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Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking., Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations., Design, Setting, and Participants: In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks., Outcome: Consensus agenda of research priorities to identify and address health care disparities in PEC., Results: PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation., Conclusions and Relevance: These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

Importance: Acute bronchiolitis is the most frequent lower respiratory tract infection in infants, yet there are no effective therapies available. Current evidence is unclear about the role of hypertonic saline (HS) for the acute treatment of bronchiolitis., Objective: To determine whether nebulized 3% HS compared with normal saline (NS) improves respiratory distress in infants with bronchiolitis not responding to standard treatments in the emergency department., Design, Setting, and Participants: A randomized clinical trial with blinding of investigators, health care providers, and parents was conducted at a single urban pediatric ED. The participants included children aged 2 to less than 24 months with their first episode of bronchiolitis and a Respiratory Distress Assessment Instrument score of 4 to 15 after nasal suctioning and a trial of nebulized albuterol., Interventions: Patients were randomized to receive either nebulized 3% HS (HS group) or NS (NS group)., Main Outcomes and Measures: The primary outcome was change in respiratory distress at 1 hour after the intervention, as measured by the Respiratory Assessment Change Score (a decrease indicates improvement). Secondary outcomes included vital signs, oxygen saturation, hospitalization, physician clinical impression, parental assessment, and adverse events., Results: The 31 patients enrolled in each treatment arm had similar baseline demographic and clinical characteristics. At 1 hour after the intervention, the HS group demonstrated significantly less improvement in the median Respiratory Assessment Change Score compared with the NS group (HS, -1 [interquartile range, -5 to 1] vs. NS, -5 [interquartile range, -6 to -2]; P = .01). There were no significant differences in heart rate, oxygen saturation, hospitalization rate, or other outcomes. There were no adverse events., Conclusions and Relevance: Infants with bronchiolitis and persistent respiratory distress after standard treatment in the emergency department had less improvement after receiving 3% HS compared with those who received NS. Based on these results and the existing evidence, administration of a single dose of 3% HS does not appear to be indicated to treat bronchiolitis in the acute care setting., Trial Registration: clinicaltrials.gov Identifier: NCT01247064.

Objective: To develop a clinical prediction rule to identify febrile young girls needing urine culture for evaluation of urinary tract infection (UTI)., Design: Prospective cohort study., Setting: Urban children's hospital emergency department., Patients: All girls younger than 2 years (N = 1469) presenting to the emergency department with fever (temperature > or =38.3 degrees C) and without an unequivocal source of fever during a 12-month period., Main Outcome Measures: The outcome of interest was UTI, defined as a catheterized urine culture with pure growth of 10(4) colonies/mL or greater. Candidate predictors included demographic, historical, and physical examination variables. Clinical prediction rules were developed using multiple logistic regression after screening variables for univariate association and reliability., Results: The presence of 2 or more of the following 5 variables-less than 12 months old, white race, temperature of 39.0 degrees C or higher, fever for 2 days or more, and absence of another source of fever on examination-predicted UTI with a sensitivity of 0.95 (95% confidence interval, 0.85-0.99) and a specificity of 0.31 (95% confidence interval, 0.28-0.34). In the study population, with an overall prevalence of UTI of 4.3%, the positive predictive value of a score of 2 or more was 6.4% and the negative predictive value of a score of less than 2 was 0.8%., Conclusion: Using this clinical decision rule, a strategy of obtaining urine cultures from girls younger than 2 years with a score of 2 or more would lead to identification of 95% of children with UTI and elimination of 30% of unnecessary urine cultures.

Objective: To determine if trauma center protocols affect the number of tests and consultations performed and the length of time spent in the emergency department or hospital., Design: A retrospective review and comparison of treatment for children with isolated head injury admitted to the emergency department before trauma center designation (group 1, 1985), and 5 years after implementation of trauma center protocols (group 2, 1991)., Setting: Urban children's hospital, level I trauma center., Results: One hundred sixty-five children met the enrollment criteria in 1985 and 162 met the criteria in 1991. Falls were the predominant mechanism of injury (55%) for both years. For patients with moderate injury (Glasgow Coma Scale score, 9-12) or severe injury (Glasgow Coma Scale score, <9), there was no difference in radiographic or laboratory evaluation. For patients with minimal head injury (Glasgow Coma Scale score, 15, no loss of consciousness, amnesia, seizure, focal neurologic findings, or persistent symptoms) and minor head injury (Glasgow Coma Scale score, >12, and loss of consciousness or amnesia), more radiologic and laboratory studies were done in 1991 that showed no clinically significant abnormalities. Patients with minimal head injury in group 2 were 14 times more likely to have cranial computed tomographic scans performed (95% confidence interval [CI], 3.4-67); 11 times more likely to have cervical spine radiographs (95% CI, 2.2-76.6); and 23 times more likely to have hepatic enzymes obtained (95% CI, 3-491). These differences persisted when analyzed by both the age of the patient and mechanism of injury., Conclusions: Application of trauma system protocols to isolated head injury patient evaluation results in increased use of laboratory and radiologic services. These practices have the potential to increase the cost of medical care without significantly improving outcome.

Two hundred thirteen infants younger than 13 months with bronchiolitis were prospectively followed up to identify the historical, physical, and laboratory clues at initial emergency department evaluation that would help to predict disease severity. Based on their total course of illness, the patients were classified as having mild (139 patients) or severe (74 patients) disease, and the initial emergency department evaluation findings of these two groups were compared. Six independent clinical and laboratory findings were identified that were strongly associated with more severe illness: (1) "ill" or "toxic" general appearance; (2) oxygen saturation less than 95%, as determined by pulse oximetry; (3) gestational age, younger than 34 weeks; (4) respiratory rate, 70/min or greater; (5) atelectasis on a chest roentgenogram; and (6) age, younger than 3 months. The infant's oxygen saturation as determined by pulse oximetry was the single best objective predictor of more severe disease.