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PURPOSE: Several studies have suggested an association between maternal smoking during pregnancy and both attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) in the offspring of women who smoke during pregnancy. However, it is unclear whether one or both of the documented links are spurious, given the considerable comorbidity between these disorders. The main aim of this study was to disentangle the association between maternal smoking during pregnancy with psychopathological outcomes, adjusting for possible confounders. METHODS: Two large, identically designed, longitudinal, case-control family studies of male and female probands with and without ADHD were combined. We used data from the nonreferred siblings of the probands from both studies (n = 536). All subjects were blindly assessed with structured diagnostic interviews. Logistic regression analysis was used to determine the adjusted effect of exposure to maternal smoking during pregnancy. RESULTS: Among all siblings, maternal smoking during pregnancy was significantly associated with ADHD, independent of CD and other covariates. In contrast, maternal smoking during pregnancy was a risk factor for CD only in siblings of control probands, after adjusting for covariates. CONCLUSIONS: These results support the hypothesis that maternal smoking during pregnancy is a risk factor for both ADHD and CD, independently of each other. However, the risk for CD appears to be conditional on family risk status. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) co-occur frequently and represent a particularly morbid clinical form of both disorders, neuroimaging research addressing this co-morbidity is scarce. Our aim was to evaluate the morphometric magnetic resonance imaging (MRI) underpinnings of the co-morbidity of ADHD with BPD, testing the hypothesis that subjects with this co-morbidity would have neuroanatomical correlates of both disorders.MethodMorphometric MRI findings were compared between 31 adults with ADHD and BPD and with those of 18 with BPD, 26 with ADHD, and 23 healthy controls. The volumes (cm3) of our regions of interest (ROIs) were estimated as a function of ADHD status, BPD status, age, sex, and omnibus brain volume using linear regression models. RESULTS: When BPD was associated with a significantly smaller orbital prefrontal cortex and larger right thalamus, this pattern was found in co-morbid subjects with ADHD plus BPD. Likewise, when ADHD was associated with significantly less neocortical gray matter, less overall frontal lobe and superior prefrontal cortex volumes, a smaller right anterior cingulate cortex and less cerebellar gray matter, so did co-morbid ADHD plus BPD subjects. CONCLUSIONS: Our results support the hypothesis that ADHD and BPD independently contribute to volumetric alterations of selective and distinct brain structures. In the co-morbid state of ADHD plus BPD, the profile of brain volumetric abnormalities consists of structures that are altered in both disorders individually. Attention to co-morbidity is necessary to help clarify the heterogeneous neuroanatomy of both BPD and ADHD. [ABSTRACT FROM AUTHOR]

BACKGROUND: A better understanding of the long-term scope and impact of the co-morbidity with oppositional defiant disorder (ODD) and conduct disorder (CD) in attention deficit hyperactivity disorder (ADHD) youth has important clinical and public health implications.MethodSubjects were assessed blindly at baseline (mean age=10.7 years), 1-year (mean age=11.9 years), 4-year (mean age=14.7 years) and 10-year follow-up (mean age=21.7 years). The subjects' lifetime diagnostic status of ADHD, ODD and CD by the 4-year follow-up were used to define four groups (Controls, ADHD, ADHD plus ODD, and ADHD plus ODD and CD). Diagnostic outcomes at the 10-year follow-up were considered positive if full criteria were met any time after the 4-year assessment (interval diagnosis). Outcomes were examined using a Kaplan-Meier survival function (persistence of ODD), logistic regression (for binary outcomes) and negative binomial regression (for count outcomes) controlling for age. RESULTS: ODD persisted in a substantial minority of subjects at the 10-year follow-up. Independent of co-morbid CD, ODD was associated with major depression in the interval between the 4-year and the 10-year follow-up. Although ODD significantly increased the risk for CD and antisocial personality disorder, CD conferred a much larger risk for these outcomes. Furthermore, only CD was associated with significantly increased risk for psychoactive substance use disorders, smoking, and bipolar disorder. CONCLUSIONS: These longitudinal findings support and extend previously reported findings from this sample at the 4-year follow-up indicating that ODD and CD follow a divergent course. They also support previous findings that ODD heralds a compromised outcome for ADHD youth grown up independently of the co-morbidity with CD. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND: Research on the overlap between attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) in males has provided useful information on the etiology, correlates, course, and nosology of this co-morbid condition. However, it is unclear how these results extend to females. Our aim was to examine the predictors, clinical characteristics, and functional outcome of CD in a sample of female youth with and without ADHD.MethodWe conducted a blind, 5-year prospective longitudinal study of girls with (n=140) and without (n=122) ADHD, aged 6-18 years at baseline. At the 5-year follow-up, 123 (88%) and 112 (92%) of the ADHD and control children respectively were reassessed at a mean age of 16.7 years. Psychiatric disorders were assessed using blind structured diagnostic interviews. RESULTS: Baseline ADHD was a significant risk factor for lifetime CD throughout childhood and adolescence [hazard ratio (HR) 5.8, 95% confidence interval (CI) 2.9-11.5, p<0.001]. Among ADHD girls, childhood-onset (<12 years) CD was predicted by paternal antisocial personality disorder (ASPD), while adolescent-onset CD (12 years) was predicted by family conflict. In addition, lifetime CD significantly predicted academic, psychiatric and sexual behavior problems in girls with ADHD at follow-up. CONCLUSIONS: ADHD is a significant risk factor for CD in girls. CD is associated with increased risk for academic, psychiatric and sexual behavior problems compared to ADHD girls without CD. Given that the therapeutic approaches indicated by ADHD and CD differ, these findings highlight the importance of improved efforts aimed at early identification and treatment of CD in girls with ADHD. [ABSTRACT FROM AUTHOR]

BACKGROUND: Our objective was to estimate the lifetime prevalence of psychopathology in a sample of youth with and without attention deficit hyperactivity disorder (ADHD) through young adulthood using contemporaneous diagnostic and analytic techniques. METHOD: We conducted a case-control, 10-year prospective study of ADHD youth. At baseline, we assessed consecutively referred male, Caucasian children with (n=140) and without (n=120) DSM-III-R ADHD, aged 6-18 years, ascertained from psychiatric and pediatric sources to allow for generalizability of results. At the 10-year follow-up, 112 (80%) and 105 (88%) of the ADHD and control children, respectively, were reassessed (mean age 22 years). We created the following categories of psychiatric disorders: Major Psychopathology (mood disorders and psychosis), Anxiety Disorders, Antisocial Disorders (conduct, oppositional-defiant, and antisocial personality disorder), Developmental Disorders (elimination, language, and tics disorder), and Substance Dependence Disorders (alcohol, drug, and nicotine dependence), as measured by blinded structured diagnostic interview. RESULTS: The lifetime prevalence for all categories of psychopathology were significantly greater in ADHD young adults compared to controls, with hazard ratios and 95% confidence intervals of 6.1 (3.5-10.7), 2.2 (1.5-3.2), 5.9 (3.9-8.8), 2.5 (1.7-3.6), and 2.0 (1.3-3.0), respectively, for the categories described above. CONCLUSIONS: By their young adult years, ADHD youth were at high risk for a wide range of adverse psychiatric outcomes including markedly elevated rates of antisocial, addictive, mood and anxiety disorders. These prospective findings provide further evidence for the high morbidity associated with ADHD across the life-cycle and stress the importance of early recognition of this disorder for prevention and intervention strategies. [ABSTRACT FROM AUTHOR]

BACKGROUND: To examine the familial associations of overt and covert antisocial behavior within the diagnosis of conduct disorder (CD) in families ascertained by referred children with attention-deficit hyperactivity disorder (ADHD), and to test if these familial associations differed between male and female probands. METHOD: Subjects were clinically-referred male and female ADHD children (n = 273) and their first-degree biological relatives (n = 807). Scores for overt and covert conduct problems were calculated by summing the DSM-III-R conduct disorder symptoms, as derived from structured diagnostic interviews. Familial aggregation analyses were conducted with multivariate regression modeling methodology. RESULTS: Proband overt scores significantly predicted the overt scores of their relatives, and proband covert scores significantly predicted the covert scores of their relatives. There was no evidence of covert symptom scores predicting overt scores or vice versa. There was some evidence that the aggregation of covert symptoms was stronger in the families of female probands. CONCLUSIONS: These results provide preliminary evidence that overt and covert conduct disorder symptoms are independently transmitted through families and may represent distinct familial syndromes. [ABSTRACT FROM AUTHOR]

Background: Diagnostic uncertainty exists surrounding the identification of radiographic pneumonia in children with wheeze. It is important to determine the prevalence and clinical predictors of pneumonia in this population to limit chest radiography (CXR) and promote judicious antibiotic use., Objectives: The objectives were to (1) estimate the prevalence of radiographic pneumonia in children with wheeze and (2) systematically review the diagnostic accuracy of clinical findings for the identification of radiographic pneumonia., Methods: Data sources were MEDLINE, PubMed Central, Cochrane Library, CINAHL, and Web of Science (January 1995 to September 2023). For study selection, two reviewers identified high-quality studies reporting on clinical characteristics associated with radiographic pneumonia in wheezing children (age 0-21 years). Using Covidence software, data regarding study characteristics, methodologic quality, and results were extracted. Data were pooled using random-effects meta-analysis., Results: A total of 8333 unique titles and abstracts were reviewed. Twelve studies, representing 7398 patients, were included. Fifteen percent of children with wheeze undergoing CXR had pneumonia. Findings associated with radiographic pneumonia included temperature ≥ 38.4°C (positive likelihood ratio [LR+] 2.1, 95% CI 1.2-3.6, specificity 85%), oxygen saturation < 92% (LR+ 3.6, 95% CI 1.4-8.9, specificity 89%), and grunting (LR+ 2.7, 95% CI 1.6-4.4, pooled specificity 91%). Factors associated with the absence of radiographic pneumonia included lack of fever (negative likelihood ratio [LR-] 0.67, 95% CI 0.52-0.85) and oxygen saturation ≥ 95% (LR- 0.64, 95% CI 0.42-0.98). Tachypnea and auscultatory findings were not associated with radiographic pneumonia., Discussion: Heterogeneity across studies limits generalizability. Additionally, all included studies overestimate the rate of radiographic pneumonia given the fact that all subjects had a CXR performed due to clinical suspicion of pneumonia., Conclusions: Radiographic pneumonia occurs in 15% of wheezing children undergoing CXR for pneumonia. Auscultatory findings and tachypnea do not differentiate children with and without pneumonia, and the rate of radiographic pneumonia is very low in the absence of fever and hypoxemia., (© 2024 Society for Academic Emergency Medicine.)

Importance: Many US children and adolescents with mental and behavioral health (MBH) conditions do not access MBH services. One contributing factor is limited insurance coverage, which is influenced by state MBH insurance parity legislation., Objective: To investigate the association of patient-level factors and the comprehensiveness of state MBH insurance legislation with perceived poor access to MBH care and perceived inadequate MBH insurance coverage for US children and adolescents., Design, Setting, and Participants: This retrospective cross-sectional study was conducted using responses by caregivers of children and adolescents aged 6 to 17 years with MBH conditions in the National Survey of Children's Health and State Mental Health Insurance Laws Dataset from 2016 to 2019. Data analyses were conducted from May 2022 to January 2024., Exposure: MBH insurance legislation comprehensiveness defined by State Mental Health Insurance Laws Dataset (SMHILD) scores (range, 0-7)., Main Outcomes and Measures: Perceived poor access to MBH care and perceived inadequacy of MBH insurance were assessed. Multivariable regression models adjusted for individual-level characteristics., Results: There were 29 876 caregivers of children and adolescents with MBH conditions during the study period representing 14 292 300 youths nationally (7 816 727 aged 12-17 years [54.7%]; 8 455 171 male [59.2%]; 292 543 Asian [2.0%], 2 076 442 Black [14.5%], and 9 942 088 White [69.6%%]; 3 202 525 Hispanic [22.4%]). A total of 3193 caregivers representing 1 770 492 children and adolescents (12.4%) perceived poor access to MBH care, and 3517 caregivers representing 1 643 260 of 13 175 295 children and adolescents (12.5%) perceived inadequate MBH insurance coverage. In multivariable models, there were higher odds of perceived poor access to MBH care among caregivers of Black (adjusted odds ratio [aOR], 1.35; 95% CI, 1.04-1.75) and Asian (aOR, 1.69; 95% CI, 1.01-2.84) compared with White children and adolescents. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to MBH care increased (aORs ranged from 1.68; 95%, CI 1.32-2.13 for 1 ACE to 4.28; 95% CI, 3.17-5.77 for ≥4 ACEs compared with no ACEs). Compared with living in states with the least comprehensive MBH insurance legislation (SMHILD score, 0-2), living in states with the most comprehensive legislation (SMHILD score, 5-7) was associated with lower odds of perceived poor access to MBH care (aOR, 0.79; 95% CI, 0.63-0.99), while living in states with moderately comprehensive legislation (score, 4) was associated with higher odds of perceived inadequate MBH insurance coverage (aOR, 1.23; 95% CI, 1.01-1.49)., Conclusions and Relevance: In this study, living in states with the most comprehensive MBH insurance legislation was associated with lower odds of perceived poor access to MBH care among caregivers for children and adolescents with MBH conditions. This finding suggests that advocacy for comprehensive mental health parity legislation may promote improved child and adolescent access to MBH services.

Study Objective: Preprocedural oxygenation (pre-emptive oxygenation started during presedation and/or induction) and procedural oxygenation (pre-emptive oxygenation started during any phase of sedation) are easy-to-use strategies with potential to decrease adverse events. Here, we describe practice patterns of preprocedural oxygenation and procedural oxygenation. We hypothesized that patients who received preprocedural oxygenation or procedural oxygenation would have a lower risk of airway/breathing/circulation interventions during sedation compared with patients without procedural oxygenation., Methods: We performed a retrospective, multicenter, cross-sectional study of pediatric sedations from April 2020 to July 2023 using the Pediatric Sedation Research Consortium multicenter database. The patient-level and sedation-level characteristics were described using frequencies and proportions, stratified by preprocedural oxygenation and procedural oxygenation status. We determined the site-level frequency of preprocedural oxygenation and procedural oxygenation use. We used inverse probability of treatment weighting to calculate the risk difference for interventions associated with preprocedural oxygenation and procedural oxygenation., Results: This study included a total of 85,599 pediatric sedations; 43,242 (50.5%) patients received preprocedural oxygenation (used oxygen before sedation and/or at induction) and a total of 52,219 (61.0%) received procedural oxygenation pre-emptively at any time during the sedation. There was no statistical difference in overall interventions with either preprocedural oxygenation (risk difference -0.06%; 95% confidence interval -4.26% to 4.14%) or procedural oxygenation (risk difference -1.07%; 95% confidence interval -6.44% to 4.30%)., Conclusion: Pre-emptive preprocedural oxygenation and procedural oxygenation were not associated with a difference in the use of airway/breathing/circulation interventions in pediatric sedations., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: To determine whether insurance status can function as a sufficient proxy for socioeconomic status in emergency medicine research by examining the concordance between insurance status and direct socioeconomic status measures in a sample of pediatric patients., Methods: We conducted a cross-sectional pilot study of patients aged 5 to 17 years in the emergency department of a quaternary care children's hospital. Socioeconomic status was measured using the highest level of the caregiver's education (low: less than bachelor's degree; high: bachelor's or greater) and previous year household income (low: <$75,000; high: ≥$75,000). We calculated the misclassification rate of insurance status (low: public; high: private) using education and income as reference standards. Results were expressed as percentages with 95% confidence intervals., Results: In total, 300 patients were enrolled (median age 11 years, 44% female). Insurance status misclassified 23% (95% CI 18% to 28%) and 14% (95% CI 10% to 19%) of patients when using caregiver education and income, respectively, as reference standards., Conclusions: Insurance status misclassified socioeconomic status in up to 23% of pediatric patients, as measured by caregivers' education and income. Emergency medicine studies of pediatric patients using insurance as a covariate to adjust for socioeconomic status may need to consider this misclassification and the resulting potential for bias. These findings require confirmation in larger, more diverse samples, including adult patients., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children., Methods: Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old., Results: We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%)., Conclusions: The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population., (Copyright © 2024 by the American Academy of Pediatrics.)

Community-acquired pneumonia (CAP) is often considered for children presenting to the emergency department (ED) with respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED visit for respiratory illness. We performed a retrospective case-control study to evaluate 7-day CAP diagnosis among children 3 months to 18 years discharged from the ED with respiratory illness from 2011 to 2021 and who receive care at 4 hospital-affiliated primary care clinics. Logistic regression was performed to assess for predictors of 7-day CAP diagnosis. Seventy-four (0.7%, 95% confidence interval [CI] = 0.6%, 0.9%) of 10 329 children were diagnosed with CAP within 7 days, and fever at the index visit was associated with increased odds of diagnosis (odds ratio [OR] = 3.32, 95% CI = 1.75-6.28). Community-acquired pneumonia diagnosis after discharge from the ED with respiratory illness is rare, even among children who are febrile at time of initial evaluation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation., Objective: To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities., Design: Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference., Setting: 202 cities with areas graded by the HOLC in the 1930s., Participants: Population of the 8597 areas assessed by the HOLC., Measurements: Nonsuicide firearm fatalities., Results: From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively., Limitation: The Gun Violence Archive relies on media coverage and police reports., Conclusion: Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today., Primary Funding Source: Fred Lovejoy Housestaff Research and Education Fund., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2496.

Objective: The aim of the study is to assess diagnostic performance of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians in children with preexisting cardiac disease., Methods: We evaluated the use of cardiac POCUS performed by PEM physicians among a convenience sample of children with preexisting cardiac disease presenting to a tertiary care pediatric ED. We assessed patient characteristics and the indication for POCUS. The test characteristics of the sonologist interpretation for the assessment of both pericardial effusion as well as left ventricular systolic dysfunction were compared with expert POCUS review by PEM physicians with POCUS fellowship training., Results: A total of 104 children with preexisting cardiac disease underwent cardiac POCUS examinations between July 2015 and December 2017. Among children with preexisting cardiac disease, structural defects were present in 72%, acquired conditions in 22%, and arrhythmias in 13% of patients. Cardiac POCUS was most frequently obtained because of chest pain (55%), dyspnea (18%), tachycardia (17%), and syncope (10%). Cardiac POCUS interpretation compared with expert review had a sensitivity of 100% (95% confidence interval [CI], 85.7-100) for pericardial effusion and 100% (95% CI, 71.5-100) for left ventricular systolic dysfunction; specificity was 97.5% (95% CI, 91.3.1-99.7) for pericardial effusion and 98.9% (95% CI, 93.8-99.8) for left ventricular systolic dysfunction., Conclusions: Cardiac POCUS demonstrates good sensitivity and specificity in diagnosing pericardial effusion and left ventricular systolic dysfunction in children with preexisting cardiac conditions when technically adequate studies are obtained. These findings support future studies of cardiac POCUS in children with preexisting cardiac conditions presenting to the ED., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To describe variation in costs for emergency department (ED) visits among children and to assess hospital and regional factors associated with costs., Methods: Cross-sectional study of all ED encounters among children under 18 years in 8 states from 2014 to 2018. The primary outcome was each hospital's mean inflation-adjusted ED costs. We evaluated variability in costs between hospitals and determined factors associated with costs using hierarchical linear models at the state, region, and hospital levels. Models adjusted for pediatric case mix, regional wages, Medicaid share, trauma status, critical access status, ownership, and market competitiveness., Results: We analyzed 22.9 million ED encounters across 713 hospitals. The median ED-level cost was $269 (range 99-1863). There was a 5.1-fold difference in median ED-level costs between the lowest- and highest-cost regions (range 119-605). ED-level costs were associated with case mix index (+38% per 10% increase, 95% confidence interval [CI] 30 to 47); wages [+7% per 10% increase, 95% CI 5 to 9]); critical access (adjusted costs, +24%, 95% CI 13 to 35); for profit status (-20%, 95% CI -26 to -14) compared with nonprofit, lowest trauma designation (+17%, 95% CI 5 to 30); teaching hospital status (+7%, 95% CI 1 to 14); highest number of inpatient beds (+13%, 95% CI 4 to 23); and Medicaid share versus quarter (Q)1 (Q2: -12%, 95% CI -18 to -7; Q3: -13%, 95% CI -19 to -7; Q4: -11%, 95% CI -17 to -4)., Conclusions: Our results suggest nonclinical factors are important drivers of pediatric health care costs., (Copyright © 2024 by the American Academy of Pediatrics.)

Introduction: The U.S. has the highest infant mortality rate among peer countries. Restrictive abortion laws may contribute to poor infant health outcomes. This ecological study investigated the association between county-level infant mortality and state-level abortion access legislation in the U.S. from 2014 to 2018., Methods: A multivariable regression analysis with the outcome of county-level infant mortality rates, controlling for the primary exposure of state-level abortion laws, and county-level factors, county-level distance to an abortion facility, and state Medicaid expansion status was performed. Incidence rate ratios and 95% CIs were reported. Analyses were conducted in 2022-2023., Results: There were 113,397 infant deaths among 19,559,660 live births (infant mortality rate=5.79 deaths/1,000 live births; 95% CI=5.75, 5.82). Black infant mortality rate (10.69/1,000) was more than twice the White infant mortality rate (4.87/1,000). In the multivariable model, increased infant mortality rates were seen in states with ≥8 restrictive laws, with the most restrictive (11-12 laws) having a 16% increased infant mortality level (adjusted incidence rate ratios=1.162; 95% CI=1.103, 1.224). Increased infant mortality rates were associated with increased county-level Black race individuals (adjusted incidence rate ratios=1.031; 95% CI=1.026, 1.037), high school education (adjusted incidence rate ratios=1.018; 95% CI=1.008, 1.029), maternal smoking (adjusted incidence rate ratios=1.025; 95% CI=1.018, 1.033), and inadequate prenatal care (adjusted incidence rate ratios=1.045; 95% CI=1.036, 1.055)., Conclusions: State-level abortion law restrictiveness is associated with higher county-level infant mortality rates. The Supreme Court decision on Dobbs versus Jackson and changes in state laws limiting abortion may affect future infant mortality., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Clinical pathways standardize healthcare utilization, but their impact on healthcare equity is poorly understood. This study aims to measure the effect of a bronchiolitis pathway on management decisions by preferred language for care., Methods: We included all emergency department encounters for patients aged 1-12 months with bronchiolitis from 1/1/2010 to 10/31/2020. The prepathway period ended 10/31/2011, and the postpathway period was 1/1/2012-10/31/2020. We performed retrospective interrupted time series analyses to assess the impact of the clinical pathway by English versus non-English preferred language on the following outcomes: chest radiography (CXR), albuterol use, 7-day return visit, 72-hour return to admission, antibiotic use, and corticosteroid use. Analyses were adjusted for presence of a complex chronic condition., Results: There were 1485 encounters in the preperiod (77% English, 14% non-English, 8% missing) and 7840 encounters in the postperiod (79% English, 15% non-English, 6% missing). CXR, antibiotic, and albuterol utilization exhibited sustained decreases over the study period. Pathway impact did not differ by preferred language for any outcome except albuterol utilization. The prepost slope effect of albuterol utilization was 10% greater in the non-English versus the English group (p for the difference by language = 0.022)., Conclusions: A clinical pathway was associated with improvements in care regardless of preferred language. More extensive studies involving multiple pathways and care settings are needed to assess the impact of clinical pathways on health equity., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To characterize types, duration, and intensity of health care utilization following pediatric concussion and to identify risk factors for increased post-concussion utilization., Methods: A retrospective cohort study of children 5 to 17 years old diagnosed with acute concussion at a quaternary center pediatric emergency department or network of associated primary care clinics. Index concussion visits were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We analyzed patterns of health care visits 6 months before and after the index visit using interrupted time-series analyses. The primary outcome was prolonged concussion-related utilization, defined as having ≥1 follow-up visits with a concussion diagnosis more than 28 days after the index visit. We used logistic regressions to identify predictors of prolonged concussion-related utilization., Results: Eight hundred nineteen index visits (median [interquartile range] age, 14 [11-16] years; 395 [48.2%] female) were included. There was a spike in utilization during the first 28 days after the index visit compared to the pre-injury period. Premorbid headache/migraine disorder (adjusted odds ratio (aOR) 2.05, 95% confidence interval [CI] 1.09-3.89) and top quartile pre-injury utilization (aOR 1.90, 95% CI 1.02-3.52) predicted prolonged concussion-related utilization. Premorbid depression/anxiety (aOR 1.55, 95% CI 1.31-1.83) and top quartile pre-injury utilization (aOR 2.29, 95% CI 1.95-2.69) predicted increased utilization intensity., Conclusions: Health care utilization is increased during the first 28 days after pediatric concussion. Children with premorbid headache/migraine disorders, premorbid depression/anxiety, and high baseline utilization are more likely to have increased post-injury health care utilization. This study will inform patient-centered treatment but may be limited by incomplete capture of post-injury utilization and generalizability., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the association of emergency department (ED) volume of children and delayed diagnosis of appendicitis., Background: Delayed diagnosis of appendicitis is common in children. The association between ED volume and delayed diagnosis is uncertain, but diagnosis-specific experience might improve diagnostic timeliness., Methods: Using Healthcare Cost and Utilization Project 8-state data from 2014 to 2019, we studied all children with appendicitis <18 years old in all EDs. The main outcome was probable delayed diagnosis: >75% likelihood that a delay occurred based on a previously validated measure. Hierarchical models tested associations between ED volumes and delay, adjusting for age, sex, and chronic conditions. We compared complication rates by delayed diagnosis occurrence., Results: Among 93,136 children with appendicitis, 3,293 (3.5%) had delayed diagnosis. Each 2-fold increase in ED volume was associated with a 6.9% (95% CI: 2.2, 11.3) decreased odds of delayed diagnosis. Each 2-fold increase in appendicitis volume was associated with a 24.1% (95% CI: 21.0, 27.0) decreased odds of delay. Those with delayed diagnosis were more likely to receive intensive care [odds ratio (OR): 1.81, 95% CI: 1.48, 2.21], have perforated appendicitis (OR: 2.81, 95% CI: 2.62, 3.02), undergo abdominal abscess drainage (OR: 2.49, 95% CI: 2.16, 2.88), have multiple abdominal surgeries (OR: 2.56, 95% CI: 2.13, 3.07), or develop sepsis (OR: 2.02, 95% CI: 1.61, 2.54)., Conclusions: Higher ED volumes were associated with a lower risk of delayed diagnosis of pediatric appendicitis. Delay was associated with complications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Exploratory pediatric cannabis poisonings are increasing. The aim of this study is to provide a national assessment of the frequency and trends of diagnostic testing and procedures in the evaluation of pediatric exploratory cannabis poisonings., Methods: This is a retrospective cross-sectional study of the Pediatric Health Information Systems database involving all cases of cannabis poisoning for children age 0-10 years between 1/2016 and 12/2021. Cannabis poisoning trends were assessed using a negative binomial regression model. A new variable named "ancillary testing" was created to isolate testing that would not confirm the diagnosis of cannabis poisoning or be used to exclude co-ingestion of acetaminophen or aspirin. Ancillary testing was assessed with regression analyses, with ancillary testing as the outcomes and year as the predictor, to assess trends over time., Results: A total of 2001 cannabis exposures among 1999 children were included. Cannabis exposures per 100,000 ED visits increased 68.7% (95% CI, 50.3, 89.3) annually. There was a median of 4 (IQR 2.0, 6.0) diagnostic tests performed per encounter. 64.5% of encounters received blood tests, 28.8% received a CT scan, and 2.4% received a lumbar puncture. Compared to White individuals, Black individuals were more likely to receive ancillary testing (OR 1.52 [95% CI, 1.23, 1.89]). Compared to those 2-6 years, those <2 years were more likely to receive ancillary testing (OR 1.55 [95% CI, 1.19, 2.02). We found no significant annual change in the odds of receiving ancillary testing (OR 1.04 [95% CI, 0.97, 1.12])., Conclusions: We found no change in the proportion of encounters associated with ancillary testing, despite increases in exploratory cannabis poisonings over the study period. Given the increasing rate of pediatric cannabis poisonings, emergency providers should consider this diagnosis early in the evaluation of a pediatric patient with acute change in mental status. While earlier use of urine drug screening may reduce ancillary testing and invasive procedures, even a positive urine drug screen does not rule out alternative pathologies and should not replace a thoughtful evaluation., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications., Design: Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022., Setting: International multicenter research network of 40 sites., Patients: Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure., Interventions: None., Measurements and Main Results: Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied., Conclusions: PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition., Competing Interests: Dr. Burns is the Pediatric Toxicology Section Editor at UpToDate; she received funding from UpToDate. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Study Objective: Identifying higher risk groups could reveal ways to prevent critical emergency department (ED) revisits. The study objectives were to determine the rate of critical ED revisits among children discharged from the ED and to identify factors associated with critical revisits., Methods: We performed a retrospective study using the Healthcare Cost and Utilization Project State ED Databases (SEDD) and the State Inpatient Databases (SID). We included data from 6 states from 2014 through 2017. Critical ED revisit was defined as either ICU admission or death within 3 days of the initial ED discharge. We included all patients younger than 21 years. The main outcome was the rate of critical ED revisit. We also determined the relative risk (RR) of a critical ED revisit for the most common index ED visit diagnoses. We used negative binomial regression to calculate incidence rate ratios (IRR) of a critical ED visit by pediatric volume and complex chronic conditions., Results: A total of 16.3 million children were discharged from an ED over the 4-year study period. There were 18,704 (0.1%) critical ED revisits, 180 (0.00001%) of whom died. Asthma (RR 2.24, 95% confidence interval [CI] [2.11 to 2.38) had the highest relative risk of a critical revisit among all ED diagnoses. Adjusting for hospital volume and patient age, patients with complex chronic conditions were also more likely to have a critical ED revisit (IRR 11.03, 95% CI, 7.76 to 15.67)., Conclusions: Critical revisits after ED discharge were uncommon among children in our study sample, with revisits resulting in patient death within 3 days of an ED discharge being rare. Given the short time interval between ED discharges, however, future research should focus on understanding higher risk patients among those with asthma and a history of complex chronic conditions., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: When ingested by children, small quantities of beta-adrenergic antagonists (BAA) are described as dangerous and even potentially lethal ("one pill can kill"). We characterize demographics, clinical characteristics, and the rate of serious outcomes among pediatric patients with reported BAA ingestions., Methods: This study was a retrospective review of U.S. patients <20 years old with reported single-agent BAA ingestions presenting to a health care facility between January 2000 and February 2020 for whom a poison control center was consulted. Data were abstracted from the National Poison Data System (NPDS). Medical outcomes were assessed by the NPDS scale of no effect, minor effect, moderate effect, major effect, and death. All relevant NPDS fatality narratives were reviewed., Results: A total of 35,436 reported exposures were identified. A total of 29,155 (82.3%) were <6 years old, of which 29,089 (99.8%) were unintentional. Twenty-five patients (<0.1%) <6 years old had major effects. A total of 2316 (8.8%) of patients with no/mild effects were admitted to a critical care unit. Of all cases, 1460 (4.1%) had hypotension and 1403 (4.0%) had bradycardia. One hundred nineteen (0.3%) developed hypoglycemia. The only four fatalities resulted from intentional ingestions in patients >10 years old who sustained cardiac arrest in the prehospital setting., Conclusions: Reported BAA ingestions in this multiyear national pediatric cohort caused infrequent toxicity, and no fatalities resulted from an unintentional ingestion. The frequency of bradycardia, hypotension, and hypoglycemia were low. While severely poisoned patients require aggressive treatment, 8.8% of patients were admitted to a critical care unit despite having no or mild effects, which suggests an opportunity to reduce resource utilization., (© 2023 Society for Academic Emergency Medicine.)

Objective: It is important to identify gaps in access and reduce health outcome disparities, understanding access to intensive care unit (ICU) beds, especially by race and ethnicity, is crucial. Our objective was to evaluate the race and ethnicity-specific 60-minute drive time accessibility of ICU beds in the United States (US)., Design: We conducted a cross-sectional study using road network analysis to determine the number of ICU beds within a 60-minute drive time, and calculated adult intensive care bed ratios per 100,000 adults. We evaluated the US population at the Census block group level and stratified our analysis by race and ethnicity and by urbanicity. We classified block groups into four access levels: no access (0 adult intensive care beds/100,000 adults), below average access (>0-19.5), average access (19.6-32.0), and above average access (>32.0). We calculated the proportion of adults in each racial and ethnic group within the four access levels., Setting: All 50 US states and the District of Columbia., Participants: Adults ≥15 years old., Main Outcome Measures: Adult intensive care beds/100,000 adults and percentage of adults national and state) within four access levels by race and ethnicity., Results: High variability existed in access to ICU beds by state, and substantial disparities by race and ethnicity. 1.8% (n = 5,038,797) of Americans had no access to an ICU bed, and 26.8% (n = 73,095,752) had below average access, within a 60-minute drive time. Racial and ethnic analysis showed high rates of disparities (no access/below average access): American Indians/Alaskan Native 12.6%/28.5%, Asian 0.7%/23.1%, Black or African American 0.6%/16.5%, Hispanic or Latino 1.4%/23.0%, Native Hawaiian and other Pacific Islander 5.2%/35.0%, and White 2.1%/29.0%. A higher percentage of rural block groups had no (5.2%) or below average access (41.2%), compared to urban block groups (0.2% no access, 26.8% below average access)., Conclusion: ICU bed availability varied substantially by geography, race and ethnicity, and by urbanicity, creating significant disparities in critical care access. The variability in ICU bed access may indicate inequalities in healthcare access overall by limiting resources for the management of critically ill patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Burdick et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The objective of our study was to examine the association between poverty and child health outcomes in school-age children referred to child protective services. We conducted a secondary analysis of children aged 5 to 9 years in the Second National Survey of Child and Adolescent Well-Being, a nationally representative longitudinal observational data set of children referred to protective services for maltreatment (2008-2012). We analyzed the association of poverty, defined as family income below the federal poverty level (FPL), with caregiver report of the child's overall health, primary care, and emergency department visits using Pearson's chi-squared test. Children below FPL compared with children above it had poorer overall health (29.8% vs 18.0%, P = .03). We also conducted a longitudinal multivariable logistic regression analysis and found poverty was associated with the child's poorer overall health at 36 months (odds ratios 2.78, 95% confidence interval 1.55-5.01). Future studies and interventions to improve health in this at-risk population should target poverty., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This study aimed to explore the health outcomes of adolescent survivors of sexual assault, as measured by subsequent emergency department (ED) utilization for mental and sexual health concerns., Methods: This retrospective cohort study used the Pediatric Health Information System (PHIS) database. We included patients aged 11-18 years seen at a PHIS hospital with a primary diagnosis of sexual assault. The control group included age- and sex-matched patients seen for an injury. Participants were followed in PHIS for 3-10 years; subsequent ED visits for suicidality, sexually transmitted infection, pelvic inflammatory disease (PID), or pregnancy were identified, and likelihoods of each were compared using Cox proportional hazards models., Results: The study population included 19,706 patients. ED return visit rates in the sexual assault and control groups were 7.9% versus 4.1% for suicidality, 1.8% versus 1.4% for sexually transmitted infection, 2.2% versus 0.8% for PID, and 1.7% versus 1.0% for pregnancy, respectively. Compared to controls, sexual assault patients were significantly more likely to return to the ED for suicidality throughout the follow-up period, with the highest hazard ratio of 6.31 (95% confidence interval 4.46-8.94) during the first 4 months. Sexual assault patients also had higher likelihood of returning for PID (hazard ratio 3.80, 95% confidence interval 3.07-4.71) throughout the follow-up period., Discussion: Adolescents seen in the ED for sexual assault were significantly more likely to return to the ED for suicidality and sexual health concerns, highlighting the need for increased allocation of research and clinical resources to improve their care., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions., Methods: This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods., Results: Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods., Conclusions: Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents., Competing Interests: The authors declare no conflicts of interest., (© 2023 Society for Academic Emergency Medicine.)

Objectives: Bacterial musculoskeletal infections (MSKIs) are challenging to diagnose because of the clinical overlap with other conditions, including Lyme arthritis. We evaluated the performance of blood biomarkers for the diagnosis of MSKIs in Lyme disease-endemic regions., Methods: We conducted a secondary analysis of a prospective cohort study of children 1 to 21 years old with monoarthritis presenting to 1 of 8 Pedi Lyme Net emergency departments for evaluation of potential Lyme disease. Our primary outcome was an MSKI, which was defined as septic arthritis, osteomyelitis or pyomyositis. We compared the diagnostic accuracy of routinely available biomarkers (absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and procalcitonin) to white blood cells for the identification of an MSKI using the area under the receiver operating characteristic curve (AUC)., Results: We identified 1423 children with monoarthritis, of which 82 (5.8%) had an MSKI, 405 (28.5%) Lyme arthritis, and 936 (65.8%) other inflammatory arthritis. When compared with white blood cell count (AUC, 0.63; 95% confidence interval [CI], 0.55-0.71), C-reactive protein (0.84; 95% CI, 0.80-0.89; P < .05), procalcitonin (0.82; 95% CI, 0.77-0.88; P < .05), and erythrocyte sedimentation rate (0.77; 95% CI, 0.71-0.82; P < .05) had higher AUCs, whereas absolute neutrophil count (0.67; 95% CI, 0.61-0.74; P < .11) had a similar AUC., Conclusions: Commonly available biomarkers can assist in the initial approach to a potential MSKI in a child. However, no single biomarker has high enough accuracy to be used in isolation, especially in Lyme disease-endemic areas., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: Central nervous system (CNS) tumor diagnoses are frequently delayed in children, which may lead to adverse outcomes and undue burdens on families. Examination of factors associated with delayed emergency department (ED) diagnosis could identify approaches to reduce delays., Study Design: We performed a case-control study using data from 2014 to 2017 for 6 states. We included children aged 6 months to 17 years with a first diagnosis of CNS tumor in the ED. Cases had a delayed diagnosis, defined as 1 or more ED visits in the 140 days preceding tumor diagnosis (the mean prediagnostic symptomatic interval for pediatric CNS tumors in the United States). Controls had no such preceding visit., Results: We included 2828 children (2139 controls, 76%; 689 cases, 24%). Among cases, 68% had 1 preceding ED visit, 21% had 2, and 11% had 3 or more. Significant predictors of delayed diagnosis included presence of a complex chronic condition (adjusted odds ratio [aOR], 9.73; 95% confidence interval [CI], 6.67-14.20), rural hospital location (aOR, 6.37; 95% CI, 1.80-22.54), nonteaching hospital status (aOR, 3.05, compared with teaching hospitals; 95% CI, 1.94-4.80), age younger than 5 years (aOR, 1.57; 95% CI, 1.16-2.12), public insurance (aOR, 1.49, compared with private; 95% CI, 1.16-1.92), and Black race (aOR, 1.42, compared with White; 95% CI, 1.01-1.98)., Conclusions: Delayed ED diagnosis of pediatric CNS tumors is common and frequently requires multiple ED encounters. Prevention of delays should focus on careful evaluation of young or chronically ill children, mitigating disparities for Black and publicly insured children, and improving pediatric readiness in rural and nonteaching EDs., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Missed diagnosis can predispose to worse condition-specific outcomes., Objective: To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis., Methods: We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance., Results: We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis., Conclusions: Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Chest radiograph (CXR) is often performed for the evaluation of community-acquired pneumonia (CAP) in the ED setting. We sought to evaluate the association of undergoing CXR with 7-day hospitalization after emergency department (ED) discharge among patients with CAP., Methods: This was a retrospective cohort study including children 3 months to 17 years discharged from any ED within 8 states from 2014 to 2019. We evaluated the association of CXR performance with 7-day hospitalization at both the patient and ED levels using mixed-effects logistic regression models accounting for markers of illness severity. Secondary outcomes included 7-day ED revisits and 7-day hospitalization with severe CAP., Results: Among 206 694 children with CAP, rates of 7-day ED revisit, hospitalization, and severe CAP were 8.9%, 1.6%, and 0.4%, respectively. After adjusting for illness severity, CXR was associated with fewer 7-day hospitalizations (1.6% vs. 1.7%, adjusted odds ratio: [aOR] 0.82, 95% confidence interval [CI]: 0.73-0.92). CXR performance varied somewhat between EDs (median 91.5%, IQR: 85.3%-95.0%). EDs in the highest quartile had fewer 7-day hospitalizations (1.4% vs 1.9%, aOR: 0.78, 95% CI: 0.65-0.94), ED revisits (8.5% vs 9.4%, aOR: 0.88, 95% CI: 0.80-0.96) and hospitalizations for severe CAP (0.3% vs. 0.5%, aOR: 0.70, 95% CI: 0.51-0.97) as compared to EDs with the lowest quartile of CXR utilization., Conclusions: Among children discharged from the ED with CAP, performance of CXR was associated with a small but significant reduction in hospitalization within 7 days. CXR may be helpful in the prognostic evaluation of children with CAP discharged from the ED., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care., Methods: We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California., Results: PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%)., Conclusions: ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2023 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Pediatric requirements include procedural skills training such as peripheral intravenous (PIV) catheter placement and bag-mask ventilation (BMV). Clinical experiences may be limited and temporally remote from scheduled teaching. Just-in-time (JIT) training prior to utilization can promote skill development and mitigate learning decay. Our objective was to assess the impact of JIT training on pediatric residents' procedural performance, knowledge, and confidence with PIV placement and BMV., Methods: Residents received standardized baseline training in both PIV placement and BMV during scheduled educational programming. Between 3 and 6 months later, participants were randomized and received JIT training for either PIV placement or BMV. JIT training included a brief video and coached practice, totaling <5 min. Each participant was videotaped performing both procedures on skills trainers. Blinded investigators scored performance using skills checklists. Pre- and postintervention knowledge was assessed using multiple-choice and short-answer items, and confidence was reported using Likert scores., Results: Seventy-two residents completed baseline training sessions: 36 were randomized to receive JIT training for PIV and 36 for BMV. Thirty-five residents in each cohort completed the curriculum. There were no significant differences between the cohorts with regard to demographics, baseline knowledge, or prior simulation experience. JIT training was associated with improved procedural performance for PIV (median 87% vs. 70%, p  < 0.001) and for BMV (mean 83% vs. 57%, p  < 0.001). Results remained significant after using regression models to adjust for differences in prior clinical experience. Improvements in knowledge or confidence were not associated with JIT training in either cohort., Conclusions: JIT training resulted in a significant improvement in resident procedural performance with PIV placement and BMV in a simulated environment. There were no differences in outcome with regard to knowledge or confidence. Future work might explore how the demonstrated benefit translates into the clinical setting., Competing Interests: The authors declare no conflicts of interest., (© 2023 Society for Academic Emergency Medicine.)

Objectives: To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis., Methods: Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined., Results: Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2-89.9) and specificity of 61.3 % (95 % confidence interval 56.0-65.4)., Conclusions: Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

To determine whether a lack of response to antipyretics was associated with bacteremia, we performed a cross-sectional study involving children with an initial temperature ≥38°C presenting to a pediatric emergency department (ED) from 2012 to 2020 who received an antipyretic and had a blood culture obtained. We assessed the association of resolution of fever at specific time points after antipyretic administration with bacteremia adjusting for age, complex chronic condition, blood culture source, type of antipyretic, and height of temperature. Among 6319 febrile children, 242 (3.8%) had bacteremia. The adjusted odds ratio of bacteremia was 1.6 (95% confidence interval: 1.2-2.2) among children who remained febrile at 180 minutes and 1.7 (1.2-2.4) among children who remained febrile at 240 minutes. Among febrile children presenting to a tertiary care ED for whom a blood culture was obtained, the response to an antipyretic varies based on the presence or absence of bacteremia.

Importance: Infant mortality in the United States is highest among peer nations; it is also inequitable, with the highest rates among Black infants. The association between tax policy and infant mortality is not well understood., Objective: To examine the association between state-level tax policy and state-level infant mortality in the US., Design, Setting, and Participants: This state-level, population-based cross-sectional study investigated the association between tax policy and infant mortality in the US from 1996 through 2019. All US infant births and deaths were included, with data obtained from the National Center for Health Statistics. Data were analyzed from November 28, 2021, to July 9, 2022., Exposures: State-level tax policy was operationalized as tax revenue per capita and tax progressivity. The Suits index was used to measure tax progressivity, with higher progressivity indicating increased tax rates for wealthier individuals., Main Outcomes and Measures: The association between tax policy and infant mortality rates was analyzed using a multivariable, negative binomial, generalized estimating equations model. Since 6 years of tax progressivity data were available (1995, 2002, 2009, 2012, 2014, and 2018), 300 state-years were included. Adjusted incidence rate ratios (aIRRs) were calculated controlling for year, state-level demographic variables, federal transfer revenue, and other revenue. Secondary analyses were conducted for racial and ethnic subgroups., Results: There were 148 336 infant deaths in the US from 1996 through 2019, including 27 861 Hispanic infants, 1882 non-Hispanic American Indian or Alaska Native infants, 5792 non-Hispanic Asian or Pacific Islander infants, 41 560 non-Hispanic Black infants, and 68 666 non-Hispanic White infants. The overall infant mortality rate was 6.29 deaths per 1000 live births. Each $1000 increase in tax revenue per capita was associated with a 2.6% decrease in the infant mortality rate (aIRR, 0.97; 95% CI, 0.95-0.99). An increase of 0.10 in the Suits index (ie, increased tax progressivity) was associated with a 4.6% decrease in the infant mortality rate (aIRR, 0.95; 95% CI, 0.91-0.99). Increased tax progressivity was associated with decreased non-Hispanic White infant mortality (aIRR, 0.95; 95% CI, 0.91-0.99), and increased tax revenue was associated with increased non-Hispanic Black infant mortality (aIRR, 1.04; 95% CI, 1.01-1.08)., Conclusions and Relevance: In this cross-sectional study, an increase in tax revenue and the Suits index of tax progressivity were both associated with decreased infant mortality. These associations varied by race and ethnicity. Tax policy is an important, modifiable social determinant of health that may influence state-level infant mortality.

Introduction: Prescription drug monitoring programs are state-run databases designed to support safe prescribing of controlled substances and reduce prescription drug misuse. We analyzed healthcare claims data to determine the association between prescription drug monitoring programs with mandated provider review and adolescent and young adult benzodiazepine prescription dispensing and overdose., Methods: We performed a state-level retrospective cohort study to evaluate the association between implementation of prescription drug monitoring programs with mandated provider review and benzodiazepine prescription dispensing and benzodiazepine-related overdoses among adolescents (13-18 years) and young adults (19-25 years) between 1 January 2008 and 31 December 2019. Data were obtained from a United States commercial health insurance company., Results: There were 74,539 (1.8%) adolescents and 246,760 (4.0%) young adults with at least one benzodiazepine prescription dispensed. Benzodiazepine overdoses occurred among 1,569 (0.04%) and 3,202 (0.05%) adolescents and young adults, respectively. Implementation of a prescription drug monitoring program with mandated provider review was associated with a 6.8% (95% CI, 1.6-11.8) yearly reduction in benzodiazepine prescription dispensing among adolescents and a 12.5% (95% CI, 9.3-15.5) yearly reduction among young adults. There was no decrease in benzodiazepine overdoses in either age group (-15.4% [95% CI, -21.5 to 3.0] and -8.0% [95% CI, -18.0 to 3.2] yearly change in adolescents and young adults, respectively)., Discussion: Consistent with prior work, our study did not find an association between prescription drug monitoring program implementation and reduction in benzodiazepine-related overdoses among adolescents and young adults. However, the substantial reduction in benzodiazepine prescription dispensing is encouraging., Conclusion: Prescription drug monitoring programs were associated with decreases in benzodiazepine prescription dispensing, but not benzodiazepine-related overdoses in this cohort of adolescents and young adults. These findings serve to inform development of further policies to address rising rates of benzodiazepine misuse and overdose in this patient population.

Study Objective: Prescription opioid use is associated with substance-related adverse outcomes among adolescents and young adults through a pathway of prescribing, diversion and misuse, and addiction and overdose. Assessing the effect of current prescription drug monitoring programs (PDMPs) on opioid prescribing and overdoses will further inform strategies to reduce opioid-related harms., Methods: We performed interrupted time series analyses to measure the association between state-level implementation of PDMPs with annual opioid prescribing and opioid-related overdoses in adolescents (13 to 18 years) and young adults (19 to 25 years) between 2008 and 2019. We focused on PDMPs that included mandatory reviews by providers. Data were obtained from a commercial insurance company., Results: Among 9,344,504 adolescents and young adults, 1,405,382 (15.0%) had a dispensed opioid prescription, and 6,262 (0.1%) received treatment for an opioid-related overdose. Mandated PDMP review was associated with a 4.2% (95% CI, 1.9% to 6.4%) reduction in annual opioid dispensations among adolescents and a 7.8% (95% CI, 4.7% to 10.9%) annual reduction among young adults. For opioid-related overdoses, mandated PDMP review was associated with a 16.1% (95% CI, 3.8 to 26.7) and 15.9% (95% CI, 7.6 to 23.4) reduction in annual opioid overdoses for adolescents and young adults, respectively., Conclusion: PDMPs were associated with sustained reductions in opioid prescribing and overdoses in adolescents and young adults. Although these findings support the value of mandated PDMPs as part of ongoing strategies to reduce opioid overdoses, further studies with prospective study designs are needed to characterize the effect of these programs fully., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Pediatric surge planning is critical in the setting of decreasing pediatric inpatient capacity. We describe a statewide assessment of pediatric inpatient bed capacity, clinical care therapies, and subspecialty availability during standard and disaster operations in Massachusetts., Methods: To assess pediatric (<18 years old) inpatient bed capacity during standard operations, we used Massachusetts Department of Public Health data from May 2021. To assess pediatric disaster capacity, therapies, and subspecialty availability in standard and disaster operations, we performed a state-wide survey of Massachusetts hospital emergency management directors from May to August 2021. From the survey, we calculated additional pediatric inpatient bed capacity during a disaster and clinical therapy and subspecialty availability during standard and disaster operations., Results: Of 64 Massachusetts acute care hospitals, 58 (91%) completed the survey. Of all licensed inpatient beds in Massachusetts (n = 11 670), 19% (n = 2159) are licensed pediatric beds. During a disaster, 171 pediatric beds could be added. During standard and disaster operations, respiratory therapies were available in 36% (n = 21) and 69% (n = 40) of hospitals, respectively, with high flow nasal cannula being most common. The only surgical subspecialist available in the majority of hospitals (>50%) during standard operations is general surgery (59%, n = 34). In a disaster, only orthopedic surgery could additionally provide services in the majority hospitals (76%; n = 44)., Conclusions: Massachusetts pediatric inpatient capacity is limited in a disaster scenario. Respiratory therapies could be available in more than half of hospitals in a disaster, but the majority of hospitals lack surgical subspecialists for children under any circumstance., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation., Methods: Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis., Results: Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice., Conclusions: This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice., Competing Interests: The authors declare no potential conflict of interest., (© 2023 Society for Academic Emergency Medicine.)

Study Objective: Injury is the leading cause of death and disability for children, making access to pediatric trauma centers crucial to pediatric trauma care. Our objective was to describe the pediatric population with timely access to a pediatric trauma center by demographics and geography in the United States., Methods: Level 1, 2, and 3 pediatric trauma center locations were provided by the American Trauma Society. Geographic information systems road network and rotor wing analysis determined US Census Block Groups with the ground and/or air access to a pediatric trauma center within a 60-minute transport time. We then described, at the national and state levels, the 2020 pediatric population (< 15 years old) with and without pediatric trauma center access by ground and air, stratified by race, ethnicity, and urbanicity., Results: There were 157 pediatric trauma centers (82 Level 1, 64 Level 2, 11 Level 3). Of the 2020 US pediatric population, 33,352,872 (54.5%) had timely access to Level 1-3 pediatric trauma centers by ground and 45,431,026 (74.1%) by air. The percentage of children with access by race and ethnicity were (by ground, by air): American Indian/Alaskan Native (31.0%, 43.5%), White (48.7%, 71.3%), Native Hawaiian/Pacific Islander (59.3%, 61.0%), Hispanic (60.2%, 76.9%), Black (64.2%, 78.0%), and Asian (76.5%, 89.5%). Only 48.2% of children living in rural block groups had access, compared with 83.6% in urban block groups., Conclusion: Significant disparities in current access to pediatric trauma centers exist by race and ethnicity, and geography, leaving some children at risk for poor trauma outcomes., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: To derive and validate a tool that retrospectively identifies delayed diagnosis of appendicitis in administrative data with high accuracy., Design: Cross-sectional study., Setting: Five paediatric emergency departments (EDs)., Participants: 669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis., Outcome: Delayed diagnosis was defined as appendicitis being present but not diagnosed at the first ED encounter based on standardised record review. The cohort was split into derivation (2/3) and validation (1/3) groups. We derived a prediction rule using logistic regression, with covariates including variables obtainable only from administrative data. The resulting trigger tool was applied to the validation group to determine area under the curve (AUC). Test characteristics were determined at two predicted probability thresholds., Results: Delayed diagnosis occurred in 471 (70.4%) patients. The tool had an AUC of 0.892 (95% CI 0.858 to 0.925) in the derivation group and 0.859 (95% CI 0.806 to 0.912) in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% (95% CI 78.2% to 89.8%) and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% (95% CI 87.4% to 98.6%) and identified 46.8% of delayed cases., Conclusions: This tool accurately identified delayed diagnosis of appendicitis. It may be used to screen for potential missed diagnoses or to specifically identify a cohort of children with delayed diagnosis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Objective: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes., Methods: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes., Results: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95)., Conclusion: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing., Methods: We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count)., Results: The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%)., Conclusions: PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses., (Copyright © 2023 by the American Academy of Pediatrics.)