Impact of the COVID-19 pandemic on pediatric faculty: a report from nine academic institutions.

BACKGROUND: The COVID-19 pandemic affected home and work routines, which may exacerbate existing academic professional disparities. Objectives were to describe the impact of the pandemic on pediatric faculty's work productivity, identify groups at risk for widening inequities, and explore mitigation strategies. METHODS: A cross-sectional study of faculty members was conducted at nine U.S. pediatric departments. Responses were analyzed by demographics, academic rank, and change in home caregiving responsibility. RESULTS: Of 5791 pediatric faculty members eligible, 1504 (26%) completed the survey. The majority were female (64%), over 40 years old (60%), and assistant professors (47%). Only 7% faculty identified as underrepresented in medicine. Overall 41% reported an increase in caregiving during the pandemic. When comparing clinical, administrative, research, and teaching activities, faculty reported worse 1-year outlook for research activities. Faculty with increased caregiving responsibilities were more likely to report concerns over delayed promotion and less likely to have a favorable outlook regarding clinical and research efforts. Participants identified preferred strategies to mitigate challenges. CONCLUSIONS: The COVID-19 pandemic negatively impacted pediatric faculty productivity with the greatest effects on those with increased caregiving responsibilities. COVID-19 was particularly disruptive to research outlook. Mitigation strategies are needed to minimize the long-term impacts on academic pediatric careers. IMPACT: The COVID-19 pandemic most negatively impacted work productivity of academic pediatric faculty with caregiving responsibilities. COVID-19 was particularly disruptive to short-term (1-year) research outlook among pediatric faculty. Faculty identified mitigation strategies to minimize the long-term impacts of the pandemic on academic pediatric career pathways.

Ketamine for Pain in Sickle Cell Disease Reduces Opioid Usage.

CONTEXT: Pain attributable to sickle cell disease (SCD) is often unpredictable, recurrent, and requires complex treatments. Subanesthetic ketamine infusion has been studied in other diseases and disorders, but there is still limited data on its efficacy in pain management for SCD. OBJECTIVES: The primary objective is to determine if subanesthetic ketamine infusion reduces pain scores and opioid requirements in hospitalized pediatric patients with SCD. RESULTS: Forty-six admissions among 22 patients between February 2018 and December 2019 were analyzed. We observed decrease in pain scores within 24 hours of ketamine initiation in 34 of 46 admissions (mean pain score per patient before ketamine initiation: 2.2-9.7, mean pain score per patient after ketamine initiation: 0-9.7; P < .05). We observed a decrease in pain scores in the remaining 12 admissions after greater than 24 hours of ketamine initiation. Opioid usage declined after ketamine infusion, with a difference of means in oral morphine equivalents before and after ketamine of 122.8 mg/day. The side effects observed with ketamine infusion included hallucinations in 11 (23.9%) admissions. Only four (8.7%) admissions required cessation of the infusion due to side effects. The readmission rate at two weeks and four weeks after first ketamine infusion was the same (12.5%) at both time points. For all patients in the cohort, the introduction of ketamine into pain regimens did not reduce the number of admissions in the year following ketamine initiation relative to the year prior. CONCLUSION: In pediatric patients with SCD, subanesthetic ketamine was safe as a continuous infusion and effectively reduced both pain scores and opioid requirements.

Research Priorities for Pediatric Emergency Care to Address Disparities by Race, Ethnicity, and Language.

Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking. Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations. Design, Setting, and Participants: In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks. Outcome: Consensus agenda of research priorities to identify and address health care disparities in PEC. Results: PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation. Conclusions and Relevance: These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Sickle Cell Disease Treatment with Arginine Therapy (STArT): study protocol for a phase 3 randomized controlled trial.

BACKGROUND: Despite substantial illness burden and healthcare utilization conferred by pain from vaso-occlusive episodes (VOE) in children with sickle cell disease (SCD), disease-modifying therapies to effectively treat SCD-VOE are lacking. The aim of the Sickle Cell Disease Treatment with Arginine Therapy (STArT) Trial is to provide definitive evidence regarding the efficacy of intravenous arginine as a treatment for acute SCD-VOE among children, adolescents, and young adults. METHODS: STArT is a double-blind, placebo-controlled, randomized, phase 3, multicenter trial of intravenous arginine therapy in 360 children, adolescents, and young adults who present with SCD-VOE. The STArT Trial is being conducted at 10 sites in the USA through the Pediatric Emergency Care Applied Research Network (PECARN). Enrollment began in 2021 and will continue for 5 years. Within 12 h of receiving their first dose of intravenous opioids, enrolled participants are randomized 1:1 to receive either (1) a one-time loading dose of L-arginine (200 mg/kg with a maximum of 20 g) administered intravenously followed by a standard dose of 100 mg/kg (maximum 10 g) three times a day or (2) a one-time placebo loading dose of normal saline followed by normal saline three times per day at equivalent volumes and duration as the study drug. Participants, research staff, and investigators are blinded to the participant's randomization. All clinical care is provided in accordance with the institution-specific standard of care for SCD-VOE based on the 2014 National Heart, Lung, and Blood Institute guidelines. The primary outcome is time to SCD-VOE pain crisis resolution, defined as the time (in hours) from study drug delivery to the last dose of parenteral opioid delivery. Secondary outcomes include total parental opioid use and patient-reported outcomes. In addition, the trial will characterize alterations in the arginine metabolome and mitochondrial function in children with SCD-VOE. DISCUSSION: Building on the foundation of established relationships between emergency medicine providers and hematologists in a multicenter research network to ensure adequate participant accrual, the STArT Trial will provide definitive information about the efficacy of intravenous arginine for the treatment of SCD-VOE for children. TRIAL REGISTRATION: The STArT Trial was registered in ClinicalTrials.gov on April 9, 2021, and enrollment began on June 21, 2021 (NCT04839354).

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective.

Children with sickle cell disease (SCD) commonly experience vaso-occlusive pain episodes (VOE) due to sickling of erythrocytes, which often requires care in the emergency department. Our objective was to assess the use and impact of intranasal fentanyl for the treatment of children with SCD-VOE on discharge from the emergency department in a multicenter study. We conducted a cross-sectional study at 20 academic pediatric emergency departments in the United States and Canada. We used logistic regression to test bivariable and multivariable associations between the outcome of discharge from the emergency department and candidate variables theoretically associated with discharge. The study included 400 patients; 215 (54%) were female. The median age was 14.6 (interquartile range 9.8, 17.6) years. Nineteen percent (n = 75) received intranasal fentanyl in the emergency department. Children who received intranasal fentanyl had nearly nine-fold greater adjusted odds of discharge from the emergency department compared to those who did not (adjusted odds ratio 8.99, 95% CI 2.81-30.56, p < .001). The rapid onset of action and ease of delivery without intravenous access offered by intranasal fentanyl make it a feasible initial parenteral analgesic in the treatment of children with SCD presenting with VOE in the acute-care setting. Further study is needed to determine potential causality of the association between intranasal fentanyl and discharge from the emergency department observed in this multicenter study.

Career Development in Pediatric Emergency Medicine: What Do We Need?

OBJECTIVES: The Women in Pediatric Emergency Medicine (PEM) subcommittee of the American Academy of Pediatrics Section on Emergency Medicine identified 2 top priorities for 2021: career development and mentorship/sponsorship. The objective of this study was to catalog and delineate the career development domains for women physicians in PEM. METHODS: After a review of the literature to identify the key areas for gaps for women in PEM, we used Q sort methodology to elicit domains for this subcommittee to address by survey of a national sample. RESULTS: One hundred fourteen discrete potential areas of interest for career development were identified by the working group based on salient themes from the literature and personal experiences. Forty-one Women in PEM subcommittee members (27%) completed the survey. The career development topics were sorted into the domains of personal (40.4%; n = 46), administrative (28.1%; n = 32), research (10.5%; n = 12), teaching (10.5%; n = 12), service (7.0%; n = 8), and clinical (3.5%; n = 4). CONCLUSIONS: This study demonstrates that the career development needs of women in PEM include a range of personal, teaching, research, administrative, clinical, and service domains. However, more than two-thirds of the career development topics were categorized into just 2 domains, administrative and personal.

Managing acute pain in children presenting to the emergency department without opioids.

Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non-pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.

Pediatric Emergency Medicine Fellowship Procedural Sedation Training: Consensus Educational Guidelines.

OBJECTIVES: Pediatric procedural sedation (PPS) is a core clinical competency of pediatric emergency medicine (PEM) fellowship training mandated by both the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Neither of these certifying bodies, however, offers specific guidance with regard to attaining and evaluating proficiency in trainees. Recent publications have revealed inconsistency in educational approaches, attending oversight, PPS service rotation experiences, and evaluation practices among PEM fellowship programs. METHODS: A select group of PEM experts in PPS, PEM fellowship directors, PEM physicians with educational roles locally and nationally, PEM fellows, and recent PEM fellowship graduates collaborated to address this opportunity for improvement. RESULTS: This consensus driven educational guideline was developed to outline PPS core topics, evaluation methodology, and resources to create or modify a PPS curriculum for PEM fellowship programs. This curriculum was developed to map to fellowship Accreditation Council for Graduate Medical Education core competencies and to use multiple modes of dissemination to meet the needs of diverse programs and learners. CONCLUSIONS: Implementation and utilization of a standardized PPS curriculum as outlined in this educational guideline will equip PEM fellows with a comprehensive PPS knowledge base. Pediatric emergency medicine fellows should graduate with the competence and confidence to deliver safe and effective PPS care. Future study after implementation of the guideline is warranted to determine its efficacy.

Vision 2020: How Caregiving and Work Productivity Outlook Shifted for Academic Pediatric Faculty.

Background: The coronavirus disease 2019 (COVID-19) pandemic has affected both home and work routines and may have exacerbated existing inequities. The objectives of this study were to describe pediatric faculty work productivity and caregiving responsibilities during the pandemic, identify groups at risk, and better understand mitigation strategy preferences. Materials and Methods: We conducted a cross-sectional electronic survey of Department of Pediatric faculty. Responses were analyzed by demographic data as well as academic context. Results: Women (p = 0.003) and junior faculty (p = 0.02) reported greater increases in caregiving responsibilities than men and senior faculty during the pandemic compared with the previous year. Faculty perceived a worse one-year outlook for their research than for their teaching or clinical responsibilities (p < 0.01). More than a third (37%) of faculty reported wellness concerns affecting job performance, which was more common among those with increased caregiving responsibility (p = 0.01). Junior faculty (p = 0.01) and those whose increased caregiving (p = 0.01) were two and threefold more likely to report that their caregiving responsibilities would affect promotion, for those likely to go up for promotion within 10 years. Preferred mitigation strategies included clear communication of expectations by leadership, acknowledging the need for adjustments in expectations, flexible work hours, and allowances for an off-line day. Conclusion: Pediatric faculty with increased caregiving responsibilities and junior faculty are at highest risk for the pandemic, affecting their readiness for promotion. Wellness concerns by faculty could affect work performance. Researchers report a worse 1-year outlook than the other groups. Faculty identified preferred strategies to potentially assist in maintaining their productivity.

Emergency department strategies to combat the opioid crisis in children and adolescents.

The opioid crisis has greatly affected not only adults but also children as well. As clinicians develop effective approaches to minimize pain and distress in children, the risks and benefits of opioids must be carefully considered. Children of parents with opioid use disorder are also at risk of living in unstable environments, performing poorly academically, engaging in future drug use, and having increased stress, which affects their development before entering adulthood. This statement focuses on the effects of the opioid crisis on children and adolescents and is intended to inform institutional policies, improve education, advocate for evidence-informed guidelines, and improve the care of children affected by the opioid epidemic who are seen in the emergency department.

Pediatric Emergency Departments and Urgent Care Visits in Houston after Hurricane Harvey.

INTRODUCTION: Natural disasters are increasingly common and devastating. It is essential to understand children's health needs during disasters as they are a particularly vulnerable population. The objective of this study was to evaluate pediatric disease burden after Hurricane Harvey compared to the preceding month and the same period in the previous year to inform pediatric disaster preparedness. METHODS: This was a retrospective cross-sectional study of patients seen at pediatric emergency departments (ED) and urgent care centers (UCC) 30 days before (late summer) and after (early fall) the hurricane and from the same time period in 2016. We collected demographic information and the first five discharge diagnoses from a network of EDs and UCCs affiliated with a quaternary care children's hospital in Houston, Texas. We calculated the odds of disease outcomes during various timeframes using binary logistic regression modeling. RESULTS: There were 20,571 (median age: 3.5 years, 48.1% female) and 18,943 (median age: 3.5 years, 47.3% female) patients in 2016 and 2017, respectively. Inpatient admission rates from the ED a month after Harvey were 20.5%, compared to 25.3% in the same period in 2016 (P<0.001). In both years, asthma and other respiratory illnesses increased from late summer to early fall. After controlling for these seasonal trends, the following diseases were more commonly seen after the hurricane: toxicological emergencies (adjusted odds ratio [aOR]: 2.61, 95% [confidence interval] CI, 1.35-5.05); trauma (aOR: 1.42, 95% CI, 1.32-1.53); and dermatological complaints (aOR: 1.34, 95% CI, 1.23-1.46). CONCLUSION: We observed increases in rashes, trauma, and toxicological diagnoses in children after a major flood. These findings highlight the need for more medication resources and public health and education measures focused on pediatric disaster preparedness and management.

Use of antitussive medications in acute cough in young children.

Acute cough, a common complaint in young children, is often the result of a viral upper respiratory infection. Cough and cold remedies generate billions of dollars in annual sales in the United States, despite a lack of evidence of their efficacy and multiple warnings by the US Food and Drug Administration. The current article begins with the best available evidence for common over-the-counter (OTC) and prescription antitussive remedies in children. The article concludes with a discussion of the pros and cons for the use of antitussives in children with cough. In general, OTC antitussive medications should not be routinely used in children under 2 years of age. In certain cases, antitussives with minimal adverse profile and some evidence of benefit may be recommended after informed counseling.

Case Report of Unusual Facial Swelling in an 8-Month-Old.

Rhabdomyolysis is a potentially life-threatening disease defined by the release of intracellular contents into the body's circulation after muscle damage. It is most commonly seen in adult patients who present with crush injuries, overexertion, or prolonged immobility due to drug and/or alcohol overdose. Fortunately, it is rare in young children. We present the case of an 8-month-old girl with progressively worsening right-sided facial swelling that was associated with significant drooling and intraoral edema. The patient had been found lying prone and wedged between a mattress and the adjacent bedroom wall. After laboratory and imaging work-up, this child's injury was the result of prolonged facial muscle compression with resultant rhabdomyolysis. The patient improved during hospital admission with intravenous (IV) fluids, two days of steroids for facial swelling, and five days of antibiotics to treat superficial cellulitis. At 2-week follow-up, her swelling resolved with minimal residual facial scarring and a mild right facial nerve palsy. This patient's unusual history and clinical presentation challenges providers to explore rhabdomyolysis as a differential diagnosis in young children who present with localized severe swelling. Topics: Facial edema, rhabdomyolysis, facial cellulitis, non-accidental trauma.

Improving the Pediatric Procedural Experience: An Analysis of Pain, Anxiety, and Satisfaction.

OBJECTIVE: The purpose of this investigation was to compare self-reported and perceived pain and anxiety among patients, caregivers, and providers before, during, and after common emergency department (ED) procedures while evaluating the impact of commonly used adjuncts on overall satisfaction. METHODS: A prospective observational study of children undergoing painful procedures in an ED was conducted from January 2015 to March 2017. Before, during, and after the procedure, patients older than 3 years of age rated their pain and anxiety. At the same time points, the provider and caregiver rated their impression of the patient's pain, and the caregiver also rated the patient's anxiety. After the procedure, satisfaction was elicited from the caregiver and the provider. RESULTS: A total of 257 children were enrolled: 150 for intravenous line placement, 53 for wound repair, and 44 for a variety of other procedures. Caregivers rated pain higher than providers before, during, and after the procedure (P values <0.001, <0.001, and 0.003, respectively). Caregivers rated anxiety higher than patients before, during and after the procedure (P values <0.001, 0.03, and 0.002, respectively). Providers were less satisfied with the 1- to 2-year age-group compared to the 8+ years age groups (P values 0.01 and 0.002). CONCLUSIONS: Caregiver perception of pain and anxiety of the patient exceeds provider and sometimes patient reports. The youngest children present a challenge for caregivers and providers and have lower satisfaction compared to older groups.

Chloral Hydrate Sedation in a Dexmedetomidine Era.

Brief Overview: The use of chloral hydrate as the primary sedation agent has declined across the nation after commercial production of the liquid formulation ceased. Although alternative sedatives have gained popularity, some pharmacies have continued to provide oral chloral hydrate by compounding it from raw ingredients. Thus, oral chloral hydrate use has continued in children despite the availability of alternative effective agents. Objective: The purpose of this investigation was to evaluate institutional chloral hydrate utilization as the primary agent for procedural sedation. Design/Methods: We conducted a retrospective study of patients given chloral hydrate for procedural sedation from October 2010 to December 2016. The hospital pharmacy database of chloral hydrate use at our 2 free-standing children's hospitals was reviewed and matched to procedure billing data. Results: There were 5874 chloral hydrate administrations for procedural sedation during the study period. The highest rates of use occurred in 2014, when there were 1420 chloral hydrate orders within our hospital. The large majority of sedations were for cardiac studies/procedures (n = 4250, 72.4%). Conclusions: Despite significant declines in use of chloral hydrate for procedural sedation across the country, local utilization of oral chloral hydrate remains high. Recent declines may be due to high-use clinical sites transitioning to alternative sedatives such as intranasal dexmedetomidine.

Focused Research Infrastructure for Postgraduate Pediatric Emergency Medicine Fellows Increases Dissemination of Scholarly Work.

BACKGROUND: Many fellows in clinically driven subspecialties may have difficulty completing and publishing their scholarly projects due to lack of prior experience in research, selection of projects that are difficult to complete during fellowship, or mentorship challenges. This may be particularly true in pediatric emergency medicine (PEM) because research time may be longitudinally integrated with clinical rotations, rather than blocked as is common in other subspecialties. We describe the creation and outcomes of a structured program to increase academic productivity of PEM fellows. METHODS: This was a retrospective cohort study of scholarly productivity (publications in peer-reviewed journals, presentation at national meetings) for PEM fellows over 17 years in one fellowship program, before and after the implementation of a structured program. We reviewed obstacles to publication for prior fellow projects when developing the curriculum. Our multifaceted program consisted of milestone development, four in-person committee meetings, and abstract and manuscript development workshops. We utilized existing faculty members, most of whom were junior faculty, as committee members. Our primary outcome was the percentage of fellows who were first authors for peer-reviewed publications for their fellowship projects. National conference presentations were the secondary outcome. RESULTS: Data for 76 PEM fellows were eligible for analysis: 44 (58%) before and 32 after programmatic implementation. There was a statistically significant increase in the percentage of fellows who published their studies (32% vs. 63%; odds ratio [OR] = 3.6, 95% confidence interval [CI] = 1.4 to 9.3) after programmatic implementation. There were no differences in conference presentations (45% vs. 63%; OR = 2.0, 95% CI = 0.8-5.1) after implementation. CONCLUSIONS: Utilizing a small group of existing, predominantly junior faculty members, we created a structured program that enhanced PEM fellows' scholarly productivity and increased publications. We believe that this model is sustainable for and generalizable to other PEM fellowship programs.

Trends in Outpatient Procedural Sedation: 2007-2018.

BACKGROUND: Pediatric subspecialists routinely provide procedural sedation outside the operating room. No large study has reported trends in outpatient pediatric procedural sedation. Our purpose in this study was to identify significant trends in outpatient procedural sedation using the Pediatric Sedation Research Consortium. METHODS: Prospectively collected data from 2007 to 2018 were used for trending procedural sedation. Patient characteristics, medications, type of providers, serious adverse events, and interventions were reported. The Cochran-Armitage test for trend was used to explore the association between the year and a given characteristic. RESULTS: A total of 432 842 sedation encounters were identified and divided into 3 4-year epochs (2007-2011, 2011-2014, and 2014-2018). There was a significant decrease in infants <3 months of age receiving procedural sedation (odds ratio = 0.97; 95% confidence interval, 0.96-0.98). A large increase was noticed in pediatric hospitalists providing procedural sedation (0.6%-9.5%; P < .001); there was a decreasing trend in sedation by other providers who were not in emergency medicine, critical care, or anesthesiology (13.9%-3.9%; P < .001). There was an increasing trend in the use of dexmedetomidine (6.3%-9.3%; P < .001) and a decreasing trend in the use of chloral hydrate (6.3%-0.01%; P < .001) and pentobarbital (7.3%-0.5%; P < .001). Serious adverse events showed a nonsignificant increase overall (1.35%-1.75%). CONCLUSIONS: We report an increase in pediatric hospitalists providing sedation and a significant decrease in the use of chloral hydrate and pentobarbital by providers. Further studies are required to see if sedation services decrease costs and optimize resource use.