Search

Temperature measurement plays a central role in determining pediatric patients' disease risk and management. However, current pediatric temperature thresholds may be outdated and not applicable to children.To characterize pediatric temperature norms and variation by patient characteristics, time of measurement, and thermometer route.In this cross-sectional study, we analyzed 134,641 well-child visits occurring between 2014-2019 at primary care clinics that routinely measured temperature. We performed bivariate and multivariable quantile regressions with clustered standard errors to determine temperature percentiles and variation by age, sex, time of measurement, and thermometer route. We performed sensitivity analyses: 1) using a cohort that excluded visits with infectious diagnoses that could explain temperature aberrations and 2) including clinic as a fixed effect.The median rectal temperature for visits of infants ≤12 months old was 37.2˚C, which was 0.4˚C higher than the median axillary temperature. The median axillary temperature for children 1-18 years old was 36.7˚C, which was 0.1˚C lower than the median values of all other routes. The 99th percentile for rectal temperatures in infants was 37.8˚C and the 99.9th percentile for axillary temperatures in children was 38.5˚C. Adjusted analyses did not demonstrate clinically significant variation in temperature by sex, age, or time of measurement.These updated temperature norms can serve as reference values in clinical practice and should be considered in the context of thermometer route used and the clinical condition being evaluated. Variations in temperature values by sex, age, and time of measurement were not clinically significant.

BACKGROUND AND OBJECTIVE Previously reported prevalence of urinary tract infections (UTIs) in infants with jaundice range from METHODS The data sources used were Medline (1946–2020) and Ovid Embase (1976–2020) through January 2020 and bibliographies of retrieved articles. We selected studies reporting UTI prevalence in young infants with jaundice. Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines. Random-effects models produced a weighted pooled event rate with 95% confidence intervals (CI). RESULTS We screened 526 unique articles by abstract and reviewed 53 full-text articles. We included 32 studies and 16 contained UA data. The overall UTI prevalence in young infants with jaundice from all 32 studies was 6.2% (95% CI, 3.9–8.9). From the 16 studies with UA data, the overall UTI prevalence was 8.7% (95% CI, 5.1–13.2), which decreased to 3.6% (95% CI, 2.0–5.8) with positive UA results included as a diagnostic criterion. CONCLUSIONS The estimated UTI prevalence in young infants with jaundice decreases substantially when UA results are incorporated into the UTI definition. Due to the heterogeneity of study subjects’ ages and definitions of jaundice, positive UA results, and UTI, there is uncertainty about the exact prevalence and about which infants with hyperbilirubinemia warrant urine testing.

Increasing preconception paternal comorbidity has been associated with adverse pregnancy outcomes. However, whether the father's health impacts the child after birth is uncertain.In the present study, we examined the association of preconception paternal metabolic syndrome status with childhood emergency department (ED) visits and hospitalizations.This is a longitudinal cohort study of children (295,355 boys and 278,735 girls) born to linked pairs of fathers and mothers in the United States between 2009 to 2016 within the IBM MarketScan35.5% (203,617/574,090) of children had at least one emergency room visit and 6.1% (35,141/574,090) of children had an inpatient admission. After adjustment, the odds of inpatient admission and emergency department visits increased in a dose-dependent fashion among fathers with higher comorbidities. Similar trends were seen for emergency department visit utilization.Increasing paternal preconception comorbidity is associated with a higher risk that a child requires emergency department and inpatient care in the first years of life. An opportunity exists to engage men in preconception counseling to optimize theirs and their offspring's health. This article is protected by copyright. All rights reserved.

OBJECTIVES Pediatric hospitalization rates are used as a marker of coronavirus disease 2019 (COVID-19) disease severity in children but may be inflated by the detection of mild or asymptomatic infection via universal screening. We aimed to classify COVID-19 hospitalizations using an existing and novel approach and to assess the interrater reliability of both approaches. METHODS This retrospective cohort study characterized severity of illness and likelihood of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as the cause of hospitalization in pediatric patients RESULTS Of 117 hospitalizations, 46 (39.3%) were asymptomatic, 33 (28.2%) had mild to moderate disease, 9 (7.7%) had severe illness, and 15 (12.8%) had critical illness (weighted κ: 0.82). A total of 14 (12%) patients had multisystem inflammatory syndrome in children. A total of 53 (45%) admissions were categorized as unlikely to be caused by SARS-CoV-2 (κ: 0.78). CONCLUSIONS Although COVID-19 has considerable associated morbidity and mortality in children, reported hospitalization rates likely lead to overestimation of the true disease burden.

Although the number of randomized controlled trials (RCTs) published each year involving adult populations is steadily rising, the annual number of RCTs published involving pediatric populations has not changed since 2005. Barriers to the broader utilization of RCTs in pediatrics include a lower prevalence of disease, less available funding, and more complicated regulatory requirements. Although child health researchers have been successful in overcoming these barriers for isolated diseases such as pediatric cancer, common pediatric diseases are underrepresented in RCTs relative to their burden. This article proposes a strategy called High-Efficiency RandOmIzed Controlled (HEROIC) trials to increase RCTs focused on common diseases among hospitalized children. HEROIC trials are multicenter RCTs that pursue the rapid, low-cost accumulation of study participants with minimal burden for individual sites. Five key strategies distinguish HEROIC trials: (1) dispersed low-volume recruitment, in which a large number of sites (50–150 hospitals) enroll a small number of participants per site (2–10 participants per site), (2) incentivizing site leads with authorship, training, education credits, and modest financial support, (3) a focus on pragmatic questions that examine simple, widely used interventions, (4) the use of a single institutional review board, integrated consent, and other efficient solutions to regulatory requirements, and (5) scaling the HEROIC trial strategy to accomplish multiple trials simultaneously. HEROIC trials can boost RCT feasibility and volume to answer fundamental clinical questions and improve care for hospitalized children.

BACKGROUND AND OBJECTIVES Recommendations for parenteral antibiotic therapy duration in bacterial meningitis in young infants are based predominantly on expert consensus. Prolonged durations are generally provided for proven and suspected meningitis and are associated with considerable costs and risks. The objective of the study was to review the literature on the duration of parenteral antibiotic therapy and outcomes of bacterial meningitis in infants METHODS We searched PubMed, Embase, and the Cochrane Library for publications until May 31, 2021. Eligible studies were published in English and included infants RESULTS Thirty-two studies were included: 1 randomized controlled trial, 25 cohort studies, and 6 case series. The randomized controlled trial found no difference in treatment failure rates between 10 and 14 days of therapy. One cohort study concluded that antibiotic courses >21 days were not associated with improved outcomes as compared with shorter courses. The remaining studies had small sample sizes and/or did not stratify outcomes by therapy duration. Meta-analysis was not possible because of the heterogeneity of the treatments and reported outcomes. CONCLUSIONS Rigorous, prospective clinical trial data are lacking to determine the optimal parenteral antibiotic duration in bacterial meningitis in young infants. Given the associated costs and risks, there is a pressing need for high-quality comparative effectiveness research to further study this question.

ObjectiveTo determine the cumulative incidence and predictors of third molar (3M, “wisdom teeth”) extractions in the US.MethodsWe retrospectively analyzed a US private dental insurance claims database to create a Kaplan-Meier curve for cumulative incidence of 3M extractions, and used Cox proportional hazards to assess associations between sex, geographic region, and extractions.ResultsBetween 2007 and 2016, by age 25, ~80% of patients underwent ≥1 tooth extraction and an estimated 50% of patients underwent ≥1 3M extraction. Factors associated with 3M extractions included female sex (adjusted hazard ratio [aHR] 1.08, 95% CI 1.07 – 1.08) and residence in the West (aHR 1.82, 95% CI 1.81-1.85) or South (aHR 1.5, 95% CI 1.49 – 1.51) geographic regions as compared to the Northeast.Conclusion3M extractions are likely the most common surgery performed in US adolescents and young adults. Significant geographic variation suggests that elucidation of the indications for this common procedure is a public health priority.

Objectives Healthcare utilization decreased during the COVID-19 pandemic, likely due to reduced transmission of infections and healthcare avoidance. Though various investigations have described these changing patterns in children, most have analyzed specific care settings. We compared healthcare utilization, prescriptions, and diagnosis patterns in children across the care continuum during the first year of the pandemic with preceding years. Study design Using national claims data, we compared enrollees under 18 years during the pre-pandemic (January 2016 –mid-March 2020) and pandemic (mid-March 2020 through March 2021) periods. The pandemic was further divided into early (mid-March through mid-June 2020) and middle (mid-June 2020 through March 2021) periods. Utilization was compared using interrupted time series. Results The mean number of pediatric enrollees/month was 2,519,755 in the pre-pandemic and 2,428,912 in the pandemic period. Utilization decreased across all settings in the early pandemic, with the greatest decrease (76.9%, 95% confidence interval [CI] 72.6–80.5%) seen for urgent care visits. Only well visits returned to pre-pandemic rates during the mid-pandemic. Hospitalizations decreased by 43% (95% CI 37.4–48.1) during the early pandemic and were still 26.6% (17.7–34.6) lower mid-pandemic. However, hospitalizations in non-psychiatric facilities for various mental health disorders increased substantially mid-pandemic. Conclusion Healthcare utilization in children dropped substantially during the first year of the pandemic, with a shift away from infectious diseases and a spike in mental health hospitalizations. These findings are important to characterize as we monitor the health of children, can be used to inform healthcare strategies during subsequent COVID-19 surges and/or future pandemics, and may help identify training gaps for pediatric trainees. Subsequent investigations should examine how changes in healthcare utilization impacted the incidence and outcomes of specific diseases.

To determine the average reported consent rate for published pediatric randomized controlled trials (RCTs) and whether this rate varies by trial characteristics.A review of pediatric RCTs published in Medline in 2009, 2010, or 2015 was performed. Secondary analyses of prior trials, trials including adults, trials not requiring consent, or trials with missing or unclear consent data were excluded. Consent rate was defined as the number of patients enrolled divided by number of eligible patients where families were approached. Random effects meta-regression was conducted to determine the weighted average consent rate.Of 2347 trials identified, 1651 were excluded. An additional 418 of 696 (60%) were excluded because the consent rate was missing or unclear. The average consent rate for 278 included RCTs was 82.6% (95% CI, 80.3%-84.8%) and was higher for vaccination compared with behavioral trials and for industry-funded compared with National Institutes of Health-funded or other government-funded trials. The average consent rate was70% for 26% of included trials. Of these trials, US trials (28/77 [36.4%]) had a higher probability of a consent rate of70% than non-US studies (35/64 [21.3%]) and multinational (9/37 [24.3%]) studies. There was slight variation by funding category.Although the average consent rate for published trials was reasonably high, approximately one-quarter of trials had consent rates of70%. Consent rates reporting has improved over time, but remains suboptimal. Our findings should assist with the planning of future pediatric RCTs, although consent data from unpublished trials are also needed.

Urinary tract infections (UTIs) are the most common bacterial infection in young infants. The American Academy of Pediatrics' (AAP) clinical practice guideline for UTIs focuses on febrile children age 2-24 months, with no guideline for infants

BACKGROUND AND OBJECTIVES Unique ethical, epidemiological, and economic factors are barriers to performing research in children. The landscape of pediatric clinical trials, including drivers of completion and timely dissemination of results, is not well understood. We aimed to characterize the prevalence of and factors associated with early discontinuation, results reporting, and publication of pediatric clinical trials registered at ClinicalTrials.gov. METHODS Cross-sectional analysis of clinical trials enrolling participants RESULTS Overall, 11.1% trials were stopped early, with recruitment failure being the predominant reason for discontinuation. Only 23.5% of completed trials reported results, and 38.8% were published within 3 years of completion. Rates of discontinuation and publication significantly improved over the study period. Among funding sources, government-sponsored trials (adjusted odds ratio [aOR], 0.72; 95% CI, 0.47–0.97) and academic trials (aOR, 0.64; 95% CI, 0.50–0.82) had lower odds of discontinuation compared with industry trials and were more likely to be published (government: aOR, 1.94 [95% CI, 1.52–2.48] academic: aOR, 1.61 [95% CI, 1.35–1.92). Academic trial investigators were the least likely to report results (aOR, 0.34; 95% CI, 0.31–0.52). CONCLUSIONS Early discontinuation and nonreporting/nonpublication of findings remain common in registered pediatric clinical trials and were associated with funding source and other trial features. Targeted efforts are needed to support trial completion and timely results dissemination toward strengthening evidence-based pediatric medicine.

BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15–1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15–1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11–1.29; P < .0001). CONCLUSIONS Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.

OBJECTIVES To determine the (1) frequency and visit characteristics of routine temperature measurement and (2) rates of interventions by temperature measurement practice and the probability of incidental fever detection. METHODS In this retrospective cohort study, we analyzed well-child visits between 2014–2019. We performed multivariable regression to characterize visits associated with routine temperature measurement and conducted generalized estimating equations regression to determine adjusted rates of interventions (antibiotic prescription, and diagnostic testing) and vaccine deferral by temperature measurement and fever status, clustered by clinic and patient. Through dual independent chart review, fever (≥100.4°F) was categorized as probable, possible, or unlikely to be incidentally detected. RESULTS Temperature measurement occurred at 155 527 of 274 351 (58.9%) well-child visits. Of 24 clinics, 16 measured temperature at >90% of visits (“routine measurement clinics”) and 8 at CONCLUSIONS Temperature measurement occurs at more than one-half of well-child visits and is a clinic-driven practice. Given the impact on subsequent interventions and vaccine deferral, the harm–benefit profile of this practice warrants consideration.

To describe and evaluate a pilot project to provide reviewer comments to authors who submitted abstracts to the Hospital-based medicine topic area for the Pediatric Academic Societies (PAS) 2021 annual meeting METHODS: Abstract reviewers were encouraged via email to include reviewer comments for authors in their abstract reviews. Unedited comments were emailed to authors shortly after the abstract decision notifications were sent. We quantified the number of reviewers who commented per abstract. Additionally, we surveyed authors and reviewers to evaluate the perceived impact of the pilot project.For 123 abstracts submitted to the Hospital-based medicine topic area, every abstract received comments from at least one reviewer, and a median (IQR) of 4 (3-5) reviewers commented per abstract. The response rates for the author and reviewer surveys were 61/114 (54%) and 54/84 (64%), respectively, and both groups of respondents generally favored the pilot program. The majority of authors (59%) made changes to their project based on the feedback provided and 96% reported that they would like to continue to receive reviewer feedback for future PAS abstract submissions. Reviewers reported spending a mean of 11 minutes reviewing each abstract. Most (85%) felt that they spent the same or slightly more (1%-25%) time reviewing than in prior years. Multiple open-ended comments were provided, largely positive.A pilot program to incorporate reviewer feedback into abstract decision notification for a large national research meeting was successful. This approach should be considered for future meetings to enhance this integral component of academic development.

On April 7, 2020, Hospital Pediatrics published a case report describing an infant who was diagnosed with and treated for Kawasaki disease (KD) and also happened to test positive for severe acute respiratory syndrome coronavirus 2, the causative agent of coronavirus disease (COVID-19).1 Before this publication, we had been reading multiple reports of vascular and multisystem inflammatory involvement in adult patients with COVID-19. Although our journal does not traditionally publish case reports, we felt that this case could help spark awareness of a possible association and trigger further investigations in children. However, we were also cognizant that the COVID-19 positivity and the KD in the published case may have been “true, true and unrelated.” We also recognized (as did the article authors) that the association, if true, had few if any clinical implications for the case in question. Since then, attention over a possible association between COVID-19 and KD and other hyperinflammatory states has mounted. On April 26, an alert was sent to general practitioners in London advising them of rising numbers of cases of a multisystem inflammatory state in children with overlapping features of toxic shock syndrome (TSS) and atypical KD. These cases were subsequently described in a correspondence in the Lancet on May 7, 2020, in which researchers detailed 8 children with critical illness characterized by severe inflammation, although not all had confirmed COVID-19 infection or exposure.2 In Bergamo, Italy, KD was diagnosed in 20 children over a short period, roughly equivalent to the total number of cases that …

The role of the urinalysis (UA) in the management of young, febrile infants is controversial. To assess how frequently infants are treated for urinary tract infection (UTI) despite having normal UA values and to compare the characteristics of infants treated for UTI who have positive versus negative UAs, we reviewed 20,570 wellappearing febrile infants 7-60 days of age evaluated at 124 hospitals in the United States who were included in a national quality improvement project. Of 19,922 infants without bacteremia and meningitis, 2,407 (12.1%) were treated for UTI, of whom 2,298 (95.5%) had an initial UA performed. UAs were negative in 337/2,298 (14.7%) treated subjects. The proportion of infants treated for UTI with negative UAs ranged from 0%-35% across hospitals. UA-negative subjects were more likely to have respiratory symptoms and less likely to have abnormal inflammatory markers than UA+ subjects, indicating that they are mounting less of an inflammatory response to their underlying illness and/or might have contaminated specimens or asymptomatic bacteriuria.

IMPORTANCE: Appropriately established pediatric reference intervals are critical to the clinical decision-making process and should reflect the physiologic changes that occur during healthy child development. Reference intervals used in pediatric care today remain highly inconsistent across a broad range of common clinical biomarkers. OBSERVATIONS: This narrative review assesses biomarker-specific pediatric reference intervals and their clinical utility with respect to the underlying biological changes occurring during development. Pediatric reference intervals from PubMed-indexed articles published from January 2015 to April 2021, commercial laboratory websites, study cohorts, and pediatric reference interval books were all examined. Although large numbers of pediatric reference intervals are published for some biomarkers, very few are used by clinical and commercial laboratories. The patterns, extent, and timing of biomarker changes are highly variable, particularly during developmental stages with rapid physiologic changes. However, many pediatric reference intervals do not capture these changes and thus do not accurately reflect the underlying biochemistry of development, resulting in significant inconsistencies between reference intervals. CONCLUSIONS AND RELEVANCE: There is a need to correctly describe the biochemistry of child development as well as to identify strategies to develop accurate and consistent pediatric reference intervals for improved pediatric care.

BACKGROUND: Bronchiolitis is often described to follow an expected clinical trajectory, with a peak in severity between days 3 and 5. This predicted trajectory may influence anticipatory guidance and clinical decision-making. We aimed to determine the association between day of illness at admission and outcomes, including hospital length of stay, receipt of positive-pressure ventilation, and total cough duration. METHODS: We compiled data from 2 multicenter prospective studies involving bronchiolitis hospitalizations in patients RESULTS: The median (interquartile range) day of illness at admission for 746 patients was 4 (2–5) days. Day of illness at admission was not associated with length of stay (coefficient 0.01 days, 95% confidence interval [CI]: −0.05 to 0.08 days), positive-pressure ventilation (adjusted odds ratio: 1.0, 95% CI: 0.9 to 1.1), or total cough duration (coefficient 0.33 days, 95% CI: −0.01 to 0.67 days). Additionally, there was no significant difference in day of illness at discharge in readmitted versus nonreadmitted patients (5.9 vs 6.4 days, P = .54). The median cough duration postdischarge was 6 days, with 65 (14.3%) patients experiencing cough for 14+ days. CONCLUSIONS: We found no associations between day of illness at admission and outcomes in bronchiolitis hospitalizations. Practitioners should exercise caution when making clinical decisions or providing anticipatory guidance based on symptom duration.

Objective To determine the frequency and predictors of temperature measurement at well-child visits in the US and report rates of interventions associated with visits at which temperature is measured and fever is detected. Study design In this cross-sectional study, we analyzed 22 518 sampled well-child visits from the National Ambulatory Medical Care Survey between 2003 and 2015. We estimated the frequency of temperature measurement and performed multivariable regression to identify patient, provider/clinic, and seasonal factors associated with the practice. We described rates of interventions (complete blood count, radiograph, urinalysis, antibiotic prescription, and emergency department/hospital referral) by measurement and fever (temperature ≥100.4 °F, ≥38.0 °C) status. Results Temperature was measured in 48.5% (95% CI 45.6-51.4) of well-child visits. Measurement was more common during visits by nonpediatric providers (aOR 2.0, 95% CI 1.6-2.5; reference: pediatricians), in Hispanic (aOR 1.9, 95% CI 1.6-2.3) and Black (aOR 1.5, 95% CI 1.2-1.9; reference: non-Hispanic White) patients, and in patients with government (aOR 2.0, 95% CI 1.7-2.4; reference: private) insurance. Interventions were more commonly pursued when temperature was measured (aOR 1.3, 95% CI 1.1-1.6) and fever was detected (aOR 3.8, 95% CI 1.5-9.4). Conclusions Temperature was measured in nearly one-half of all well-child visits. Interventions were more common when temperature was measured and fever was detected. The value of routine temperature measurement during well-child visits warrants further evaluation.

BACKGROUND:Because of the impact of continuous pulse oximetry (CPOX) on the overdiagnosis of hypoxemia in bronchiolitis, the American Academy of Pediatrics and the Choosing Wisely campaign have issued recommendations for intermittent monitoring. Parental preferences for monitoring may impact adoption of these recommendations, but these perspectives are poorly understood.METHODS:Using this cross-sectional survey, we explored parental perspectives on CPOX monitoring before discharge and 1 week after bronchiolitis hospitalizations. During the 1-week call, half of the participants were randomly assigned to receive a verbal statement on the potential harms of CPOX to determine if conveying the concept of overdiagnosis can change parental preferences on monitoring frequency. An aggregate variable measuring favorable perceptions of CPOX was created to determine CPOX affinity predictors.RESULTS:In-hospital interviews were completed on 357 patients, of which 306 (86%) completed the 1-week follow-up. Although 25% of parents agreed or strongly agreed that hospital monitors made them feel anxious, 98% agreed that the monitors were helpful. Compared to other vital signs, respiratory rate (87%) and oxygen saturation (84%) were commonly rated as “extremely important.” Providing an educational statement on CPOX comparatively decreased parental desire for continuous monitoring (40% vs 20%; P < .001). Although there were no significant predictors of CPOX affinity, the effect size of the educational intervention was higher in college-educated parents.CONCLUSIONS:Parents find security in CPOX. A brief statement on the potential harms of CPOX use had an impact on stated monitoring preferences. Parental perspectives are important to consider because they may influence the adoption of intermittent monitoring.

This cross-sectional study examines the association between article citations, Altmetric attention scores, and cumulative page views of pediatric research articles from 4 high-impact medical journals.

Background A landmark 2015 trial on early exposure to peanuts led to expert recommendations for screening and early peanut introduction in high-risk (severe eczema and/or egg allergy) infants, but the impact of this paradigm shift on allergy testing and diagnosis is unknown. Objective We assessed the effects of the Learning Early About Peanut Allergy (LEAP) trial and guideline publications on allergy testing and food allergy diagnoses in infants. Methods In this retrospective cohort study, deidentified administrative health claims from a commercial and Medicare advantage claims database were used. Infants with at least 1 year of continuous coverage were selected using newborn codes for birth hospitalizations from January 2010 to June 2018. Interrupted time series models were used to compare the prevalence of allergy testing before and after LEAP publication in February 2015 and formal guideline publication in January 2017. Results For 487,533 included infants, allergy testing increased after LEAP (risk ratio [RR]: 1.11 [95% confidence interval (CI), 1.07-1.15]) and guidelines (1.21 [1.18-1.23]). This increase of testing was also seen in infants not considered high risk, both after LEAP (1.12 [1.08-1.17]) and guidelines (1.20 [1.16, 1.23]). For first-time allergy tests, post-guideline median number of allergens tested was 9 for serum tests and 10 for skin tests. Post-guidelines, there was a significant increase in diagnosis of peanut (RR: 1.08 [1.00, 1.16]), egg (1.12 [1.05, 1.20]), and other food allergies (excluding milk) (1.22 [1.14, 1.31]). Conclusion Allergy testing has increased, including in non–high-risk infants. Multiallergen testing may be contributing to an increase in the diagnosis of other food allergies.

Background Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs. Methods We conducted a multisite retrospective cohort study of children Results Of the 482 children included, 81% were female and the median age was 3.3 years (interquartile range: 0.8-8). Fifty-four children (11.2%) received long parenteral therapy (median duration: 7 days). Predictors of long parenteral therapy included age Conclusions Long parenteral therapy was associated with age

BACKGROUND: High costs of hospitalization may contribute to financial difficulties for some families. OBJECTIVE: To examine the prevalence of financial distress and medical financial burden in families of hospitalized children and identify factors that can predict financial difficulties. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of parents of hospitalized children at six children’s hospitals between October 2017 and November 2018. MAIN OUTCOMES AND MEASURES: The outcomes were high financial distress and medical financial burden. Multivariable logistic regression identified predictors of each outcome. The primary predictor variable was level of chronic disease (complex chronic disease, C-CD; noncomplex chronic disease, NC-CD; no chronic disease, no-CD). RESULTS: Of 644 invited participants, 526 (82%) were enrolled, with 125 (24%) experiencing high financial distress, and 160 (30%) reporting medical financial burden. Of those, 86 (54%) indicated their medical financial burden was caused by costs associated with their hospitalized child. Neither C-CD nor NC-CD were associated with high financial distress. Child-related medical financial burden was associated with both C-CD and NC-CD (adjusted odds ratio [AOR], 4.98; 95% CI, 2.41-10.29; and AOR, 2.57; 95% CI, 1.11-5.93), compared to no-CD. Although household poverty level was associated with both measures, financial difficulties occurred in all family income brackets. CONCLUSION: Financial difficulties are common in families of hospitalized children. Low-income families and those who have children with chronic conditions are at particular risk; however, financial difficulties affect all subsets of the pediatric population. Hospitalization may be a prime opportunity to identify and engage families at risk for financial distress and medical financial burden.

OBJECTIVES: To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics. METHODS: We performed a retrospective study of children RESULTS: Of the 316 children included, 78% were girls and the median age was 2.4 years (interquartile range 0.6–6.5). Children were evaluated in the emergency department (56%) or clinic (43%), and 90% were started on a cephalosporin. A total of 7 of 316 children (2.2%; 95% confidence interval 0.8%–4.5%) experienced escalation of care. For the 230 children (73%) with clinical response recorded, 192 of 230 (83.5%; 95% confidence interval 78.0%–88.0%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria improved or resolved in 16 of 19 (84%) and urine cultures sterilized in 11 of 17 (65%). CONCLUSIONS: Most children with third-generation cephalosporin-resistant UTIs started on discordant antibiotics experienced initial clinical improvement, and few required escalation of care. Our findings suggest that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results.

Key Points Question What are the prevalence and cost associated with a set of low-value services across US children's hospitals? Findings This cross-sectional study used an evidence-based low-value care calculator to estimate prevalence and cost of low-value services among 1 011 950 encounters across 49 children’s hospitals contributing to the Pediatric Health Information System database. The prevalence of low-value care ranged from less than 1% to 60% across measures, with nearly $17 million in standardized cost attributable to 30 measured low-value services. Meaning This study found that low-value care was costly, but prevalence varied widely across measured services; use of this calculator may aid in prioritization of deimplementation initiatives., Importance The scope of low-value care in children’s hospitals is poorly understood. Objective To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children’s hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures Eligible condition-specific hospital encounters. Main Outcomes and Measures The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery., This cross-sectional study uses a calculator of hospital-based pediatric low-value care to estimate the proportion and volume of low-value services and their associated standardized costs delivered in US children’s hospitals.

OBJECTIVES: Variability exists in the treatment of neonates with urinary tract infection (UTI), potentially reflecting an overuse of resources. A cross-sectional vignette survey was designed to examine variability in physician preferences for intravenous (IV) antibiotic duration, genitourinary imaging, and prophylactic antibiotics and to evaluate drivers of resource use. METHODS: The survey was administered to a random sample of pediatricians through the American Medical Association’s Physician Masterfile. Respondents were provided with a case vignette of a 2-week-old neonate with a febrile UTI and asked to indicate preferences for IV antibiotic duration and rank drivers of this decision. Respondents were also asked whether they would obtain a voiding cystourethrogram (VCUG) and, regardless of preference, randomly presented with a normal result or bilateral grade II vesicoureteral reflux. The survey was delivered electronically to facilitate skip logic and randomization. RESULTS: A total of 279 surveys were completed. Preference for total IV antibiotic duration differed significantly (P < .001) across specialty, with a median duration of 2 days for general pediatricians/hospitalists, 7 days for neonatologists, and 5 days for infectious disease pediatricians. For the 47% (n = 131) who did not want a VCUG, 24/61 (39%) wanted prophylactic antibiotics when presented with grade II vesicoureteral reflux (P < .001). CONCLUSIONS: Subspecialty status appeared to be the most influential driver of IV antibiotic duration in the treatment of UTI. A substantial proportion of pediatricians who initially expressed a preference against ordering a VCUG wished to prescribe prophylactic antibiotics when results were abnormal, which suggests that even unwanted diagnostic test results drive treatment decisions.

Key Points Question What are the preferences and experiences of parents regarding cost transparency in the care of their hospitalized child? Findings In this cross-sectional survey study of 526 parents of hospitalized children, 398 (76%) believed it was important to know the costs of their child’s care, and 397 (75%) wanted a hospital employee to discuss these costs. However, only 36 parents (7%) reported having a cost discussion during admission. Meaning These findings suggest that most families desire cost transparency in the care of their hospitalized child, but cost conversations rarely happen in the inpatient setting., This cross-sectional survey study of parents of hospitalized children quantifies parental preferences, experiences, and barriers concerning cost transparency in hospital care., Importance Health care in the US is often expensive for families; however, there is little transparency in the cost of medical services. The extent to which parents want cost transparency in their children’s care is not well characterized. Objective To explore the preferences and experiences of parents of hospitalized children regarding the discussion and consideration of health care costs in the inpatient care of their children. Design, Setting, and Participants This cross-sectional multicenter survey study included 6 geographically diverse university-affiliated US children’s hospitals from November 3, 2017, to November 8, 2018. Participants included a convenience sample of English- and Spanish-speaking parents of hospitalized children nearing hospital discharge. Data were analyzed from January 1, 2020, to June 25, 2021. Main Outcomes and Measures Parents’ preferences and experiences regarding transparency of their child’s health care costs. Multivariable linear regression examined associations between clinical and sociodemographic variables with parents’ preferences for knowing, discussing, and considering costs in the clinical setting. Factors included family financial difficulties, child’s level of chronic disease, insurance payer, deductible, family poverty level, race, ethnicity, parental educational level, and study site. Results Of 644 invited participants, 526 (82%) were enrolled (290 [55%] male), of whom 362 (69%) were White individuals, 400 (76%) were non-Hispanic/Latino individuals, and 274 (52%) had children with private insurance. Overall, 397 families (75%) wanted to discuss their child’s medical costs, but only 36 (7%) reported having a cost conversation. If cost discussions were to occur, 294 families (56%) would prefer to speak to a financial counselor. Ninety-eight families (19%) worried discussing costs would hurt the quality of their child’s care. Families with a medical financial burden unrelated to their hospitalized child had higher mean agreement that their child’s physician should consider the family’s costs in medical decision-making than families without a medical financial burden (effect size, 0.55 [95% CI, 0.18-0.92]). No variables were consistently associated with cost transparency preferences. Conclusions and Relevance Most parents want to discuss their child’s costs during an acute hospitalization. Discussions of health care costs may be an important, relatively unexplored component of family-centered care. However, these discussions rarely occur, indicating a tremendous opportunity to engage and support families in this issue.

Background Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown.Objective We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types.Methods Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014.Results We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches.Conclusions Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.

The advent of pulse oximetry as a widely adopted technology has transformed the overall clinical assessment of children with acute respiratory illness. One result of this transformation is a stronger clinical focus on treating hypoxemia in young children hospitalized with common respiratory illnesses, such as bronchiolitis, asthma, and pneumonia. For example, in acute viral bronchiolitis, international guidelines provide lower-limit oxygen saturation thresholds despite a weak evidence base and lack of consensus on the specific values. Nonetheless, advice to keep oxygen saturations above a precise threshold can be found in almost every bronchiolitis order set or hospital pathway. On the other hand, there has not been much debate about the opposite end of the spectrum: an upper saturation boundary once supplemental oxygen is administered for these common pediatric conditions. Pulse oximetry readings of 100% are not generally treated as abnormal, but they can represent a wide variety of Pao2 values and tissue oxygen delivery; thus, some readings of 100% while on supplemental oxygen will likely constitute tissue hyperoxia. Furthermore, nebulized therapies given in the hospital setting are typically driven by the flow of 100% oxygen from centralized supply lines, thus providing another source of exposure, which can be substantial for patients on continuously nebulized treatments. Nevertheless, there is a dearth of pediatric research on the scope of the exposure and the potential for harm from excess oxygen … Address correspondence to Shawn L. Ralston, MD, MS, Division of Quality and Safety, Johns Hopkins Children’s Center, 1800 N Orleans St, Baltimore, MD 21287. E-mail: sralsto3{at}jhmi.edu

BACKGROUND:Substantial variability exists in the care of febrile, well-appearing infants. We aimed to assess the impact of a national quality initiative on appropriate hospitalization and length of stay (LOS) in this population.METHODS:The initiative, entitled Reducing Variability in the Infant Sepsis Evaluation (REVISE), was designed to standardize care for well-appearing infants ages 7 to 60 days evaluated for fever without an obvious source. Twelve months of baseline and 12 months of implementation data were collected from emergency departments and inpatient units. Ill-appearing infants and those with comorbid conditions were excluded. Participating sites received change tools, run charts, a mobile application, live webinars, coaching, and a LISTSERV. Analyses were performed via statistical process control charts and interrupted time series regression. The 2 outcome measures were the percentage of hospitalized infants who were evaluated and hospitalized appropriately and the percentage of hospitalized infants who were discharged with an appropriate LOS.RESULTS:In total, 124 hospitals from 38 states provided data on 20 570 infants. The median site improvement in percentages of infants who were evaluated and hospitalized appropriately and in those with appropriate LOS was 5.3% (interquartile range = −2.5% to 13.7%) and 15.5% (interquartile range = 2.9 to 31.3), respectively. Special cause variation toward the target was identified for both measures. There was no change in delayed treatment or missed bacterial infections (slope difference 0.1; 95% confidence interval, −8.3 to 9.1).CONCLUSIONS:Reducing Variability in the Infant Sepsis Evaluation noted improvement in key aspects of febrile infant management. Similar projects may be used to improve care in other clinical conditions.

BACKGROUND AND OBJECTIVES:To determine factors associated with cerebrospinal fluid (CSF) testing in febrile young infants with a positive urinalysis and assess the probability of delayed diagnosis of bacterial meningitis in infants treated for urinary tract infection (UTI) without CSF testing.METHODS:We performed a retrospective cohort study using data from the Reducing Excessive Variability in Infant Sepsis Evaluation quality improvement project. A total of 20 570 well-appearing febrile infants 7 to 60 days old presenting to 124 hospitals from 2015 to 2017 were included. A mixed-effects logistic regression was conducted to determine factors associated with CSF testing. Delayed meningitis was defined as a new diagnosis of bacterial meningitis within 7 days of discharge.RESULTS:Overall, 3572 infants had a positive urinalysis; 2511 (70.3%) underwent CSF testing. There was wide variation by site, with CSF testing rates ranging from 64% to 100% for infants 7 to 30 days old and 10% to 100% for infants 31 to 60 days old. Factors associated with CSF testing included: age 7 to 30 days (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 3.8–5.5), abnormal inflammatory markers (aOR: 2.2; 95% CI: 1.8–2.5), and site volume >300 febrile infants per year (aOR: 1.8; 95% CI: 1.2–2.6). Among 505 infants treated for UTI without CSF testing, there were 0 (95% CI: 0%–0.6%) cases of delayed meningitis.CONCLUSIONS:There was wide variation in CSF testing in febrile infants with a positive urinalysis. Among infants treated for UTI without CSF testing (mostly 31 to 60-day-old infants), there were no cases of delayed meningitis within 7 days of discharge, suggesting that routine CSF testing of infants 31 to 60 days old with a positive urinalysis may not be necessary.

Triage of patients to the PICU or general ward has important quality and cost implications. Mistriaging a patient to the general ward may cause delays in needed care, with the potential for increased morbidity and mortality.1,2 However, mistriage of patients who do not require critical care interventions to a PICU also has consequences, including increased health care costs for the family; use of limited PICU beds, nurses, and physicians; and heightened familial stress.3–5 Additionally, there may be different expectations for testing and treatment in the ICU environment compared with the acute care ward, even for similar cases, resulting in unneeded tests and treatments.6,7 In this month’s issue of Hospital Pediatrics , Nadeau et al8 describe characteristics and outcomes of a cohort of pediatric patients triaged to the general ward who were subsequently transferred to the PICU within 24 hours of admission (early PICU transfers) between 2007 and 2016. The authors found that 841 of 82 397 (1%) general ward admissions required early PICU transfers. The median time to PICU transfer was 9.1 hours, with an interquartile range of 5.1 to 14.9 hours, meaning that only a small proportion of transfers occurred within the first few hours after admission. A majority of transfers (65%) were due to respiratory deterioration. Of the 841 subjects transferred, …

OBJECTIVES To explore parent attitudes toward discussing their child’s health care costs in the inpatient setting and to identify strategies for health care providers to engage in cost discussions with parents. METHODS: Using purposeful sampling, we conducted semistructured interviews between October 2017 and February 2018 with parents of children with and without chronic disease who received care at a tertiary academic children’s hospital. Researchers coded the data using applied thematic analysis to identify salient themes and organized them into a conceptual model. RESULTS: We interviewed 42 parents and identified 2 major domains. Categories in the first domain related to factors that influence the parent’s desire to discuss health care costs in the inpatient setting, including responsibility for out-of-pocket expenses, understanding their child’s insurance coverage, parent responses to financial stress, and their child’s severity of illness on hospital presentation. Categories in the second domain related to parent preference regarding the execution of cost discussions. Parents felt these discussions should be optional and individualized to meet the unique values and preferences of families. They highlighted concerns regarding physician involvement in these discussions; their preference instead was to explore financial issues with a financial counselor or social worker. CONCLUSIONS: Parents recommended that cost discussions in the inpatient setting should be optional and based on the needs of the family. Families expressed a desire for physicians to introduce rather than conduct cost discussions. Specific recommendations from parents for these discussions may be used to inform the initiation and improvement of cost discussions with families during inpatient encounters.

Underuse and overuse of medical interventions, failure to use interventions known to be effective, and provision of tests or interventions in which benefits do not exceed harms are types of low-value care. The Lown Institute's Right Care Alliance Children's Health Council identified five "do" recommendations that highlight underuse and five "don't" recommendations that highlight overuse in children's health care. The five "do" recommendations include: do provide access to long-acting reversible contraception for adolescents, do use nonpharmacologic interventions first for treatment of attention-deficit/hyperactivity disorder, do discuss quality of life for children with complex medical conditions using a shared decision-making model and access resources such as palliative care subspecialists, do promote childhood literacy development by providing free, age-appropriate books in clinical settings, and do screen for socioeconomic status of the patient and family and provide access to community health and wellness resources. The five "don't" recommendations include: don't routinely prescribe antibiotics in children two to 12 years of age with a middle ear infection, don't perform computed tomography of the head for children with minor head trauma, don't use albuterol in children with bronchiolitis, don't routinely screen for hyperlipidemia in children and adolescents, and don't routinely perform preparticipation sports evaluations. These 10 examples of underuse and overuse were identified with the intent of improving health care value and promoting "Right Care."

Importance Efforts to combat medical overuse have gained traction in recent years, but success has been intermittent and shortcomings have been recognized. A commitment to a strong evidence base is needed to more broadly engage clinicians and reduce overuse. Observations A structured MEDLINE search and a manual review of tables of contents from selected high-impact journals was performed to identify original research published in 2017 relevant to pediatric overuse. Articles were scored from low to high for 3 categories: quality of methods, magnitude of potential harm, and number of patients potentially harmed. The top-scoring articles presented in this review highlight examples of safe reductions in treatment intensity, including in the setting of cancer, appendicitis, acute respiratory tract infection, and elective anesthesia. This year’s articles also provide cautionary examples of rational interventions adopted without a full understanding of potential harms, including pharmacologic migraine therapies, docosahexaenoic acid supplementation for preterm neonates, tight glycemic control for individuals with critically illness, and prophylactic antibiotics for children with vesicoureteral reflux. Conclusions and Relevance The articles represent high-quality, original research from 2017 that may help mitigate overuse. These works should be fundamental to the maturation of the pediatric overuse field.

Importance Posthospitalization follow-up visits are prescribed frequently for children with bronchiolitis. The rationale for this practice is unclear, but prior work has indicated that families value these visits for the reassurance provided. The overall risks and benefits of scheduled visits have not been evaluated. Objective To assess whether an as-needed posthospitalization follow-up visit is noninferior to a scheduled posthospitalization follow-up visit with respect to reducing anxiety among parents of children hospitalized for bronchiolitis. Design, Setting, and Participants This open-label, noninferiority randomized clinical trial, performed between January 1, 2018, and April 31, 2019, assessed children younger than 24 months of age hospitalized for bronchiolitis at 2 children’s hospitals (Primary Children’s Hospital, Salt Lake City, Utah, and Lucile Packard Children’s Hospital, Palo Alto, California) and 2 community hospitals (Intermountain Riverton Hospital, Riverton, Utah, and Packard El Camino Hospital, Mountain View, California). Data analysis was performed in an intention-to-treat manner. Interventions Randomization (1:1) to a scheduled (n = 151) vs an as-needed (n = 153) posthospitalization follow-up visit. Main Outcome and Measures The primary outcome was parental anxiety 7 days after hospital discharge, measured using the anxiety portion of the Hospital Anxiety and Depression Scale, which ranged from 0 to 28 points, with higher scores indicating greater anxiety. Fourteen prespecified secondary outcomes were assessed. Results Among 304 children randomized (median age, 8 months; interquartile range, 3-14 months; 179 [59%] male), the primary outcome was available for 269 patients (88%). A total of 106 children (81%) in the scheduled follow-up group attended a scheduled posthospitalization visit compared with 26 children (19%) in the as-needed group (absolute difference, 62%; 95% CI, 53%-71%). The mean (SD) 7-day parental anxiety score was 3.9 (3.5) among the as-needed posthospitalization follow-up group and 4.2 (3.5) among the scheduled group (absolute difference, −0.3 points; 95% CI, −1.0 to 0.4 points), with the upper bound of the 95% CI within the prespecified noninferiority margin of 1.1 points. Aside from a decreased mean number of clinic visits (absolute difference, −0.6 visits per patient; 95% CI, −0.4 to −0.8 visits per patient) among the as-needed group, there were no significant between-group differences in secondary outcomes, including readmissions (any hospital readmission before symptom resolution: absolute difference, −1.6%; 95% CI, −5.7% to 2.5%) and symptom duration (time from discharge to cough resolution: absolute difference, −0.6 days; 95% CI, −2.4 to 1.2 days; time from discharge to child reported “back to normal”: absolute difference, −0.8 days; 95% CI, −2.7 to 1.0 days; and time from discharge to symptom resolution: absolute difference, −0.6 days; 95% CI, −2.5 to 1.3 days). Conclusions and Relevance Among parents of children hospitalized for bronchiolitis, an as-needed posthospitalization follow-up visit is noninferior to a scheduled posthospitalization follow-up visit with respect to reducing parental anxiety. These findings support as-needed follow-up as an effective posthospitalization follow-up strategy. Trial Registration ClinicalTrials.gov Identifier:NCT03354325

Importance Medical overuse is common in pediatrics and may lead to unnecessary care, resource use, and patient harm. Timely scrutiny of established and emerging practices can identify areas of overuse and empower clinicians to reconsider the balance of harms and benefits of the medical care that they provide. A literature review was conducted to identify the most important areas of pediatric medical overuse in 2018. Observations Consistent with prior methods, a structured MEDLINE search and manual table of contents review of selected pediatric journals for the 2018 literature was conducted identifying articles pertaining to pediatric medical overuse. The structured MEDLINE search consisted of a PubMed search for articles with the Medical Subject Headings termhealth services misuseormedical overuseor article titles containing the termunnecessary,inappropriate,overutilization, oroveruse. Articles containing the termoveruse injuryoroveruse injurieswere excluded, along with articles not published in English and those not constituting original research. The same search was performed using Embase with the additional Emtree termunnecessary procedure. Each article was evaluated by 3 independent raters for quality of methods, magnitude of potential harm, and number of patients potentially harmed. Ten articles were identified based on scores and appraisal of overall potential harm. This year’s review identified both established and emerging practices that may warrant deimplementation. Examples of such established practices include antibiotic prophylaxis for urinary tract infections, routine opioid prescriptions, prolonged antibiotic courses for latent tuberculosis, and routine intensive care admission and pharmacologic therapy for neonatal abstinence syndrome. Emerging practices that merit greater inspection and discouragement of widespread adoption include postdischarge nurse-led home visits, probiotics for gastroenteritis, and intensive cardiac screening programs for athletes. Conclusions and Relevance This year’s review highlights established and emerging practices that represent medical overuse in the pediatric setting. Deimplementation of disproven practices and careful examination of emerging practices are imperative to prevent unnecessary resource use and patient harm.

Importance Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults. Objective To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population. Design, Setting, and Participants This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category. Exposures Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving the prescription, and had 12 months of health plan coverage after receiving the prescription. Two age- and sex-matched opioid-nonexposed control individuals were selected for each opioid-exposed individual and were assigned a corresponding phantom prescription date. Main Outcomes and Measures Receipt of an opioid prescription within 90 to 365 days, a health care encounter diagnosis associated with opioid abuse within 365 days, and all-cause mortality within 365 days of the index opioid or phantom prescription date. Results Among 754 002 individuals with continuous enrollment in 2015, 97 462 patients (12.9%) received 1 or more opioid prescriptions, of whom 29 791 (30.6%) received prescriptions supplied by a dental clinician. The opioid-exposed cohort included 14 888 participants (7882 women [52.9%], 11 273 white [75.7%], with mean [SD] age, 21.8 [2.4] years), and the randomly selected opioid-nonexposed cohort included 29 776 participants (15 764 women [52.9%], 20 078 [67.4%] white, with mean [SD] age, 21.8 [2.4] years). Among the 14 888 individuals in the index dental opioid cohort, 1021 (6.9%) received another opioid prescription 90 to 365 days later compared with 30 of 29 776 (0.1%) opioid-nonexposed controls (adjusted absolute risk difference, 6.8%; 95% CI, 6.3%-7.2%), and 866 opioid-exposed individuals (5.8%) experienced 1 or more subsequent health care encounters with an opioid abuse–related diagnosis compared with 115 opioid-nonexposed controls (0.4%) (adjusted absolute risk difference, 5.3%; 95% CI, 5.0%-5.7%). There was only 1 death in each cohort. Conclusions and Relevance The findings suggest that a substantial proportion of adolescents and young adults are exposed to opioids through dental clinicians. Use of these prescriptions may be associated with an increased risk of subsequent opioid use and abuse.