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OBJECTIVES Racemic epinephrine (RE) is commonly administered for croup in the emergency department (ED). Our objectives were to examine variation in RE use between EDs, to determine whether ED variation in RE use is associated with hospital or patient factors, and to evaluate the associations between the rates of hospital-specific ED RE use and patient outcomes. METHODS We performed a retrospective cohort study using the Pediatric Heath Information System of children aged 3 months to 10 years with croup in the ED. We used mixed-effects regression to calculate risk-standardized proportions of patients receiving RE in each ED and to analyze the relationship between risk-standardized institutional RE use and individual patient odds of hospital admission, ICU admission, and ED revisits. RESULTS We analyzed 231 683 patient visits from 39 hospitals. ED administration of RE varied from 14% to 48% of visits (median, 24.5%; interquartile range, 20.0%–27.8%). A total of 8.6% of patients were hospitalized and 1% were admitted to the ICU. After standardizing for case mix and site effects, increasing ED use of RE per site was associated with increasing patient odds of hospital admission (odds ratio [OR], 1.39–95%; confidence interval [CI], 1.01–1.91), but not ICU admission (OR, 1.39; 95% CI, 0.99–1.97) or ED revisit (OR, 1.00; 95% CI, 0.92–1.09). CONCLUSIONS In this large, observational study, RE administration varied widely across EDs. Increased RE use by site was associated with increased odds of hospital admission for individual patients when controlling for patient factors. These results suggest further standardization of RE use in children with croup is warranted.

BACKGROUNDEmergency department (ED) presentation for croup is thought to occur more often at night, but evidence for its diurnal variation is sparse. Our objectives were to describe the diurnal patterns of ED presentation in children with croup and to determine whether time of arrival associated with severe clinical outcomes.METHODSWe conducted a retrospective cohort study using the Pediatric Health Information System. We included children 3 months to 11 years of age with an ED encounter for croup from 2016 through 2020. We quantified ED encounters by arrival hour and used generalized linear mixed-effects models to determine association between arrival time and racemic epinephrine use, hospitalization, intensive care unit (ICU) admission, and revisits.RESULTSThere was considerable diurnal variation in ED visits for croup. A total of 126 186 children (60.1%) presented to the ED at night (between 8 pm and 8 am), and 83 763 children presented during the day (39.9%). Peak arrival time was 12:00 am (14 189 encounters) and the nadir was at 2:00 pm (5231 encounters). Children presenting during overnight hours had increased odds of the use of racemic epinephrine (odds ratio [OR] 1.33; 95% confidence interval [95% CI], 1.30-1.36), but reduced odds of hospitalization (OR 0.76; 95% CI, 0.73-0.78), ICU admission (OR 0.61; 95% CI, 0.58-0.68), and 3 day ED revisits (OR 0.86; 95% CI, 0.83-0.90).CONCLUSIONSChildren with croup present to the ED more commonly at night. Children presenting to the ED with croup at night have greater odds of being treated with racemic epinephrine, but reduced odds of hospitalization, ICU admission, and return visits.

To quantify the risk of malignancy following the emergency department (ED) diagnosis of Bell's Palsy (BP) using a large retrospective cohort.We performed a cohort study using the Pediatric Health Information System database. We included all children (6 months - 17 years) from 2011 to 2020 with an ED diagnosis of BP. We excluded children with previous neurologic chronic condition or malignancy diagnosed during or prior to the index visit. Our primary outcome was diagnosis of malignancy within 60 days following the index ED visit. We compared clinical characteristics between children with and without new-onset malignancy.Of 12,272 encounters for BP, 41 had a new oncologic diagnosis within 60 days (0.33%, 95% confidence interval [CI]: 0.25-0.45%). Median time to oncologic diagnosis was 22 days. Primary CNS malignancy (59%) and leukemia (17.1%) were the most common diagnoses. Younger children had a higher incidence of new oncologic diagnosis compared with older children. Incidences were 0.68% (95% CI 0.36-1.3%), 0.70% (95% CI 0.38-1.3%), 0.26% (95% CI 0.15-0.47%), and 0.21% (95% CI 0.12-0.37%) for children aged2 years, 2-5 years, 6-11 years, and 12-17 years respectively.We found a small but potentially clinically significant rate of new-onset oncologic diagnosis within 60 days after BP diagnosis in the ED, especially in children younger than 5 years. Further studies of the diagnostic utility of laboratory testing or neuroimaging and the risk of empiric steroids in children with BP are needed.

Transient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS.We performed a cohort study using the Pediatric Heath Information System of children 1-10 years diagnosed with TS in the ED. We determined rates of missed bacterial musculoskeletal infection (defined as a new diagnosis of septic arthritis, osteomyelitis, or pyomyositis within 14 days of initial ED visit). We described the initial diagnostic evaluation and ED management of children diagnosed with TS and variability between sites.We analyzed 6419 encounters from 37 hospitals. 62 (1.0%, 95%CI: 0.7-1.2%) children were diagnosed with a missed bacterial musculoskeletal infection. Children with missed infection were younger than those without (median age 2.6 vs. 4.6 years, p0.01). Serum laboratory testing was performed in 76% of encounters with minimal variation across sites. There was significant variation in the rates of hip ultrasound by site (2 to 92%), which has increased in use over time (from 42% in 2016 to 62% in 2021).In this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear.

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 …

Objectives Chest radiographs (CXRs) are often performed in children with respiratory illness to inform the decision to prescribe antibiotics. Our objective was to determine the factors associated with clinicians' plans to treat with antibiotics prior to knowledge of CXR results and the associations between preradiograph plans with antibiotic prescription and return to medical care. Methods Previously healthy children aged 3 months to 18 years with a CXR for suspected pneumonia were enrolled in a prospective cohort study in the emergency department. Our primary outcomes were antibiotic prescription or administration in the emergency department and medical care sought within 7 to 15 days after discharge. Inverse probability treatment weighting was used to limit bias due to treatment selection. Inverse probability treatment weighting was included in a logistic regression model estimating the association between the intention to give antibiotics and outcomes. Results Providers planned to prescribe antibiotics prior to CXR in 68 children (34.9%). There was no difference in the presence of radiographic pneumonia between those with and without a plan for antibiotics. Children who had a plan for antibiotics were more likely to receive antibiotics than those without (odds ratio [OR], 6.39; 95% confidence interval [CI], 3.7-11.0). This association was stronger than the association between radiographic pneumonia and antibiotic receipt (OR, 3.49; 95% CI, 1.98-6.14). Children prescribed antibiotics were more likely to seek care after discharge than children who were not (OR, 1.85; 95% CI, 1.13-3.05). Conclusions Intention to prescribe antibiotics based on clinical impression was the strongest predictor of antibiotic prescription in our study. Prescribing antibiotics may lead to subsequent medical care after controlling for radiographic pneumonia.

Supplemental Digital Content is available in the text., Introduction: Constipation is a common problem in pediatric patients. Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department 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 pediatric emergency department and urgent care in patients ages 6 months to 21 years and decrease AXR use by 20% and sustain this reduction for 12 months. Methods: This prospective QI project involved a multidisciplinary team at a large urban pediatric tertiary care center. The study team constructed a key driver diagram and identified interventions, such as creating a standardized evaluation and management algorithm for constipation, using free open-access medical education platforms, incorporating the electronic medical record interface, and expanding educational conferences to include standardized approach and discharge instructions for patients with constipation across all acuity levels. The primary measure of AXR utilization was tracked overtime on a statistical process control chart to evaluate the impact of interventions. Results: The percentage of visits for constipation that included an AXR decreased from a baseline of 49.6%–37.1%, a 25% reduction. Length-of-stay, return visits within 7 days, and inpatient admissions remained unchanged by the interventions. Conclusions: QI methodology successfully decreased AXR utilization in the evaluation of constipation across a broad spectrum of acuity levels. Further interventions may help to decrease the length of stay and further decrease AXR utilization.

OBJECTIVES: Use of high-flow nasal cannula (HFNC) for bronchiolitis has increased, but data describing the current use and impact of this therapy are limited. Our objective with this study was to describe the use of HFNC for bronchiolitis in a pediatric emergency department (ED) from 2013 to 2019 and to explore associations with clinical outcomes. METHODS: This was a retrospective cohort study of children aged 2 to 24 months with the diagnosis of bronchiolitis. The primary outcome was HFNC initiation in the ED. Secondary outcomes included admission rate, ICU (PICU) admission, transfer to PICU from floor, and endotracheal intubation. An adjusted interrupted times series analysis was performed to analyze changes in rates of primary and secondary outcomes over time. RESULTS: In total 11 149 children met inclusion criteria; 902 (8.1%) were initiated on HFNC. The rate of HFNC initiation increased from 1.3% in 2012–2013 to 17.0% in 2018–2019 (Ptrend ≤ .001). Less than 30% of children initiated on HFNC were hypoxic. There were no significant changes over time in rates of hospital admission, PICU admission, or PICU transfer, adjusting for clinical severity, seasonality, and provider variation. Intubation rate increased over the study period. CONCLUSIONS: We found a 13-fold increase in HFNC use over a 6-year period with no evidence of improvement in clinically meaningful outcomes. Clinical benefit should be clearly defined before further expansion of the use of HFNC for bronchiolitis in the ED.

* 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.

BACKGROUND AND OBJECTIVES: Antibiotic therapy is often prescribed for suspected community-acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our objective in this study was to investigate the association between antibiotic prescription and treatment failure in children with suspected CAP who are discharged from the hospital emergency department (ED). METHODS: We performed a prospective cohort study of children (ages 3 months–18 years) who were discharged from the ED with suspected CAP. The primary exposure was antibiotic receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic change within 7–15 days from the ED visit). The secondary outcomes included parent-reported quality-of-life measures. Propensity score matching was used to limit potential bias attributable to treatment selection between children who did and did not receive an antibiotic prescription. RESULTS: Of 337 eligible children, 294 were matched on the basis of propensity score. There was no statistical difference in treatment failure between children who received antibiotics and those who did not (odds ratio 1.0; 95% confidence interval 0.45–2.2). There was no difference in the proportion of children with return visits with hospitalization (3.4% with antibiotics versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-reported quality-of-life measures. CONCLUSIONS: Among children with suspected CAP, the outcomes were not statistically different between those who did and did not receive an antibiotic prescription.

Vomiting is a common pediatric complaint seen frequently in both pediatric and general emergency departments. Obstructive causes of vomiting are rare outside of the newborn period compared to more benign causes such as viral gastroenteritis. Timely recognition of these rarer causes of obstruction is essential for optimal care. This case highlights a severe presentation of chronic isolated vomiting caused by obstruction. It serves as a strong reminder to emergency care providers that obstruction can occur outside of the newborn period and, if unrecognized, can result in significant morbidity.

OBJECTIVES: Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS: We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children’s Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS: By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS: Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.

Diabetic neuropathy is the most common complication of diabetes mellitus, and there are currently no effective treatments for this condition. In this Review, Leinninger et al. discuss the proposed role of mitochondrial degeneration in the pathogenesis of diabetic neuropathy, and highlight potential mitochondrial sites for therapeutic intervention. Diabetic neuropathy (DN) is the most common complication of diabetes mellitus, and it imposes a considerable burden on a patient's quality of life and the health-care system. Despite the prevalence and severity of DN, there are no effective treatments. Pathogenetic evidence suggests that DN is marked by degeneration of dorsal root ganglion (DRG) neurons in peripheral nerves, and that DRG mitochondria are particularly affected. DRG mitochondria are especially vulnerable because they are the origin of reactive oxygen species production in the hyperglycemic neuron. Accumulating evidence indicates that neuronal mitochondria are subject to damage at the level of their DNA, and their outer and inner membranes, and also via deregulation of mitochondrial fission and fusion proteins that control mitochondrial shape and number. This Review will survey the mechanisms of mitochondrial degeneration in the pathogenesis of DN, highlighting potential mitochondrial sites for therapeutic intervention.