The year 2023 brought us waves of advances in technology, increasing vaccine hesitancy, an ongoing behavioral health crisis, and civil unrest overseas which continues to echo throughout the world.
Pediatric hospitalists witness first-hand how these circumstances impact the breadth of disease processes in childhood and beyond. Hospitalists are at the forefront of addressing issues that often spread beyond the hospital in caring for this vulnerable population.
In this update, we aimed to highlight work relevant to newborn through adolescent care stages, to reflect on pertinent areas for future research in the field of pediatric hospital medicine, and to recognize how social factors contribute to the health and well-being of hospitalized children.
In this article, we identify the top 10 publications in pediatric hospital medicine for 2023, as presented at the Pediatric Update at SHM Converge 2024 in San Diego. Four of those articles are summarized here.
Eat, sleep, console approach or usual care for neonatal opioid withdrawal
Young L, Ounpraseuth ST, et al. Eat, sleep, console approach or usual care for neonatal opioid withdrawal. N Engl J Med. 2023;388(25):2326-37.
Background: Treatment for neonatal opioid withdrawal syndrome in the past depended on subjective, observer-scored systems. There were concerns that these systems overestimated the need for pharmacologic therapies.1 The Eat, Sleep, Console Care Tool assesses the infant’s ability to eat, sleep, and be consoled with nonpharmacologic interventions before administrating medications.
Findings: A multicenter, stepped-wedged, cluster-randomized controlled trial was conducted at 26 U.S. hospitals in the ACT NOW Collaborative. During the first trial period, all infants with neonatal opioid withdrawal syndrome were treated according to usual care practices at their site. After training and implementation of the new protocol, infants with opioid withdrawal were cared for using the Eat, Sleep, Console Care Tool. The mean length of time from birth until medical readiness for discharge was shorter in the eat, sleep, console group (8.2 days) than in the usual-care group (14.9 days) with an adjusted mean difference of 6.7 days (95% confidence interval [CI], 4.7 to 8.8) The infants in the eat, sleep, console group saw a reduction in pharmacologic therapy to 19.5%, compared to 52% in the usual-care group.
Practice implications— Infants with neonatal opioid withdrawal syndrome treated according to the eat, sleep, console approach have significantly reduced time to readiness for discharge, likely due to the decrease in pharmacologic therapy. There were no safety concerns compared to usual care during the hospitalization and in the three months following birth. Further adoption of this protocol by hospitals can continue to ensure the safety of this approach and provide more longitudinal data.
Child opportunity index and rehospitalization for ambulatory care sensitive conditions at US children’s hospitals
Parikh K, Lopez MA, et al. Child opportunity index and rehospitalization for ambulatory care sensitive conditions at US children’s hospitals. Hosp Pediatr. 2023;13(11):1028-37.
Background: The child opportunity index (COI) measures neighborhood factors that contribute to a child’s ability to thrive.2 Ambulatory care sensitive conditions (ACSC) are those for which the risk of hospitalization can be decreased when children receive effective outpatient healthcare. Social and economic factors are associated with healthcare utilization for ACSC, but limited research currently exists regarding rehospitalization trends for ACSC based on COI.3 This study aimed to examine the association between COI and rehospitalizations for ACSC.
Findings: This retrospective cohort study used the pediatric health information system (PHIS) database to identify children under 18 years old with hospitalizations for ACSC in 2017-2018. They collected COI information and examined the proportion of children from different COI levels with rehospitalizations for ACSC within one year; 184,478 children were hospitalized for ACSC during the study timeframe. After adjusting for age, sex, complex medical conditions, and mental health diagnoses, 18.7% of patients from very low COI neighborhoods had rehospitalizations within one year for ACSC, compared to 13.5% of children from very high COI neighborhoods, a statistically significant difference. Patients from very low COI neighborhoods had an adjusted odds ratio of 1.14 for readmission within one year, and 1.51 for two or more readmissions within one year, compared to patients from very high COI neighborhoods.
Practice implications—Readmissions for ACSC were significantly higher for children from lower-opportunity neighborhoods. Childhood health depends on multiple factors that go beyond their primary practitioners, including those influenced by healthcare systems and patients’ environments. This study highlights opportunities to improve health outcomes and reduce preventable healthcare utilization for children living in low-opportunity neighborhoods by incorporating COI data into clinical practice, partnering with community programs, and examining the role that each individual COI factor plays in health and healthcare utilization.
Medical child welfare task force: A multidisciplinary approach to identifying medical child abuse
Vega S, Nienow SM, et al. Medical child welfare task force: A multidisciplinary approach to identifying medical child abuse. Pediatrics. 2023;151(2):e2022058926. doi: 10.1542/peds.2022-058926.
Background: Medical child abuse (MCA) is a form of child abuse in which caregivers invent, exaggerate, or induce symptoms in a child resulting in harmful medical care.4 MCA is associated with high morbidity and mortality and can be extremely difficult to diagnose.5 Following a long-standing case of MCA in the healthcare system associated with this article, an MCA Welfare Taskforce was created. The process of creation and implementation of the task force, as well as pertinent outcomes thus far, are summarized in this article.
Findings: A root-cause analysis before task force creation identified that inadequate knowledge about the recognition and management of MCA, insufficient collaboration among involved practitioners, and lack of effective means to communicate or track concerns in the electronic health record were the most pressing deficits in management of the sentinel MCA case. To assist with ongoing case identification and management, education was provided to clinicians about recognizing indicators of MCA, a dashboard was created to track and communicate about patients with concern for MCA, and frequent team meetings were held to discuss cases and develop management plans. From 2019 to 2022, 44 cases were reviewed by the task force, of which 15 patients were diagnosed with MCA and 14 with overutilization of healthcare. Twenty-two patients were referred to child protective services—seven had resolutions of symptoms after removal from the home, and 15 underwent safety monitoring while the medical team de-escalated care. Most practitioners who interacted with the task force felt their ability to recognize and manage MCA improved and that the task force was beneficial to them and their patients. However, most physicians also felt they would benefit from ongoing education on the topic.
Practice implications— This article highlights three main areas of focus for improving care for patients who are victims of MCA, with the first being education. It is imperative that all pediatric practitioners familiarize themselves with indicators of MCA, as its diagnosis is complex and requires the input of a patient’s entire medical team. The second area of focus is communication. We must communicate concerns with other practitioners, including those in the outpatient setting and other healthcare systems when there is a concern for MCA, as this is often the only way to see the bigger picture of healthcare misuse. Finally, as there are often no dedicated resources or funding to see to MCA cases, the authors of this article express hope that their work will influence other institutions to take on similar efforts and advocate for the means to care for children who are victims of MCA.
Bivalent prefusion F vaccine in pregnancy to prevent RSV illness in infants
Kampmann B, Madhi SA, et al. Bivalent prefusion F vaccine in pregnancy to prevent RSV illness in infants. N Engl J Med. 2023;388(16):1451-64.
Background: Respiratory syncytial virus (RSV) is the most common cause of acute lower respiratory tract illness. Particularly in low- and middle-income countries, RSV is one of the leading causes of death in infants less than six months of age.6,7 The bivalent RSV prefusion F protein-based vaccine was trialed for safety in women during their second and third trimesters, but the efficacy of preventing RSV-associated infections in their infants had not yet been studied on a large scale.8
Findings: This double-blind, randomized, placebo-controlled trial took place in 18 countries over four RSV seasons. In the study, women who were 24 to 36 weeks pregnant were given either the bivalent RSV prefusion F protein-based vaccine or the placebo. Within 90 days after birth, six infants of mothers in the vaccine group compared to 33 infants of those in the placebo group had medically attended, severe, RSV-associated, lower respiratory tract illness (vaccine efficacy, 81.8%; 99.5% confidence interval [CI], 40.6 to 96.3). Within 180 days after birth, there were 19 cases of severe, RSV-associated, lower respiratory tract illness in the vaccine group compared to 62 cases in the placebo group (vaccine efficacy, 69.4%; 97.58% CI, 44.3 to 84.1).
Practice implications—Infants whose mothers received the RSV vaccine had a greater reduction in severe RSV-associated lower respiratory tract infections. While the use of nirsevimab, an anti-RSV monoclonal antibody, also reduces rates of medically attended RSV-associated lower respiratory tract infections, it is not widely available.9 With the help of the RSV vaccine, there is hope for a greater reduction in RSV-associated hospitalizations and deaths worldwide.
Remaining top-10 articles
Tweet M, Nemanich A, et al. Pediatric edible cannabis exposures and acute toxicity: 2017-2021. Pediatrics. 2023;151(2):e2022057761. doi: 10.1542/peds.2022-057761. This study evaluates trends in pediatric cannabis edible ingestions in children younger than age 6 with regard to toxicity, medical outcome, and healthcare utilization for the years 2017-2021.
Shaikh N, Lee S, et al. Support for the use of a new cutoff to define a positive urine culture in young children. Pediatrics. 2023;152(4):e2023061931. doi: 10.1542/peds.2023-061931. Conventional urine culture selects for a narrow range of organisms that grow well in aerobic conditions. In contrast, examination of bacterial gene sequences in the urine provides a relatively unbiased evaluation of the organisms present. Thus, by using 16S ribosomal ribonucleic acid gene amplicon sequencing as the reference standard, we can now assess the accuracy of urine culture in diagnosing urinary tract infections.
Rajbhandari P, Glick AF, et al. Linguistic services for hospitalized children with non-English language preference: A PRIS network survey. Hosp Pediatr. 2023;13(3):191-203. Linguistic services are critical to providing equitable healthcare for families with non-English language preference (NELP). Despite evidence of provider disuse and misuse of linguistic services and resultant adverse outcomes, few studies have assessed the practices of pediatric hospitalists related to the use of linguistic services. This study’s objectives were to evaluate the current practices of communication and linguistic services used by pediatric hospitalists for hospitalized children with NELP and the barriers encountered in their use.
Miyata K, Bainto EV, et al. Infliximab for intensification of primary therapy for patients with Kawasaki disease and coronary artery aneurysms at diagnosis. Arch Dis Child. 2023;108(10):833-838. Children with Kawasaki disease and an initial echocardiogram that demonstrates coronary artery aneurysms (CAAs, Z score ≥2.5) are at high risk for severe cardiovascular complications. This study sought to determine if primary adjunctive infliximab treatment at a dose of either 5 or 10 mg/kg, compared with intravenous immunoglobulin alone, is associated with a greater likelihood of CAA regression in patients with Kawasaki disease with CAA at the time of diagnosis.
Breuner C, Alderman EM, et al. The hospitalized adolescent. Pediatrics. 2023;151(2):e2022060647. doi: 10.1542/peds.2022-060647. This clinical report provides pediatricians with evidence-based information on developmentally appropriate, comprehensive clinical care for hospitalized adolescents, including opportunities and challenges facing pediatricians when caring for specific hospitalized adolescent populations.
Kooiman L, Blankespoor F, et al. High-flow oxygen therapy in moderate to severe bronchiolitis: a randomised controlled trial. Arch Dis Child. 2023;108(6):455-60. High-flow oxygen therapy is being used increasingly in infants with bronchiolitis, despite a lack of convincing evidence of its superiority over low-flow. This study aimed to compare the effect of high-flow to low-flow in moderate to severe bronchiolitis.
Dr.Vargas
Dr. ten Hope
Dr. Vargas is a medicine-pediatrics hospitalist and clinical assistant professor at the University of California San Diego. She works as a pediatric hospitalist and inpatient eating disorder hospitalist at Rady Children’s Hospital–San Diego and as a medicine hospitalist at VA San Diego Healthcare System where she serves as the nocturnist supervisor. Dr. ten Hope is a second-year pediatric hospital medicine fellow at Phoenix Children’s Hospital in Phoenix. She will be staying on as faculty in the hospital medicine division starting in August of 2024.
References
- Wachman EM, Houghton M, et al. A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts’ PNQIN collaborative. J Perinatol. 2020;40(10):1560-9.
- Acevedo-Garcia D, Noelke C, et al. Racial and ethnic inequities in children’s neighborhoods: evidence from the new Child Opportunity Index 2.0. Health Aff (Millwood). 2020;39(10):1693-701.
- Krager MK, Puls HT, et al. The Child Opportunity Index 2.0 and hospitalizations for ambulatory care sensitive conditions. Pediatrics. 2021;148(2):e2020032755. doi:10.1542/peds.2020-032755.
- Roesler T, Jenny C. Medical child abuse: beyond Munchausen syndrome by proxy. Elk Grove Village, Ill.: American Academy of Pediatrics; 2008. doi: 10.1542/9781581105131
- Flaherty EG, Macmillan HL, et al. Caregiver-fabricated illness in a child: a manifestation of child maltreatment. Pediatrics. 2013;132(3):590-7.
- Li Y, Wang X, et al. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in children younger than 5 years in 2019: a systematic analysis. Lancet. 2022;399(10340):2047-64.
- Wildenbeest JG, Billard M, et al. The burden of respiratory syncytial virus in healthy term-born infants in Europe: a prospective birth cohort study. Lancet Respir Med. 2022;11(4):341-53.
- Simões EAF, Center KJ, et al. Prefusion F protein-based respiratory syncytial virus immunization in pregnancy. N Engl J Med. 2022;386(17):1615-26.
- Hammitt LL, Dagan R, et al. Nirsevimab for prevention of RSV in healthy late-preterm and term infants. N Engl J Med. 2022;386(9):837-46.