Cardiac atrial pathology in Duchenne muscular dystrophy.

INTRODUCTION/AIMS: Duchenne muscular dystrophy (DMD) is characterized by fibrofatty replacement of muscle. This has been documented in the ventricular myocardium of DMD patients, but there is limited description of atrial involvement. The purpose of this study is to examine the arrhythmia and ectopy burden in patients with DMD and non-DMD dilated cardiomyopathy (DCM) and to characterize the cardiac histopathologic changes in DMD patients across the disease spectrum. METHODS: This was a retrospective analysis of age-matched patients with DMD and non-DMD DCM who received a Holter monitor and cardiac imaging within 100 days of each other between 2010 and 2020. Twenty-four-hour Holter monitors were classified based on the most recent left ventricular ejection fraction at the time of monitoring. Cardiac histopathologic specimens from whole-heart examinations at the time of autopsy from three DMD patients and one DCM patient were reviewed. RESULTS: A total of 367 patients with 1299 Holter monitor recordings were included over the study period, with 94% representing DMD patients and 6% non-DMD DCM. Patients with DMD had more atrial ectopy across the cardiac function spectrum (p < 0.05). There was no difference in ventricular ectopy. Four DMD patients developed symptomatic atrial arrhythmias. Autopsy specimens from DMD patients demonstrated fibrofatty infiltration of both atrial and ventricular myocardium. DISCUSSION: The atrial myocardium in patients with DMD is unique. Autopsy specimens reveal fibofatty replacement of the atrial myocardium, which may be a nidus for both ectopy and arrhythmias in DMD patients.

Atrial arrhythmias following lung transplant: a single pediatric center experience.

Background: Outcomes after lung transplant (LTx) in children have slowly improved. Although atrial arrhythmia (AA) is a common and adverse complication following LTx among adults, there is limited data on pediatric recipients. We detail our pediatric single-center experience while providing further insights on occurrence and management of AA following LTx. Methods: A retrospective analysis of LTx recipients at a pediatric LTx program from 2014 to 2022 was performed. We investigated timing of occurrence and management of AA following LTx, and its effect on post-LTx outcome. Results: Three out of nineteen (15%) pediatric LTx recipients developed AA. The timing of occurrence was 9-10 days following LTx. Those patients in the older age group (age >12 years old) were the only ones who developed AA. Developing AA did not have a negative effect on hospital stay duration or short-term mortality. All LTx recipients with AA were discharged home on therapy that was discontinued at 6 months for those who was on mono-therapy without recurrence of AA. Conclusions: AA is an early post-operative complication in older children and younger adults undergoing LTx at a pediatric center. Early recognition and aggressive management can mitigate any morbidity or mortality. Future investigations should explore factors that place this population at risk for AA in order to prevent this complication post-operatively.

Incidence and outcome of arrhythmias and electrical disease in patients with Trisomy 18.

Patients with Trisomy 18 have a high incidence of cardiac anomalies and are associated with early death. Because of early mortality, electrical system disease and arrhythmia has been difficult to delineate and the incidence remain unknown. We sought to describe the association and clinical outcomes of electrical system disease and cardiac tachy-arrhythmias in patients with Trisomy 18. This was a retrospective, single institutional study. All patients with Trisomy 18 were included in the study. Patient characteristics, congenital heart disease (CHD), conduction system and clinical tachy-arrhythmia data were collected on all patients. Outcomes including cardiac surgical interventions, electrical system interventions and death were collected until the time of study. Patients with tachy-arrhythmias/electrical system involvement were compared to those without to identify potential associated variables. A total of 54 patients with Trisomy 18 were included in analysis. The majority of patients was female and had associated CHD. AV nodal conduction system abnormalities with either first or second degree AV block were common (15%) as was QTc prolongation (37%). Tachy-arrhythmias were common with 22% of patients having at least one form of tachy-arrhythmia and associated with concomitant conduction system disease (p = 0.002). Tachy-arrhythmias were typically treatable with monitoring or medication with eventual resolution without need for procedural intervention. Although early death was common, there were no causes of death associated with tachy-arrhythmia or conduction system disease. In conclusion, patients with Trisomy 18 have a high incidence of conduction system abnormalities and burden of clinical tachy-arrhythmias. Although frequent, electrical system disease did not affect patient outcome or difficultly of care delivery.

Transesophageal pacing studies reduce readmission but prolong initial admission in infants with supraventricular tachycardia: A cost-comparison analysis.

Background: Supraventricular tachycardia (SVT) is a common arrhythmia. Infants with SVT are often admitted to initiate antiarrhythmics. Transesophageal pacing (TEP) studies can be used to guide therapy prior to discharge. Objective: The objective of this study was to investigate the impact of TEP studies on length of stay (LOS), readmission, and cost in infants with SVT. Methods: This was a 2-site retrospective review of infants with SVT. One site (Center TEPS) utilized TEP studies in all patients. The other (Center NOTEP) did not. Patients with structural heart disease, patients with gestational age <34 weeks, and patients diagnosed after 6 months were excluded. At Center TEPS, repeat TEP studies were performed after titration of medication until SVT was not inducible. Primary endpoints were LOS and readmission for breakthrough SVT within 31 days of discharge. Hospital reimbursement data were utilized for cost-effectiveness analysis. Results: The cohort included 131 patients, 59 in Center TEPS and 72 in Center NOTEP. One patient was readmitted in Center TEPS vs 17 in Center NOTEP (1.6% vs 23.6%; P ≤ .001). Median LOS was longer for Center TEPS at 118.0 (interquartile range [IQR] 74.0-189.5) hours vs Center NOTEP at 66.9 (IQR 45.5-118.3) hours (P = .001). Twenty-one patients had multiple TEP studies. Median length of readmission for Center NOTEP was 65 (IQR 41-101) hours. Including readmission costs, utilization of TEP studies resulted in a probability-weighted cost of $45,531 per patient compared with $31,087 per patient without TEP studies. Conclusion: Utilization of TEP studies was associated with decreased readmission rates but longer LOS and greater cost compared with SVT management without TEP studies.

Outcomes in Infants with Supraventricular Tachycardia: Risk Factors for Readmission, Recurrence and Ablation.

Supraventricular tachycardia (SVT) is the most common arrhythmia in infants. Once diagnosed, infants are admitted for antiarrhythmic therapy and discharged after observation. There are limited data on risk factors for readmission and readmission rates, while on medication. The objective of this study was to investigate risk factors for readmission and outcomes in infants diagnosed with SVT. This is a single-center retrospective study over a 10-year period of infants under 6 months of age with documented SVT. Infants with congenital heart disease requiring surgical or catheter intervention, gestational age less than 32 weeks or diagnosis of atrial flutter or fibrillation were excluded. The primary outcome was readmission within 31 days of hospital discharge. Long term need for ablation and eventual discontinuation of medications were assessed. Ninety patients were included. Beta blockers were the initial therapy in 66 and 28 required a medication change. Nineteen were readmitted within 31 days of discharge. The only clinical factor associated with early readmission was presence of ventricular pre-excitation (6/19 vs. 8/71, p = 0.03). Patients who were readmitted within 31 days had a longer length of treatment (12 [11.5, 22.0] vs. 10 [7.5, 12.0] months, p = 0.007) and were more likely to undergo ablation (4/19 vs. 2/71, p = 0.017). In this cohort of infants with SVT, readmission was common and ventricular pre-excitation was identified as a risk factor for readmission. Infants who were readmitted within 31 days of discharge had longer length of antiarrhythmic therapy and were more likely to undergo catheter ablation.

Predictors and Outcomes of Arrhythmia on Stage I Palliation of Single Ventricle Patients.

BACKGROUND: Arrhythmias are common in single ventricle patients though their effect on outcomes during stage I palliation (S1P) is unclear. OBJECTIVES: The authors sought to study associated risks for arrhythmia in patients undergoing S1P for single ventricle disease and evaluate the outcome of arrhythmias and their treatment strategies on survival. METHODS: Retrospective patient, surgical, medication, and arrhythmia data were obtained from the NPC-QIC (National Pediatric Cardiology Quality Improvement Collaborative) database. Bivariate analysis of variables associated with arrhythmias, as well as those associated with survival, was performed at the time of stage II palliation. Appropriate variables were included in multivariate modeling. RESULTS: Of the 2,048 patients included in the study, 36% had arrhythmia noted during their S1P hospitalization, with supraventricular tachycardia (12%) and focal atrial tachycardia (11%) the most common. At S1P discharge, 11% of patients were on an antiarrhythmic medication. Arrhythmias were associated with lower survival and increased hospital length of stay. Heterotaxy syndrome, younger age at S1P, male sex, and additional anomalies were associated with increased risk of arrhythmia in multivariable modeling (P ≤ 0.01). Arrhythmia and female sex were associated with increased mortality, whereas antiarrhythmic medication and digoxin use were associated with decreased mortality (P ≤ 0.003, model area under the curve = 0.79). The use of antiarrhythmic medications within the subcohort of arrhythmia patients was also associated with decreased risk of mortality (P < 0.0001; odds ratio: 2.0-7.2). CONCLUSIONS: Arrhythmias are common during admission for S1P and associated with poor outcomes. The use of antiarrhythmic medications may improve survival, though future studies are needed.

Continuous Arrhythmia Monitoring in Pediatric and Adult Patients With Left Ventricular Noncompaction.

Patients with left ventricular noncompaction (LVNC) are at risk of clinically significant arrhythmias and sudden death. We evaluated whether implantable loop recorders could detect significant arrhythmias that might be missed in these patients during annual Holter monitoring. Selected pediatric and adult patients with LVNC who consented to implantable loop recorder placement were monitored for 3 years (study duration, 10 April 2014-9 December 2019). Fourteen subjects were included (age range, 6.5-36.4 yr; 8 males). Of 13 patients who remained after one device extrusion, one underwent implantable cardioverter-defibrillator placement. Four patients (31%) had significant arrhythmias: atrial tachycardia (n=2), nonsustained ventricular tachycardia (n=1), and atrial fibrillation (n=1). All 4 events were clinically asymptomatic and not associated with left ventricular ejection fraction. In addition, a high frequency of benign arrhythmic patterns was detected. Implantable loop recorders enable continuous, long-term detection of important subclinical arrhythmias in selected patients who have LVNC. These devices may prove to be most valuable in patients who have LVNC and moderate or greater ventricular dysfunction.

Multicenter Outcomes of Catheter Ablation for Atrioventricular Reciprocating Tachycardia Mediated by Twin Atrioventricular Nodes.

OBJECTIVES: This study sought to describe the electrophysiologic properties and catheter ablation outcomes for atrioventricular reciprocating tacchycardia via twin atrioventricular nodes (T-AVRT). BACKGROUND: Although catheter ablation for T-AVRT is an established entity, there are few data on the electrophysiological properties and outcomes of this procedure. METHODS: An international, multicenter study was conducted to collect retrospective procedural and outcomes data for catheter ablation of T-AVRT. RESULTS: Fifty-nine patients with T-AVRT were identified (median age at procedure, 8 years [interquartile range: 4.4-17.0 years]; 49% male). Of these, 55 (93%) were diagnosed with heterotaxy syndrome (right atrial isomerism in 39, left atrial isomerism in 8, and indeterminate in 8). Twenty-three (39%) had undergone Fontan operation (12 extracardiac, 11 lateral tunnel). After the Fontan operation, atrial access was conduit or baffle puncture in 15 (65%), fenestration in 5 (22%), and retrograde in 3 (13%). Acute success was achieved in 43 (91%) of 47 attempts (targeting an anterior node in 23 and posterior node in 24). There was no high-grade AV block or change in QRS duration. Over a median of 3.8 years, there were 3 recurrences. Of 7 patients with failed index procedure or recurrent T-AVRT, 6 (86%) were associated with anatomical hurdles such as prior Fontan or catheter course through an interrupted inferior vena cava-to-azygous vein continuation (P = 0.11). CONCLUSIONS: T-AVRT can be targeted successfully with low risk for recurrence. Complications were rare in this population. Anatomical challenges were common among patients with reduced short and long-term efficacy, representing opportunities for improvement in procedural timing and planning.

Outcomes of Implantable Loop Monitoring in Patients <21 Years of Age.

Rhythm-symptom correlation in pediatric patients with syncope/palpitations or at risk cohorts can be difficult, but important given potential associations with treatable or malignant arrhythmia. We sought to evaluate the use, efficacy and outcomes of implantable loop recorders (ILR) in pediatrics. We conducted a retrospective study of pediatric patients (<21 years) with implanted ILR. Patient/historical characteristics and ILR indication were obtained. Outcomes including symptom documentation, arrhythmia detection and ILR based changes in medical care were identified. Comparison of outcomes were performed based on implant indication. Additional sub-analyses were performed in syncope-indication patients comparing those with and without changes in clinical management. A total of 116 patients with ILR implant were identified (79 syncope/37 other). Symptoms were documented 58% of patients (syncope 68% vs nonsyncope 35%; p = 0.002). A total of 37% of patients had a documented clinically significant arrhythmia and 25% of patients had a resultant change in clinical management independent of implant indication. Arrhythmia type was dependent on implant indication with nonsyncope patients having more ventricular arrhythmias. Pacemaker/defibrillator implantation and mediation management were the majority of the clinical changes. In conclusion, IRL utilization in selected pediatric populations is associated with high efficacy and supports clinical management. ILR efficacy is similar regardless of indication although patients with nonsyncope indications had a higher frequency of ventricular arrhythmias as opposed to asystole and heart block in syncope indications. The majority of arrhythmic findings occurred in the first 12 months, and new technology that would allow for less invasive monitoring for 6 to 12 months may be of value.

Predictors and outcomes of heart block during surgical stage I palliation of patients with a single ventricle: A report from the NPC-QIC.

BACKGROUND: Mortality in cohorts with a single ventricle remains high with multiple associated factors. The effect of heart block during stage I palliation remains unclear. OBJECTIVE: The purpose of this study was to study patient and surgical risks of heart block and its effect on 12-month transplant-free survival in patients with a single ventricle. METHODS: Patient, surgical, outcome data and heart block status (transient and permanent) were obtained from the National Pediatric Cardiology Quality Improvement Collaborative single ventricle database. Bivariate analysis was performed comparing patients with and without heart block, and multivariate modeling was used to identify variables associated with block. One-year outcomes were analyzed to identify variables associated with lower 12-month transplant-free survival. RESULTS: In total, 1423 patients were identified, of whom 28 (2%) developed heart block (second degree or complete) during their surgical admission. Associated risk factors for block included heterotaxy syndrome (odds ratio [OR] 6.4) and atrial flutter/fibrillation (OR 3.8). Patients with heart block had lower 12-month survival, though only in patients with complete heart block as opposed to second degree block. At 12 months of age, 43% (12/28) of patients with heart block died and were more likely to experience mortality at 12 months than patients without block (OR 4.9; 95% confidence interval 1.4-17.5; P = .01). CONCLUSION: Although rare, complete heart block after stage I palliation represents an additional risk of poor outcomes in this high-risk patient population. Heterotaxy syndrome was the most significant risk factor for the development of heart block after stage I palliation. The role of transient block in outcomes and potential rescue with long-term pacing remains unknown and requires additional study.

Outcomes of Pediatric Patients With Defibrillators Following Initial Presentation With Sudden Cardiac Arrest.

BACKGROUND: Implantable cardioverter defibrillators (ICD) are recommended for secondary prevention after sudden cardiac arrest (SCA). The outcomes of pediatric patients receiving an ICD after SCA remain unclear. The objective of this study is to evaluate outcomes, future risk for appropriate shocks, and identify characteristics associated with appropriate ICD therapy during follow-up. METHODS: Multicenter retrospective analysis of patients (age ≤21 years) without prior cardiac disease who received an ICD following SCA. Patient/device characteristics, cardiac function, and underlying diagnoses were collected, along with SCA event characteristics. Patient outcomes including complications and device therapies were analyzed. RESULTS: In total, 106 patients were included, median age 14.7 years. Twenty (19%) received appropriate shocks and 16 (15%) received inappropriate shocks (median follow-up 3 years). First-degree relative with SCA was associated with appropriate shocks (P<0.05). In total, 40% patients were considered idiopathic. Channelopathy was the most frequent late diagnosis not made at time of presentation. Neither underlying diagnosis nor idiopathic status was associated with increased incidence of appropriate shock. Monomorphic ventricular tachycardia (hazard ratio, 4.6 [1.2-17.3]) and family history of sudden death (hazard ratio, 6.5 [1.4-29.8]) were associated with freedom from appropriate shock in a multivariable model (area under the receiver operating characteristic curve, 0.8). Time from diagnoses to evaluation demonstrated a nonlinear association with freedom from appropriate shock (P=0.015). In patients >2 years from implantation, younger age (P=0.02) and positive exercise test (P=0.04) were associated with appropriate shock. CONCLUSIONS: The risk of future device therapy is high in pediatric patients receiving an ICD after SCA, irrelevant of underlying disease. Lack of a definitive diagnosis after SCA was not associated with lower risk of subsequent events and does not obviate the need for secondary prophylaxis.

Progressive QRS Duration and Ventricular Dysfunction in Pediatric Patients with Chronic Ventricular Pacing.

Pacemakers are a mainstay of therapy for patients with congenital and acquired heart block, but ventricular pacing is related to ventricular dysfunction. We sought to evaluate patient and device characteristics associated with ventricular dysfunction in pediatric patients with chronic ventricular pacing. This was a retrospective cohort of pediatric patients with heart block and chronic ventricular pacing. Patient, ECG, and device characteristics were analyzed to determine factors associated with ventricular dysfunction. Longitudinal ECG and echocardiogram parameters were obtained to track changes in QRS and systemic ventricular systolic function over time. In total, 82 patients were included (median age at implant 0.81 years). Over a follow-up time of 6.1 years, 18% developed ventricular dysfunction. Patients with dysfunction had greater current QRS duration (p = 0.002) compared to those with preserved function with a similar time from device implantation. There was no difference between lead location or age at device implantation. QRS duration increased with time from implant and the resultant ΔQRS was associated with ventricular dysfunction (p = 0.01). QRS duration >162 ms was associated with a 5.8 (2-9)-fold increased risk for dysfunction. Transvenous leads were associated with longer QRS duration with no difference compared to epicardial leads in development of ventricular dysfunction. This study demonstrated that the absolute paced QRS duration and Δpaced QRS were association with long-term ventricular dysfunction independent of how long a given patient was paced. Patients in high-risk categories may benefit from close echocardiographic monitoring. Whether permissive junctional rhythm or His bundle/biventricular pacing decreases the rate of dysfunction needs further study.

Wearable cardioverter-defibrillators in pediatric cardiomyopathy: A cost-utility analysis.

BACKGROUND: Dilated cardiomyopathy (DCM) is the most common cardiomyopathy in children. Patients with severe cardiac dysfunction are thought to be at risk of sudden cardiac arrest (SCA). After diagnosis, a period of medical optimization is recommended before permanent implantable cardioverter-defibrillator (ICD) implantation. Wearable cardioverter-defibrillators (WCDs) provide an option for arrhythmia protection as an outpatient during this optimization. OBJECTIVE: The purpose of this study was to determine the strategy that optimizes cost and survival during medical optimization of a patient with DCM before ICD placement. METHODS: A Markov state transition model was constructed for the 3 clinical approaches to compare costs, clinical outcomes, and quality of life: (1) "Inpatient," (2) "Home-WCD," and (3) "Home-No WCD." Transitional probabilities, costs, and utility metrics were extracted from the existing literature. Cost-effectiveness was assessed comparing each paradigm's incremental cost-effectiveness ratio against a societal willingness-to-pay threshold of $50,000 per quality-adjusted life year. RESULTS: The cost-utility analysis illustrated that Home-WCD met the willingness-to-pay threshold with an incremental cost-effectiveness ratio of $20,103 per quality-adjusted life year and 4 mortalities prevented per 100 patients as compared with Home-No WCD. One-way sensitivity analyses demonstrated that Home-No WCD became the most cost-effective solution when the probability of SCA fell below 0.2% per week, the probability of SCA survival with a WCD fell below 9.8%, or the probability of SCA survival with Home-No WCD quadrupled from base-case assumptions. CONCLUSION: Based on the existing literature probabilities of SCA in pediatric patients with DCM undergoing medical optimization before ICD implantation, sending a patient home with a WCD may be a cost-effective strategy.

Can noninvasive testing identify benign patterns of suggested pre-excitation on electrocardiogram?

BACKGROUND: The presence of anterograde conduction through an accessory pathway (AP) has been linked to sudden cardiac death. Unfortunately, pre-excitation associated with classic pathways can be difficult to differentiate from benign APs such as nodofascicular fibers. OBJECTIVE: Identifying characteristics on electrocardiogram (ECG) and exercise that differentiate classic and benign AP connections in suggested pre-excitation patterns. METHODS: Retrospective review of patients presenting between 1995 and 2017 with ventricular pre-excitation on ECG, determined to have either typical left-lateral AP during electrophysiology study (EPS), or benign, or no AP determined by either transesophageal electrophysiology study (TEP), or EPS. RESULTS: A total of 96 patients were included, 14.2 years (4-24), 45% female, 90% Caucasian. Of these, 60 (63%) had a classic APs identified on EPS and 58 (97%) underwent successful ablation. Conversely, 36 (37%) had benign pathways identified. ECG findings differed between the groups: PR-interval 102 versus 120 ms (P < .0001), QRS-duration 110 versus 102 ms (P < .0001), QRS-axis 74 versus 59 degrees (P = .0005), and QRS onset to peak R/S in limb leads 64 versus 42 ms (P < .0001), and precordial leads 66 versus 46 ms (P < .0001). Change in QRS duration during exercise differed between the groups: 25 versus 2 ms (P < .0001) and ECG characteristics identified the presence of an AP with 97% sensitivity and 94% negative predictive value. CONCLUSION: Classic and benign APs exhibit different ECG characteristics, though clinical overlap does not allow for absolute differentiation. These data may help with risk stratification decision making though does not obviate the need for additional invasive testing.

Ventricular force-frequency relationships during biventricular or multisite pacing in congenital heart disease.

BACKGROUND: Traditional indices to evaluate biventricular (BiV) pacing are load dependent, fail to assess dynamic changes, and may not be appropriate in patients with congenital heart disease (CHD). We therefore measured the force-frequency relationship (FFR) using tissue Doppler-derived isovolumic acceleration (IVA) to assess the dynamic adaption of the myocardium and its variability with different ventricular pacing strategies. METHODS: This was a prospective pilot study of pediatric and young adult CHD patients with biventricular or multisite pacing systems. Color-coded myocardial velocities were recorded at the base of the systemic ventricular free wall. IVA was calculated at resting heart rate and with incremental pacing. FFR curves were obtained by plotting IVA against heart rate for different ventricular pacing strategies. RESULTS: Ten patients were included (mean: 22 ± 7 years). The FFR identified a best and worst ventricular pacing strategy for each patient, based on the AUC at baseline, submaximal, and peak heart rates (P < .001). However, there was no single best ventricular pacing strategy that was optimal for all patients. Additionally, the best ventricular pacing strategy often differed within the same patient at different heart rates. CONCLUSION: This novel assessment demonstrates a wide variability in optimal ventricular pacing strategy. These inherent differences may play a role in the unpredictable clinical response to BiV pacing in CHD, and emphasizes an individualized approach. Furthermore, the optimal ventricular pacing varies with heart rate within individuals, suggesting that rate-responsive ventricular pacing modulation may be required to optimize ventricular performance.

A Standardized Cardiac Protocol for Pediatric Drug Ingestion Hospital Admissions.

To optimize patient resource utilization and safety, we created a standard-of-care guideline for pediatric drug ingestion hospital admissions. METHODS: A multidisciplinary committee developed specific telemetry guidelines for pediatric drug ingestion hospital admissions at a tertiary pediatric hospital. The guidelines stipulated inpatient admission with telemetry monitoring for the following criteria: (1) corrected QT interval (interval between the Q wave and T wave on a standard EKG)≥ 500 ms, (2) ingestion of an antiarrhythmic medication, or (3) ingestion of a tricyclic antidepressant. We created guidelines for electrocardiogram frequency for nontelemetry admissions. We implemented these guidelines in November 2015 in partnership with the Emergency Medicine Department and Poison Control Center. We reviewed medical records of all these admissions between January 1, 2015, and July 31, 2016, and divided patients into preintervention (January 1, 2015 to November 30, 2015) and postintervention (December 1, 2015 to July 31, 2016) groups. We used statistical process control charts and methodology to monitor changes over time. RESULTS: There were a total of 622 drug ingestion admissions during the study period. We admitted 69 patients (11%) to the cardiac acute care unit (CACU) for telemetry monitoring. The preintervention period included 61 admissions (5.5 CACU admissions per month). The postintervention period included 8 admissions (1.1 CACU admissions per month). This difference reflects an overall absolute decrease of 87%. There was no evidence of an increase in the rate of intensive care unit utilization, rapid response events, or adverse events in the postintervention period. CONCLUSIONS: A standardized admission protocol for pediatric drug ingestions can safely improve resource utilization.