 (0.0-0.0) cc/kg vs 12.0 (8.2-14.3) cc/kg; P < 0.0001] versus placebo. No difference was observed between treatment groups in blood loss, laboratory coagulation tests, use of other blood components, or incidence of adverse events. FIBTEM amplitude of maximum clot firmness values was significantly higher among patients treated with human fibrinogen concentrate versus placebo (P ≤ 0.0001). No significant differences were observed in post-drug HEPTEM, INTEM, and EXTEM results. Human fibrinogen concentrate (70 mg/kg) administered after the termination of cardiopulmonary bypass reduced the need for transfusion with cryoprecipitate in a neonate and infant patient population.ClinicalTrials.gov identifier: NCT02822599.

Seated Outcome Measures in Children With Duchenne Muscular Dystrophy.

PURPOSE: Quantifiable motor strength measures to assess disease severity throughout the continuum of Duchenne muscular dystrophy (DMD) are needed. To study the feasibility of seated trunk strength using hand-held dynamometry (HHD) and caregiver-reported subjective functional independence measures in boys with DMD. METHODS: Prospective, cross-sectional, observational study of 18 participants with DMD enrolled from pediatric muscular dystrophy clinic during routine clinical assessment. Hand-held dynamometry, seated reach distance test and Pediatric Evaluation of Disability Inventory (PEDI) were administered. RESULTS: All study participants regardless of the walking status were able to complete the seated function tests demonstrating feasibility. The age of the participants correlated negatively with PEDI mobility and positively with HHD extension scores. The seated measures did not statistically correlate with PEDI mobility scores. CONCLUSIONS: Seated motor strength measures and PEDI mobility scores are feasible. The PEDI mobility and HHD extension scores correlate with age. Study limitations included single-center experience and cross-sectional data. VIDEO ABSTRACT LINK: https://www.dropbox.com/s/s4r0k7o6s0tfbkb/PT-Seated-Measures-And-DMD-2022.mp4?dl=0.

Physical Literacy in Elementary Physical Education: A Survey of Fundamental Movement Skill Practice Patterns.

PURPOSE: To describe fundamental movement skill (FMS) practice patterns in the elementary physical education (PE) curriculum. METHODS: A cross-sectional survey was sent to PE teachers of grades 1 through 6. Sixty-eight responses were included for analysis. RESULTS: Only 38.2% of teachers taught all 12 FMS components. Compared with PE teachers for grades 4 to 6, a significantly higher proportion of PE teachers for grades 1 to 3 taught all 12 FMS and used direct instruction methods. For children falling behind, only 8.8% reported referring to an exercise program and no PE teacher sought a health care referral. A video abstract can be found in Supplemental Digital Content 1 (available at: http://links.lww.com/PPT/A342).

Liposomal Bupivacaine Infiltration After Median Sternotomy in Pediatric Cardiac Surgery.

OBJECTIVE: The present study retrospectively ascertained whether liposomal bupivacaine (LB) injected subcutaneously after median sternotomy incisions in pediatric cardiac surgery patients is as efficacious as the ON-Q PainBuster pump (ON-Q) (Avonas Medical, Alpharetta, GA). DESIGN: Retrospective cohort comparison. SETTING: Pediatric hospital. PARTICIPANTS: Cardiac surgery patients who were treated with LB for elective cardiac surgery. INTERVENTIONS: Patients received 4 mg/kg of LB admixed with 0.25% bupivacaine and 0.9% normal saline. These patients were compared with an age- and procedure-matched control group of similar size treated with the ON-Q pump (continuous infusion 0.25% bupivacaine via subcutaneous catheter). Total analgesics used and route, other analgesics or sedatives, and pain scores (first 24 hours and cumulative) were tracked for 96 hours after surgery. MEASUREMENTS AND MAIN RESULTS: A total of 222 patients were equally divided between the two groups. Overall, the median (interquartile range) age was 6.5 (3.8-12.7) years. Unadjusted analysis suggested that patients in the LB group were administered a significantly higher dose of intravenous acetaminophen (77.4 v 60.0 mg/kg; p < 0.05). Extubation in the operating room was significantly higher in the LB patients (p < 0.05). Narcotic (morphine) administration was significantly higher in the ON-Q group (100.0% v 95.5%; p < 0.05). Although the median pain score within the first 24 hours was higher in LB patients (27.0 v 17.0; p < 0.05), there was a significantly greater difference observed in the Numeric Rating Scale area under the curve for the ON-Q group. CONCLUSIONS: LB is at least as effective as the ON-Q is for providing analgesia after median sternotomy incision in children.

Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial.

PURPOSE: As rapid discharge protocols for pediatric spine fusion shorten stays, gastrointestinal (GI) complications are uncovered and cause delays in discharge. A pre-operative carbohydrate (CHO) drink has been shown to improve perioperative GI symptoms and functional return but has not been examined in pediatric spine patients. We aimed to determine if a preoperative CHO drink is safe in pediatric spine fusion patients, and if it improves their comfort scores and return of bowel function. METHODS: We prospectively randomized ASA-1 and -2 pediatric spine fusion patients to either a pre-anesthesia carbohydrate drink 2 h prior to surgery or to a control group (standard 8 h NPO), blinded to surgical team. We documented time to return to flatus, bowel movement, GI symptoms, and comfort scores for 72 h post-operatively or until discharge. RESULTS: 62 patients were randomized. There was no significant differences between the groups' pre-operative characteristics, surgical details, nor post-operative morphine dose equivalents, except for EBL (405 cc control, 340 cc CHO drink, p = 0.044). There were no perioperative complications related to ingestion of the CHO drink. CHO group had a positive trend for earlier return of flatus (21% vs. 3% return at 12 h), and comfort scores for anxiety and abdominal pain, but no statistically significant differences. There was no difference in length of stay or time to first bowel movement. CONCLUSION: There were no complications related to ingestion of a CHO drink 2 h prior to pediatric spinal fusion surgery. Further studies are needed to develop a study blinded to the participants with larger sample size. Level of evidence I.

Putting the coach in the game: Current and future state of surgical coaching in pediatric urology.

BACKGROUND: Surgical coaching has been proposed as a mechanism to fill gaps in proficiency and encourage continued growth following formal surgical training. Coaching benefits have been demonstrated in other surgical fields; however, have not been evaluated within pediatric urology. The aims of this study were to survey members of The Societies for Pediatric Urology (SPU) to assess the current understanding and utilization of surgical coaching while gauging interest, potential barriers and personal goals for participation in a coaching program. METHODS: Following IRB approval, members of the SPU were invited to electronically complete an anonymous survey which assessed 4 domains: 1) understanding of surgical coaching principles, 2) current utilization, 3) interest and potential barriers to participation, and 4) personal surgical goals. To evaluate understanding, questions with predefined correct answers on the key principles of coaching were posed either in multiple choice or True/False format to the SPU membership. RESULTS: Of the 674 pediatric urologists invited, 146 completed the survey (22%). Of those, 46% correctly responded the definition of surgical coaching. Coaching utilization was reported in 27% of respondents currently or having previously participated in a surgical coaching program. Despite current participation rates, only 6 surgeons (4%) have completed training in surgical coaching, despite 79% expressing interest to participate in a surgical coaching program. The most influential barrier to participating in a coaching program was time commitment. Respondents largely prioritized technical and cognitive skill improvement as their primary goals for coaching (see figure below). CONCLUSIONS: While interest in surgical coaching is high among pediatric urologists, the principles of surgical coaching were not universally understood. Furthermore, formal coach training is markedly deficient, representing a gap in our profession and an opportunity for significant avenues for improvement, especially for technical and cognitive skills. Development of a coaching model based on these results would best suit the needs of pediatric urologists providing that the time commitment barrier for these endeavors can be mitigated and/or reconciled.

Multi-center implementation of rapid whole genome sequencing provides additional evidence of its utility in the pediatric inpatient setting.

Objective: Multi-center implementation of rapid whole genome sequencing with assessment of the clinical utility of rapid whole genome sequencing (rWGS), including positive, negative and uncertain results, in admitted infants with a suspected genetic disease. Study design: rWGS tests were ordered at eight hospitals between November 2017 and April 2020. Investigators completed a survey of demographic data, Human Phenotype Ontology (HPO) terms, test results and impacts of results on clinical care. Results: A total of 188 patients, on general hospital floors and intensive care unit (ICU) settings, underwent rWGS testing. Racial and ethnic characteristics of the tested infants were broadly representative of births in the country at large. 35% of infants received a diagnostic result in a median of 6 days. The most common HPO terms for tested infants indicated an abnormality of the nervous system, followed by the cardiovascular system, the digestive system, the respiratory system and the head and neck. Providers indicated a major change in clinical management because of rWGS for 32% of infants tested overall and 70% of those with a diagnostic result. Also, 7% of infants with a negative rWGS result and 23% with a variant of unknown significance (VUS) had a major change in management due to testing. Conclusions: Our study demonstrates that the implementation of rWGS is feasible across diverse institutions, and provides additional evidence to support the clinical utility of rWGS in a demographically representative sample of admitted infants and includes assessment of the clinical impact of uncertain rWGS results in addition to both positive and negative results.

Comparison of Cavity Preparation Times Using Conventional High-Speed Handpiece Versus Er, Cr:YSGG Laser: A Pilot Study with Pediatric Dental Residents.

PURPOSE: The purpose of this study was to compare pediatric dental residents' comfort levels and cavity preparation time using an Er, Cr:YSGG laser versus a conventional high-speed handpiece. METHODS: This cross-sectional study was conducted on residents with no past restorative dental laser experience. A mixed-effects model was used to evaluate the difference in total time and comfort level between the laser and high-speed handpiece groups. RESULTS: A total of 131 teeth (high-speed handpiece group equals 79; laser group equals 52) were completed. The adjusted result showed that the estimated average difference in preparation time among the laser group was 1.92 minutes longer per tooth compared to the high-speed handpiece group. Similarly, when using a laser, residents had a 0.74 times lower rate of comfort compared to the high-speed handpiece group. CONCLUSIONS: The total preparation time required for restorative treatment with a laser was significantly higher than the total time with a high-speed handpiece. Additionally, the comfort level was also lower using a laser compared to a high-speed preparation.

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.

Assessing the Current Research Infrastructure of Pediatric Dentistry Residency Programs: An Update for 2020.

Purpose: To assess the research infrastructure of pediatric dentistry residency programs in the United States and to determine the variables associated with increased scholarly activity. Methods: A 21-item questionnaire assessing program characteristics, research infrastructure, publication output and grants secured, barriers to scholarly activity, and satisfaction with current research infrastructure was developed and administered to program directors from March through June 2020. Results: Of 94 programs, 43 (46 percent) responded; 22 (51 percent) were hospital-based (H), 15 (35 percent) combined hospital-university-based (C), and six (14 percent) university-based (U). Most programs (77 percent) offered protected time to residents with varying time allocation (P<0.001). Forty-four percent of programs did not offer any protected time for faculty (P=0.001). Median number of faculty publications, resident publications, and grants were highest for U (16, five, and five, respectively) and lowest for H (zero, zero, and zero) (P<0.001; P=0.03; P<0.001). Number of total full-time faculty, full-time board-certified faculty, and full-time faculty with advanced degrees were associated with increased publications and grants secured. Interference with revenue-generating clinical time was the largest barrier to publication. Conclusion: Although university-based programs exhibit the infrastructure most conducive to scholarly activity, these findings suggest pediatric dentistry residency programs may lack resources and infrastructure to generate high quality research.

Prescribing Prevalence of Medications With Potential Genotype-Guided Dosing in Pediatric Patients.

Importance: Genotype-guided prescribing in pediatrics could prevent adverse drug reactions and improve therapeutic response. Clinical pharmacogenetic implementation guidelines are available for many medications commonly prescribed to children. Frequencies of medication prescription and actionable genotypes (genotypes where a prescribing change may be indicated) inform the potential value of pharmacogenetic implementation. Objective: To assess potential opportunities for genotype-guided prescribing in pediatric populations among multiple health systems by examining the prevalence of prescriptions for each drug with the highest level of evidence (Clinical Pharmacogenetics Implementation Consortium level A) and estimating the prevalence of potential actionable prescribing decisions. Design, Setting, and Participants: This serial cross-sectional study of prescribing prevalences in 16 health systems included electronic health records data from pediatric inpatient and outpatient encounters from January 1, 2011, to December 31, 2017. The health systems included academic medical centers with free-standing children's hospitals and community hospitals that were part of an adult health care system. Participants included approximately 2.9 million patients younger than 21 years observed per year. Data were analyzed from June 5, 2018, to April 14, 2020. Exposures: Prescription of 38 level A medications based on electronic health records. Main Outcomes and Measures: Annual prevalence of level A medication prescribing and estimated actionable exposures, calculated by combining estimated site-year prevalences across sites with each site weighted equally. Results: Data from approximately 2.9 million pediatric patients (median age, 8 [interquartile range, 2-16] years; 50.7% female, 62.3% White) were analyzed for a typical calendar year. The annual prescribing prevalence of at least 1 level A drug ranged from 7987 to 10 629 per 100 000 patients with increasing trends from 2011 to 2014. The most prescribed level A drug was the antiemetic ondansetron (annual prevalence of exposure, 8107 [95% CI, 8077-8137] per 100 000 children). Among commonly prescribed opioids, annual prevalence per 100 000 patients was 295 (95% CI, 273-317) for tramadol, 571 (95% CI, 557-586) for codeine, and 2116 (95% CI, 2097-2135) for oxycodone. The antidepressants citalopram, escitalopram, and amitriptyline were also commonly prescribed (annual prevalence, approximately 250 per 100 000 patients for each). Estimated prevalences of actionable exposures were highest for oxycodone and ondansetron (>300 per 100 000 patients annually). CYP2D6 and CYP2C19 substrates were more frequently prescribed than medications influenced by other genes. Conclusions and Relevance: These findings suggest that opportunities for pharmacogenetic implementation among pediatric patients in the US are abundant. As expected, the greatest opportunity exists with implementing CYP2D6 and CYP2C19 pharmacogenetic guidance for commonly prescribed antiemetics, analgesics, and antidepressants.