Clindamycin Pharmacokinetics and Safety in Preterm and Term Infants.

Clindamycin may be active against methicillin-resistant Staphylococcus aureus, a common pathogen causing sepsis in infants, but optimal dosing in this population is unknown. We performed a multicenter, prospective pharmacokinetic (PK) and safety study of clindamycin in infants. We analyzed the data using a population PK analysis approach and included samples from two additional pediatric trials. Intravenous data were collected from 62 infants (135 plasma PK samples) with postnatal ages of <121 days (median [range] gestational age of 28 weeks [23 to 42] and postnatal age of 17 days [1 to 115]). In addition to body weight, postmenstrual age (PMA) and plasma protein concentrations (albumin and alpha-1 acid glycoprotein) were found to be significantly associated with clearance and volume of distribution, respectively. Clearance reached 50% of the adult value at PMA of 39.5 weeks. Simulated PMA-based intravenous dosing regimens administered every 8 h (≤32 weeks PMA, 5 mg/kg; 32 to 40 weeks PMA, 7 mg/kg; >40 to 60 weeks PMA, 9 mg/kg) resulted in an unbound, steady-state concentration at half the dosing interval greater than a MIC for S. aureus of 0.12 µg/ml in >90% of infants. There were no adverse events related to clindamycin use. (This study has been registered at ClinicalTrials.gov under registration no. NCT01728363.).

Differences in testing for drugs of abuse amongst racial and ethnic groups at children's hospitals.

OBJECTIVES: Racial and ethnic differences in drug testing have been described among adults and newborns. Less is known regarding testing patterns among children and adolescents. We sought to describe the association between race and ethnicity and drug testing at US children's hospitals. We hypothesized that non-Hispanic White children undergo drug testing less often than children from other groups. METHODS: We conducted a retrospective cohort study of emergency department (ED)-only encounters and hospitalizations for children diagnosed with a condition for which drug testing may be indicated (abuse or neglect, burns, malnutrition, head injury, vomiting, altered mental status or syncope, psychiatric, self-harm, and seizure) at 41 children's hospitals participating in the Pediatric Health Information System during 2018 and 2021. We compared drug testing rates among (non-Hispanic) Asian, (non-Hispanic) Black, Hispanic, and (non-Hispanic) White children overall, by condition and patient cohort (ED-only vs. hospitalized) and across hospitals. RESULTS: Among 920,755 encounters, 13.6% underwent drug testing. Black children were tested at significantly higher rates overall (adjusted odds ratio [aOR]: 1.18; 1.05-1.33) than White children. Black-White testing differences were observed in the hospitalized cohort (aOR: 1.42; 1.18-1.69) but not among ED-only encounters (aOR: 1.07; 0.92-1.26). Asian, Hispanic, and White children underwent testing at similar rates. Testing varied by diagnosis and across hospitals. CONCLUSIONS: Hospitalized Black children were more likely than White children to undergo drug testing at US children's hospitals, though this varied by diagnosis and hospital. Our results support efforts to better understand and address healthcare disparities, including the contributions of implicit bias and structural racism.

Impact of a Quality Improvement Initiative to Optimize the Discharge Process of Pediatric Gastroenterology Patients at an Academic Children's Hospital.

Discharge is an important and complex process that can be optimized to reduce inpatient healthcare inefficiency and waste. This study aimed to increase the percentage of patients discharged before 1 pm by 20% from an academic inpatient pediatric gastroenterology service (IPGS), over 6 months. METHODS: We conducted a preintervention and postintervention study of patients discharged from IPGS. Patients discharged from January to June 2016, and those following our intervention from June to December 2016, were studied. Interventions included (1) implementation of the electronic medical record medical and logistical discharge criteria checklists for the 4 most common IPGS discharge diagnoses, (2) standardization of the rounds process to prioritize discharge, (3) education of nursing staff and families about the role they played in discharge. Process, outcome, and balancing measures were analyzed. RESULTS: Three hundred fifty-five total discharges were studied. Between the preintervention and postintervention groups, there were no significant improvements in discharge order time, physical discharge time, discharge response time, or discharges before 1 pm. The balancing measure of 30-day readmission was unaffected. However, length of stay (LOS) index, calculated as the ratio of actual to expected LOS, improved; when translated into days, LOS declined by 1 day, with potential associated savings of $373,000. CONCLUSIONS: Interventions to improve discharge timeliness on IPGS service demonstrated mixed effectiveness. Only LOS index improved. Further iterative quality improvement interventions are needed to continue optimizing discharge timeliness and change the culture of pediatric discharge on inpatient subspecialty services in academic children's hospitals.

Prospective Assessment of Pill-Swallowing Ability in Pediatric Patients.

Difficulty with pill-swallowing ability (PSA) is common in children, yet formal evaluation is rare. The objective of this study was to prospectively evaluate and compare PSA of inpatient and outpatient children using the Pediatric Oral Medications Screener. We identified children aged 3 to 17 years admitted to a general or subspecialty pediatric service at a university hospital or outpatient clinic. Using the Pediatric Oral Medications Screener, patients were observed swallowing 3 different-sized placebo pills (5 mm tablet, 10 mm tablet, and 22 mm capsule), and subjective measures were assessed from parents and children. We analyzed 47 inpatients and 62 outpatients. Sixteen percent of patients could not swallow any pill, 11% only swallowed the small pill, 14% swallowed up to the medium pill, and 60% swallowed all formulations. After controlling for multiple factors, inpatients had superior PSA compared with outpatients ( P = .004). These results suggest targeted inpatient screening and widespread outpatient screening would likely identify children with reduced PSA.

Family member presence for procedures: the resident's perspective.

OBJECTIVE: To describe resident acceptance of and comfort with family member presence (FMP) during pediatric invasive procedures and resuscitation in a large, multicenter pediatric residency program. To determine if increased level of training impacts on opinion toward FMP for procedures. DESIGN AND METHODS: Seventy-six residents of postgraduate levels 1-4 were administered a survey about FMP for procedures. The survey consisted of 4 Likert-scale questions and 1 multiple-choice question of resident acceptance of and comfort with FMP during procedures and cardiopulmonary resuscitation (CPR). Statistical analysis was performed using the Mann-Whitney U test and one-way analysis of variance (ANOVA). RESULTS: Fifty-three residents (70%) responded. Residents were accepting of FMP during procedures, with a mean score of 3.9/5. However, residents were less accepting of FMP presence during CPR, with a mean score of 2.84/5. There was a trend toward increased comfort and acceptance of FMP with increased level of training; however, this was not statistically significant. In our study, nearly one half of residents (45%) reported that their major reservation toward FMP was that resident anxiety could result in procedure or resuscitation failure. CONCLUSION: The residents in our pediatric training program generally accept FMP for procedures. Residents were less accepting of FMP for CPR than for procedures. Residents most commonly oppose FMP for procedures because they believe this will make them anxious and lead to failure. This information provides insight into the implementation of FMP for procedures in a medical education setting.

Effectiveness of pediatric pill swallowing interventions: a systematic review.

BACKGROUND AND OBJECTIVE: Pediatric patients commonly have difficulty swallowing pills. Targeted interventions have shown to improve medication administration and treatment compliance. The objective was to evaluate studies performed on pill swallowing interventions in the pediatric population since 1987. METHODS: We performed a comprehensive PubMed search and a bibliography review to identify articles for our review. We selected articles published in English between December 1986 and December 2013 that included >10 participants aged 0 to 21 years with pill swallowing difficulties without a comorbid condition affecting their swallowing. Reviewers extracted the relevant information and rated the quality of each study as "poor," "fair," or "good" based on the sample size and study design. RESULTS: We identified 4 cohort studies and 1 case series that met our criteria. All 5 studies found their intervention to be successful in teaching children how to swallow pills. Interventions included behavioral therapies, flavored throat spray, verbal instructions, specialized pill cup, and head posture training. Quality ratings differed between the articles, with 3 articles rated as "fair," 1 article as "good," and 1 article as "poor." CONCLUSIONS: Pill swallowing difficulties are a barrier that can be overcome with a variety of successful interventions. Addressing this problem and researching more effective ways of implementing these interventions can help improve medication administration and compliance in the pediatric population.

A model of determining a fair market value for teaching residents: who profits?

CONTEXT: Centers for Medicare & Medicaid Services (CMS) Health Resources and Services Administration Children's Hospitals Graduate Medical Education (GME) Payment Program now supports freestanding children's teaching hospitals. OBJECTIVE: To analyze the fair market value impact of GME payment on resident teaching efforts in our pediatric intensive care unit (PICU). DESIGN: Cost-accounting model, developed from a 1-year retrospective, descriptive, single-institution, longitudinal study, applied to physician teachers, residents, and CMS. SETTING: Sixteen-bed PICU in a freestanding, university-affiliated children's teaching hospital. PARTICIPANTS: Pediatric critical care physicians, second-year residents. MAIN OUTCOME MEASURES: Cost of physician opportunity time; CMS investment return; the teaching physicians' investment return; residents' investment return; service balance between CMS and teaching service investment margins; economic balance points; fair market value. RESULTS: GME payments to our hospital increased 4.8-fold from 577 886 dollars to 2 772 606 dollars during a 1-year period. Critical care physicians' teaching opportunity cost rose from 250 097 dollars to 262 215 dollars to provide 1523 educational hours (6853 relative value units). Residents' net financial value for service provided to the PICU rose from 245 964 dollars to 317 299 dollars. There is an uneven return on investment in resident education for CMS, critical care physicians, and residents. Economic balance points are achievable for the present educational efforts of the CMS, critical care physicians, and residents if the present direct medical education payment increases from 29.38% to 36%. CONCLUSIONS: The current CMS Health Resources and Services Administration Children's Hospitals GME Payment Program produces uneven investment returns for CMS, critical care physicians, and residents. We propose a cost-accounting model, based on perceived production capability measured in relative value units and available GME funds, that would allow a clinical service to balance and obtain a fair market value for the resident education efforts of CMS, physician teachers, and residents.