National Trends in Voiding Cystourethrograms During Hospitalization for Young Infants With Urinary Tract Infections.

OBJECTIVES: The American Academy of Pediatrics published a guideline in 2011 recommending against the routine use of voiding cystourethrogram (VCUG) in infants aged 2 to 24 months with first febrile urinary tract infection (UTI); however, the rates of VCUG for infants aged <2 months are unknown. The objective of this study was to determine the trend in VCUG performance during index hospitalization among infants aged 0 to 2 months with UTI. METHODS: This retrospective cohort study included infants aged birth to 2 months hospitalized with a UTI from 2008 to 2019 across 38 institutions in the Pediatric Health Information System. Outcome measures included recurrent UTI within 1 year, vesicoureteral reflux diagnosis within 1 year and antiurinary reflux procedure performed within 2 years. Trends over time were compared between preguideline (2008-2011) and postguideline periods (2012-2019) using piecewise mixed-effects logistic regression. RESULTS: The odds of VCUG decreased by 21% per year in the preguideline period (adjusted odds ratio, 0.79; 95% confidence interval, 0.77-0.81; P < .001) versus 20% (adjusted odds ratio, 0.80; 95% confidence interval, 0.77-0.83; P < .001) in the postguideline period. The preguideline and postguideline difference was not statistically significant (P = .60). There was no difference in the postguideline odds of UTI within 1 year (P = .07), whereas the odds of vesicoureteral reflux diagnosis (P < .001) and antiurinary reflux procedure performance (P < .001) decreased. CONCLUSIONS: VCUG performance during hospitalization has declined over the past decade among young infants hospitalized with UTI. Further work is needed to determine the optimal approach to imaging in these young infants.

Pediatric Trainees as Parents: Perspectives From a Pandemic.

OBJECTIVES: Resident parents are at the intersection of converging challenges during the coronavirus disease 2019 (COVID-19) pandemic, and their perspective has yet to be explored. This qualitative study aimed to identify themes related to the experience of pediatric resident parents during the COVID-19 pandemic. METHODS: We performed semistructured interviews with pediatric residents who were also parents. Using thematic analysis, transcripts were analyzed iteratively until theoretical sufficiency was achieved. RESULTS: Twelve residents were interviewed from 9 pediatric residency programs. Five major themes, representing conflicts or tensions experienced by participants, were defined by the data: 1) Duty as a doctor versus duty as a parent; 2) Balance of work obligations versus childcare challenges; 3) Appreciation of added support versus worry about peers' perceptions of accommodations; 4) Gratitude for the recognition of challenges faced by resident parents versus fear of reversion to the norm; and 5) Protective impact of parenthood versus challenges to mental health. CONCLUSIONS: Both parents and healthcare workers faced innumerable challenges during the COVID-19 pandemic, and this exploration of the experiences of pediatric resident parents provides a unique lens for examining the tensions that this group faced. Our results may allow residency programs to better support their pediatric resident parents during this crisis.

Pediatric Trainees as Parents: Perspectives on Parenthood From Pediatric Resident Parents.

OBJECTIVES: Prior work across medical and surgical specialties shows that parenthood during residency training is associated with challenges including limited parental leave, lack of accommodations for breastfeeding, and concerns about career impact. Less is known about the experience of parenthood during pediatric residency training. The objective of this study was to identify themes related to the experience of parenthood during pediatric residency. METHODS: In this qualitative study using thematic analysis, we performed semistructured interviews with participants who were currently in pediatric residency or had graduated in the previous 3 years and were parents during residency. Participants were recruited by e-mail. Data were collected and analyzed iteratively until thematic saturation was achieved. Two independent reviewers coded each transcript. Codes were grouped into categories and then into dominant themes. RESULTS: Thirty-one residents were interviewed from 13 pediatric residency programs. Four major themes regarding the experience of parenthood during pediatric residency were defined by the data: 1) the struggles of parenthood and residency exacerbate each other; 2) institutional modifiers strongly influence the experiences of resident parents; 3) resident parents develop skills and perspectives that enhance their pediatric training; and 4) although levels of support for pediatric resident parents vary, the culture of pediatrics positively influences the experience of parenthood in residency. CONCLUSIONS: There are numerous challenges navigating parenthood and residency, but institutional policies and culture can modify the experience. Importantly, the educational value of parenthood to pediatric training was immense. Our findings may be used to design interventions to support parenting during residency.

Association Between Bronchiolitis Patient Volume and Continuous Pulse Oximetry Monitoring in 25 Hospitals.

Continuous pulse oximetry monitoring in stable patients with bronchiolitis is discouraged by national guidelines in order to reduce overuse, yet wide practice variation exists among hospitals. Understanding the association between monitoring overuse and hospital unit-level factors may identify areas for improvement. Conducted at 25 sites from the Pediatric Research in Inpatient Settings (PRIS) Network's Eliminating Monitoring Overuse (EMO) study, this substudy used data from 2,366 in-person observations of pulse oximetry use in patients with bronchiolitis to determine whether hospital unit-level factors were associated with variation in pulse oximetry use for patients in whom continuous monitoring is not indicated. Hospital units were classified by bronchiolitis admission burden. Monitoring rates were analyzed in a mixed-effects model that accounted for variation in baseline monitoring rates among hospitals and adjusted for covariates significantly associated with continuous pulse oximetry monitoring use in the primary study's analysis. Low burden units (<10% of total admissions) had a 2.16-fold increased odds of pulse oximetry overuse compared to high burden units (≥40% of total admissions) (95% CI, 1.27-3.69; P = .01). These results suggest that units caring for a lower percentage of patients with bronchiolitis are more likely to overuse pulse oximetry despite national guidelines.

Encouraging Entrustment: A Qualitative Study of Resident Behaviors That Promote Entrustment.

PURPOSE: To explore resident and attending physician perceptions of resident behaviors and skills that demonstrate trustworthiness and promote entrustment by supervisors. METHOD: Using grounded theory methodology, the authors conducted 3 focus groups with pediatric residents from the Boston Combined Residency Program and 3 focus groups with attending physicians who were either general pediatric hospitalists or other pediatric subspecialists at Boston Children's Hospital and Boston Medical Center in Boston, Massachusetts, from May to December 2018. Data were collected and analyzed iteratively until theoretical saturation was achieved. Three independent reviewers coded each transcript. Codes were grouped into dominant themes to develop a conceptual model. RESULTS: Twelve residents and 18 attending physicians participated in the focus groups. Participants described actions that they felt actively demonstrated residents' trustworthiness within previously described domains of trustworthiness. Four modifiers emerged that affect a resident's progression from trustworthiness to entrustment: (1) self-management, (2) relationships, (3) self-advocacy, and (4) patient-centeredness. Findings were synthesized into a conceptual model depicting how trainees can promote their own entrustment by supervisors. CONCLUSIONS: Trainees must actively demonstrate their trustworthiness to be entrusted. This study proposes that trainees can further gain entrustment through self-management, relationships, self-advocacy, and patient-centeredness. When they understand the actions and behaviors that promote entrustment, trainees may be better able to foster autonomy and progress toward more independent clinical practice. These findings add to existing evidence regarding entrustment and provide a novel, actionable framework for trainees to increase their own entrustment.

The effect of traumatic lumbar puncture on hospitalization rate for febrile infants 28 to 60 days of age.

OBJECTIVES: The authors measured the effect of a traumatic or unsuccessful lumbar puncture (LP) on the management of febrile infants. METHODS: This was a 10-year retrospective cross-sectional study of low-risk infants by the "Boston" criteria 28 to 60 days of age presenting to the emergency department for evaluation of fever. "Normal LP" infants had cerebrospinal fluid (CSF) WBC < 10 × 10(6) cells/L. "Traumatic" or "unsuccessful LP" infants had CSF red blood cell count ≥ 10 × 10(9) cells/L or no CSF cell counts obtained, respectively. A serious bacterial infection (SBI) was defined as growth of a bacterial pathogen from culture. The hospitalization and SBI rates were compared between infants with normal versus traumatic or unsuccessful LPs. RESULTS: Of the 929 study infants, 756 (81.4%) had normal LPs, and 173 (18.6%) had traumatic or unsuccessful LPs. Infants with traumatic or unsuccessful LPs had a higher hospitalization rate (72.3% traumatic or unsuccessful LP vs. 18.1% normal LP; difference = 54.1%; 95% confidence interval [CI] = 46.4% to 60.8%), but a similar SBI rate (2.9% vs. 4.1%; difference = 1.2%; 95% CI = -2.7% to 3.6%). No infant had proven bacterial meningitis (0% risk, 95% CI = 0 to 0.3%). CONCLUSIONS: Low-risk infants aged 28 to 60 days with traumatic or unsuccessful LPs are more frequently hospitalized, although SBI rates were similar to those of infants with normal LPs.