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a abstract BACKGROUND AND OBJECTIVES: Bronchiolitis, the most common reason for hospitalization in children younger than 1 year in the United States, has no proven therapies effective beyond supportive care. We aimed to investigate the effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis. METHODS:We conducted a prospective, randomized, double-blind, controlled trial in an urban tertiary care children's hospital in 227 infants younger than 12 months old admitted with a diagnosis of bronchiolitis (190 completed the study); 113 infants were randomized to HS (93 completed the study), and 114 to NS (97 completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS every 4 hours from enrollment until hospital discharge. The primary outcome was median LOS. Secondary outcomes were total adverse events, subdivided as clinical worsening and readmissions.RESULTS: Patient characteristics were similar in groups. In intention-to-treat analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days (1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar between groups (9% vs 8%, P = .97).CONCLUSIONS: Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.WHAT'S KNOWN ON THIS SUBJECT: Bronchiolitis, the most frequent reason for hospitalization for infants younger than 1 year of age, has no proven treatments beyond supportive care. Although early studies suggested a potential benefit from 3% hypertonic saline, more recent studies have conflicting results. WHAT THIS STUDY ADDS:This prospective, randomized, double-blind, controlled trial in infants admitted with bronchiolitis (including patients with a history of previous wheeze) demonstrated no difference in length of stay between those who received hypertonic saline or normal saline without bronchodilators.

Pediatric firearm-related deaths and injuries are a national public health crisis. In this Special Review Article, we characterize the epidemiology of firearm-related injuries in the United States and discuss public health programs, the role of pediatricians, and legislative efforts to address this health crisis. Firearm-related injuries are leading causes of unintentional injury deaths in children and adolescents. Children are more likely to be victims of unintentional injuries, the majority of which occur in the home, and adolescents are more likely to suffer from intentional injuries due to either assault or suicide attempts. Guns are present in 18% to 64% of US households, with significant variability by geographic region. Almost 40% of parents erroneously believe their children are unaware of the storage location of household guns, and 22% of parents wrongly believe that their children have never handled household guns. Public health interventions to increase firearm safety have demonstrated varying results, but the most effective programs have provided free gun safety devices to families. Pediatricians should continue working to reduce gun violence by asking patients and their families about firearm access, encouraging safe storage, and supporting firearm-related injury prevention research. Pediatricians should also play a role in educating trainees about gun violence. From a legislative perspective, universal background checks have been shown to decrease firearm homicides across all ages, and child safety laws have been shown to decrease unintentional firearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucial to halt the epidemic of pediatric firearm-related injury.

Background Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. Methods The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16–19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16–19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). Discussion The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. Trial registration ClinicalTrials.gov,NCT05132322. Registered on November 10, 2021.