Elective caesarean section and bronchiolitis hospitalization: A retrospective cohort study.

BACKGROUND: We sought to evaluate whether elective caesarean section is associated with subsequent hospitalization for bronchiolitis. METHODS: This is a retrospective cohort study that used the electronic medical record database of Clalit Health Services, the largest healthcare fund in Israel, serving over 4.5 million members and over half of the total population. The primary outcome was bronchiolitis admission in the first 2 years of life. We performed logistic regression analyses to identify independent associations. We repeated the analysis using boosted decision tree machine learning techniques to confirm our findings. RESULTS: There were 124 553 infants enrolled between 2008 and 2010, and 5168 (4.1%) were hospitalized for bronchiolitis in the first 2 years of life. In logistic regression models stratified by seasons, elective caesarean section birth was associated with 15% increased odds (95% CI: 1.02-1.30) for infants born in the fall season, 28% increased odds (95% CI: 1.11, 1.47) for those born in the winter, 35% increased odds (95% CI: 1.12-1.62) for those born in the spring and 37% increased odds (95% CI: 1.18-1.60) for those born in the summer. In the boosted gradient decision tree analysis, the area under the curve for risk of bronchiolitis admission was 0.663 (95% CI: 0.652, 0.674) with timing of birth as the most important feature. CONCLUSION: Elective caesarean section, a potentially modifiable risk factor, is associated with increased odds of hospitalization for bronchiolitis in the first 2 years of life. These data should be considered when scheduling elective caesarean sections especially for infants born in spring and summer months.

Azithromycin treatment in children hospitalized with asthma: a retrospective cohort study.

Objective: Azithromycin has anti-inflammatory properties in the lungs and decreases the duration of asthma-like episodes in children. We sought to evaluate length of stay (LOS) and readmission rates of children receiving azithromycin therapy during hospitalization for acute asthma exacerbations.Methods: This was a retrospective cohort study at an urban, quaternary-care children's hospital including patients under 18 years old hospitalized for asthma, without concurrent infection, from 2002 to 2011. The primary predictor was azithromycin therapy administered within 48 hours of admission. The primary outcome was LOS and the secondary outcomes were 7, 30, and 90-day hospital readmission rates for asthma.Results: Azithromycin therapy was administered to 174 (3%) of 5335 unique patients admitted for asthma, without concurrent infection, over the 10-year period. The overall median LOS was 2.3 days [Interquartile range, 1.8-3.1] and 9% (480) were readmitted for asthma within 90 days of discharge. Azithromycin therapy was associated with a 20% (11 hour) longer LOS (adjusted beta coefficient for log-transformed LOS, 0.18; 95% Confidence Interval (CI): 0.11-0.26), less than the 29% (16 hour) difference determined a priori as clinically relevant. Azithromycin therapy was not associated with 90-day readmission for asthma (adjusted odds ratio, 0.89; 95% CI: 0.46-1.72]. The limited number of 7 and 30-day readmissions in the azithromycin treated group precluded adjusted analysis.Conclusions: Azithromycin therapy was not associated with a clinically relevant difference in hospital LOS or with readmission rates for children hospitalized with asthma. Prospective trials are needed to determine the clinical effects of azithromycin therapy in children with asthma.

Rickettsialpox in a Pediatric Patient.

Rickettsialpox is a rare vector-borne rickettsiosis that manifests in hosts living in urban populations, particularly in New York City. The following is a case discussion of a 12-year-old girl with history of fever and right-ankle swelling. She was initially evaluated and treated for cellulitis. She later developed a maculopapular rash completing the classic triad for rickettsialpox: black eschar, papular rash, and fever. Her convalescent rickettsial titers returned positive, confirming the diagnosis of rickettsialpox.

Deployed: One Pediatric Department's Experience of Adult Care During COVID-19.

OBJECTIVES: The number of hospitalized coronavirus disease 2019 patients in March 2020 to April 2020 in our New York City hospital required increased physician staffing, including deployment of pediatricians to adult care. To improve the deployment process, we sought to understand the mindset, preparations for, and experience during deployment of pediatric faculty in our institution. METHODS: Faculty members of the Department of Pediatrics completed pre- and postsurveys evaluating perspectives, fears, and preparations relevant to deployment. Demographic characteristics of the faculty members were collected. Survey questions included Likert scale, multiple choice, and free-text responses. Descriptive statistics, Fisher's exact test, and χ2 test were used to compare groups. Free-text responses were categorized by topic. Survey responses were shared with leadership in real time and adjustments to the deployment process made. RESULTS: The predeployment survey was sent to 202 pediatric faculty members, with a 29% (n = 59) completion rate. Of the 36 deployed faculty, 29 (81%) completed all items of the postsurvey. The majority (74%, n = 42) expressed discomfort with care of adults and fear and/or nervousness about deployment (61%, n = 35). Most faculty (88%, n = 52) prepared for deployment and cited local guidelines and published literature as helpful preparation materials (55%, n = 16). Dissemination of details about schedules and role clarification before deployment were areas for improvement. CONCLUSIONS: Pediatric faculty facing deployment to adult care have concerns about the process of deployment as well as the work itself. Specific information distributed in advance, along with consistent and frequent communication, may help mitigate these fears.

Factors Associated With Asthma Diagnosis Within Five Years of a Bronchiolitis Hospitalization: A Retrospective Cohort Study in a High Asthma Prevalence Population.

OBJECTIVES: Bronchiolitis, the leading cause of infant hospitalizations in the United States, is associated with increased risk of childhood asthma. We hypothesized that factors during a bronchiolitis hospitalization were associated with subsequent asthma. METHODS: This is a retrospective cohort study at an urban, tertiary-care children's hospital of infants <12 months old, hospitalized for bronchiolitis. The primary outcome measure was an asthma diagnosis, defined as a billing code for an asthma visit or a prescription for controller medication, within 5 years of discharge from the bronchiolitis hospitalization. RESULTS: There were 534 infants hospitalized for bronchiolitis, of which 294 (55.1%) were diagnosed with asthma, and 102 (19.1%) were hospitalized for asthma within 5 years of discharge. There was significant interaction between age and family history. In both models, female sex was protective (odds ratio [OR] 0.46). Age and race were only associated with asthma in infants without a family history of asthma: age (OR 1.19; 95% confidence interval 1.08-1.32) and race (OR 4.06; 95% confidence interval 1.56-10.58). Hospitalization length, ICU stay, albuterol treatments received, supplemental oxygen, respiratory support, highest respiratory rate, and respiratory syncytial virus infection were not associated with asthma diagnosis. CONCLUSIONS: More than 55% of infants hospitalized for bronchiolitis developed asthma within 5 years of discharge. Demographic and family history variables were independently associated with asthma. However, hospital-based variables during the bronchiolitis hospitalization were not independently associated with asthma. These results can direct further research and differentiate anticipatory guidance for infants with bronchiolitis at risk for asthma.

Contextual Factors Associated With Quality Improvement Success in a Multisite Ambulatory Setting.

The Model for Understanding Success in Quality (MUSIQ) is a framework of contextual factors for quality improvement (QI) projects. We sought to determine which MUSIQ contextual factors were associated with successful QI initiatives. In a cross-sectional survey study, at a 21-site, ambulatory, urban primary care network, a modified MUSIQ survey tool questionnaire was administered to QI team members. The primary analysis associated objective measures of QI success with MUSIQ contextual factors. Objective QI success was defined as reaching goal percentages of adult patients with diabetes achieving glycated hemoglobin less than 8% and/or pediatric patients who had received combination toddler vaccines. Objective outcomes were compared with a subjective, self-reported outcome measure of QI success because previous literature found subjective outcomes were associated with specific MUSIQ factors. In the 143 survey responses collected, across 21 sites, no contextual factors from the MUSIQ survey were associated with either the adult or pediatric objective measure of QI project success. In a post hoc analysis, objective and subjective measures of success were often not associated and/or negatively correlated. In conclusion, contextual factors were not associated with objective measures of QI outcomes, in contrast to previous studies finding associations with subjective QI outcome measures.

Risk Factors for Respiratory Decompensation Among Healthy Infants With Bronchiolitis.

BACKGROUND: Although most children with bronchiolitis only require supportive care, some decompensate and require ventilatory support. We examined predictors of respiratory decompensation among hospitalized children to identify which patients may benefit from expectant monitoring. METHODS: We examined children ≤24 months old with bronchiolitis admitted to the general infant and toddler floor. Children with pneumonia or comorbidities were excluded. Demographic and clinical characteristics were abstracted from a clinical database and medical records. Respiratory decompensation was defined as the need for initiating high-flow nasal cannula oxygen, continuous positive airway pressure, nasal intermittent mandatory ventilation, bilevel positive airway pressure, or intubation. A multivariable logistic regression model was constructed to identify independent predictors of respiratory decompensation. RESULTS: A total of 1217 children were included. The median age was 6.9 months, 41% were girls, 49% were Hispanic, 21% were black, and 18% were premature. Significant independent predictors of respiratory decompensation were age ≤3 months (odds ratio [OR]: 3.25; 95% confidence interval [CI]: 2.09-5.07), age 3 to 6 months (OR: 1.76; 95% CI: 1.04-3.0), black race (OR: 1.94; 95% CI: 1.27-2.95), emergency department hypoxemia (OR: 2.34; 95% CI: 1.30-4.21), and retractions or accessory muscle use (OR: 2.26; 95% CI: 1.48-3.46). Children with 0 of 4 predictors were found to have a low risk of decompensation (3%). CONCLUSIONS: Young age, black race, emergency department hypoxemia, and retractions or accessory muscle use were associated with respiratory decompensation in children with bronchiolitis. These factors should be considered at presentation, as they identify children who require a higher level of respiratory monitoring and support and others who may not benefit.

3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Bronchiolitis, the most common reason for hospitalization in children younger than 1 year in the United States, has no proven therapies effective beyond supportive care. We aimed to investigate the effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis. METHODS: We conducted a prospective, randomized, double-blind, controlled trial in an urban tertiary care children's hospital in 227 infants younger than 12 months old admitted with a diagnosis of bronchiolitis (190 completed the study); 113 infants were randomized to HS (93 completed the study), and 114 to NS (97 completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS every 4 hours from enrollment until hospital discharge. The primary outcome was median LOS. Secondary outcomes were total adverse events, subdivided as clinical worsening and readmissions. RESULTS: Patient characteristics were similar in groups. In intention-to-treat analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days (1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar between groups (9% vs 8%, P = .97). CONCLUSIONS: Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.