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.

OBJECTIVES To assess an educational intervention (BeSMART) for parents of hospitalized children on behaviors, beliefs, and knowledge about firearm safety. METHODS A randomized controlled, 3-arm preintervention and postintervention study compared BeSMART video and handout interventions (with and without physician review) to tobacco smoke videos and handouts (control) on parental behaviors, beliefs, and knowledge. Eligibility criteria included parents and/or guardians residing with hospitalized children aged <20 years. The primary outcome was a change in parent-reported frequency of asking about guns in homes visited by their children preintervention to 1 month after intervention. Secondary outcomes were parent-reported likelihood of asking about guns in others’ homes immediately postintervention and change in firearm safety beliefs and/or knowledge in the intervention versus control group, analyzed with analysis of variance. McNemar’s and paired t tests compared changes within groups, and generalized estimating equations compared change between groups for the primary outcome. RESULTS A total of 225 participants enrolled. Both intervention and control groups revealed significant increase mean in parent-reported Likert score of frequency of asking about guns within groups preintervention to 1 month after intervention (BeSMART: 1.5 to 2.3, P = .04; BeSMART + physician review: 1.4 to 1.9, P = .03; control: 1.4 to 2.3, P = .01). Change between groups was not significant (P = .81). Immediately postintervention, intervention groups reported higher likelihood of asking about guns (P < .001). Study groups revealed no significant differences in beliefs. Firearm safety knowledge increased significantly in the intervention groups. CONCLUSIONS BeSMART firearm injury prevention intervention in a hospital setting increased parental knowledge regarding firearm safety. Immediately postintervention, BeSMART groups reported higher likelihood of asking about guns in others’ homes compared with controls. At 1 month after intervention, all groups reported increased frequency asking about guns. Future investigations are needed to understand the duration of intervention impact.

BACKGROUND: High-flow nasal cannula (HFNC), a form of noninvasive respiratory support, is effective for the treatment of respiratory distress in ICUs. Although HFNC has been used outside of the ICU, there is little research that examines its safety in this less-monitored setting. METHODS: Children < 24 months old admitted with bronchiolitis to a pediatric floor at a tertiary care center from April 1 2013, to March 31 2015, were identified by using standard diagnostic codes. Exclusion criteria were concomitant pneumonia or complex comorbidities. Demographic and clinical characteristics were abstracted. Outcomes included transfer to the ICU, higher levels of respiratory support, intubation, pneumothorax, or aspiration events. RESULTS: Eighty children admitted with bronchiolitis who were treated with HFNC while on the pediatric floor were examined. The median age was 4.6 months, 45% were girls, and the majority were either Hispanic (41%) or black (36%). Flow ranged from 3 to 10 L/min. Thirty-three subjects (41% of the sample) required subsequent transfer to the ICU. No children were intubated or developed a pneumothorax. Eighty-three percent were fed while on HFNC. No children had an aspiration event. CONCLUSIONS: HFNC may be a safe modality of respiratory support outside of the ICU for children ages < 24 months with bronchiolitis and without comorbidities up to a maximum flow of 10 L/min. There were no adverse events among the subjects who were fed while on HFNC.

Urinary tract infection (UTI), when left undiagnosed, can lead to renal damage and dysfunction. Understanding how to diagnose, manage, and follow up a UTI is crucial to preventing such consequences.UTI may be classified as cystitis/ pyelonephritis, first/recurrent infection, or complicated/uncomplicated infection. Infections are considered complicated with the following factors: functional or anatomic abnormality of the urinary tract, an indwelling urinary catheter, recent urinary tract instru-mentation, male sex, pregnancy, recent antibiotic use, or immunosuppression. Although the focus of this In Brief is on uncomplicated cystitis, it is important to understand the risk factors for recurrence and complications when evaluating a child who has cystitis for the first time. In teenagers, uncomplicated cystitis is associated most commonly with sexual activity, and counseling is imperative to prevent future infections.Although the overall prevalence of UTI in febrile infants is approximately 5%, certain children are more at risk than others. Risk factors for UTI in a young child include sex (girls Ͼ boys), age (boys Ͻ1 years of age, girls Ͻ5 years of age), race (white Ͼ African American), circumcision (infant boys not circumcised Ͼ those circumcised), first-degree relative who has a history of recurrent UTIs, recent antibiotic use, catheterization, immunocompromise (renal transplantation, acquired immune deficiency syndrome, diabetes mellitus), constipation, voiding dysfunction, vesicoureteral reflux (VUR), neurogenic bladder, and urinary tract obstruction. For adolescents, the use of barrier contraception with spermicide increases the risk for UTI. Among infants, human milk is protective.In all age groups, the most common pathogen causing cystitis is Escherichia coli. In neonates, group B streptococci are a particular concern. Immunocompromised hosts are at risk for infection with less typical agents, such as Enterococcus, BK virus, Pseudomonas aeruginosa, and Candida albicans. Adolescent girls commonly have Staphylococcus saprophyticus infection. Many other agents have been associated with cystitis, including a wide range of gram-negative rods and cocci, grampositive cocci, adenovirus, and both Chlamydia trachomatis and Ureaplasma urealyticum. Lactobacillus, coagulasenegative staphylococci, and Corynebacterium are typical normal flora in children.Children who have cystitis often do not present with the characteristic signs and symptoms seen in adults. The history of a child who has fever should include documentation of the risk factors described previously to evaluate for UTI. Infants younger than 60 to 90 days of age may have vague and nonspecific symptoms, such as failure to thrive, diarrhea, vomiting, irritability, lethargy, malodorous urine, jaundice, and fever. In children younger than 5 years of age, fever and gastrointestinal symptoms are most common. The classic lower urinary tract symptoms of dysuria, urgency, frequency, incontinence, and suprapubic abdominal pain are more common after 5 years of age. The ...

Residents and physician assistants are interrupted at a rate of 57 interruptions per 100 orders placed. This may contribute to ordering errors and worsen patient safety. Efforts should be made to decrease interruptions during the ordering process and track their effects on medication errors.

Gun violence is a US public health crisis. Approximately 7000 children are hospitalized each year because of firearm-related injuries. As pediatric hospitalists, we are poised to address this crisis, whether we care directly for patients who are victims of gun violence. In this article, we aim to provide practical tools and opportunities for pediatric hospitalists to address the epidemic of gun safety and gun violence prevention, including specifics related to the inpatient setting. We provide a framework to act within 4 domains: clinical care, advocacy, education and research.

Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.

BACKGROUND: Little is known about what hospital and emergency department (ED) factors predict performance in pediatric quality improvement efforts. OBJECTIVES: Identify site characteristics and implementation strategies associated with improvements in pediatric asthma care. METHODS: In this secondary analysis, we used data from a national quality collaborative. Data on site factors were collected via survey of implementation leaders. Data on quality measures were collected via chart review of children with a primary diagnosis of asthma. ED measures included severity assessment at triage, corticosteroid administration within 60 minutes, avoidance of chest radiographs, and discharge from the hospital. Inpatient measures included early administration of bronchodilator via metered-dose inhaler, screening for tobacco exposure, and caregiver referral to smoking cessation resources. We used multilevel regression models to determine associations between site factors and changes in mean compliance across all measures. RESULTS: Sixty-four EDs and 70 inpatient units participated. Baseline compliance was similar by site characteristics. We found significantly greater increases in compliance in EDs within nonteaching versus teaching hospitals (12% vs 5%), smaller versus larger hospitals (10% vs 4%), and rural and urban versus suburban settings (6%–7% vs 3%). In inpatient units, we also found significantly greater increases in compliance in nonteaching versus teaching hospitals (36% vs 17%) and community versus children’s hospitals (23% vs 14%). Changes in compliance were not associated with organizational readiness or number of audit and feedback sessions or improvement cycles. CONCLUSIONS: Specific hospital and ED characteristics are associated with improvements in pediatric asthma care. Identifying setting-specific barriers may facilitate more targeted implementation support.