Pediatric Ambulatory Care Research Articles

Association between Unmet Social Need and Ambulatory Quality of Care for US Children

ObjectivesChildren who experience socioeconomic adversity often have worse health; however, less is known about their quality of care. We sought to evaluate the association between parent/caregiver-reported socioeconomic adversity and quality of pediatric primary, acute, and chronic ambulatory care on a national level. MethodsThis was a retrospective cohort study of 5368 representative US children (1–17 years) in the 2021 Medical Expenditure Panel Survey. Socioeconomic adversity was defined as parent/caregiver-reported food, housing, transportation, or utility insecurity in the past 12 months. Outcomes included 10 quality measures of primary, acute, and chronic care, and experience of care measured through parent/caregiver survey. We described variation in socioeconomic adversity and used multivariable regression to examine associations with quality outcomes. ResultsOne-third of parent/caregivers reported socioeconomic adversity. Food insecurity (23.6%) was most common followed by utility (19.5%), housing (15.0%), and transportation (4.7%) insecurity. Black (53.2%) and Hispanic (46.9%) parent/caregivers experienced the highest rates of socioeconomic adversity. Children with socioeconomic adversity received lower quality of care for four quality measures, including more frequent Emergency Department visits (Odds Ratio (OR)= 1.69 [95% Confidence Interval (CI): 1.28–2.23]), less favorable asthma medication ratio (OR=0.04 [95% CI: 0.01–0.31]), and less frequent well child (OR=0.73 [95% CI: 0.59–0.90]) and dental care (OR=0.76 [95% CI: 0.63–0.94], P < .05 for all). There were no statistically significant differences in experience of care. ConclusionsSocioeconomic adversity is common among US children with disproportionate impact on Black and Hispanic families. There are significant disparities in pediatric primary, acute, and chronic care quality, based on parent/caregiver-reported socioeconomic adversity, highlighting the need for systems-level interventions.

Determining infection prevention staffing needs for the pediatric ambulatory and procedural care setting.

Recent analyses suggest thatexisting infection preventionist (IP) staffing ratios do not reflect the scope of institutional needsafter accounting for complexity and non-inpatient locations. We sought to determine the current IP staffing level required to address the complexity and scope of our pediatric ambulatory and procedural operations. This needs assessment was adapted from previous analyses by Bartles et al (2018). We surveyed IPs covering ambulatory/procedural locations regarding clinical complexity indicators and estimated hours per week spent engaged in IP activities. The reported hours were used to calculate total IP hours per week and associated full-time equivalents (FTEs). Half (118/237) of surveyed locations/services reported at least 1 complexity indicator, while nearly 9% (21/237) reported 3 or more complexity indicators. IPs spent 181.0h/wk focused on ambulatory/procedural locations, equating to 4.5 FTEs. Infection prevention and control leadership used these findings to successfully add 4 IP FTEs to the department. These FTEs will allow increased ambulatory/procedural IP support, improved regulatory readiness, and increased quality improvement initiatives. Assessing the complexity and scope of pediatric ambulatory/procedural locations can be a valuable tool for (1) advocating for overall IP staffing increases at a system level and(2) determining the distribution of IP time and resources in such locations.

Feasibility of safe outpatient treatment in pediatric patients following intraventricular radioimmunotherapy with 131I-omburtamab for leptomeningeal disease

BackgroundRadiolabeled antibody 131I-omburtamab was administered intraventricularly in patients with leptomeningeal disease under an institutionally approved study (#NCT03275402). Radiation safety precautions were tailored for individual patients, enabling outpatient treatment based on in-depth, evidence-based recommendations for such precautions. The imperative advancement of streamlined therapeutic administration procedures, eliminating the necessity for inpatient isolation and resource-intensive measures, holds pivotal significance. This development bears broader implications for analogous therapies within the pediatric patient demographic.MethodsIntraventricular radioimmunotherapy (RIT) with 925–1850 MBq (25–50 mCi) of 131I-omburtamab was administered via the Ommaya reservoir, in designated rooms within the pediatric ambulatory care center. Dosimeters were provided to staff involved in patient care to evaluate exposure during injection and post-administration. Post-administration exposure rate readings from the patient on contact, at 0.3 m, and at 1 m were taken within the first 30 min, and the room was surveyed after patient discharge. Duration of radiation exposure was calculated using standard U.S. Nuclear Regulatory Commission (US NRC) regulatory guidance recommendations combined with mean exposure rates and whole-body clearance estimates. Exposure rate measurements and clearance data provided patient-specific precautions for four cohorts by age: < 3 y/o, 3–10 y/o, 10–18 y/o, and 18+.ResultsPost-administration exposure rates for patients ranged from 0.16 to 0.46 µSv/hr/MBq at 0.3 m and 0.03–0.08 µSv/hr/MBq at 1 m. Radiation exposure precautions ranged from 1 to 10 days after release for the four evaluated cohorts. Based on the highest measured exposure rates and slowest whole-body clearance, the longest precautions were approximately 78% lower than the regulatory guidance recommendations. Radiation exposure to staff associated with 131I-omburtamab per administration was substantially below the annual regulatory threshold for individual exposure monitoring.Conclusion131I-omburtamab can be administered on an outpatient basis, using appropriate patient-based radiation safety precautions that employ patient-specific exposure rate and biological clearance parameters. This trial is registered with the National Library of Medicine’s ClinicalTrials.gov. The registration number is NCT03275402, and it was registered on 7 September 2017. The web link is included here. https://clinicaltrials.gov/study/NCT03275402.

Trends in C reactive protein testing: a retrospective cohort study in paediatric ambulatory care settings

ObjectivesThis study aims to investigate C reactive protein (CRP) testing practices in paediatric ambulatory care across British primary care and accident and emergency (A&E) departments.Design, setting, participantsThis retrospective cohort study...

Economic Impact of COVID-19 on a Free-Standing Pediatric Ambulatory Center.

Operating safely throughout the coronavirus disease 2019 (COVID-19) pandemic has required surgical centers to adapt and raise their level of readiness. Intuitively, additional expenses related to such adaptation may have resulted in an increase in the cost of surgical care. However, little is known about the magnitude of such an increase, and no study has evaluated the temporal variation in the costs of care throughout the pandemic. The aim of the current study was to evaluate the impact of COVID-19 on the cost of surgical and anesthetic care in a free-standing, pediatric ambulatory care center. We performed a retrospective review of the electronic medical record (EMR) and financial data for pediatric ambulatory settings between 2019 and 2020 (April - August) from our tertiary care children's hospital. The primary outcomes were the inflation-adjusted surgical cost for elective tonsillectomy, adenoidectomy, and tympanostomy tubes (BTI) placement procedures in children less than 18 years of age. These data were obtained from financial databases and aggregated into categories including anesthesia services, operating room services, recovery room services, and supply and medical devices. Costs per case to provide care were significantly higher following the COVID-19 pandemic in 2020 compared to 2019 across all services: anesthesia ($1,268 versus $1,143; cost ratio (CR): 1.11, 95% confidence interval (CI): 1.08 - 1.14, P-value < 0.001), operating room ($1,221 vs. $1,255; CR: 1.03, 95% CI: 1.02 - 1.04, P-value < 0.001), recovery room ($659 vs. $751; CR: 1.14, 95% CI: 1.10 - 1.18, P-value < 0.001), and supply ($150 vs. $271; CR: 1.81, 95% CI: 1.26 - 2.6, P-value = 0.001). There was an overall increase in healthcare service costs in 2020, with significant fluctuations in the early and mid-year months. Our study identified specific economic impacts of COVID-19 on free-standing pediatric ambulatory centers, thereby highlighting the need for innovative practices with cost containment for sustainability of such specialized centers when dealing with future pandemics related to COVID-19 or other viral pathogens.

Febrile Seizures: An Updated Narrative Review for Pediatric Ambulatory Care Providers.

While generally self-limited, febrile seizures result in significant familial distress. Ambulatory pediatric care providers must be prepared to counsel families on the causes, risk factors, management principles, and prognosis of children with febrile seizures. To provide an updated, evidence-based review of febrile seizures focused on the needs of an ambulatory pediatric care provider. A narrative review of the literature prioritizing landmark articles, metanalyses, longitudinal population longitudinal cohort studies and national level guidelines. Febrile seizures are aberrant physiological responses to fever in children caused by complex interactions of cytokine mediated neuroinflammation, environmental triggers, and genetic predisposition. Other than investigations to determine fever etiology, routine bloodwork, lumbar punctures, neuroimaging and electroencephalograms are low yield. The general prognosis is excellent, however, clinicians should be aware of long-term outcomes including: cognitive impairment with non-simple febrile seizures; neuropsychiatric associations; recurrent febrile seizure and epilepsy risk factors; and the association between complex febrile seizures and sudden unexpected death. Children with a high risk of recurrence, complex febrile seizures, limited access to care, or extreme parental anxiety may benefit from intermittent oral diazepam prophylaxis. Clinicians should consider four management priorities: 1) terminating the seizure; 2) excluding critical differential diagnoses; 3) investigating fever etiology; and 4) providing adequate counselling to families. The clinical approach and prognosis of febrile seizure can be based on subtype. Children with non-simple (i.e. complex or febrile status epilepticus) febrile seizures require closer care than the vast majority of children with simple febrile seizures, who have excellent outcomes.

Screening for Emotional Problems in Pediatric Hospital Outpatient Clinics: Psychometric Traits of the Pediatric Symptom Checklist (Hebrew Version).

This study assessed feasibility and psychometric properties of the Hebrew parent version of the Pediatric Symptom Checklist (PSC-17), aiming to improve treatment access for children and adolescents with behavioral and mental needs through early screening. The PSC-17 and the Strengths and Difficulties Questionnaire (SDQ) were filled in the waiting room, at three ambulatory clinics in a tertiary pediatric center, by 274 parents using a tablet or their cellphone. Demographic and clinical data were retrieved from patients' files. PSC results were compared to SDQ results and assessed vis-a-vis a psychiatric diagnosis, determined previously and independently by trained pediatric psychiatrists for 78 pediatric patients who attended these clinics. Construct and discriminant validity of the PSC-17 Hebrew version were good. Sensitivity, specificity, and positive and negative predictive values are presented. The PSC-17 (Hebrew version) was found to be a feasible tool for mental health screening at pediatric ambulatory care clinics.

Racial and Gender Disparities in Suicide and Mental Health Care Utilization in a Pediatric Primary Care Setting

PurposeWe examined racial and gender disparities in the underrecognition of mental health disorders in adolescents and young adults as defined by a suicide-related diagnosis without a previous mental or behavioral health diagnosis. MethodsWe employed a series of adjusted mixed multilevel logistic regression models to determine the odds of specific mental health diagnoses (anxiety, depression, and suicide-related) in a large, U.S. pediatric ambulatory care group (ages 8–20 years) using Electronic Medical Record Data. ResultsUsing the reference group of White males, White females had 17% increased odds of having a suicide-related diagnosis (odds ratio (OR) 1.17, 95% confidence intervals (CI) 1.03, 1.34) and Black females had 48% increased odds of suicide-related diagnosis (OR 1.48, 95% CI 1.28, 1.71). Conversely, White females had 75% increased odds of recorded anxiety (OR 1.75, 95% CI 1.62, 1.89), Black males had 62% decreased odds of anxiety (OR 0.38, 95% CI 0.33, 0.42), and Black females had 33% decreased odds of anxiety (OR 0.67, 95% CI 0.60, 0.74). White females had 81% increased odds of having recorded depression (OR 1.81, 95% CI 1.62, 2.04) and Black females had 80% increased odds of underrecognized need for mental or behavioral health diagnosis services (OR 1.80, 95% CI 1.53, 2.13) as defined by a suicide-related diagnosis without a previous mental health diagnosis. DiscussionBlack adolescents and young adult patients are either not accessing or identified as needing mental health services at the same rates as their White peers, and Black females are experiencing the most underrecognition of need for mental health services.

Humanitarian Outpatient Pediatric Endeavor (HOPE): A Novel Specialist Ambulatory Health-Care Concept in Conflict Areas.

With the collapse of the medical system in Syria, Israel began providing Syrians with humanitarian aid, first to the war-injured and then general medical treatment. We developed a novel specialist ambulatory care concept to provide medical care for Syrian children. Children with their caregivers were transported by bus across the border from Syria to our medical center in Israel for day-stay outpatient-clinic advanced evaluation and treatment due to coordination between Syrian, Red Cross, and Israeli authorities, including Israeli Defense Forces. This retrospective field report includes 371 Syrian children treated as outpatients at Galilee Medical Center between January 2016 and September 2018. In our experience, this novel pediatric ambulatory care concept has been feasible, efficient, and successful in providing specialist care for children in a crisis region devoid of access to health care. We believe it can also serve adult patients and be implemented in other crises and disasters scenarios.

A budget impact analysis of cost to implement a whole child health focused, family-based intervention in primary care for children with elevated BMI

BackgroundAlthough the cost of implementing evidence-based interventions (EBIs) is a key determinant of adoption, lack of cost information is widespread. We previously evaluated the cost of preparing to implement Family Check-Up 4 Health (FCU4Health), an individually tailored, evidence-based parenting program that takes a whole child approach, with effects on both behavioral health and health behavior outcomes, in primary care settings. This study estimates the cost of implementation, including preparation.MethodsWe assessed the cost of FCU4Health across the preparation and implementation phases spanning 32 months and 1 week (October 1, 2016–June 13, 2019) in a type 2 hybrid effectiveness-implementation study. This family-level randomized controlled trial took place in Arizona with n = 113 predominantly low-income, Latino families with children ages > 5.5 to < 13 years. Using electronic cost capture and time-based activity-driven methods, budget impact analysis from the perspective of a future FCU4Health adopting entity—namely, ambulatory pediatric care clinicians—was used to estimate the cost of implementation. Labor costs were based on 2021 Bureau of Labor Statistics Occupational Employment Statistics, NIH-directed salary cap levels or known salaries, plus fringe benefits at a standard rate of 30%. Non-labor costs were based on actual amounts spent from receipts and invoices.ResultsThe cost of FCU4Health implementation to 113 families was $268,886 ($2380 per family). Actual per family cost varied widely, as individual tailoring resulted in families receiving a range of 1–15 sessions. The estimated cost of replicating implementation for future sites ranged from $37,636-$72,372 ($333–$641 per family). Using our previously reported preparation costs (i.e., $174,489; $1544 per family), with estimated replication costs of $18,524–$21,836 ($164–$193 per family), the total cost of delivering FCU4Health was $443,375 ($3924 per family), with total estimated replication costs of $56,160–$94,208 ($497-$834 per family).ConclusionsThis study provides a baseline for costs associated with implementation of an individually tailored parenting program. Results provide critical information for decision makers and a model for future economic analysis and can be used to inform optimization thresholds for implementation and, when necessary, benchmarks for program adaptation to promote scale-up.Trial registrationThis trial was prospectively registered on January 6, 2017, at ClinicalTrials.gov (NCT03013309).

Assessing Strengths, Challenges, and Equity Via Pragmatic Evaluation of a Social Care Program

ObjectiveModels of pragmatic social care program evaluations are needed as many are clinical services programs and are not focused on research, limiting the ability to address key evidence gaps. We describe the use of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to conduct a pragmatic evaluation of a pediatric ambulatory social care program. MethodsOur evaluation was based on automated electronic health record data on clinics, community partners, social care program processes, and social needs screen data linked to patient sociodemographic characteristics from February 2020 to September 2021. Two Reach outcomes were assessed: 1) the proportion of eligible patients that completed social needs screening and 2) the proportion of positive screens that receive social care program follow-up. The Effectiveness outcome was meeting families’ resource need(s). ResultsReach among eligible patients who completed screening was 79.2%. Reach for positive screens receiving social care program referrals demonstrated a higher proportion of referrals among patients with a preferred healthcare language (PHL) of Spanish (45.1%) compared to English (31.2%, P < .001). Effectiveness analyses demonstrated that overall, 75.1% of social care program referrals had all social resource needs met, 17.5% had some needs met, and 7.4% had no needs met. The percent of patients with all resource needs met was higher for patients with PHL of Spanish or Non-English, Non-Spanish (79% for each respectively) compared to English (73%, P = .023). ConclusionsMaximizing automated data collection is likely the most feasible way for social care programs to complete evaluation activities outside of the research context.

Increasing capacity in acute day care settings: patients' experiences of a pop-up day care unit

The unit operated fortnightly between December 2020 and March 2021. Family feedback on the service was collated via an online survey. 72 respondents found NHB acceptable; 70 (97%) would be happy to return; 63 (90.3%) preferred the NHB to attending Bristol Royal Hospital for Children or had no preference for their appointments. Positive comments focused on service organisation and clinical environment. Families valued the availability of the close, free parking. The minimal negative comments related to travel directions, lack of catering facilities and the small number of toilets. The pop-up service model was highly acceptable to families. This highlights the need for appropriate hospital services to explore similar initiatives beyond traditional healthcare settings in order to ensure that the provision of equitable health care is in line with the NHS Long Term Plan.

Post Amoxicillin Challenge Hypersensitivity Reactions Are Mild And Similar To Their Index Reactions

Amoxicillin is one of the most used antibiotics in pediatric ambulatory care and allergic reactions can be distressing to families. However, it is important to evaluate if the reactions represents a true hypersensitivity reaction.

Parent satisfaction survey in a pediatric ambulatory care clinic utilizing an interprofessional education model

BackgroundInterprofessional education (IPE) is a required component of health professional education in order to produce effective collaborators prior to entering the work force. Little data focus on the use of IPE clinics to assess patient or caregiver satisfaction with or perceptions of interprofessional care in pediatric ambulatory care. PurposeTo determine caregiver satisfaction in a student-led, IPE pediatric gastroenterology (GI) clinic. MethodCaregivers completed an optional survey to assess satisfaction with and perception of IPE care. DiscussionAnalysis included 160 survey responses. The responses were overwhelmingly positive with 100% of caregivers ‘Very happy/satisfied’ with the care of their child and 87% of respondents preferred team-based care to seeing a sole provider. Caregivers perceived the care received to be thorough, time-saving, and valuable. ConclusionsCaregivers are mostly satisfied with a pediatric IPE clinic. More studies are required to assess IPE effects on patient outcomes and caregiver satisfaction in the pediatric ambulatory care setting.

Social needs screening and referral in pediatric primary care clinics: a multiple case study

BackgroundUnmet social risks such as housing, food insecurity and safety concerns are associated with adverse health outcomes in adults and children. Experimentation with social needs screening in primary care is currently underway throughout the United States. Pediatric primary care practices are well-positioned to amplify the effects of social needs screening and referral programs because all members of the household have the potential to benefit from connection to needed social services; however, more research is needed to determine effective implementation strategies.MethodsTo describe common implementation barriers and facilitators, we conducted 48 in-depth qualitative interviews with leadership, providers and staff between November 2018 and June 2019 as part of a multiple case study of social needs screening and referral programs based out of four pediatric ambulatory care clinics in New York City. Interviews were recorded, transcribed and coded using a protocol-driven, template-based rapid analysis approach designed for pragmatic health services research. In addition to analyzing content for our study, we delivered timely findings to each site individually in order to facilitate quality improvement changes in close-to-real time.ResultsEffective implementation strategies included tailoring screening tools to meet the needs of families seen at the clinic and reflect the resources available in the community, hiring dedicated staff to manage the program, building strong and lasting partnerships with community-based organizations, establishing shared communication methods between partners, and utilizing technology for efficient tracking of screening data. Respondents were enthusiastic about the value of their programs and the impact on families, but remained concerned about long-term sustainability after the grant period.ConclusionImplementation of social needs screening and referral interventions is dependent on contextual factors including the nature of family needs and the availability of intraorganizational and community resources to address those needs. Additional research is needed to prospectively test promising implementation strategies that were found to be effective across sites in this study. Sustainability of programs is challenging, and future research should also explore measurable outcomes and payment structures to support such interventions in pediatric settings, as well as aim to better understand caregiver perspectives to improve engagement.

Transition to an interactive virtual skills-fair for a pediatric ambulatory care center

Competency assessment in healthcare organizations is an ongoing effort “focused on (assessing) the specific knowledge, technical skills, and abilities required (of nurses) to deliver safe, quality care” (The Joint Commission [TJC], 2022, para. 9). The TJC does not specify what competencies to assess or the time between assessments. It is up to each healthcare organization to create a plan based on the skill level of its nursing staff, “the needs of its patient population, conditions or diseases treated, and the equipment it uses” (TJC, 2022, para.12).

General practitioner-centred paediatric primary care reduces risk of hospitalisation for mental disorders in children and adolescents with ADHD: findings from a retrospective cohort study

Background General practitioners (GPs) play an essential role in the sustainable management of attention-deficit/hyperactivity disorder (ADHD). To our knowledge, the healthcare programme described here is the first integrated care programme for paediatric ambulatory care embedded in GP-centred-healthcare in Germany. Objectives To compare the health-service-utilisation of patients with ADHD enrolled in a GP-centred-paediatric-primary-care-programme with usual care in terms of disease-related hospitalisation, pharmacotherapy and psychotherapy. Methods In 2018, we conducted a retrospective cohort study of 3- to 18-year-old patients with ADHD in Baden-Wuerttemberg, southern Germany. The intervention group (IG) comprised patients enrolled in a GP-centred-paediatric-primary-healthcare-programme and consulted a participating GP for ADHD at least once. GP-centred-paediatric-primary-care provides high continuity of care, facilitated access to specialist care, extended routine examinations and enhanced transition to adult healthcare. Patients in the control group (CG) received usual care, meaning they consulted a non-participating GP for ADHD at least once. Main outcomes were disease-related hospitalisation, pharmacotherapy and psychotherapy. Multivariable logistic regression was performed to compare groups. Results A total of 2317 patients were included in IG and 4177 patients in CG. Mean age was 8.9 ± 4.4. The risk of mental-disorder-related hospitalisations was lower in IG than CG (odds ratio (OR): 0.666, 95% confidence interval (CI): 0.509–0.871). The prescription rate for stimulants was lower in IG (OR: 0.817; 95% CI: 0.732–0.912). There was no statistically significant difference in the participation rate of patients in cognitive behavioural therapy between groups (OR: 0.752; 95% CI: 0.523–1.080). Conclusion Children and adolescents with ADHD enrolled in GP-centred-paediatric-primary-care are at lower risk of mental-disorder-related hospitalisation and less likely to receive stimulants.

Point-of-care diagnostic technology in paediatric ambulatory care: a qualitative interview study of English clinicians and stakeholders

Point-of-care (POC) tests have the potential to improve paediatric healthcare. However, both the development and evaluation of POC technology have almost solely been focused on adults. We aimed to explore...

National Trends in Pediatric Ambulatory Telehealth Utilization and Follow-Up Care.

Introduction: As telemedicine becomes standard in pediatrics, further research is required to ensure optimal adoption. This study seeks to characterize visits best suited for telemedicine by analyzing usage trends and encounter attributes associated with immediate in-person follow-up. Methods: Analysis of ambulatory pediatric encounters from the first quarter of 2021 in a nationwide insurance claims database. Results: Telemedicine comprised 9.5% (138,346) of ambulatory encounters. Among telemedicine visits, 7.5% (10,304) yielded in-person follow-up within 3 days. Encounters involving infants and diagnoses of the perinatal period were most frequently followed by in-person visits (11% and 20%, respectively). Mental health visits were least likely to have in-person follow-up. Conclusions: In 2021, telemedicine remained a common modality of care in pediatrics. Varying medical needs still require in-person evaluation, whereas other diagnoses may be conducive to even greater expansion. Insights from this study inform further research into optimization of pediatric telemedicine utilization and development of guidelines.

Accuracy of Antibiotic Prescription Dosing for Urinary Tract Infections in a Regional Pediatric Ambulatory Care Setting.

Antibiotics are the most common class of medication prescribed in pediatrics, with the majority of prescriptions occurring in the outpatient setting. Our objective was to evaluate the accuracy of antibiotic dose, frequency, and formulation prescribed for urinary tract infections (UTIs) in the pediatric ambulatory care setting. This was a retrospective review of electronic medical records conducted at 2 suburban pediatric practices in a mid-sized metropolitan region. Encounter-related prescriptions were identified using UTI-associated International Classification of Diseases, 10th Revision codes. Patients aged 2 months through 18 years were included if they had been prescribed an oral antibiotic for the treatment of UTI. Antibiotic dose, frequency, and formulation were considered accurate if consistent with clinical guidelines and tertiary dosing references. Nearly 1 in 4 prescriptions had dosing inaccuracies. The proportion of errors was highest with amoxicillin-clavulanate (75%; 9/12) and amoxicillin (52%; 33/64). The most common reasons for dosing incorrectly were "low dose" or "unnecessarily high dose." Additionally, 55% of the included prescriptions were for oral suspensions, and 1 in 4 of these were dosed incorrectly. Inaccuracies in antibiotic prescribing for pediatric UTI are common, including for frequently prescribed agents and oral formulations. To address these missed opportunities for stewardship in the outpatient setting, key educational sessions with providers should include reviewing optimal antibiotic dosing for uropathogens and highlighting common errors when oral suspensions are prescribed.