Postoperative Opioid Analgesia Impacts Resource Utilization in Infants Undergoing Pyloromyotomy.

BACKGROUND: Opioid analgesia is often avoided in infants undergoing pyloromyotomy. Previous studies highlight an association between opioid use and prolonged hospitalization after pyloromyotomy. However, the impact of opioid use on healthcare resource utilization and cost is unknown. We hypothesized that use of opioids after pyloromyotomy is associated with increased resource utilization and costs. METHODS: A retrospective cohort study was conducted identifying healthy infants aged <6 mo with a diagnosis of pyloric stenosis who underwent pyloromyotomy from 2005 to 2015 among 47 children's hospitals using the Pediatric Health Information System database. Time of opioid exposure was categorized as day of surgery (DOS) alone, postoperative use alone, or combined DOS and postoperative use. Primary outcomes were the standardized unit cost, a proxy for resource utilization, billed charges to the patient/insurer, and hospital costs. A multivariable log-linear mixed-effects model was used to adjust for patient and hospital level factors. RESULTS: Overall, 11,008 infants underwent pyloromyotomy with 2842 (26%) receiving perioperative opioids. Most opioid use was confined to the DOS alone (n = 2,158, 19.6%). Infants who received opioids on DOS and postoperatively exhibited 13% (95% confidence interval [CI]: 7%-20%, P-value <0.001) higher total resource utilization compared with infants who did not receive any opioids. Billed charges were 3% higher (95% CI: 0%-5%, P-value = 0.034) for infants receiving opioids isolated to the postoperative period alone and 6% higher (95% CI: 2%-11%, P-value = 0.004) for infants receiving opioids on the DOS and postoperatively. CONCLUSIONS: Postoperative opioid use among infants who underwent pyloromyotomy was associated with increased resource utilization and costs.

Symptomatic catheter-associated thrombosis in pediatric trauma patients: Choose your access wisely.

BACKGROUND: Traumatic injury and the presence of a central venous catheter are 2 of the strongest risk factors for venous thromboembolism in children. The purpose of this study was to determine the incidence of symptomatic, catheter-associated thrombosis in critically injured children. We hypothesized that femoral venous catheters are associated with a greater rate of thrombotic complications when compared with all other central venous access points. METHODS: We reviewed a retrospective cohort (2006-2016) of injured children (≤18 years) admitted to a pediatric intensive care unit with central access placed ≤7 days from admission. Symptomatic, catheter-associated thrombosis was determined by radiographic evidence. Poisson regression was used to compare the incidence of catheter-associated thrombosis per 1,000 catheter days between femoral and nonfemoral catheters. All comparisons were 2-tailed with α = 0.05. RESULTS: We examined 209 pediatric trauma patients with central access (65% femoral, 19% subclavian, 11% arm vein, and 5% internal jugular). Femoral catheters were removed earlier (median [interquartile range] 4 [2-7] vs 8 [3-12] days, P < .001) and were larger in diameter (5 Fr [4-7] vs 4 Fr [4-4], P < .001) when compared with all other catheters. Catheter-associated thrombosis was more frequent in femoral versus nonfemoral catheters (18.4 vs 3.5 per 1,000 catheter days, P = .01). CONCLUSION: Femoral venous catheters are associated with a greater incidence of symptomatic, catheter-associated thrombosis in pediatric trauma patients. When central venous access is indicated for injured children, the femoral site should be avoided. If a femoral venous catheter is necessary, use of a smaller catheter should be considered.

Identifying Targets to Improve Coding of Child Physical Abuse at a Pediatric Trauma Center.

Child physical abuse is a leading cause of morbidity and mortality in young children. Identification of abused children is challenging, and can affect risk-adjusted benchmarking of trauma center performance. The purpose of this project was to understand diagnosis coding capture rates for child abuse and develop a standardized approach to clinician documentation to improve trauma registry capture. A retrospective cohort was obtained including all admitted trauma patients with injuries from known or suspected abusive mechanism in 2017. Patients who received forensic workup for child physical abuse were classified as "no abuse," "suspected abuse," and "confirmed abuse" using narratives from social work notes. Our trauma registry was used to abstract International Classification of Diseases, Tenth Revision (ICD-10) diagnostic and external cause codes for each patient. Abuse classifications defined by chart review were then compared with coding in the registry using crosstabs. A total of 115 patients were identified as having a forensic workup for child physical abuse. Patients who underwent forensic workup were classified as: 40% no abuse, 37% suspected abuse, and 23% confirmed abuse at the time of discharge. Three patients (6%) with a negative forensic workup were overcoded as suspected abuse in our trauma registry. Among patients with clinically confirmed abuse, our trauma registry identified only 63% by diagnostic codes and only 33% by external cause codes. Child physical abuse is frequently undercoded, and clear clinical documentation of the level of suspicion of abuse at discharge is needed to accurately identify abused patients.

Interactive Education is Associated With Lower Incidence of Pedestrian-Related Injury in Children.

BACKGROUND: Pedestrian-related injuries are a significant contributor to preventable mortality and disability in children. We hypothesized that interactive pedestrian safety education is associated with increased knowledge, safe crosswalk behaviors, and lower incidence of pedestrian-related injuries in elementary school-aged children. METHODS: An interactive street-crossing simulation was implemented at target elementary schools in Los Angeles County beginning in 2009. Mixed-methods were used to evaluate the impact of this intervention. Multiple-choice examinations were used to test pedestrian safety knowledge, anonymous observations were used to assess street-crossing behaviors, and statewide traffic records were used to report pedestrian injuries in elementary school-aged (4-11 y) children in participating school districts. Pedestrian injury incidence was compared 1 y before and after the intervention, standardized to the incidence in the entire City of Los Angeles. RESULTS: A total of 1424 and 1522 children completed the pretest and post-test, respectively. Correct answers increased for nine of ten questions (all P < 0.01). Children more frequently looked both ways before crossing the street after the intervention (10% versus 41%, P < 0.001). There were 6 reported pedestrian-related injuries in intervention school districts in the year before the intervention and 2 injuries in the year after the intervention, resulting in a significantly lower injury incidence (standardized rate ratio 0.28; 95% CI, 0.11-0.73). CONCLUSION: Pedestrian safety education at Los Angeles elementary schools was associated with increased knowledge, safe street-crossing behavior, and lower incidence of pediatric pedestrian-related injury. Formal pedestrian safety education should be considered with injury prevention efforts in similar urban communities.

Pediatric firearm injuries in Los Angeles County: Younger children are more likely to be the victims of unintentional firearm injury.

BACKGROUND: Firearm injuries are now the third leading cause of death in children. Understanding the circumstances surrounding pediatric firearm injuries will allow for targeted injury prevention efforts. We hypothesized that younger children are more likely to be victims of unintentional firearm injury. METHODS: A multicenter, retrospective review of patients <18 years old who sustained firearm injuries in Los Angeles County from 2006 to 2015 was performed. Unintentional injuries were defined as accidental firearm discharge without violent intent. Intentional injuries were defined as firearm discharge with intent to injure (including suicide). RESULTS: After review of 304 pediatric firearm injuries, 206 had sufficient narrative to determine intent with 10% of injuries classified as unintentional. Unintentional injuries were more common in younger children, more frequently caused by a firearm from within the home, and more likely to involve friend/family (all p < 0.05). Intentional injuries were associated with more injuries and accounted for all deaths in our study cohort. CONCLUSIONS: In pediatric firearm injury, younger children are more susceptible to unintentional injuries, but intentional injuries are more common overall. Future interventions need to target both intentional violence in older children and unintentional firearm injury in young children if the frequency is to be reduced. TYPE OF STUDY: Epidemiologic study. LEVEL OF EVIDENCE: Level III.

Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation.

PURPOSE: Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients. METHODS: An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children's hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation. RESULTS: Survey response rate was 49% (n = 93/190) pre-simulation, 22% (n = 42/190) post-simulation, and 79% (n = 150/190) at 2-year follow-up. These providers reported more anxiety (p = 0.01) and less confidence (p = 0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p = 0.02) and greater confidence (p = 0.01), compared to untrained providers. CONCLUSIONS: Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence. LEVEL OF EVIDENCE: II, Prospective cohort.

Pediatric breast masses: an argument for observation.

BACKGROUND: Pediatric breast masses can be a diagnostic challenge. Nearly all are benign, but there is no consensus on which should be removed. We hypothesized that children with asymptomatic breast lesions can be safely managed nonoperatively. METHODS: We performed a single-institution retrospective review of children (≤18 y) who underwent breast mass excision from 2008 to 2016. Male patients with gynecomastia and those who had needle biopsy without formal excision were excluded. Pearson correlation was used to compare ultrasound and pathologic size. Kruskal-Wallis test was used to compare size and final diagnosis. RESULTS: One hundred ninety-six patients were included (96% female). Mean age was 15 ± 3 y. Most patients (71%) presented with a painless mass. Preoperative ultrasound was obtained in 70%. Pathology included fibroadenoma (81.5%), tubular adenoma (5%), benign phyllodes tumor (3%), benign fibroepithelial neoplasm (0.5%), and other benign lesions (10%). There were no malignant lesions. Ultrasound size had a Pearson correlation of 0.84 with pathologic size (P < 0.0001). There was no association between the size and final diagnosis. CONCLUSIONS: Over 9 y, all pediatric breast masses removed at a single center were benign, most commonly fibroadenoma. Ultrasound was an accurate predictor of size, but large lesions did not necessarily confer a high malignancy risk. Observation is appropriate for asymptomatic breast masses in children. Decision for surgery should be individualized and not based on size alone.

Anticoagulation results in increased line salvage for children with intestinal failure and central venous thrombosis.

PURPOSE: The purpose of this study was to investigate whether anticoagulation (AC) results in thrombus resolution and increased line longevity in children with intestinal failure (IF) and catheter-associated central venous thrombosis (CVT). METHODS: A retrospective, single institution review was performed of children with IF who were dependent on parenteral nutrition with known CVT between 2006 and 2017. Frequency of catheter-related complications including infection, occlusion, and breakage were compared 18months prior to and after starting AC. Thrombus resolution during anticoagulation was also determined. Data were analyzed using Poisson regression. p-Values <0.05 were considered significant. RESULTS: Eighteen children had ≥1 CVT, with the subclavian vein most commonly thrombosed (44%). All children were treated with low molecular weight heparin, and 6 patients (33%) had clot resolution on re-imaging while receiving AC. Bloodstream infections decreased from 7.9 to 4.4 per 1000 catheter days during AC (p=0.01), and the number of infections requiring catheter replacement decreased from 3.0 to 1.0 per 1000 catheter days (p=0.01). There were no significant differences in line occlusions or breakages. CONCLUSION: Anticoagulation for children with intestinal failure and central venous thrombosis may prevent thrombus propagation, and decrease blood stream infections and line replacements. Further research is needed to determine optimal dosing and duration of therapy. LEVEL OF EVIDENCE: III; Retrospective Comparative Study.

Heads Up, Phones Down: A Pedestrian Safety Intervention on Distracted Crosswalk Behavior.

Cell phone use has been implicated in driver distraction and motor vehicle crashes, and more recently has been associated with distracted pedestrians. There are limited data on interventions aimed at this important public health issue. We hypothesized that the use of a visual intervention near street crossings would decrease the frequency of distracted behaviors of pedestrians. We performed a prospective observational cohort study examining painted sidewalk stencils reading, "Heads Up, Phones Down" as an intervention to decrease cell phone distractions amongst pedestrians. These stenciled messages were placed at a children's hospital, middle school, and high school in Los Angeles County. Anonymous observations of pedestrian distractions (texting, talking on a phone, headphone use, and other) were conducted before, 1 week after, and 4 months after the intervention. Distractions were compared before and after intervention using Chi square tests. A total of 11,533 pedestrians were observed, with 71% children and 29% adults. Total distractions decreased from 23% pre-intervention to 17% 1 week after stencil placement (p < 0.01), but this was not sustained at 4 months (23%, p = 0.4). A sustained decrease was observed only for texting at 4 months post-intervention (8.5% vs. 6.8%, p < 0.01). A simple visual intervention reduced distracted cell phone usage in pedestrians crossing the street, but this was most effective early after the intervention. Future studies are warranted to determine how to sustain this effect over time and how to minimize other types of distractions.

Growth Trajectory in Children With Short Bowel Syndrome During the First 2 Years of Life.

OBJECTIVES: Infants with short bowel syndrome (SBS) require diligent nutritional support for adequate growth. Enteral independence is a primary goal, but must be balanced with ensuring sufficient nutrition. We aimed to describe growth trajectory in infants with SBS as function of nutritional intake during first 2 years of life. METHODS: Infants with SBS were reviewed (2008-2016). z Scores for weight, height, and head circumference (HC) were recorded at birth, 3, 6, 12, 18, and 24 months. Nutritional intake, serum liver enzyme, and bilirubin levels were assessed at all time points. Pearson correlation coefficients were used to measure association with P < 0.05 considered significant. RESULTS: Forty-one infants were included, with median gestational age of 34 weeks (interquartile range [IQR] 29-36 weeks). Median small bowel length was 36 cm (IQR 26-52 cm) and median % expected small bowel length was 28% (IQR 20%-42%). Mean z scores for weight and length were >0 at birth, but <0 from 3 months to 2 years. HC remained <0 throughout the study. Mean z scores at 2 years for weight, length, HC, and weight-for-length were -0.90 (SD 1.1), -1.33 (SD 1.4), -0.67 (SD 1.2), and -0.12 (SD 1.2), respectively. Percentage calories from PN was positively correlated with weight in the first 3 months of life (P = 0.01). CONCLUSIONS: Babies with SBS are high risk for poor growth during the first 2 years of life. Although weaning PN is important for these patients, doing so too quickly in infancy may contribute to compromised growth. The long-term impact on overall development is not known.