Infant Modified Constraint-Induced Movement Therapy Paired With Neuromuscular Electrical Stimulation: A Feasibility Study.

PURPOSE: To determine the feasibility of modified constraint-induced movement therapy (mCIMT) paired with neuromuscular electrical stimulation (NMES) for infants with asymmetrical hand function (AHF). METHODS: Five infants received an experimental ABA design: (A1) 3 weeks of our Standard AHF Care, (B) 3 weeks mCIMT-NMES, and (A2) 3 weeks of our Standard AHF Care. Parents tracked key data in a daily log, and infants were assessed 4 times using the Hand Assessment for Infants and Peabody Developmental Motor Scale-2. RESULTS: There was a high level of participant enrollment, visit frequency adherence, and compliance with the treatment protocol. No adverse events were reported. Mean Hand Assessment for Infants Both Hands measure scores changed more after mCIMT-NMES than after our Standard AHF Care. CONCLUSIONS: mCIMT-NMES is a feasible early intervention for infants with AHF at risk for unilateral cerebral palsy. A future study in a larger sample should examine the efficacy of mCIMT-NMES in this population.

Multicentre, retrospective cohort study protocol to identify racial and ethnic differences in acute kidney injuries in children and adolescents with diabetic ketoacidosis.

INTRODUCTION: Approximately 40% of children with diabetic ketoacidosis (DKA) develop acute kidney injury (AKI), which increases the risk of chronic kidney damage. At present, there is limited knowledge of racial or ethnic differences in diabetes-related kidney injury in children with diabetes. Understanding whether such differences exist will provide a foundation for addressing disparities in diabetes care that may continue into adulthood. Further, it is currently unclear which children are at risk to develop worsening or sustained DKA-related AKI. The primary aim is to determine whether race and ethnicity are associated with DKA-related AKI. The secondary aim is to determine factors associated with sustained AKI in children with DKA. METHODS AND ANALYSIS: This retrospective, multicentre, cross-sectional study of children with type 1 or type 2 diabetes with DKA will be conducted through the Paediatric Emergency Medicine Collaborative Research Committee. Children aged 2-18 years who were treated in a participating emergency department between 1 January 2020 and 31 December 2023 will be included. Children with non-ketotic hyperglycaemic-hyperosmolar state or who were transferred from an outside facility will be excluded. The relevant predictor is race and ethnicity. The primary outcome is the presence of AKI, defined by Kidney Disease: Improving Global Outcomes criteria. The secondary outcome is 'sustained' AKI, defined as having AKI ≥48 hours, unresolved AKI at last creatinine measurement or need for renal replacement therapy. Statistical inference of the associations between predictors (ie, race and ethnicity) and outcomes (ie, AKI and sustained AKI) will use random effects regression models, accounting for hospital variation and clustering. ETHICS AND DISSEMINATION: The Institutional Review Board of Children's Minnesota approved this study. 12 additional sites have obtained institutional review board approval, and all sites will obtain local approval prior to participation. Results will be presented at local or national conferences and for publication in peer-reviewed journals.

Evaluation of Automated Finger Compression for Capillary Refill Time Measurement in Pediatrics.

OBJECTIVES: Early shock reversal is crucial to improve patient outcomes. Capillary refill time (CRT) is clinically important to identify and monitor shock in children but has issues with inconsistency. To minimize inconsistency, we evaluated a CRT monitoring system using an automated compression device. Our objective was to determine proper compression pressure in children. METHODS: Clinician force for CRT was collected during manual CRT measurement as a reference for automated compression in a previous study (12.9 N, 95% confidence interval, 12.5-13.4; n = 454). An automated compression device with a soft inflation bladder was fitted with a force sensor. We evaluated the effectiveness of the automated pressure to eliminate pulsatile blood flow from the distal phalange. Median and variance of CRT analysis at each pressure was compared. RESULTS: A comparison of pressures at 300 to 500 mm Hg on a simulated finger yielded a force of 5 to 10 N, and these pressures were subsequently used for automated compression for CRT. Automated compression was tested in 44 subjects (median age, 33 months; interquartile range [IQR], 14-56 months). At interim analysis of 17 subjects, there was significant difference in the waveform with residual pulsatile blood flow (9/50: 18% at 300 mm Hg, 5/50:10% at 400 mm Hg, 0/51: 0% at 500 mm Hg, P = 0.008). With subsequent enrollment of 27 subjects at 400 and 500 mm Hg, none had residual pulsatile blood flow. There was no difference in the CRT: median 1.8 (IQR, 1.06-2.875) in 400 mm Hg vs median 1.87 (IQR, 1.25-2.8325) in 500 mm Hg, P = 0.81. The variance of CRT was significantly larger in 400 mm Hg: 2.99 in 400 mm Hg vs. 1.35 in 500 mm Hg, P = 0.02, Levene's test. Intraclass correlation coefficient for automated CRT was 0.56 at 400 mm Hg and 0.78 at 500 mm Hg. CONCLUSIONS: Using clinician CRT measurement data, we determined either 400 or 500 mm Hg is an appropriate pressure for automated CRT, although 500 mm Hg demonstrates superior consistency.

Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department.

OBJECTIVE: To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN: We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, using data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS: In total, 94 884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI 0.66-0.75) and 26% (aOR 0.74; 95% CI 0.69-0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI 0.73-0.86) and 22% (aOR 0.78; 95% CI 0.71-0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly greater among Asian children (aOR 2.12; 95% CI 1.19-3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS: Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.

Prenatal and postpartum depression diagnosis in a large health system: prevalence and disparities.

BACKGROUND/OBJECTIVES/INTRODUCTION: Depression during pregnancy or postpartum carries the same risks as general depression as well as additional risks specific to pregnancy, infant health and maternal well-being. The purpose of this study is to document the prevalence of depression symptoms and diagnosis during pregnancy and in the first 3 months postpartum among a cohort of women receiving prenatal care in a large health system. Secondarily, we examine variability in screening results and diagnosis by race, ethnicity, language, economic status and other maternal characteristics during pregnancy and postpartum. PATIENTS/MATERIALS AND METHODS: A retrospective study with two cohorts of patients screened for depression during pregnancy and postpartum. Out of 7807 patients with at least three prenatal care visits and a delivery in 2016, 6725 were screened for depression (87%) at least once during pregnancy or postpartum. Another 259 were excluded because of missing race data. The final sample consisted of 6523 prenatal care patients who were screened for depression; 4914 were screened for depression in pregnancy, 4619 were screened postpartum (0-3 months). There were 3010 screened during both periods who are present in both the pregnancy and postpartum cohorts. Depression screening results are from the Patient Health Questionnaire (PHQ-9) and diagnosis of depression was measured using ICD codes. For patients screened more than once during either time period, the highest score is used for analysis. RESULTS: Approximately, 11% of women had a positive depression screen as indicated by an elevated PHQ-9 score (>10) during pregnancy (11.3%) or postpartum (10.7%). Prevalence of depression diagnosis was similar in the two periods: 12.6% during pregnancy and 13.0% postpartum. A diagnosis of depression during pregnancy was most prevalent among women who were age 24 and younger (19.7%), single (20.5%), publicly insured (17.8%), multiracial (24.1%) or Native American (23.8%), and among women with a history of depression in the past year (58.9%). Among women with a positive depression screen, Black women were less than half as likely as White women to receive a diagnosis in adjusted models (AOR 0.40, CI: 0.23-0.71, p = .002). This difference was not present postpartum. CONCLUSIONS: Depression symptoms and diagnoses differ by maternal characteristics during pregnancy with some groups at substantially higher risk. Efforts to examine disparities in screening and diagnosis are needed to identify reasons for variability in prenatal depression diagnosis between Black and White women.Key messagesWomen who were young, single, have public insurance, and women who identify as multiracial or non-Hispanic (NH) Native American were most likely to have a positive depression screen or a diagnosis for depression.After adjustment for confounders, NH Black women with a positive depression screen were about half as likely to have a diagnosis of depression during pregnancy as NH White women.Awareness of the differing prevalence of depression risk screening results, diagnoses and potential for variation in diagnosis may identify opportunities to improve equity in the delivery of essential mental health care to all patients.

Impact of Clinical Guidelines on Hospital Utilization in Children With Croup.

OBJECTIVES: To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission. METHODS: Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year. RESULTS: Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant. CONCLUSIONS: Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.

Variation in Organizational Clinical Practice Guidelines for Croup.

BACKGROUND: Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition. OBJECTIVES: To describe variation in CPGs across US children's hospitals. METHODS: We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement. RESULTS: Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores. CONCLUSIONS: Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers.

Pediatric peanut aspirations before and after 2015 recommendation for early peanut exposure.

OBJECTIVES: To investigate if there has been an increase in peanut foreign body aspirations (FBA) in children since the publication of the Learning Early About Peanut Allergy (LEAP) trial, which revealed that early exposure to peanut-containing foods prevented peanut allergies in children at risk of atopic disease. METHODS: Retrospective chart reviews were conducted separately at two pediatric institutions. Institutions One and Two reviewed children less than 7 years old who underwent bronchoscopy for FBA over ten-year periods between January 2007 and September 2017 and November 2008 and May 2018, respectively. The proportion of FBAs attributed to peanuts was compared before and after the publication LEAP. RESULTS: Out of 515 reviewed cases, there was no change in pediatric peanut aspirations prior to and following the LEAP trial and AAP guideline change (33.5% vs 31.4%, p = 0.70). At Institution One, 317 patients met inclusion criteria. When comparing FBAs before and after LEAP, there were no significant changes in the rate of peanut aspiration (53.5% vs. 45.1%, p = 0.17). Institution Two also found no significant increase in the rate of peanut aspirations before and after the Addendum Guidelines (41.4% vs. 28.6%, p = 0.65) upon review of 198 cases. CONCLUSIONS: Multiple institutions demonstrated a non-significant change in the rate of peanut FBAs following the AAP recommendation. Given that peanuts comprise a large proportion of FBAs, it is important to continue to track peanut aspirations. Longer term data tracking is needed from more institutions to further understand how recommendations from other specialties and the media impacts pediatric aspiration outcomes.

Declining Rates of Legg-Calvé-Perthes Surgery in the United States: National Trends Using the Kids' Inpatient Database and Pediatric Health Information System.

BACKGROUND: In 2004 and 2008 two large prospective, multicenter studies were published which resulted in improved understanding of operative indications for the treatment of Legg-Calvé-Perthes disease (LCPD) based on patient age, disease severity, and resultant radiographic outcomes. The primary aim of this study is to evaluate the trends in surgical management of LCPD in the United States prior, and subsequent to, the publication of these landmark studies. METHODS: Cross-sectional retrospective analysis of US pediatric hospitalizations for the surgical management of LCPD was conducted using the Kids' Inpatient Database from 2000 to 2016. Patients 12 years of age and younger were included who had a primary admission diagnosis of LCPD and a LCPD-related procedure during the hospitalization. Data was subsequently weighted to produce national-level estimates and variables pertaining to patient age group, procedure, demographics, and hospital characteristics were analyzed. In a post hoc analysis, the results of the Kids' Inpatient Database were also corroborated with the Pediatric Health Information System database. RESULTS: A weighted sample of 2786 LCPD surgical admissions met inclusion and exclusion criteria; 11.2% of surgical admissions were patients below 6 years of age, 35.9% were 6 to 8 years of age, and 52.9% were above 8 years of age. There was a significant decrease in admissions for surgical management of LCPD in all age groups over time, however there was no appreciable change in the proportion of LCPD surgical admissions performed among the above 8 to below 12, above 6 to below 8, or below 6 years age groups. Femoral osteotomy remained the most common surgical procedure, while other osteotomy types, including pelvic and unspecified osteotomies involving the hip, decreased over time ( P <0.001). CONCLUSIONS: There is a decreasing rate of hospital admissions for LCPD surgery since 2000, perhaps indicating a decline in incidence of disease. Furthermore, despite evidence supporting LCPD surgical outcomes related to patient age, there has been no change in the proportion of patients undergoing surgery by age group over time. LEVEL OF EVIDENCE: Level III-retrospective study.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair.

OBJECTIVES: Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores. METHODS: We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables. RESULTS: We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score. CONCLUSION: The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Omphalitis Hospitalizations at a US Children's Hospital.

OBJECTIVES: To describe demographics, presentation, resource use, and outcomes of patients diagnosed with omphalitis. METHODS: This was a retrospective descriptive study of infants with omphalitis at a children's hospital system between January 2006 and December 2020. Presentation, resource use, and outcomes (omphalitis complications [eg, necrotizing fasciitis], 30-day related cause revisit, and death) were described. RESULTS: Ninety-one patients had a primary or secondary International Classification of Diseases, Ninth or 10th Revision, code for omphalitis. Seventy-eight patients were included in analysis (47 with omphalitis as primary reason for admission). Patients with omphalitis as the primary reason for admission presented with rash (44 of 47, 93.6%), fussiness/irritability (19 of 47, 40.4%), and fever (6 of 47, 12.8%). C-reactive protein was minimally elevated, with a median of 0.4 mg/dL (interquartile range 0.29-0.85).Among all patients, blood cultures were positive in 3 (3 of 78, 3.8%) and most had positive wound cultures (70 of 78, 89.7%), with primarily gram-positive organisms. Median duration of intravenous antibiotics was 5 days (interquartile range 3-7). No patients had complications of omphalitis or death. Five patients (5 of 78, 6.4%) had a 30-day revisit for a related cause. CONCLUSIONS: We found variation in presentation and management of patients with omphalitis at our tertiary children's hospital system. Wound cultures, but not blood tests, were helpful in guiding management in the majority of cases. There were no complications of omphalitis or deaths.

Pediatric Simulation of Intrinsic PEEP and Patient-Ventilator Trigger Asynchrony During Mechanical Ventilation.

BACKGROUND: Intrinsic PEEP during mechanical ventilation occurs when there is insufficient time for expiration to functional residual capacity before the next inspiration, resulting in air trapping. Increased expiratory resistance (RE), too rapid of a patient or ventilator breathing rate, or a longer inspiratory to expiratory time ratio (TI/TE) can all be causes of intrinsic PEEP. Intrinsic PEEP can result in increased work of breathing and patient-ventilator asynchrony (PVA) during patient-triggered breaths. We hypothesized that the difference between intrinsic PEEP and ventilator PEEP acts as an inspiratory load resulting in trigger asynchrony that needs to be overcome by increased respiratory muscle pressure (Pmus). METHODS: Using a Servo lung model (ASL 5000) and LTV 1200 ventilator in pressure control mode, we developed a passive model demonstrating how elevated RE increases intrinsic PEEP above ventilator PEEP. We also developed an active model investigating the effects of RE and intrinsic PEEP on trigger asynchrony (expressed as percentage of patient-initiated breaths that failed to trigger). We then studied if trigger asynchrony could be reduced by increased Pmus. RESULTS: Intrinsic PEEP increased significantly with increasing RE (r = 0.97, P = .006). Multivariate logistic regression analysis showed that both RE and negative Pmus levels affect trigger asynchrony (P < .001). CONCLUSIONS: A passive lung model describes the development of increasing intrinsic PEEP with increasing RE at a given ventilator breathing rate. An active lung model shows how this can lead to trigger asynchrony since the Pmus needed to trigger a breath is greater with increased RE, as the inspiratory muscles must overcome intrinsic PEEP. This model will lend itself to the study of intrinsic PEEP engendered by a higher ventilator breathing rate, as well as higher TI/TE, and will be useful in ventilator simulation scenarios of PVA. The model also suggests that increasing ventilator PEEP to match intrinsic PEEP can improve trigger asynchrony through a reduction in RE.

Comparison of Bedside and Video-Based Capillary Refill Time Assessment in Children.

OBJECTIVES: Capillary refill time (CRT) to assess peripheral perfusion in children with suspected shock may be subject to poor reproducibility. Our objectives were to compare video-based and bedside CRT assessment using a standardized protocol and evaluate interrater and intrarater consistency of video-based CRT (VB-CRT) assessment. We hypothesized that measurement errors associated with raters would be low for both standardized bedside CRT and VB-CRT as well as VB-CRT across raters. METHODS: Ninety-nine children (aged 1-12 y) had 5 consecutive bedside CRT assessments by an experienced critical care clinician following a standardized protocol. Each CRT assessment was video recorded on a black background. Thirty video clips (10 with bedside CRT < 1 s, 10 with CRT 1-2 s, and 10 with CRT > 2 s) were randomly selected and presented to 10 clinicians twice in randomized order. They were instructed to push a button when they visualized release of compression and completion of a capillary refill. The correlation and absolute difference between bedside and VB-CRT were assessed. Consistency across raters and within each rater was analyzed using the intraclass correlation coefficient (ICC). A Generalizability study was performed to evaluate sources of variation. RESULTS: We found moderate agreement between bedside and VB-CRT observations (r = 0.65; P < 0.001). The VB-CRT values were shorter by 0.17 s (95% confidence interval, 0.09-0.25; P < 0.001) on average compared with bedside CRT. There was moderate agreement in VB-CRT across raters (ICC = 0.61). Consistency of repeated VB-CRT within each rater was moderate (ICC = 0.71). Generalizability study revealed the source of largest variance was from individual patient video clips (57%), followed by interaction of the VB-CRT reviewer and patient video clip (10.7%). CONCLUSIONS: Bedside and VB-CRT observations showed moderate consistency. Using video-based assessment, moderate consistency was also observed across raters and within each rater. Further investigation to standardize and automate CRT measurement is warranted.

Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup.

BACKGROUND: Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department. METHODS: At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures. RESULTS: There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits. CONCLUSIONS: Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.

Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children's Hospitals.

Importance: The Child Opportunity Index 2.0 (COI) assesses neighborhood resources and conditions that influence health. It is unclear whether the COI scores are associated with health outcomes by race and ethnicity among children with type 1 diabetes (T1D). Objective: To determine whether COI categories are associated with diabetes-related outcomes by race and ethnicity, including readmissions for diabetic ketoacidosis (DKA) and co-occurring acute kidney injury (AKI) or cerebral edema (CE). Design, Setting, and Participants: This cross-sectional study included children discharged with a primary diagnosis of T1D with DKA between January 1, 2009, and December 31, 2018. Merged data were obtained from the Pediatric Health Information System and COI. Participants included children and adolescents younger than 21 years with an encounter for DKA. Data were analyzed from April 29, 2021, to January 5, 2022. Exposures: Neighborhood opportunity, measured with the COI as an ordered, categorical score (where a higher score indicates more opportunity), and race and ethnicity. Main Outcomes and Measures: The primary outcome was readmission for DKA within 30 and 365 days from an index visit. Secondary outcomes included the proportion of encounters with AKI or CE. Mixed-effects logistic regression was used to generate probabilities of readmission, AKI, and CE for each quintile of COI category by race and ethnicity. Results: A total of 72 726 patient encounters were identified, including 38 924 (53.5%) for girls; the median patient age was 13 (IQR, 9-15) years. In terms of race and ethnicity, 600 (0.8%) of the encounters occurred in Asian patients, 9969 (13.7%) occurred in Hispanic patients, 16 876 (23.2%) occurred in non-Hispanic Black (hereinafter Black) patients, 40 129 (55.2%) occurred in non-Hispanic White (hereinafter White) patients, and 5152 (7.1%) occurred in patients of other race or ethnicity. The probability of readmission within 365 days was significantly higher among Black children with a very low COI category compared with Hispanic children (risk difference, 7.8 [95% CI, 6.0-9.6] percentage points) and White children (risk difference, 7.5 [95% CI, 5.9-9.1] percentage points) at the same COI category. Similar differences were seen for children with very high COI scores and across racial groups. The COI category was not associated with AKI or CE. However, race and ethnicity constituted a significant factor associated with AKI across all COI categories. The probability of AKI was 6.8% among Black children compared with 4.2% among Hispanic children (risk difference, 2.5 [95% CI, 1.7-3.3] percentage points) and 4.8% among White children (risk difference, 2.0 [95% CI, 1.3-2.6] percentage points). Conclusions and Relevance: These results suggest that Black children with T1D experience disparities in health outcomes compared with other racial and ethnic groups with similar COI categories. Measures to prevent readmissions for DKA should include interventions that target racial disparities and community factors.

Novel Uses of Traditional Algorithms for Septic Arthritis.

BACKGROUND: Pediatric musculoskeletal infection (MSKI) is a bacterial infection of the bone, joint, and/or muscle that can be difficult to diagnose. The Kocher and Caird algorithms were developed to distinguish septic arthritis (SA) from transient synovitis (TS) in the hip. These algorithms have been applied to all patients presenting with painful, swollen monoarticular joints regardless of suspicion for SA. The aim of this analysis was to assess the test performance of Kocher and Caird to distinguish MSKI among all pediatric patients presenting with monoarticular joint pain. A secondary aim was to validate the original algorithms. METHODS: We conducted a secondary analysis of a prospective cohort study evaluating the test performance of procalcitonin for suspected SA in a pediatric emergency department. Patients aged 0 to 16 years old who presented with a painful or swollen monoarticular joint were considered for enrollment. We compared the test performance of the traditional algorithms in an expanded population of MSKI versus alternate joint pain using sensitivity, specificity, and area under the curve (AUC). As a sensitivity analysis, missing data for predictors like temperature, erythrocyte sedimentation rate, C-reactive protein, and inability to bear weight were multiply imputed using the Stata program, mi impute, for changed equations. RESULTS: The Caird algorithm had better test performance compared to the Kocher in all populations. Both algorithms were most discriminative in comparing SA to TS in all joints (AUC: 0.84 Caird and 0.75 Kocher). However, the Caird criteria performed almost as well discriminating MSKI from other causes of monoarticular joint pain in all joints (AUC: 0.79; 95% confidence interval: 0.72, 0.85) and nonhip joints (AUC: 0.80; 95% confidence interval: 0.71, 0.88). CONCLUSION: Based on the findings of this study, it is clinically reasonable to apply the Caird algorithm to pediatric patients presenting with monoarticular joint pain of medium and large joints such as the knee, ankle, shoulder, elbow, and wrist, in addition to the hip. LEVEL OF EVIDENCE: Level III-retrospective study of novel applications of SA algorithms.

Feasibility trial of weighted blankets as an intervention for emergence delirium in postoperative pediatric patients.

BACKGROUND: Emergence delirium (ED) is a significant problem in the post anesthesia care unit (PACU), resulting in dislodgement of medical devices, patient and staff injury, prolonged recovery, and parent dissatisfaction. Parental requests for the use of weighted blankets in the hospital setting have increased. However, while weighted blankets have shown potential as treatment for anxiety in adults and children, no studies have demonstrated their safe use with children in the hospital setting. PURPOSE: To explore the safety of weighted blanket use with children in the PACU as an intervention for ED, a feasibility study was conducted. DESIGN AND METHODOLOGY: A convenience sample of 93 participants, aged three to 10 years were recruited. Watcha scores, vital signs, length of wear time, and reason for blanket removal were recorded for all patients. RESULTS: Eighty-five patients completed the study. Four participants experienced vital signs outside the defined safety parameters, with only one experiencing an adverse event (1.2%). This was consistent with the historic adverse event rate of 1% for the study site. Staff did not report issues with the use or cleaning of the blankets. Of interest, there was significant correlation between ED and suspected pain. CONCLUSION: The study demonstrated weighted blanket use is safe and feasible with children in the hospital setting, Additional studies are needed to determine the effectiveness of weighted blankets as an intervention for ED and the impact pain may have on the severity and prevalence of ED.