Qualitative Study of Food Insecurity in Hospitalized Pediatric Patients during the COVID-19 Pandemic.

OBJECTIVES: Food insecurity (FI) is defined as limited or uncertain access to sufficient food for a healthy and active lifestyle. Our objective was to explore how the coronavirus disease 2019 (COVID-19) pandemic affected the FI status of pediatric patients and their families through interviewing caregivers who screen positive for FI. METHODS: Caregivers of all hospitalized patients at a tertiary children's hospital who screen positive for FI with a two-question screening tool were approached about enrolling in the study. Those who consented completed a presurvey and participated in a semistructured individual interview. Interviews were audio recorded, transcribed, and analyzed according to the guidelines of thematic analysis using NVivo 12. RESULTS: Interviews were conducted with 15 caregivers between July 2021 and January 2022. Caregivers were 100% female and 80% Black, 13% White, and 7% Hispanic/Latinx, with a mean age of 33 years. Seventy-three percent did not experience FI until the COVID-19 pandemic. Themes include lost wages, mothers forced out of the workforce due to childcare limitations, inflation and shortages of goods, increased stress/anxiety for caregivers and children, the centrality of extended family support, and the necessity/inadequacy of federal food programs. CONCLUSIONS: The COVID-19 pandemic impacted unemployment and poverty and consequently exacerbated FI. Our findings point to the need to focus on proximal societal solutions, such as federal policies aimed at food assistance and childcare. Understanding the challenges related to FI that caregivers and patients experience can improve screening, support, and treatment of patients presenting for care and inform the design of necessary interventions for individuals and communities beyond COVID-19.

Trends in Anthropometric Measurements of Internationally Adopted Children.

OBJECTIVE: The objective of this study was to describe anthropometric measures from internationally adopted children. Internationally adopted children are at risk for poor growth and development and there is no standardized growth chart evaluation for internationally adopted children due to variations in growth, genetics, and environmental exposures. METHODS: This is a retrospective chart review of 882 patients seen in an international adoption clinic between 2010 and 2017. Anthropometric measurements were converted to Z scores for weight, height, head circumference, and body mass index. RESULTS: A total of 41 countries and 16 subregions were represented. Central America, northern Africa, southern Africa, and southern Europe were the only subregions that had positive mean Z scores for weight, and southeast Asia had the lowest mean Z score for weight (n = 40, -1.76). No subregion had a positive mean Z score for height, and western Asia had the lowest overall mean Z score for height (n = 2, -2.44). Mean Z score for body mass index was positive in several subregions. CONCLUSIONS: Growth is an important predictor of health and development, and this study adds to the literature on growth patterns of internationally adopted children.

Infant Safe Sleep Knowledge, Attitudes, and Behaviors by Physicians at an Academic Children's Hospital.

Sudden unexpected infant death (SUID) is the leading cause of death for infants. Physician advice on safe sleep is an important source of information for families. We sought to evaluate the safe sleep knowledge, attitudes, and behaviors of physicians by distributing a cross-sectional survey at a freestanding children's hospital. The survey included demographics, knowledge items, attitudinal assessment, and frequency of providing safe sleep guidance. Multivariable linear regression and logistic regression were used to evaluate associations between variables. 398 physicians were surveyed with 124 responses (31%). Females, those who received safe sleep training, and those who see infants in daily practice had higher knowledge scores. Physicians with higher knowledge scores had more positive attitudes toward safe sleep and provided safe sleep education to patients more often. Our study underlies the importance of education and repeated exposure in forming positive attitudes toward safe sleep recommendations and leads to increased provision of safe sleep guidance.

Food Insecurity Screening of Hospitalized Patients: A Descriptive Analysis.

OBJECTIVES: The purpose of this study is to describe an advocacy effort to implement a food insecurity (FI) screening during hospital admission and describe characteristics of hospitalized patients with household FI. METHODS: This is a descriptive study after the implementation of FI screening at a quaternary-care children's hospital in the Southeastern United States between August 2020 and April 2021. The Hunger Vital Sign, a 2-question screening tool for FI, was added to the intake questionnaire performed on inpatient admissions. A positive screen triggered a social work consult to connect patients with resources. Chart review and statistical analyses were performed on patients with household FI. RESULTS: There were 7751 hospital admissions during the study period, of which 4777 (61.6%) had an FI screen completed. Among those with a completed screen, 233 patients (4.9%) were positive for household FI. Patients with household FI were more likely to be Black (P <.001) and have Medicaid (P <.001). Social work documented care specific to FI in 125 of the 233 (56%) FI patients, of which 39 (31%) were not enrolled in the Women, Infants, and Children Program/Supplemental Nutrition Assistance Program. CONCLUSIONS: This initiative highlights hospitalization as an opportunity to screen for FI using a multidisciplinary approach. Our findings underscore the importance of identifying FI with the goal of reducing FI and mitigating the adverse effects of FI on child health outcomes.

De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative.

Bronchiolitis is the most common cause for hospitalization in the first year of life, with hypoxemia and acute respiratory failure as major determinants leading to hospitalization. In addition, the lack of existing guidelines for weaning and discontinuing supplemental oxygen, including high-flow nasal cannula, may contribute to prolonged hospitalization and increased resource utilization. Methods: This single-center quality improvement initiative assessed the effect of implementing a standardized care process for weaning and discontinuing high-flow oxygen for patients hospitalized with bronchiolitis. Patients aged 1-24 months with bronchiolitis admitted to the general wards or ICU step-down unit from February 1, 2018, and January 31, 2020 were included in the study. Primary outcomes included length of stay and time on supplemental oxygen, with time on high-flow oxygen and length of time in ICU step-down unit as secondary outcomes. Balancing measures included transfer rate to Pediatric Intensive Care Unit, intubation rate, 7- and 30-day readmission rates, and 7- and 30-day ED visits after discharge. Results: Following the standardized care process implementation, the mean length of stay decreased from 60.7 hours to 46.7 hours (P < 0.01). In addition, the mean time on any supplemental oxygen decreased by 47% (P < 0.01), the mean time on high-flow oxygen decreased by 45% (P < 0.01), and the mean time in the ICU step-down unit decreased by 27% (P =< 0.01). Balancing measures remained unchanged with no statistically significant differences. Conclusion: Implementing a standardized care process for weaning and discontinuing high-flow oxygen may reduce the length of stay and resource utilization for patients hospitalized with bronchiolitis.

Improving Adherence to Safe Sleep Guidelines for Hospitalized Infants at a Children's Hospital.

INTRODUCTION: Sudden unexpected infant deaths are a major problem nationally. We had poor adherence to safe sleep recommendations locally at our institution. Given the significance of this problem, hospital administration at a tertiary children's hospital tasked a multidisciplinary group of faculty and staff with improving sleep environments for hospitalized infants. METHODS: Our safe sleep task force implemented targeted interventions using the American Academy of Pediatrics policy statement as the gold standard and based on hospital data to address areas of greatest nonadherence to recommendations. We aimed to improve weekly average adherence to 95% over 12 months. A proportions process control chart (p-chart) tracked average weekly adherence over a 52-week time frame. In addition, we performed Student's t-testing to evaluate differences in adherence over time. RESULTS: There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = -15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= -21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules. CONCLUSIONS: Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Clinical guideline highlights for the hospitalist: Focused updates to pediatric asthma management.

GUIDELINE TITLE: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC) Expert Panel Working Group1 RELEASE DATE: Online: December 3, 2020 PRIOR VERSIONS: 1991, 1997, 2002, 2007 DEVELOPER: NAEPPCC Expert Panel Working Group (referred to as "the Expert Panel") of the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health FUNDING SOURCE: NHLBI of the National Institutes of Health TARGET POPULATION: Adults and children with asthma and recurrent wheezing.

Tobacco Screening and Use in Hospitalized Adolescents at a Children's Hospital.

OBJECTIVES: With this study, we aim to evaluate inpatient adolescent screening for tobacco, as well as the relationship between tobacco and other substance use, tobacco types used, and cessation interventions. METHODS: A retrospective chart review of inpatient hospital admissions of adolescents aged ≥13 years to a tertiary care, freestanding, urban children's hospital in 2018 was performed. Tobacco use-related variables were entered into a multiple logistic regression model in which the adjusted odds ratios were determined. Variables found to be significant in bivariate analysis were included as covariates in the model by using SAS 9.4 software (SAS Institute, Inc, Cary, NC). RESULTS: There were 4412 admissions of adolescents aged ≥13 years during the study period, of which 370 (8.4%) adolescents were screened for tobacco use by physicians. Significant factors associated with being screened included age 16 to 18 years, white race, and admission to the pediatric hospital medicine service. There were 93 (25.1%) tobacco users identified, of whom the majority reported concomitant caretaker use (78.6%), alcohol use (52.7%), and marijuana use (70.8%). The most commonly reported tobacco type used was cigarettes at 50.5%. Cessation intervention was documented in 8 tobacco users. CONCLUSIONS: Tobacco use screening of hospitalized adolescents aged ≥13 years was performed infrequently and was not standardized among physicians. Tobacco use was identified in 25.1% of those screened, and cessation interventions were inconsistently performed. This study suggests a need for universal, standardized tobacco use screening in inpatient adolescents and identifies a missed opportunity for treatment of tobacco dependence.

Pigmented Villonodular Synovitis Mimicking an Acute Septic Hip in an Eight-Year-Old Male.

Pigmented villonodular synovitis (PVNS) is a less common but known cause of joint pain in the adult population. PVNS in pediatric patients is even more rare, with only case reports of occurrence in persons under the age of 18 years. Presentation is typically that of more insidious pain and limited range of motion, and is primarily seen in the knee joint. Diagnosis can be suspected with imaging, but ultimately surgical intervention is needed for tissue confirmation. We present a case of PVNS in a pediatric patient with acute symptoms concerning for a septic joint. The patient's workup revealed a large effusion on hip ultrasound, with operative intervention pursued and further imaging deferred given the patient's symptom burden. A 4 × 1 × 1.5 cm intra-articular pigmented mass excised from the synovium in the operating room. The patient's symptoms improved after the procedure, with pathology showing sheets of plump mononuclear cells in a collagenized stroma with hemosiderin deposits, confirming the diagnosis. This case highlights the importance of keeping non-infectious etiologies in the differential diagnosis of acute onset joint pain.

Residential instability, neighborhood deprivation, and pediatric asthma outcomes.

INTRODUCTION: Limited work has directly compared the role of different neighborhood factors or examined their interactive effects on pediatric asthma outcomes. Our objective was to quantify the main and interactive effects of neighborhood deprivation and residential instability (RI) on pediatric asthma outcomes. METHODS: We conducted a retrospective cross-sectional study of patients with a primary diagnosis of asthma hospitalized at a tertiary care pediatric hospital. Residential addresses at the index hospitalization were linked to the state area deprivation index (ADI). RI was coded as the number of residences in the past 4 years. Logistic and ordinal regression and Cox regression survival analyses were used to estimate the effect on the primary outcomes of chronic asthma severity (intermittent, mild persistent, moderate persistent, severe persistent/other) as defined by the National Heart, Lung, and Blood Institute, severe hospitalization (requiring continuous albuterol or intensive care unit care), and time to emergency department (ED) readmission and rehospitalization within 365 days of the index visit, respectively. RESULTS: In the sample (N = 664), 21% had severe persistent/other asthma, 22% had severe hospitalization, 37% were readmitted to the ED, and 19% were rehospitalized. Increasing RI was independently associated with more severe chronic asthma (odds ratio = 1.18, 95% confidence interval [CI] = 1.05, 1.32, P = .004), greater risk of 365-day ED readmission (hazard ratio [HR] = 1.10, 95% CI = 1.05, 1.15, P < .0001), and greater risk of 365-day rehospitalization (HR = 1.09, 95% CI = 1.03, 1.14, P = .002). There were no significant associations between ADI and these outcomes. Further, we did not find significant evidence of interactive effects. CONCLUSIONS: RI appears to be modestly associated with pediatric asthma outcomes, independent of current neighborhood deprivation.

Splenic infarction from vascular torsion in a child with normal splenic anatomy.

This is a case of an 8-year-old, Caucasian boy with a complex prior medical history who presented with worsening, acute, left-sided abdominal pain and fever after empiric treatment for a urinary tract infection. Repeat urinalysis was negative for infection. A renal ultrasound assessing for occult perinephric abscess or nephronia revealed normal kidneys but found a tubular structure adjacent to the left kidney. A CT scan further revealed a splenic infarction secondary to torsion. He had a surgical evaluation but was treated empirically with piperacillin/tazobactam for 10 days due to concern for infectious complications following splenic infarction. He had complete resolution of his pain and symptoms. He received routine vaccines for asplenia prior to being discharged home without any further sequelae.

Quality Improvement Project to Improve Screening for Tobacco Use in Adolescent Inpatients at a Children's Hospital.

Tobacco use begins in adolescence for the majority of smokers. The purpose of this study was to increase screening and reporting of tobacco use in hospitalized adolescents at a tertiary care children's hospital. We completed a nursing focus group to understand challenges and completed four iterative Plan-Do-Study-Act cycles, which included: (1) in-person nursing education regarding tobacco use screening, (2) addition of an e-cigarette-specific screening question, (3) the creation and dissemination of an educational video for nursing, and (4) adding the video as a mandatory component of nursing orientation. Run charts of the percentage of patients screened who reported tobacco use were created. Absolute counts of tobacco products used were also captured. From January 2016 to September 2018, 12,999 patients ≥13 years of age were admitted to the hospital. At baseline, 90.1% of patients were screened and 4.8% reported tobacco use. While the absolute number of adolescents reporting e-cigarette use increased from zero patients per month at baseline to five, the percentage of patients screened and reporting tobacco use was unchanged; the majority of e-cigarette users reported use of other tobacco products. This study demonstrates that adding e-cigarettes to screening increases reporting and suggests systems level changes are needed to improve tobacco use reporting.

Predictors of Hospital Reuse Among Publicly Insured Children Hospitalized for Status Asthmaticus.

BACKGROUND: Asthma is a common cause of pediatric hospitalization. Nonadherence to asthma medications is associated with worse outcomes; however, there is a paucity of data regarding posthospitalization prescription filling and hospital reuse. Our objective was to identify patients at risk for hospital reuse after being hospitalized for asthma. METHODS: This is a retrospective study of patients with asthma who were discharged from a children's hospital in which we use Medicaid claims data to evaluate prescription fills within 30 days and 12 months. Chart reviews were used for demographics, chronic asthma severity, admission severity, and hospital reuse. t and χ2 tests were performed for continuous and categorical variables. A generalized linear mixed model was fitted to predict the odds of hospital reuse, which was defined as requiring an emergency department visit or rehospitalization. Survival analysis using log-rank testing was used for modeling the time to hospital reuse. RESULTS: Fifty-four percent of patients discharged with asthma had hospital reuse within 1 year of discharge. There was no association between hospital reuse and prescription filling for systemic steroids (odds ratio [OR] 1.30; confidence interval [CI]: 0.85-2.00; P = .21) or controller medications (OR 1.5; CI: 0.92-2.52; P = .10). There was a higher number of controller and systemic steroid prescription fills over 12 months for patients with hospital reuse. The factors associated with greater odds of hospital reuse were severity of chronic asthma diagnosis (P = .03) as well as African American race (OR 1.92; CI: 1.17-3.13; P = .01). CONCLUSIONS: For Medicaid-insured patients discharged with asthma, worse chronic asthma severity and African American race were associated with greater odds of hospital reuse. Decreased prescription filling was not associated with greater odds of hospital reuse.

Small intestine polypoid arteriovenous malformation: a stepwise approach to diagnosis in a paediatric case.

We report a case of acute gastrointestinal haemorrhage due to a small intestine polypoid arteriovenous malformation (AVM) in a patient with a remote history of obscure gastrointestinal bleeding (OGIB) 8 years earlier. The diagnosis of a small intestine AVM was made using video capsule endoscopy (VCE) and confirmed using single-balloon push enteroscopy. The lesion was marked with submucosal tattoo to aid in subsequent surgical resection of the lesion with primary duodenoduodenostomy. Since our patient's initial bleeding episode, a variety of advanced tools have become widely available to aid in the localisation of OGIB. This case illustrates the use of a stepwise approach using new medical technology to identify and manage OGIB in children. VCE and push enteroscopy proved to be important diagnostic modalities in this paediatric case.