Samuel C. Stubblefield, MD

Clinical question

Does use of corticosteroids or infliximab in addition to intravenous immunoglobulin improve cardiac outcomes in children with Kawasaki disease and enlarged coronary arteries?

Background

Kawasaki disease is a medium-vessel vasculitis primarily of young children. While the underlying cause remains unknown, treatment with intravenous immunoglobulin (IVIG) substantially lowers the risk of coronary artery aneurysms (CAA), the most serious sequelae of Kawasaki disease. Recent studies have suggested that – in cases of high-risk or treatment-resistant Kawasaki disease – using an immunomodulator, such as a corticosteroid or a TNF-alpha blocker, may improve outcomes, though these studies involved relatively small and homogeneous patient populations. It is unknown if these medications could prevent progression of CAA.

Study design

Retrospective multicenter study.

Setting

Two freestanding children’s hospitals and one mother-child hospital.

Synopsis

The study identified 121 children diagnosed with Kawasaki disease with CAA (z score 2.5-10) from 2008 through 2017 treated at the three study hospitals. Children with giant CAA at the time of diagnosis (z score greater than 10) or significant preexisting congenital heart disease were excluded.

All study hospitals had protocols for treatment of Kawasaki disease: Center 1 used IVIG and corticosteroids, Center 2 used IVIG and infliximab, and Center 3 used IVIG alone. Patients at all centers also received aspirin. Center 1 used methylprednisolone IV initially, changing to oral prednisolone after clinical improvement. The researchers reviewed the charts of each patient and classified them as having complete or incomplete Kawasaki disease. They assigned z scores for CAA size based on both initial and follow-up echocardiograms. The primary outcome was change in z score of CAA over the first year.

The population of patients treated at each center was significantly different. Center 1 reported older patients (median age 2.6 vs. 2.0 and 1.1), as well as a higher rate of male patients (83% vs. 77% and 58%). However, there was no difference in baseline z scores between centers. Patients who initially received IVIG and corticosteroids were less likely to require additional therapy because of persistent fever versus those receiving IVIG only, or IVIG and infliximab (0% vs. 21% vs. 14%, P = .03).

Patients receiving IVIG and corticosteroids, or IVIG and infliximab, were less likely to have progression of CAA size, with 23% and 24% having an increase in z score of more than 1 versus 58% of those who received IVIG alone. No group had significant differences in maximum z score, the rate of giant aneurysms, or the rate of regression of CAA.

Bottom line

Using IVIG + corticosteroids or IVIG + infliximab versus IVIG alone for children with Kawasaki disease with coronary artery aneurysms decreases the rate of aneurysm enlargement.

Citation

Dionne A et al. Treatment intensification in patients with Kawasaki disease and coronary aneurysm at diagnosis. Pediatrics. May 2019:e20183341. doi: 10.1542/peds.2018-3341.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question

Does use of corticosteroids or infliximab in addition to intravenous immunoglobulin improve cardiac outcomes in children with Kawasaki disease and enlarged coronary arteries?

Background

Kawasaki disease is a medium-vessel vasculitis primarily of young children. While the underlying cause remains unknown, treatment with intravenous immunoglobulin (IVIG) substantially lowers the risk of coronary artery aneurysms (CAA), the most serious sequelae of Kawasaki disease. Recent studies have suggested that – in cases of high-risk or treatment-resistant Kawasaki disease – using an immunomodulator, such as a corticosteroid or a TNF-alpha blocker, may improve outcomes, though these studies involved relatively small and homogeneous patient populations. It is unknown if these medications could prevent progression of CAA.

Study design

Retrospective multicenter study.

Setting

Two freestanding children’s hospitals and one mother-child hospital.

Synopsis

The study identified 121 children diagnosed with Kawasaki disease with CAA (z score 2.5-10) from 2008 through 2017 treated at the three study hospitals. Children with giant CAA at the time of diagnosis (z score greater than 10) or significant preexisting congenital heart disease were excluded.

All study hospitals had protocols for treatment of Kawasaki disease: Center 1 used IVIG and corticosteroids, Center 2 used IVIG and infliximab, and Center 3 used IVIG alone. Patients at all centers also received aspirin. Center 1 used methylprednisolone IV initially, changing to oral prednisolone after clinical improvement. The researchers reviewed the charts of each patient and classified them as having complete or incomplete Kawasaki disease. They assigned z scores for CAA size based on both initial and follow-up echocardiograms. The primary outcome was change in z score of CAA over the first year.

The population of patients treated at each center was significantly different. Center 1 reported older patients (median age 2.6 vs. 2.0 and 1.1), as well as a higher rate of male patients (83% vs. 77% and 58%). However, there was no difference in baseline z scores between centers. Patients who initially received IVIG and corticosteroids were less likely to require additional therapy because of persistent fever versus those receiving IVIG only, or IVIG and infliximab (0% vs. 21% vs. 14%, P = .03).

Patients receiving IVIG and corticosteroids, or IVIG and infliximab, were less likely to have progression of CAA size, with 23% and 24% having an increase in z score of more than 1 versus 58% of those who received IVIG alone. No group had significant differences in maximum z score, the rate of giant aneurysms, or the rate of regression of CAA.

Bottom line

Using IVIG + corticosteroids or IVIG + infliximab versus IVIG alone for children with Kawasaki disease with coronary artery aneurysms decreases the rate of aneurysm enlargement.

Citation

Dionne A et al. Treatment intensification in patients with Kawasaki disease and coronary aneurysm at diagnosis. Pediatrics. May 2019:e20183341. doi: 10.1542/peds.2018-3341.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question

Does use of corticosteroids or infliximab in addition to intravenous immunoglobulin improve cardiac outcomes in children with Kawasaki disease and enlarged coronary arteries?

Background

Kawasaki disease is a medium-vessel vasculitis primarily of young children. While the underlying cause remains unknown, treatment with intravenous immunoglobulin (IVIG) substantially lowers the risk of coronary artery aneurysms (CAA), the most serious sequelae of Kawasaki disease. Recent studies have suggested that – in cases of high-risk or treatment-resistant Kawasaki disease – using an immunomodulator, such as a corticosteroid or a TNF-alpha blocker, may improve outcomes, though these studies involved relatively small and homogeneous patient populations. It is unknown if these medications could prevent progression of CAA.

Study design

Retrospective multicenter study.

Setting

Two freestanding children’s hospitals and one mother-child hospital.

Synopsis

The study identified 121 children diagnosed with Kawasaki disease with CAA (z score 2.5-10) from 2008 through 2017 treated at the three study hospitals. Children with giant CAA at the time of diagnosis (z score greater than 10) or significant preexisting congenital heart disease were excluded.

All study hospitals had protocols for treatment of Kawasaki disease: Center 1 used IVIG and corticosteroids, Center 2 used IVIG and infliximab, and Center 3 used IVIG alone. Patients at all centers also received aspirin. Center 1 used methylprednisolone IV initially, changing to oral prednisolone after clinical improvement. The researchers reviewed the charts of each patient and classified them as having complete or incomplete Kawasaki disease. They assigned z scores for CAA size based on both initial and follow-up echocardiograms. The primary outcome was change in z score of CAA over the first year.

The population of patients treated at each center was significantly different. Center 1 reported older patients (median age 2.6 vs. 2.0 and 1.1), as well as a higher rate of male patients (83% vs. 77% and 58%). However, there was no difference in baseline z scores between centers. Patients who initially received IVIG and corticosteroids were less likely to require additional therapy because of persistent fever versus those receiving IVIG only, or IVIG and infliximab (0% vs. 21% vs. 14%, P = .03).

Patients receiving IVIG and corticosteroids, or IVIG and infliximab, were less likely to have progression of CAA size, with 23% and 24% having an increase in z score of more than 1 versus 58% of those who received IVIG alone. No group had significant differences in maximum z score, the rate of giant aneurysms, or the rate of regression of CAA.

Bottom line

Using IVIG + corticosteroids or IVIG + infliximab versus IVIG alone for children with Kawasaki disease with coronary artery aneurysms decreases the rate of aneurysm enlargement.

Citation

Dionne A et al. Treatment intensification in patients with Kawasaki disease and coronary aneurysm at diagnosis. Pediatrics. May 2019:e20183341. doi: 10.1542/peds.2018-3341.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question

What is the optimal way to manage analgesia during neonatal circumcision?

Background

Neonatal circumcision is one of the most commonly performed surgical procedures. The American Academy of Pediatrics in 2012 noted that the health benefits outweigh the minor risks of the procedure, but that parents should make the decision to circumcise based on their own cultural, ethical, and religious beliefs.

One of the primary risks of neonatal circumcision is pain during and after the procedure. Multiple methods for managing analgesia exist, but it is unknown what combination of methods is optimal. Usual analgesia techniques include: local anesthetic cream composed of lidocaine and prilocaine (EMLA) applied to the skin prior to the procedure; oral sucrose solution given throughout the procedure; dorsal penile nerve block (DPNB); and penile ring block (RB).
 

Study design

Single-center, double-blinded, randomized, controlled trial.

Setting

Multispecialty freestanding hospital.

Synopsis

Parents of infant boys born at 36-41 weeks’ gestation who chose to have their children circumcised were offered participation in the study. Of 83 eligible participants, 70 were randomized, with 10 in the control group (EMLA only) and 20 in each intervention (EMLA + sucrose, EMLA + sucrose + RB, EMLA + sucrose + DPNB). A single pediatric urologist performed all circumcisions using the Gomco clamp technique.

A video camera recorded the infant’s face and upper torso during the procedure. Two researchers, who were blinded to the analgesia plan, scored these videos using a modified Neonatal Infant Pain Scale (NIPS). The NIPS used ranged from 0 to 6, with 6 considered severe pain. For rating purposes, the procedure was divided into 6 stages with a NIPS score assigned at each stage. There were no significant differences in baseline characteristics among the groups; no significant differences in the duration of the procedure by intervention; and there were no complications. Interrater reliability for the NIPS was good (kappa, 0.84). All interventions were superior to EMLA alone, with significantly decreased NIPS for all stages of the procedure. No significant differences in NIPS were found among the following:

EMLA + sucrose.

EMLA + sucrose + RB.

EMLA + sucrose + DPNB (for any stage of the procedure).



The one exception was that following lysis of foreskin adhesions, EMLA + sucrose + RB was superior (NIPS 2.25 for EMLA + sucrose + RB vs. NIPS 4.4 for EMLA + sucrose + DPNB vs. NIPS 4.3 for EMLA + sucrose vs. NIPS 5.8 for EMLA alone). In terms of crying time during the procedure, all interventions were significantly superior to EMLA alone. Of the interventions, crying time was statistically and clinically significantly shorter with EMLA + sucrose + RB (5.78 seconds vs. 11.5 for EMLA + sucrose + DPNB vs. 16.5 for EMLA + sucrose vs. 45.4 for EMLA alone). This was a single-center study and the procedures were performed by a pediatric urologist rather than by a general pediatrician, which potentially limits applicability.
 

Bottom line

All tested analgesia modalities for neonatal circumcision were superior to EMLA alone. The most effective analgesia of those tested was EMLA + sucrose + penile ring block.

Citation

Sharara-Chami R et al. Combination analgesia for neonatal circumcision: a randomized controlled trial. Pediatrics. 2017. doi: 10.1542/peds.2017-1935.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question

What is the optimal way to manage analgesia during neonatal circumcision?

Background

Neonatal circumcision is one of the most commonly performed surgical procedures. The American Academy of Pediatrics in 2012 noted that the health benefits outweigh the minor risks of the procedure, but that parents should make the decision to circumcise based on their own cultural, ethical, and religious beliefs.

One of the primary risks of neonatal circumcision is pain during and after the procedure. Multiple methods for managing analgesia exist, but it is unknown what combination of methods is optimal. Usual analgesia techniques include: local anesthetic cream composed of lidocaine and prilocaine (EMLA) applied to the skin prior to the procedure; oral sucrose solution given throughout the procedure; dorsal penile nerve block (DPNB); and penile ring block (RB).
 

Study design

Single-center, double-blinded, randomized, controlled trial.

Setting

Multispecialty freestanding hospital.

Synopsis

Parents of infant boys born at 36-41 weeks’ gestation who chose to have their children circumcised were offered participation in the study. Of 83 eligible participants, 70 were randomized, with 10 in the control group (EMLA only) and 20 in each intervention (EMLA + sucrose, EMLA + sucrose + RB, EMLA + sucrose + DPNB). A single pediatric urologist performed all circumcisions using the Gomco clamp technique.

A video camera recorded the infant’s face and upper torso during the procedure. Two researchers, who were blinded to the analgesia plan, scored these videos using a modified Neonatal Infant Pain Scale (NIPS). The NIPS used ranged from 0 to 6, with 6 considered severe pain. For rating purposes, the procedure was divided into 6 stages with a NIPS score assigned at each stage. There were no significant differences in baseline characteristics among the groups; no significant differences in the duration of the procedure by intervention; and there were no complications. Interrater reliability for the NIPS was good (kappa, 0.84). All interventions were superior to EMLA alone, with significantly decreased NIPS for all stages of the procedure. No significant differences in NIPS were found among the following:

EMLA + sucrose.

EMLA + sucrose + RB.

EMLA + sucrose + DPNB (for any stage of the procedure).



The one exception was that following lysis of foreskin adhesions, EMLA + sucrose + RB was superior (NIPS 2.25 for EMLA + sucrose + RB vs. NIPS 4.4 for EMLA + sucrose + DPNB vs. NIPS 4.3 for EMLA + sucrose vs. NIPS 5.8 for EMLA alone). In terms of crying time during the procedure, all interventions were significantly superior to EMLA alone. Of the interventions, crying time was statistically and clinically significantly shorter with EMLA + sucrose + RB (5.78 seconds vs. 11.5 for EMLA + sucrose + DPNB vs. 16.5 for EMLA + sucrose vs. 45.4 for EMLA alone). This was a single-center study and the procedures were performed by a pediatric urologist rather than by a general pediatrician, which potentially limits applicability.
 

Bottom line

All tested analgesia modalities for neonatal circumcision were superior to EMLA alone. The most effective analgesia of those tested was EMLA + sucrose + penile ring block.

Citation

Sharara-Chami R et al. Combination analgesia for neonatal circumcision: a randomized controlled trial. Pediatrics. 2017. doi: 10.1542/peds.2017-1935.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question

What is the optimal way to manage analgesia during neonatal circumcision?

Background

Neonatal circumcision is one of the most commonly performed surgical procedures. The American Academy of Pediatrics in 2012 noted that the health benefits outweigh the minor risks of the procedure, but that parents should make the decision to circumcise based on their own cultural, ethical, and religious beliefs.

One of the primary risks of neonatal circumcision is pain during and after the procedure. Multiple methods for managing analgesia exist, but it is unknown what combination of methods is optimal. Usual analgesia techniques include: local anesthetic cream composed of lidocaine and prilocaine (EMLA) applied to the skin prior to the procedure; oral sucrose solution given throughout the procedure; dorsal penile nerve block (DPNB); and penile ring block (RB).
 

Study design

Single-center, double-blinded, randomized, controlled trial.

Setting

Multispecialty freestanding hospital.

Synopsis

Parents of infant boys born at 36-41 weeks’ gestation who chose to have their children circumcised were offered participation in the study. Of 83 eligible participants, 70 were randomized, with 10 in the control group (EMLA only) and 20 in each intervention (EMLA + sucrose, EMLA + sucrose + RB, EMLA + sucrose + DPNB). A single pediatric urologist performed all circumcisions using the Gomco clamp technique.

A video camera recorded the infant’s face and upper torso during the procedure. Two researchers, who were blinded to the analgesia plan, scored these videos using a modified Neonatal Infant Pain Scale (NIPS). The NIPS used ranged from 0 to 6, with 6 considered severe pain. For rating purposes, the procedure was divided into 6 stages with a NIPS score assigned at each stage. There were no significant differences in baseline characteristics among the groups; no significant differences in the duration of the procedure by intervention; and there were no complications. Interrater reliability for the NIPS was good (kappa, 0.84). All interventions were superior to EMLA alone, with significantly decreased NIPS for all stages of the procedure. No significant differences in NIPS were found among the following:

EMLA + sucrose.

EMLA + sucrose + RB.

EMLA + sucrose + DPNB (for any stage of the procedure).



The one exception was that following lysis of foreskin adhesions, EMLA + sucrose + RB was superior (NIPS 2.25 for EMLA + sucrose + RB vs. NIPS 4.4 for EMLA + sucrose + DPNB vs. NIPS 4.3 for EMLA + sucrose vs. NIPS 5.8 for EMLA alone). In terms of crying time during the procedure, all interventions were significantly superior to EMLA alone. Of the interventions, crying time was statistically and clinically significantly shorter with EMLA + sucrose + RB (5.78 seconds vs. 11.5 for EMLA + sucrose + DPNB vs. 16.5 for EMLA + sucrose vs. 45.4 for EMLA alone). This was a single-center study and the procedures were performed by a pediatric urologist rather than by a general pediatrician, which potentially limits applicability.
 

Bottom line

All tested analgesia modalities for neonatal circumcision were superior to EMLA alone. The most effective analgesia of those tested was EMLA + sucrose + penile ring block.

Citation

Sharara-Chami R et al. Combination analgesia for neonatal circumcision: a randomized controlled trial. Pediatrics. 2017. doi: 10.1542/peds.2017-1935.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question

Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?

Background

High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.

Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.¹ An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
 

Study design

Single-center prospective observational trial.

Setting

24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.

Synopsis

A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.

Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.

A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).

Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
 

Bottom line

The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.

Citation

Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.

Reference

1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.

Clinical question

Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?

Background

High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.

Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.¹ An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
 

Study design

Single-center prospective observational trial.

Setting

24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.

Synopsis

A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.

Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.

A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).

Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
 

Bottom line

The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.

Citation

Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.

Reference

1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.

Clinical question

Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?

Background

High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.

Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.¹ An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
 

Study design

Single-center prospective observational trial.

Setting

24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.

Synopsis

A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.

Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.

A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).

Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
 

Bottom line

The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.

Citation

Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.

Reference

1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.

Clinical question

What are the differences in rates of treatment failure, duration of hospitalization, and cost between nonoperative treatment (NOT) for acute uncomplicated appendicitis versus urgent appendectomy?

Background

Acute appendicitis is found in around 5% of children presenting for urgent or emergent evaluation of abdominal pain. It is the most common illness prompting emergency abdominal surgery in children.

Study design

Meta-analysis.

Search strategy

PubMed, MEDLINE, EMBASE, and Cochrane Library were searched for relevant studies. This search identified 527 potential articles, of which the authors examined the full text of 68 and ultimately identified 5 single-center trials for analysis (4 prospective cohort trials and 1 randomized, controlled trial).

Synopsis

A total of 404 patients with uncomplicated appendicitis were seen in all trials: 168 received NOT and 236 received standard surgical care (urgent appendectomy). In the single randomized, controlled trial, patients were assigned NOT or surgical care randomly. In the other trials parental preference directed therapy.

The heterogeneity of the design, populations, definitions of illness, duration of follow-up, and NOT treatment regimens made the meta-analysis challenging. Antibiotic options for NOT varied by center but included a course of IV antibiotics followed by 7-10 days of oral antibiotics. NOT success was defined as no need for surgery within 48 hours and no recurrence of appendicitis within 1 month. Of the 236 patients who received standard surgical care, all had appendicitis and 1 had a complication requiring repeat operation. Of the NOT group, 16 (9.5%) had treatment failures, including 3 with perforated appendicitis, and 45 (27%) went on to have an appendectomy within the following year, yielding a risk ratio of failure versus standard treatment of 8.9 (95% confidence interval, 2.7-29.8). A subgroup analysis of patients with appendicoliths who received NOT found that these patients experienced a substantially increased risk of treatment failures and recurrent appendicitis with the risk ratio versus NOT without appendicolith of 10.4 (95% CI, 1.5-74). Of the 30 patients who experienced treatment failure with NOT, 15 had appendicoliths. NOT lengthened hospital stays by 14.3 hours (95% CI, 7.5-21.1) but led to lower total costs by $1,310 (95% CI, $920-$1,690).
 

Bottom line

NOT may be a reasonable alternative to standard surgical management for acute uncomplicated appendicitis without appendicolith in children, with a success rate of greater than 90%. Further larger, randomized prospective studies are required to establish its safety and efficacy.

Citation

Huang L et al. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: A meta-analysis. JAMA Pediatr. 2017;171(5):426-34.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.

Clinical question

What are the differences in rates of treatment failure, duration of hospitalization, and cost between nonoperative treatment (NOT) for acute uncomplicated appendicitis versus urgent appendectomy?

Background

Acute appendicitis is found in around 5% of children presenting for urgent or emergent evaluation of abdominal pain. It is the most common illness prompting emergency abdominal surgery in children.

Study design

Meta-analysis.

Search strategy

PubMed, MEDLINE, EMBASE, and Cochrane Library were searched for relevant studies. This search identified 527 potential articles, of which the authors examined the full text of 68 and ultimately identified 5 single-center trials for analysis (4 prospective cohort trials and 1 randomized, controlled trial).

Synopsis

A total of 404 patients with uncomplicated appendicitis were seen in all trials: 168 received NOT and 236 received standard surgical care (urgent appendectomy). In the single randomized, controlled trial, patients were assigned NOT or surgical care randomly. In the other trials parental preference directed therapy.

The heterogeneity of the design, populations, definitions of illness, duration of follow-up, and NOT treatment regimens made the meta-analysis challenging. Antibiotic options for NOT varied by center but included a course of IV antibiotics followed by 7-10 days of oral antibiotics. NOT success was defined as no need for surgery within 48 hours and no recurrence of appendicitis within 1 month. Of the 236 patients who received standard surgical care, all had appendicitis and 1 had a complication requiring repeat operation. Of the NOT group, 16 (9.5%) had treatment failures, including 3 with perforated appendicitis, and 45 (27%) went on to have an appendectomy within the following year, yielding a risk ratio of failure versus standard treatment of 8.9 (95% confidence interval, 2.7-29.8). A subgroup analysis of patients with appendicoliths who received NOT found that these patients experienced a substantially increased risk of treatment failures and recurrent appendicitis with the risk ratio versus NOT without appendicolith of 10.4 (95% CI, 1.5-74). Of the 30 patients who experienced treatment failure with NOT, 15 had appendicoliths. NOT lengthened hospital stays by 14.3 hours (95% CI, 7.5-21.1) but led to lower total costs by $1,310 (95% CI, $920-$1,690).
 

Bottom line

NOT may be a reasonable alternative to standard surgical management for acute uncomplicated appendicitis without appendicolith in children, with a success rate of greater than 90%. Further larger, randomized prospective studies are required to establish its safety and efficacy.

Citation

Huang L et al. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: A meta-analysis. JAMA Pediatr. 2017;171(5):426-34.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.

Clinical question

What are the differences in rates of treatment failure, duration of hospitalization, and cost between nonoperative treatment (NOT) for acute uncomplicated appendicitis versus urgent appendectomy?

Background

Acute appendicitis is found in around 5% of children presenting for urgent or emergent evaluation of abdominal pain. It is the most common illness prompting emergency abdominal surgery in children.

Study design

Meta-analysis.

Search strategy

PubMed, MEDLINE, EMBASE, and Cochrane Library were searched for relevant studies. This search identified 527 potential articles, of which the authors examined the full text of 68 and ultimately identified 5 single-center trials for analysis (4 prospective cohort trials and 1 randomized, controlled trial).

Synopsis

A total of 404 patients with uncomplicated appendicitis were seen in all trials: 168 received NOT and 236 received standard surgical care (urgent appendectomy). In the single randomized, controlled trial, patients were assigned NOT or surgical care randomly. In the other trials parental preference directed therapy.

The heterogeneity of the design, populations, definitions of illness, duration of follow-up, and NOT treatment regimens made the meta-analysis challenging. Antibiotic options for NOT varied by center but included a course of IV antibiotics followed by 7-10 days of oral antibiotics. NOT success was defined as no need for surgery within 48 hours and no recurrence of appendicitis within 1 month. Of the 236 patients who received standard surgical care, all had appendicitis and 1 had a complication requiring repeat operation. Of the NOT group, 16 (9.5%) had treatment failures, including 3 with perforated appendicitis, and 45 (27%) went on to have an appendectomy within the following year, yielding a risk ratio of failure versus standard treatment of 8.9 (95% confidence interval, 2.7-29.8). A subgroup analysis of patients with appendicoliths who received NOT found that these patients experienced a substantially increased risk of treatment failures and recurrent appendicitis with the risk ratio versus NOT without appendicolith of 10.4 (95% CI, 1.5-74). Of the 30 patients who experienced treatment failure with NOT, 15 had appendicoliths. NOT lengthened hospital stays by 14.3 hours (95% CI, 7.5-21.1) but led to lower total costs by $1,310 (95% CI, $920-$1,690).
 

Bottom line

NOT may be a reasonable alternative to standard surgical management for acute uncomplicated appendicitis without appendicolith in children, with a success rate of greater than 90%. Further larger, randomized prospective studies are required to establish its safety and efficacy.

Citation

Huang L et al. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: A meta-analysis. JAMA Pediatr. 2017;171(5):426-34.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.

Clinical question: Are oral antibiotics as effective as intravenous (IV) antibiotics in the treatment of complicated pneumonia after discharge to home?

Background: Pneumonia is the most common illness among hospitalized children and adolescents (excluding neonates). Among children admitted with community acquired pneumonia, 15% may develop a complicated pneumonia (one with a pleural effusion or empyema). Treatment for these complicated pneumonias may include a variety of invasive procedures, such as video-assisted thorascopic surgery or chest tube placement.

Typically, a long course of antibiotics is prescribed on discharge, which may be oral or parenterally administered via a peripherally inserted central catheter (PICC). Previous studies have shown that oral antibiotics are equivalent to parenteral antibiotics for outpatient treatment of osteomyelitis. However, little evidence exists comparing the effectiveness of the two routes in treating complicated pneumonia.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: Are oral antibiotics as effective as intravenous (IV) antibiotics in the treatment of complicated pneumonia after discharge to home?

Background: Pneumonia is the most common illness among hospitalized children and adolescents (excluding neonates). Among children admitted with community acquired pneumonia, 15% may develop a complicated pneumonia (one with a pleural effusion or empyema). Treatment for these complicated pneumonias may include a variety of invasive procedures, such as video-assisted thorascopic surgery or chest tube placement.

Typically, a long course of antibiotics is prescribed on discharge, which may be oral or parenterally administered via a peripherally inserted central catheter (PICC). Previous studies have shown that oral antibiotics are equivalent to parenteral antibiotics for outpatient treatment of osteomyelitis. However, little evidence exists comparing the effectiveness of the two routes in treating complicated pneumonia.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: Are oral antibiotics as effective as intravenous (IV) antibiotics in the treatment of complicated pneumonia after discharge to home?

Background: Pneumonia is the most common illness among hospitalized children and adolescents (excluding neonates). Among children admitted with community acquired pneumonia, 15% may develop a complicated pneumonia (one with a pleural effusion or empyema). Treatment for these complicated pneumonias may include a variety of invasive procedures, such as video-assisted thorascopic surgery or chest tube placement.

Typically, a long course of antibiotics is prescribed on discharge, which may be oral or parenterally administered via a peripherally inserted central catheter (PICC). Previous studies have shown that oral antibiotics are equivalent to parenteral antibiotics for outpatient treatment of osteomyelitis. However, little evidence exists comparing the effectiveness of the two routes in treating complicated pneumonia.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: What are the effects of implementing standardized clinical pathways on length of stay, cost, readmissions, and patient quality of life?

Background: As payment models shift from volume- to value-based models, standardized clinical pathways are one option to simultaneously provide high-value care, improve quality, and control costs. Studies of individual clinical pathways suggest that they may be helpful in decreasing utilization, but the measured impact has varied significantly. It is unknown how much of the measured effect is due to the pathway and how much is due to the clinical factors of the disease or patient population studied. No prior studies have evaluated a suite of clinical pathways in pediatric populations.

Study design: Retrospective cohort study.

Setting: Single, 250-bed, tertiary care, freestanding children’s hospital.

Synopsis: Over four years, 15 clinical pathways were created for common pediatric medical, surgical, and psychiatric complaints (urinary tract infection, diabetes, both diabetic ketoacidosis [DKA] and non-DKA, fractures, spinal surgery, croup, neonatal jaundice, neonatal fever, depressive disorders, pyloric stenosis, pneumonia, tonsillectomy and adenoidectomy, disruptive behavior, and cellulitis/abscess).

The pathways were implemented when they were complete, with guidelines coming online throughout the study period. Implementation included an order set in the electronic medical record that included relevant literature references and decision support, online training, and integration into the clinical workflow for providers and nurses. Use of the pathways was monitored, and they were reviewed on at least a quarterly basis and revised, if necessary.

The authors examined pathway use for eligible patients, hospital costs, length of stay, 30-day readmissions, and parent-reported quality of life, both before and after pathway implementation. Patients meeting criteria for complex chronic conditions were excluded from the study.

Before implementation, 3,808 admissions fulfilled pathway criteria, and 2,902 fulfilled criteria after implementation. The pathway for depressive disorders was the most used pathway, with 411 admissions and 95% of eligible patients on the pathway. Both pyloric stenosis and neonatal jaundice had 100% pathway use.

The lowest rate of pathway use was for urinary tract infection (20%). Pathway implementation slowed the rate of rise of hospital costs. Prior to study implementation, the costs were increasing by $126 per month. Following implementation, costs decreased by $29 per month (95% CI, $100 decrease to $34 increase; P=.001). Post-implementation, the length of stay for pathway-eligible patients began a statistically significant downward trend at a rate that yielded a decrease in length of stay of 8.6 hours over a year (P=0.02). There were no differences in 30-day readmissions or parent-reported quality of life.

Bottom line: Systematic development and implementation of clinical pathways for a variety of conditions can contain costs and decrease length of stay while maintaining clinical outcomes and not increasing readmissions.

Citation: Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized clinical pathways for hospitalized children and outcomes. Pediatrics. 2016;137(4). pii:e20151202. doi:10.1542/peds.2015-1202.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: What are the effects of implementing standardized clinical pathways on length of stay, cost, readmissions, and patient quality of life?

Background: As payment models shift from volume- to value-based models, standardized clinical pathways are one option to simultaneously provide high-value care, improve quality, and control costs. Studies of individual clinical pathways suggest that they may be helpful in decreasing utilization, but the measured impact has varied significantly. It is unknown how much of the measured effect is due to the pathway and how much is due to the clinical factors of the disease or patient population studied. No prior studies have evaluated a suite of clinical pathways in pediatric populations.

Study design: Retrospective cohort study.

Setting: Single, 250-bed, tertiary care, freestanding children’s hospital.

Synopsis: Over four years, 15 clinical pathways were created for common pediatric medical, surgical, and psychiatric complaints (urinary tract infection, diabetes, both diabetic ketoacidosis [DKA] and non-DKA, fractures, spinal surgery, croup, neonatal jaundice, neonatal fever, depressive disorders, pyloric stenosis, pneumonia, tonsillectomy and adenoidectomy, disruptive behavior, and cellulitis/abscess).

The pathways were implemented when they were complete, with guidelines coming online throughout the study period. Implementation included an order set in the electronic medical record that included relevant literature references and decision support, online training, and integration into the clinical workflow for providers and nurses. Use of the pathways was monitored, and they were reviewed on at least a quarterly basis and revised, if necessary.

The authors examined pathway use for eligible patients, hospital costs, length of stay, 30-day readmissions, and parent-reported quality of life, both before and after pathway implementation. Patients meeting criteria for complex chronic conditions were excluded from the study.

Before implementation, 3,808 admissions fulfilled pathway criteria, and 2,902 fulfilled criteria after implementation. The pathway for depressive disorders was the most used pathway, with 411 admissions and 95% of eligible patients on the pathway. Both pyloric stenosis and neonatal jaundice had 100% pathway use.

The lowest rate of pathway use was for urinary tract infection (20%). Pathway implementation slowed the rate of rise of hospital costs. Prior to study implementation, the costs were increasing by $126 per month. Following implementation, costs decreased by $29 per month (95% CI, $100 decrease to $34 increase; P=.001). Post-implementation, the length of stay for pathway-eligible patients began a statistically significant downward trend at a rate that yielded a decrease in length of stay of 8.6 hours over a year (P=0.02). There were no differences in 30-day readmissions or parent-reported quality of life.

Bottom line: Systematic development and implementation of clinical pathways for a variety of conditions can contain costs and decrease length of stay while maintaining clinical outcomes and not increasing readmissions.

Citation: Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized clinical pathways for hospitalized children and outcomes. Pediatrics. 2016;137(4). pii:e20151202. doi:10.1542/peds.2015-1202.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: What are the effects of implementing standardized clinical pathways on length of stay, cost, readmissions, and patient quality of life?

Background: As payment models shift from volume- to value-based models, standardized clinical pathways are one option to simultaneously provide high-value care, improve quality, and control costs. Studies of individual clinical pathways suggest that they may be helpful in decreasing utilization, but the measured impact has varied significantly. It is unknown how much of the measured effect is due to the pathway and how much is due to the clinical factors of the disease or patient population studied. No prior studies have evaluated a suite of clinical pathways in pediatric populations.

Study design: Retrospective cohort study.

Setting: Single, 250-bed, tertiary care, freestanding children’s hospital.

Synopsis: Over four years, 15 clinical pathways were created for common pediatric medical, surgical, and psychiatric complaints (urinary tract infection, diabetes, both diabetic ketoacidosis [DKA] and non-DKA, fractures, spinal surgery, croup, neonatal jaundice, neonatal fever, depressive disorders, pyloric stenosis, pneumonia, tonsillectomy and adenoidectomy, disruptive behavior, and cellulitis/abscess).

The pathways were implemented when they were complete, with guidelines coming online throughout the study period. Implementation included an order set in the electronic medical record that included relevant literature references and decision support, online training, and integration into the clinical workflow for providers and nurses. Use of the pathways was monitored, and they were reviewed on at least a quarterly basis and revised, if necessary.

The authors examined pathway use for eligible patients, hospital costs, length of stay, 30-day readmissions, and parent-reported quality of life, both before and after pathway implementation. Patients meeting criteria for complex chronic conditions were excluded from the study.

Before implementation, 3,808 admissions fulfilled pathway criteria, and 2,902 fulfilled criteria after implementation. The pathway for depressive disorders was the most used pathway, with 411 admissions and 95% of eligible patients on the pathway. Both pyloric stenosis and neonatal jaundice had 100% pathway use.

The lowest rate of pathway use was for urinary tract infection (20%). Pathway implementation slowed the rate of rise of hospital costs. Prior to study implementation, the costs were increasing by $126 per month. Following implementation, costs decreased by $29 per month (95% CI, $100 decrease to $34 increase; P=.001). Post-implementation, the length of stay for pathway-eligible patients began a statistically significant downward trend at a rate that yielded a decrease in length of stay of 8.6 hours over a year (P=0.02). There were no differences in 30-day readmissions or parent-reported quality of life.

Bottom line: Systematic development and implementation of clinical pathways for a variety of conditions can contain costs and decrease length of stay while maintaining clinical outcomes and not increasing readmissions.

Citation: Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized clinical pathways for hospitalized children and outcomes. Pediatrics. 2016;137(4). pii:e20151202. doi:10.1542/peds.2015-1202.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can a trigger tool identify harms for hospitalized children?

Background: An estimated 400,000 people die annually in the United States as a result of hospital-associated harm. The Centers for Medicare and Medicaid Services define harm as “unintended physical injury … by medical care that required additional monitoring, treatment, or hospitalization or that resulted in death.” Although harm is common, voluntary reporting of events has been shown to capture only 2%-8% of harm. Global Trigger Tools (GTT) are an alternative to voluntary reports. These tools use “triggers,” or clues, to help reviewers identify potential harms when reviewing the electronic heath record. The Institute for Healthcare Improvement (IHI) has created an adult-focused GTT; however, no pediatric-focused GTT exists.

Study design: Cross-sectional, retrospective chart review.

Setting: Children <22 years old discharged from six freestanding U.S. children’s hospitals in February 2012.

Synopsis: In a prior paper, the authors described how they used a modified Delphi technique to develop a pediatric GTT based upon the IHI GTT. Here they piloted this new pediatric-focused GTT through a retrospective chart review. One clinical nonphysician reviewer and one physician reviewer were selected from each site and received training on use of the pediatric GTT and the identification of harms. One hundred charts from each site were randomly selected for application of the GTT. The reviewers examined the charts for harms and then applied the GTT. When reviewers found a harm, they determined the likelihood that the harm was preventable.

Of the 600 records reviewed, 240 harms were found. The GTT identified 1,093 potential harms, leading to identification of 204 harms. The remaining 36 harms did not cause a trigger and were found by chart review. The positive predictive value of the aggregate GTT was 22%. There were 40 harms per 100 patients, and 24.3% of patients had one or more harm. Sixty-eight percent of harms were of the least severe type, and only one led to a patient death. The most common harms were intravenous catheter infiltration, respiratory distress, constipation, pain, and surgical complications.

Bottom line: The pediatric GTT appears to be a moderately sensitive indicator for inpatient pediatric harm. Inpatient pediatric harm occurs frequently, with about one in four pediatric inpatients suffering from harm. Serious harm appears uncommon.

Citation: Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.

Clinical question: Can a trigger tool identify harms for hospitalized children?

Background: An estimated 400,000 people die annually in the United States as a result of hospital-associated harm. The Centers for Medicare and Medicaid Services define harm as “unintended physical injury … by medical care that required additional monitoring, treatment, or hospitalization or that resulted in death.” Although harm is common, voluntary reporting of events has been shown to capture only 2%-8% of harm. Global Trigger Tools (GTT) are an alternative to voluntary reports. These tools use “triggers,” or clues, to help reviewers identify potential harms when reviewing the electronic heath record. The Institute for Healthcare Improvement (IHI) has created an adult-focused GTT; however, no pediatric-focused GTT exists.

Study design: Cross-sectional, retrospective chart review.

Setting: Children <22 years old discharged from six freestanding U.S. children’s hospitals in February 2012.

Synopsis: In a prior paper, the authors described how they used a modified Delphi technique to develop a pediatric GTT based upon the IHI GTT. Here they piloted this new pediatric-focused GTT through a retrospective chart review. One clinical nonphysician reviewer and one physician reviewer were selected from each site and received training on use of the pediatric GTT and the identification of harms. One hundred charts from each site were randomly selected for application of the GTT. The reviewers examined the charts for harms and then applied the GTT. When reviewers found a harm, they determined the likelihood that the harm was preventable.

Of the 600 records reviewed, 240 harms were found. The GTT identified 1,093 potential harms, leading to identification of 204 harms. The remaining 36 harms did not cause a trigger and were found by chart review. The positive predictive value of the aggregate GTT was 22%. There were 40 harms per 100 patients, and 24.3% of patients had one or more harm. Sixty-eight percent of harms were of the least severe type, and only one led to a patient death. The most common harms were intravenous catheter infiltration, respiratory distress, constipation, pain, and surgical complications.

Bottom line: The pediatric GTT appears to be a moderately sensitive indicator for inpatient pediatric harm. Inpatient pediatric harm occurs frequently, with about one in four pediatric inpatients suffering from harm. Serious harm appears uncommon.

Citation: Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.

Clinical question: Can a trigger tool identify harms for hospitalized children?

Background: An estimated 400,000 people die annually in the United States as a result of hospital-associated harm. The Centers for Medicare and Medicaid Services define harm as “unintended physical injury … by medical care that required additional monitoring, treatment, or hospitalization or that resulted in death.” Although harm is common, voluntary reporting of events has been shown to capture only 2%-8% of harm. Global Trigger Tools (GTT) are an alternative to voluntary reports. These tools use “triggers,” or clues, to help reviewers identify potential harms when reviewing the electronic heath record. The Institute for Healthcare Improvement (IHI) has created an adult-focused GTT; however, no pediatric-focused GTT exists.

Study design: Cross-sectional, retrospective chart review.

Setting: Children <22 years old discharged from six freestanding U.S. children’s hospitals in February 2012.

Synopsis: In a prior paper, the authors described how they used a modified Delphi technique to develop a pediatric GTT based upon the IHI GTT. Here they piloted this new pediatric-focused GTT through a retrospective chart review. One clinical nonphysician reviewer and one physician reviewer were selected from each site and received training on use of the pediatric GTT and the identification of harms. One hundred charts from each site were randomly selected for application of the GTT. The reviewers examined the charts for harms and then applied the GTT. When reviewers found a harm, they determined the likelihood that the harm was preventable.

Of the 600 records reviewed, 240 harms were found. The GTT identified 1,093 potential harms, leading to identification of 204 harms. The remaining 36 harms did not cause a trigger and were found by chart review. The positive predictive value of the aggregate GTT was 22%. There were 40 harms per 100 patients, and 24.3% of patients had one or more harm. Sixty-eight percent of harms were of the least severe type, and only one led to a patient death. The most common harms were intravenous catheter infiltration, respiratory distress, constipation, pain, and surgical complications.

Bottom line: The pediatric GTT appears to be a moderately sensitive indicator for inpatient pediatric harm. Inpatient pediatric harm occurs frequently, with about one in four pediatric inpatients suffering from harm. Serious harm appears uncommon.

Citation: Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.

Clinical question: Have the causative organisms in pediatric bacteremia changed over time concurrent with introduction of the pneumococcal conjugate vaccine?

Background: Previous research has shown introduction of polyvalent pneumococcal conjugate vaccine led to changes in the organisms causing meningitis and otitis media, and patterns of nasopharyngeal colonization. Pneumococcus, historically, was a common cause of bacteremia. The availability of pneumococcal conjugate vaccine may have changed the organisms causing bacteremia in children.

Study design: Retrospective chart review and time series.

Setting: Children presenting to the ED of Alder Hey Children’s Hospital in Liverpool, England, from 2001 to 2011.

Synopsis: Five hundred seventy-five episodes of bacteremia were found in 525 children. Infants most commonly had E. coli and Group B streptococcal infections; children over age five most commonly had S. aureus. The introduction of the pneumococcal conjugate vaccine decreased pneumococcal bacteremia by 49% over the study period. This decrease was accompanied by an increase in Gram-negative bacteremia. Susceptibility to empiric antibiotics (third-generation cephalosporins) dropped from 96% to 83%. Over the study period, more children presented with central venous lines, which was felt to be due to increasing outpatient use of total parenteral nutrition (TPN).

Bottom line: Vaccination against pneumococcus is changing the microbiology of pediatric bacteremia, with fewer vaccine-preventable Gram-positive infections and more Gram-negative infections. This increases the likelihood of resistance to third-generation cephalosporins as empiric antibiotic.

Citation: Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4): 635-642.

Clinical question: Have the causative organisms in pediatric bacteremia changed over time concurrent with introduction of the pneumococcal conjugate vaccine?

Background: Previous research has shown introduction of polyvalent pneumococcal conjugate vaccine led to changes in the organisms causing meningitis and otitis media, and patterns of nasopharyngeal colonization. Pneumococcus, historically, was a common cause of bacteremia. The availability of pneumococcal conjugate vaccine may have changed the organisms causing bacteremia in children.

Study design: Retrospective chart review and time series.

Setting: Children presenting to the ED of Alder Hey Children’s Hospital in Liverpool, England, from 2001 to 2011.

Synopsis: Five hundred seventy-five episodes of bacteremia were found in 525 children. Infants most commonly had E. coli and Group B streptococcal infections; children over age five most commonly had S. aureus. The introduction of the pneumococcal conjugate vaccine decreased pneumococcal bacteremia by 49% over the study period. This decrease was accompanied by an increase in Gram-negative bacteremia. Susceptibility to empiric antibiotics (third-generation cephalosporins) dropped from 96% to 83%. Over the study period, more children presented with central venous lines, which was felt to be due to increasing outpatient use of total parenteral nutrition (TPN).

Bottom line: Vaccination against pneumococcus is changing the microbiology of pediatric bacteremia, with fewer vaccine-preventable Gram-positive infections and more Gram-negative infections. This increases the likelihood of resistance to third-generation cephalosporins as empiric antibiotic.

Citation: Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4): 635-642.

Clinical question: Have the causative organisms in pediatric bacteremia changed over time concurrent with introduction of the pneumococcal conjugate vaccine?

Background: Previous research has shown introduction of polyvalent pneumococcal conjugate vaccine led to changes in the organisms causing meningitis and otitis media, and patterns of nasopharyngeal colonization. Pneumococcus, historically, was a common cause of bacteremia. The availability of pneumococcal conjugate vaccine may have changed the organisms causing bacteremia in children.

Study design: Retrospective chart review and time series.

Setting: Children presenting to the ED of Alder Hey Children’s Hospital in Liverpool, England, from 2001 to 2011.

Synopsis: Five hundred seventy-five episodes of bacteremia were found in 525 children. Infants most commonly had E. coli and Group B streptococcal infections; children over age five most commonly had S. aureus. The introduction of the pneumococcal conjugate vaccine decreased pneumococcal bacteremia by 49% over the study period. This decrease was accompanied by an increase in Gram-negative bacteremia. Susceptibility to empiric antibiotics (third-generation cephalosporins) dropped from 96% to 83%. Over the study period, more children presented with central venous lines, which was felt to be due to increasing outpatient use of total parenteral nutrition (TPN).

Bottom line: Vaccination against pneumococcus is changing the microbiology of pediatric bacteremia, with fewer vaccine-preventable Gram-positive infections and more Gram-negative infections. This increases the likelihood of resistance to third-generation cephalosporins as empiric antibiotic.

Citation: Irwin AD, Drew RJ, Marshall P, et al. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics. 2015;135(4): 635-642.