Quaternary Care Children's Hospital Research Articles

Mother's Milk Donation to a Human Milk Bank During Bereavement: Circumstances Associated with Completing the Donation Process.

Background: Bereaved mothers describe positive experiences donating breast milk and negative experiences when not informed of opportunities to donate. Predictors of whether mothers donate milk are unknown, impairing efforts to optimize support in completing donation. Objective: To define circumstances associated with completing mother's milk (MM) donation during bereavement. Methods: A retrospective cohort study included dyads of bereaved mothers and their deceased children if a child's death occurred on-site at a quaternary care children's hospital during 2016-2020, the child had documentation of MM availability, and age at death <24 months. The primary outcome was the completion of MM donation to the milk bank. Multivariate logistic regression measured associations between clinical variables and odds of completion. Results: Of 124 deceased children with documented MM exposure, 34 mothers (28%) of 35 of those children completed MM donation, donating a mean of 13.7 liters (SD 16.8). The child's race/ethnicity documented in the medical record was White for 25 (71%), Black/African American (AA) for 1 (3%), Asian for 1 (3%), and Hispanic/Latino for 8 (23%). Referenced to mothers of White children, being a mother of an AA [OR 0.05 (95% CI: 0.01-0.43)] or Asian [0.08 (0.01-0.75)] child was associated with lower odds of donation. Referenced to mothers delivering full term (≥37 weeks'), mothers delivering <34 weeks showed higher odds [5.0 (1.5-17.5)] of donation. Conclusion: Relatively few bereaved mothers of children with indicators of MM exposure completed donation. The results suggest an opportunity to ensure bereaved mothers are uniformly informed and supported in donating.

A matched analysis of the use of high flow nasal cannula for pediatric severe acute asthma.

The high-flow nasal cannula (HFNC) device is commonly used to treat pediatric severe acute asthma. However, there is little evidence regarding its effectiveness in real-world practice. We sought to compare the physiologic effects and clinical outcomes for children treated for severe acute asthma with HFNC versus matched controls. This was a single-center retrospective matched cohort study at a quaternary care children's hospital. Children ages 2-18 hospitalized for severe acute asthma from 2015 to 2022 were included. Encounters receiving treatment with HFNC within the first 24 h of hospitalization were included as cases. Controls were primarily treated with oxygen facemask. Logistic regression 1:1 propensity score matching was done using demographics, initial vital signs, and medications. The primary outcome was an improvement in clinical asthma symptoms in the first 24 h of hospitalization measured as percent change from initial. Of 693 eligible cases, 443 were matched to eligible controls. Propensity scores were closely aligned between the cohorts, with the only significant difference in clinical characteristics being a higher percentage of patients of Black race in the control group (54.3% vs. 46.6%; p = 0.02). Compared to the matched controls, the HFNC cohort had smaller improvements in heart rate (-11.5% [-20.9; -0.9] vs. -14.7% [-22.6;-5.7]; p < 0.01), respiratory rate (-14.3% [-27.9;5.4] vs. -16.7% [-31.5;0.0]; p = 0.03), and pediatric asthma severity score (-14.3% [-28.6;0.0] vs. -20.0% [-33.3;0.0]; p < 0.01) after 24 h of hospitalization. The HFNC cohort also had longer pediatric intensive care unit (PICU) length of stay (LOS) (1.5 days [1.1;2.1] vs. 1.2 days [0.9;1.8]; p < 0.01) and hospital LOS (2.8 days [2.1;3.8] vs. 2.5 days [1.9;3.4]; p < 0.01). When subgrouping to younger patients (2-3 years old), or those with the highest severity scores (PASS > 9), those treated with HFNC had no difference in clinical symptom improvements but maintained a longer PICU LOS. Encounters using HFNC for severe acute pediatric asthma had decreased clinical improvement in 24 h of hospitalization compared to matched controls and increased LOS. Specific subgroups of younger patients and those with the highest severity scores showed no differences in clinical symptom improvement suggesting differential effects in specific patient populations.

Pharmacokinetic Factors Associated With Early Meropenem Target Attainment in Pediatric Severe Sepsis.

To determine the frequency of early meropenem concentration target attainment (TA) in critically ill children with severe sepsis; to explore clinical, therapeutic, and pharmacokinetic factors associated with TA; and to assess how fluid resuscitation and volume status relate to early TA. Retrospective analysis of prospective observational cohort study. PICU in a single academic quaternary care children's hospital. Twenty-nine patients starting meropenem for severe sepsis (characterized as need for positive pressure ventilation, vasopressors, or ≥ 40 mL/kg bolused fluid), of which 17 were newly escalated to PICU level care. None. Concentration-time profiles were analyzed using modeling software employing opportunistic sampling, Bayesian estimation, and a population pharmacokinetic model. Time above four times minimum inhibitory concentration (T > 4×MIC), using the susceptibility breakpoint of 1 µg/mL, was determined for each patient over the first 24 hours of meropenem therapy, as well as individual clearance and volume of distribution (Vd) estimates. Twenty-one of 29 patients met a target of 40%T > MIC 4 μg/mL. Reaching TA, vs. not, was associated with lower meropenem clearance. We failed to identify a difference in Vd or an association between the TA group and age, weight, creatinine-based estimated glomerular filtration rate (eGFR), or the amount of fluid administered. eGFR was, however, negatively correlated with overall T > MIC. Eight of 29 pediatric patients with early severe sepsis did not meet the selected TA threshold within the first 24 hours of meropenem therapy. Higher clearance was associated with failure to meet targets. Identifying patients likely to have higher meropenem clearance could help with dosing regimens.

A retrospective observational cohort study of the anesthetic management and outcomes of pediatric patients with Alexander disease undergoing lumbar puncture or magnetic resonance imaging.

Alexander disease is a rare, progressive leukodystrophy, which predisposes patients to complications under general anesthesia due to clinical manifestations including developmental delay, seizures, dysphagia, vomiting, and sleep apnea. However, study of anesthetic outcomes is limited. Our aim was to describe patient characteristics, anesthetic techniques, and anesthesia-related complications for Alexander disease patients undergoing magnetic resonance imaging and/or lumbar puncture at a quaternary-care children's hospital. We performed a retrospective review of anesthetic outcomes in patients with Alexander disease enrolled in a prospective observational study. Included patients had diagnosed Alexander disease and underwent magnetic resonance imaging and/or lumbar puncture at our institution. We excluded anesthetics for other procedures or at outside institutions. Collected data included patient characteristics, anesthetic techniques, medications, and complications under anesthesia and in the subsequent 24 h. We performed descriptive statistics as appropriate. Forty patients undergoing 64 procedures met inclusion criteria. Fifty-six procedures (87.5%) required general anesthesia or monitored anesthesia care (MAC) and eight (12.5%) did not. The general anesthesia/MAC group tended to be younger than nonanesthetized patients (median age 6 years [IQR 3.8; 9] vs. 14.5 years [IQR 12.8; 17.5]). In both groups, dysphagia (78.6% vs. 87.5%, respectively), seizures (62.5% vs. 25%), and recurrent vomiting (17.9% vs. 25%) were frequently reported preprocedure symptoms. Inhalational induction was common (N = 48; 85.7%), and two (3.6%) underwent rapid sequence induction. Serious complications were rare, with no aspiration or seizures. Hypotension resolving with ephedrine occurred in eight cases (14.3%). One patient each (1.8%) experienced postprocedure emergence agitation or vomiting. Fifty-three (94.6%) were ambulatory procedures. No inpatients required escalation in acuity of care. In this single-center study, patients with Alexander disease did not experience frequent or irreversible complications while undergoing general anesthesia/MAC. Co-morbid symptoms were not increased postanesthesia. Some patients may not require anesthesia to complete short procedures.

Identification of severe acute pediatric asthma phenotypes using unsupervised machine learning.

More targeted management of severe acute pediatric asthma could improve clinical outcomes. To identify distinct clinical phenotypes of severe acute pediatric asthma using variables obtained in the first 12 h of hospitalization. We conducted a retrospective cohort study in a quaternary care children's hospital from 2014 to 2022. Encounters for children ages 2-18 years admitted to the hospital for asthma were included. We used consensus k means clustering with patient demographics, vital signs, diagnostics, and laboratory data obtained in the first 12 h of hospitalization. The study population included 683 encounters divided into derivation (80%) and validation (20%) sets, and two distinct clusters were identified. Compared to Cluster 1 in the derivation set, Cluster 2 encounters (177 [32%]) were older (11 years [8; 14] vs. 5 years [3; 8]; p < .01) and more commonly males (63% vs. 53%; p = .03) of Black race (51% vs. 40%; p = .03) with non-Hispanic ethnicity (96% vs. 84%; p < .01). Cluster 2 encounters had smaller improvements in vital signs at 12-h including percent change in heart rate (-1.7 [-11.7; 12.7] vs. -7.8 [-18.5; 1.7]; p < .01), and respiratory rate (0.0 [-20.0; 22.2] vs. -11.4 [-27.3; 9.0]; p < .01). Encounters in Cluster 2 had lower percentages of neutrophils (70.0 [55.0; 83.0] vs. 85.0 [77.0; 90.0]; p < .01) and higher percentages of lymphocytes (17.0 [8.0; 32.0] vs. 9.0 [5.3; 14.0]; p < .01). Cluster 2 encounters had higher rates of invasive mechanical ventilation (23% vs. 5%; p < .01), longer hospital length of stay (4.5 [2.6; 8.8] vs. 2.9 [2.0; 4.3]; p < .01), and a higher mortality rate (7.3% vs. 0.0%; p < .01). The predicted cluster assignments in the validation set shared the same ratio (~2:1), and many of the same characteristics. We identified two clinical phenotypes of severe acute pediatric asthma which exhibited distinct clinical features and outcomes.

Pediatric cerebrospinal fluid rhinorrhea caused by low flow vascular anomaly of the temporal bone: A case series

ObjectiveAtraumatic cerebrospinal fluid (CSF) rhinorrhea is uncommon in children and necessitates a multi-disciplinary evaluation for an etiology. Underlying osseous abnormality due to extensive or multifocal low flow vascular anomaly should be considered as a potential cause of spontaneous CSF leak. Treatment of multifocal low flow vascular anomalies may include medical and surgical approaches. In this series, we seek to determine the presenting signs and symptoms and medical and surgical treatment options for multifocal or extensive low flow vascular anomalies. MethodsA retrospective case series at a quaternary care children's hospital was compiled. All children with CSF rhinorrhea diagnosed and treated for multifocal low flow vascular anomalies at our institution were included. A total of four patients were identified. ResultsAll four patients had delay in initial diagnosis of underlying cause of meningitis and CSF rhinorrhea. Average age at diagnosis of multifocal low flow vascular anomaly was 7 years. This was on average 4 years after initial presentation for medical attention. Treatment approach was multidisciplinary and included medical management with sirolimus and bisphosphonates as well as surgical approaches to the skull base (lateral and anterior) to prevent CSF egress. ConclusionConsideration of multifocal low flow vascular anomaly should be included in any pediatric patient presenting with CSF rhinorrhea.

Body Image Concerns in Adolescent and Young Adult Oncology Patients within Six Months of Upfront Diagnosis.

This cross-sectional study described prevalent body image (BI) concerns among adolescents and young adults (AYAs) with neoplasms who received treatment at a quaternary care children's hospital. Thirty-two AYAs, aged 15-39 years, completed questionnaires assessing BI within six months of diagnosis. The most frequently endorsed questionnaire items included the following: desire for increased physical fitness (62.5%), self-consciousness about hair (45.2%), weight dissatisfaction (40.6%), lack of strength (37.5%), wearing loose clothing to hide one's body (37.5%), decreased agility (34.4%), shape dissatisfaction (32.2%), and self-perception of too much body fat (31.3%). Awareness of AYA BI concerns during treatment may generate early intervention targeting this complex issue.

Progesterone for Neurodevelopment in Fetuses With Congenital Heart Defects

Neurodevelopmental outcomes for children with congenital heart defects (CHD) have improved minimally over the past 20 years. To assess the feasibility and tolerability of maternal progesterone therapy as well as the magnitude of the effect on neurodevelopment for fetuses with CHD. This double-blinded individually randomized parallel-group clinical trial of vaginal natural progesterone therapy vs placebo in participants carrying fetuses with CHD was conducted between July 2014 and November 2021 at a quaternary care children's hospital. Participants included maternal-fetal dyads where the fetus had CHD identified before 28 weeks' gestational age and was likely to need surgery with cardiopulmonary bypass in the neonatal period. Exclusion criteria included a major genetic or extracardiac anomaly other than 22q11 deletion syndrome and known contraindication to progesterone. Statistical analysis was performed June 2022 to April 2024. Participants were 1:1 block-randomized to vaginal progesterone or placebo by diagnosis: hypoplastic left heart syndrome (HLHS), transposition of the great arteries (TGA), and other CHD diagnoses. Treatment was administered twice daily between 28 and up to 39 weeks' gestational age. The primary outcome was the motor score of the Bayley Scales of Infant and Toddler Development-III; secondary outcomes included language and cognitive scales. Exploratory prespecified subgroups included cardiac diagnosis, fetal sex, genetic profile, and maternal fetal environment. The 102 enrolled fetuses primarily had HLHS (n = 52 [50.9%]) and TGA (n = 38 [37.3%]), were more frequently male (n = 67 [65.7%]), and without genetic anomalies (n = 61 [59.8%]). The mean motor score differed by 2.5 units (90% CI, -1.9 to 6.9 units; P = .34) for progesterone compared with placebo, a value not statistically different from 0. Exploratory subgroup analyses suggested treatment heterogeneity for the motor score for cardiac diagnosis (P for interaction = .03) and fetal sex (P for interaction = .04), but not genetic profile (P for interaction = .16) or maternal-fetal environment (P for interaction = .70). In this randomized clinical trial of maternal progesterone therapy, the overall effect was not statistically different from 0. Subgroup analyses suggest heterogeneity of the response to progesterone among CHD diagnosis and fetal sex. ClinicalTrials.gov Identifier: NCT02133573.

Parent Perspectives on Documentation and Sharing of Health-Related Social Needs Data.

Parents of pediatric patients are key stakeholders in the design and implementation of health-related social needs (HRSN) screening programs. Yet, there is little research exploring their perspectives on the documentation and sharing of HRSN data. We aimed to examine parents' preferences regarding how HRSN data are documented and shared. We conducted semi-structured interviews with parents of hospitalized children participating in an HRSN screening program at a quaternary care children's hospital. Interviews were coded using an inductive and deductive approach to identify emergent themes. The 20 interviewed parents were uniformly female with 55% identifying as Black or African American and 20% identifying as Hispanic or Latino. Parents expressed comfort with electronic health record documentation of HRSN data and the use of International Classification of Diseases, 10th Revision Z codes as long as this information was used to provide families with meaningful support. Most parents viewed social workers and medical teams as the most appropriate recipients of HRSN data. Few parents felt comfortable with HRSN data being shared with payors. Parents desired transparency around HRSN data sharing. Many expressed concerns that documentation and sharing of HRSN data could lead to unwanted or unsafe disclosures or result in child welfare referrals. Parents expressed comfort with HRSN documentation and sharing with health care providers, but requested that providers be transparent and respect parental preferences regarding data sharing to mitigate potential harms. When implementing HRSN support programs, health systems and payors should prioritize transparency around documentation and data sharing with families.

Use of temporary tracheostomy occlusion to reduce the risk of sternal wound infection after sternotomy in congenital cardiac surgery.

To describe a method of reducing the risk of sternal wound infection after sternotomy in children with a pre-existing tracheostomy. To report our outcomes using this method from 1 January, 2013 to 31 August, 2023. We describe a method for temporarily occluding the tracheal stoma with a removable implant with the primary goal of reducing the risk of sternotomy wound infection by preventing soilage due to tracheostomal secretions. We then performed a retrospective review of all children who underwent temporary tracheostomal occlusion between 1 January, 2013 and 31 August, 2023 at our quaternary care children's hospital. Clinical variables were extracted from the hospital medical records. The rates of antibiotic use and minor and major complications during the period when the stoma plug was in place were recorded. Totally, 19 patients underwent tracheal stoma plugging prior to sternotomy and were included in our analysis. There were two cases of sternal wound infection; one case occurred while the stoma plug was in place, and one developed four days following plug removal. There was one minor complication, with one patient requiring stoma revision via serial dilation at bedside at the time of recannulation. There were no deaths. Temporary occlusion of the tracheal stoma with an impermeable plug is a viable option for reducing the risk of sternal wound infection in children with a pre-existing tracheostomy who are undergoing sternotomy.

Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis.

Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.

High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation.

To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. Quaternary care children's hospital. Pediatric patients undergoing ECPR. None. Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

Pediatric resident use, perceptions, and desires for improvement of a clinical secure messaging application

BackgroundHospitals are transitioning away from traditional pagers to secure text messaging (STM) applications. STM is perceived to improve efficiency and accessibility. There is limited research on user's impressions of how STM impacts patient safety, provider wellness, and quality of patient care. ObjectivesTo understand the use and perceptions of a clinical STM by pediatric residents at a free-standing quaternary care children's hospital. MethodsA survey was conducted of pediatric residents regarding their experience with Diagnotes®. Demographic data were obtained along with use patterns, ability to perform tasks, and perceptions of intended purpose. Further questions evaluated agreement with communication strategies and satisfaction with features. Three open-ended questions asked about experience where STM impacted (1) patient care coordination and (2) patient safety. A final question asked for any additional STM feedback. ResultsOf 169 surveys, there were 112 respondents (66.3 % response rate). Respondents unanimously endorsed daily STM use on their personal mobile devices with good knowledge of basic features. Respondents were overall satisfied with Diagnotes® (73.9 %) including the ability to communicate efficiently (84.8 %) and effectively (79.5 %). Yet only 32.1 % were satisfied with Diagnotes® training. Only 59.5 % believed Diagnotes® was appropriate for urgent patient care needs and only 43.2 % believed its purpose was to inform the team of patient emergencies. Key qualitative themes included improved coordination of patient care tasks through STM, but there were concerns raised around sending and receiving messages, the additional cognitive burden placed by STM, and differences in culture of use that created conflict. ConclusionsDiagnotes® is viewed positively including use for effective coordination of patient care and familiarity of functions of Diagnotes®. Barriers included unclear interprofessional expectations for use. Future research should incorporate a broad range of healthcare professionals' perceptions and co-creation of STM best practice guidelines for use, including around urgent or emergent patient care issues.

To transfuse or not to transfuse? A pilot study evaluating preoperative transfusion practices for pediatric sickle cell patients undergoing central venous access procedures

IntroductionPerioperative transfusion guidelines for pediatric sickle cell disease (SCD) patients are underdeveloped. The American Society of Hematology (ASH) provides transfusion recommendations for procedures requiring general anesthesia and lasting >1 hour. However, many pediatric SCD patients require long term central venous access and these short procedures do not fall within these guidelines. The objective of this study is to investigate our institutional preoperative transfusion practices in central venous access procedures. MethodsA retrospective chart review was performed from 2018 to 2022 of SCD patients who underwent a line placement or removal at a stand-alone quaternary care children's hospital. Clinical information including demographics, Hgb levels, number of transfusions, and postoperative complications were collected. Statistical analysis was performed using Fisher exact and Wilcoxon rank sum tests. ResultsA total of 30 patients underwent 34 venous access procedures (76 % line placement, 36 % line removal). Half of the patients (15) had an initial Hgb <9 g/dL. There were no significant differences in the demographics, complications, or readmission rates between patients with an initial Hgb <9 or >9 g/dL. Significantly more patients received a preoperative blood transfusion in patients with a Hgb <9 g/dL compared to those with a Hgb >9 g/dL (73% vs 20 %, p = 0.01) Length of stay, postoperative complications, intraoperative transfusion, and readmission rates were not significantly different in patients who received a preoperative transfusion. ConclusionWe encountered variability in the preoperative transfusion threshold; however, outcomes remained similar with no significant differences based on preoperative Hgb. Future studies focused on quality, safety, and resource allocation are needed for development of practice recommendations.

A Comparison of Ketamine and Midazolam as First-Line Anesthetic Infusions for Pediatric Status Epilepticus.

Pediatric refractory status epilepticus (RSE) often requires management with anesthetic infusions, but few data compare first-line anesthetics. This study aimed to compare the efficacy and adverse effects of midazolam and ketamine infusions as first-line anesthetics for pediatric RSE. Retrospective single-center study of consecutive study participants treated with ketamine or midazolam as the first-line anesthetic infusions for RSE at a quaternary care children's hospital from December 1, 2017, until September 15, 2021. We identified 117 study participants (28 neonates), including 79 (68%) who received midazolam and 38 (32%) who received ketamine as the first-line anesthetic infusions. Seizures terminated more often in study participants administered ketamine (61%, 23/38) than midazolam (28%, 22/79; odds ratio [OR] 3.97, 95% confidence interval [CI] 1.76-8.98; P < 0.01). Adverse effects occurred more often in study participants administered midazolam (24%, 20/79) than ketamine (3%, 1/38; OR 12.54, 95% CI 1.61-97.43; P = 0.016). Study participants administered ketamine were younger, ketamine was used more often for children with acute symptomatic seizures, and midazolam was used more often for children with epilepsy. Multivariable logistic regression of seizure termination by first-line anesthetic infusion (ketamine or midazolam) including age at SE onset, SE etiology category, and individual seizure duration at anesthetic infusion initiation indicated seizures were more likely to terminate following ketamine than midazolam (OR 4.00, 95% CI 1.69-9.49; P = 0.002) and adverse effects were more likely following midazolam than ketamine (OR 13.41, 95% CI 1.61-111.04; P = 0.016). Survival to discharge was higher among study participants who received midazolam (82%, 65/79) than ketamine (55%, 21/38; P = 0.002), although treating clinicians did not attribute any deaths to ketamine or midazolam. Among children and neonates with RSE, ketamine was more often followed by seizure termination and less often associated with adverse effects than midazolam when administered as the first-line anesthetic infusion. Further prospective data are needed to compare first-line anesthetics for RSE.

Long-Term Outcomes of Pediatric Traumatic Brain Injury Following Inpatient Rehabilitation.

Assess residual disability in youth with traumatic brain injury (TBI) treated in a pediatric inpatient rehabilitation unit and examine associations of disability with inpatient status and measures of concurrent functioning. Large, urban, quaternary care children's hospital in the Midwestern United States. Forty-five youth aged 6 to 18 years treated in an inpatient rehabilitation unit for mild-complicated to severe TBI at a minimum of 12 months postdischarge (mean = 3.5 years). Retrospective chart review of clinical data collected from standard clinical care at admission and discharge combined with follow-up data examining current functioning at the time of study enrollment. Glasgow Outcome Scale-Extended, Pediatric Revision (GOS-E Peds), Neurology Quality of Life Measurement System Short Form (NeuroQOL) Social Interaction with Peers and Cognitive Short Forms, Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale, Strengths and Difficulties Questionnaire, and the Behavior Rating Inventory of Executive Function, 2nd Edition (BRIEF-2). Based on parent report at follow-up, 62% of the children had residual TBI-related disabilities on the GOS-E Peds, while 38% reported "good recovery." Children with residual disability also reported more long-term problems in overall health, social relationships, emotional regulation, behaviors, and executive functioning than those with no residual disability. Measures of functional independence and cognitive recovery at discharge were associated with these impairments. More than half of the children with TBI in this study had residual disability more than 1 year after inpatient rehabilitation. Findings highlight the associations between measures of functional independence and cognitive recovery during inpatient rehabilitation with later outcomes and underscore the need for continued services to support the needs of children with TBI following their inpatient rehabilitation stay.

Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study.

We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.

Social Determinants of Health in Early Otologic and Audiologic Evaluation in an Interdisciplinary Cleft-Craniofacial Clinic.

Investigate associations between socioeconomic indicators of healthcare access with family compliance with cleft-related otologic and audiologic care within an interdisciplinary model. Retrospective case series. Children born 2005-2015 who presented to the Cleft-Craniofacial Clinic (CCC) at a quaternary care children's hospital. Associations between main outcome measures and Area Deprivation Index (ADI), median household income for zip code, distance from hospital, and insurance status were evaluated. Cleft types, ages at presentation to outpatient clinic (cleft, otolaryngology, and audiology), and ages at procedures (first tympanostomy tube insertion (TTI), lip repair, and palatoplasty) were measured. Most patients were male (147/230, 64%) with cleft lip and palate (157/230, 68%). Median age at first cleft, otolaryngology, and audiology visits were 7 days, 86 days, and 5.9 months, respectively. Private insurance predicted lower no-show rates (p = .04). Age at first CCC visit was younger for patients with private insurance (p = .04) and older for those who lived further from the hospital (p = .002). Age at lip repair was positively correlated with national ADI (p = .03). However, no socioeconomic status (SES) proxy or proximity to hospital was associated with delays in first otolaryngology or audiology examination or TTI. Once children become established within an interdisciplinary CCC, SES appears to bear little influence on cleft-related otologic and audiologic care. Future efforts should aim to elucidate which aspects of the interdisciplinary model maximize multisystem cleft care coordination and increase access for higher risk populations.

Development of a Deep Learning Model for Retinal Hemorrhage Detection on Head Computed Tomography in Young Children

Abusive head trauma (AHT) in children is often missed in medical encounters, and retinal hemorrhage (RH) is considered strong evidence for AHT. Although head computed tomography (CT) is obtained routinely, all but exceptionally large RHs are undetectable on CT images in children. To examine whether deep learning-based image analysis can detect RH on pediatric head CT. This diagnostic study included 301 patients diagnosed with AHT who underwent head CT and dilated fundoscopic examinations at a quaternary care children's hospital. The study assessed a deep learning model using axial slices from 218 segmented globes with RH and 384 globes without RH between May 1, 2007, and March 31, 2021. Two additional light gradient boosting machine (GBM) models were assessed: one that used demographic characteristics and common brain findings in AHT and another that combined the deep learning model's risk prediction plus the same demographic characteristics and brain findings. Sensitivity (recall), specificity, precision, accuracy, F1 score, and area under the curve (AUC) for each model predicting the presence or absence of RH in globes were assessed. Globe regions that influenced the deep learning model predictions were visualized in saliency maps. The contributions of demographic and standard CT features were assessed by Shapley additive explanation. The final study population included 301 patients (187 [62.1%] male; median [range] age, 4.6 [0.1-35.8] months). A total of 120 patients (39.9%) had RH on fundoscopic examinations. The deep learning model performed as follows: sensitivity, 79.6%; specificity, 79.2%; positive predictive value (precision), 68.6%; negative predictive value, 87.1%; accuracy, 79.3%; F1 score, 73.7%; and AUC, 0.83 (95% CI, 0.75-0.91). The AUCs were 0.80 (95% CI, 0.69-0.91) for the general light GBM model and 0.86 (95% CI, 0.79-0.93) for the combined light GBM model. Sensitivities of all models were similar, whereas the specificities of the deep learning and combined light GBM models were higher than those of the light GBM model. The findings of this diagnostic study indicate that a deep learning-based image analysis of globes on pediatric head CTs can predict the presence of RH. After prospective external validation, a deep learning model incorporated into CT image analysis software could calibrate clinical suspicion for AHT and provide decision support for which patients urgently need fundoscopic examinations.

Identifying and Mitigating Disparities in Central Line–Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups

Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.