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Background Constipation is a common problem in pediatric patients. Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department (PED) for diagnosis despite their poor reliability to rule out underlying pathology or prognostic ability to determine the degree of constipation. The goal of this quality improvement (QI) initiative was to standardize the diagnosis and management of constipation in the PED and Urgent Care (UC) in patients ages 6 months to 21 years as well as to decrease AXR use. Methodology This prospective QI project involved a multidisciplinary team at a large urban …

* Abbreviations: HS — : hypertonic saline LOS — : length of stay NMA — : network meta-analysis Viral bronchiolitis is one of the most common reasons for infant hospitalization in the United States. Despite the morbidity attributable to the disease, there are no generally recommended therapeutic strategies for bronchiolitis other than supportive care.1 The pull of the therapeutic vacuum surrounding this disease has been noted in the pages of this journal for at least 50 years, with Wright and Beem2 writing in 1965 that “energies should not be frittered away by the annoyance of unnecessary or futile medications and procedures” for the child with bronchiolitis. Pairwise meta-analyses, the pinnacle of the traditional evidence pyramid, have been controversial in settling the question of which, if any, therapies are effective for bronchiolitis. For example, multiple meta-analyses examining the benefit of nebulized hypertonic saline (HS) on hospital length of stay (LOS) have revealed disparate conclusions.3 Brooks et al4 suggested that the beneficial effect of HS on LOS noted in previous meta-analyses was likely due to heterogeneity and imbalance of baseline patient characteristics.5 Using newer statistical techniques, such as trial sequential analysis, researchers have attempted to … Address correspondence to Matthew J. Lipshaw, MD, MS, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45229. E-mail: matthew.lipshaw{at}cchmc.org

OBJECTIVES:To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).METHODS:We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.RESULTS:Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%–1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%–3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%–1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.CONCLUSION:Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.