Although evidence supports clinicians to "safely do less" for febrile infants assessed as low risk of serious bacterial infection (SBI), early discharge may increase caregiver concern and reduce satisfaction with care. We captured the self-reported satisfaction and concerns for families enrolled in the study of fever, blood cultures and readiness for discharge in infants less than 3months old (FeBRILe3), a prospective safety assessment of early discharge of low-risk febrile infants, to aid evaluation of this practice. An updated local policy was implemented at 2 Western Australian hospitals allowing febrile infants (<3months old) fulfilling low-risk criteria for SBI to be discharged from 24 hours after admission. An electronic survey was administered 7 to 10days postdischarge to caregivers of 500 febrile infants admitted August 2019 to December 2021. The survey included free-text and 5-point Likert-scale questions on hospitalization/discharge experiences. Responses were evaluated by length of stay (LOS; <36 hours, 36 hours to <48 hours, or >=48 hours) and risk-stratification (low-risk or nonlow-risk) groups. Caregiver responses were obtained for 298 infants (60%). Fifty-one infants (17%) were discharged before 36 hours, including 7 of 38 infants fulfilling low-risk criteria. Sixty-eight infants (23%) were discharged between 36 hours and less than 48 hours. Ninety-one percent of caregivers "agreed" or "strongly agreed" their infant was ready for home at time of discharge. Responses were comparable for low-risk infants discharged before 36 hours (86%) vs after 36 hours (93%). Most caregivers (84%) "agreed" or "strongly agreed" that discharge timing enabled a quick return to family routine. Caregivers of low-risk infants discharged before 36 hours missed fewer workdays (median 1.5 vs 2.5days for LOS >=36 hours). Free-text feedback identified the importance to caregivers of clear communication and shared decision-making. Early discharge was related to high caregiver satisfaction, regardless of risk stratification, supporting continued implementation of this policy. Strengthening communication and streamlining discharge processes may further enhance satisfaction and support early discharge.

Functional constipation affects 9.5% to 14.4% of children worldwide, and fecal impaction requiring hospitalization is increasingly common. Despite its growing prevalence and associated costs, there are no consensus guidelines for inpatient management. To systematically review the literature on inpatient management of pediatric fecal impaction and identify knowledge gaps and research priorities. We conducted a scoping review of studies and hospital protocols describing inpatient treatment of pediatric fecal impaction or severe constipation. Data were extracted on interventions, outcomes, definitions of success, and study quality. Fifteen studies and 6 hospital protocols met inclusion criteria. There was substantial variability in treatment approaches, including the choice and administration route of polyethylene glycol (PEG), use of adjunctive rectal therapies, and criteria for successful cleanout. PEG-based regimens were most commonly used and generally effective, but approaches ranged from oral to nasogastric and rectal delivery. Some studies showed that outcomes of oral PEG mirrored outpatient regimens, raising questions about the necessity of hospitalization in select cases. Long-term outcomes were infrequently reported, but they revealed high rates of reimpaction, readmissions, and health care reutilization, suggesting that inpatient cleanouts may not provide longstanding benefit. Inpatient management of pediatric fecal impaction is effective for acute disimpaction but is characterized by heterogeneity in practice and limited long-term benefit. High rates of reimpaction and health care reutilization highlight the need for standardized criteria to guide hospitalization decisions and for evidence-based care models that reduce unnecessary admissions. Future research should prioritize multicenter studies to establish consensus definitions and evaluate long-term outcomes.

Point-of-care ultrasonography (POCUS) provides rapid diagnostic and procedural support in conditions commonly encountered by pediatric hospitalists. It has been increasingly incorporated into undergraduate and graduate medical education, yet the extent of POCUS training in pediatric hospital medicine (PHM) fellowship is unknown. This study aims to describe the current state of POCUS education in PHM fellowships, perspectives on its value, and barriers to implementation. A survey was developed by PHM and POCUS experts and distributed electronically to PHM fellows and fellowship program directors (PDs) and associate PDs (APDs) between August and October 2022. Comparative analyses were conducted based on respondent and program characteristics. The response rate was 72% (183/253). Forty-two percent of PDs/APDs reported that their program provides POCUS training. The most common applications taught were lung, soft-tissue, and cardiac examinations and procedural guidance. Compared with PDs/APDs, fellows agreed more strongly that POCUS should be included in fellowship training (P < .001) and reported a greater desire for advanced hands-on skills (P < .001) than PDs/APDs' expectations. Barriers to training included a lack of qualified instructors, limited access to needed technology, and the absence of a standard PHM-specific curriculum. More than one-third of PHM fellowship programs offer some POCUS training; however, significant barriers remain. Trainees are increasingly entering fellowship with POCUS experience, perhaps influencing their perspectives on its value and desire for higher-level skills. Expanding POCUS education in PHM fellowship offers a unique opportunity for trainees to develop clinical skills that can distinguish them as fellowship graduates and improve patient care.

Asthma ranks third in pediatric hospital admissions, costing $452.2 million annually in the United States.1 Household food insecurity (HFI) is associated with higher rates of asthma in children.2–4 However, the potential impact of HFI and inpatient food insecurity (IFI), food insecurity experienced by caregivers during a child’s hospitalization, on hospital outcomes have not been explored among pediatric patients with asthma. We theorize that patients with asthma and IFI represent a distinct population from those with HFI (Figure 1). In this study we assess whether IFI and/or HFI are associated with increased length of stay (LOS), and we hypothesize that HFI and IFI are both associated with increased LOS in pediatric patients with asthma.Data were retrospectively captured at 1 children’s hospital within an academic medical center in North Carolina between May 2022 and December 2023. IFI was measured using a 3-item screening tool adapted from modified HFI surveys to assess the IFI of caregivers during a hospitalization.5 HFI was measured via the 2-item Hunger Vital Sign. Nursing staff screened caregivers at least once during the hospitalization and documented results in the electronic health record (EHR). Eligible participants with asthma were identified by International Classification of Diseases, Tenth Revision codes starting with J45 from the visit diagnoses, problem list, and medical history. IFI and HFI status and participant characteristics were compared using chi-square or t tests. To improve normalization, we Winsorized at the 95th percentile (11 days) and log-transformed the LOS variable. We used linear regression to assess the association of IFI and HFI with LOS in patients with asthma, adjusting for child age, sex, race, ethnicity, language, and insurance type. Secondary analyses examined the association of LOS with (1) IFI in patients without HFI, (2) HFI in patients without IFI, and (3) a model including both HFI and IFI; all models were adjusted for same covariates as primary analyses. After analyses using log-transformed data, estimates for the beta coefficient and 95% CIs were exponentiated. Analyses were performed using Stata SE (version 14.2; College Station, TX). This study was approved by the Wake Forest University School of Medicine Institutional Review Board.Of 21 071 hospital encounters, 3236 had a diagnosis of asthma; 1459 of these encounters included screening for IFI, 1001 for HFI, 547 for both IFI and HFI, and 1323 had no documented screening (Tables 1 and 2). Characteristics of screened and unscreened participants are found in Supplemental Table 1. IFI was more common among children with Medicaid insurance (Table 1). Of participants screened for both, of those with IFI, 40% screened negative for HFI. The median (IQR) LOS was 2 (1-3) days. Participants with IFI had a statistically significant 1.39 days longer LOS and participants with HFI had 1.42 days longer LOS compared with those without IFI and HFI, respectively (Table 3). In secondary analyses, LOS was not significantly associated with (1) IFI among participants without HFI, (2) HFI among participants without IFI, or (3) IFI or HFI when both were included in a single model (Supplemental Table 2).IFI and HFI were both associated with a longer LOS in hospitalized children with asthma. Despite some overlap, IFI and HFI screening captured distinct populations, as 40% of children with IFI screened negative for HFI, highlighting a population of families with food support at home but who may struggle to afford food during a child’s hospitalization. No association of IFI or HFI with LOS in secondary analyses is likely attributed to the small sample size of participants screened for both IFI and HFI.Our finding of increased LOS is consistent with another study showing the association of longer LOS with IFI/HFI.5 Although etiologies remain unknown, we hypothesize that increased LOS is secondary to increased asthma disease severity, requiring prolonged hospital interventions. Previous work demonstrated decreased asthma-related emergency department visits among those receiving governmental food benefits among pediatric patients with asthma, suggesting improved asthma control.6 Future studies should explore if pediatric patients admitted for asthma with HFI or IFI require increased interventions compared with those without HFI or IFI.Study limitations include data from a single institution, lack of universal IFI and HFI screening, inclusion of all children with asthma as a diagnosis in the EHR, and the occurrence of the study during the COVID-19 pandemic when HFI rates were lower.

The American Academy of Pediatrics (AAP) published guidelines in 2021 recommending the use of inflammatory markers (IMs), including procalcitonin (PCT), to evaluate febrile infants and identify those at low risk for bacterial infection for whom clinicians may forego antibiotics. This quality improvement (QI) project aimed to safely decrease antibiotic administration in febrile infants 22 to 56days old presenting to the emergency department from a baseline of 46% to 36% within 1year, inclusive of race and ethnicity and preferred language. A multidisciplinary team identified interventions including clinical pathway updates, clinical decision support (CDS), and education, which were implemented in 4 Plan-Do-Study-Act cycles. Statistical process control methodology was used to analyze the primary outcome measure (percentage of patients receiving antibiotics) and the process measure (percentage of infants with PCT result). The balancing measure was missed bacteremia or bacterial meningitis. Antibiotic use decreased from 46% to 33%, with the greatest decrease in infants 22 to 28days old (from 86% to 43%). We decreased antibiotic use in non-Hispanic white infants but not non-Hispanic Black infants. PCT use increased from 4% to 97%, and there were no disparities in obtaining IMs. There were no missed cases of bacteremia or bacterial meningitis during the intervention. Using a QI framework, we aligned clinical pathway updates, CDS, and education with AAP guidelines to safely reduce unnecessary antibiotic exposure in febrile infants as young as 22days old. Future work should focus on ensuring equitable decreases in antibiotic exposure.

Pediatric neuroinflammatory disorders (NIDs) pose significant health and financial challenges, yet comprehensive cost estimates are lacking. These conditions likely contribute disproportionately to health care expenditures. To assess the burden of NID-related hospitalizations, we analyzed Texas hospital administrative records. We used the Texas Health Care Information Collection Inpatient Public Use Data File (2016-2023) to explore drivers of inpatient resource use for NIDs. Pediatric hospitalizations with a primary diagnosis of acute disseminated encephalomyelitis, encephalitis and encephalomyelitis (E/EM), multiple sclerosis/neuromyelitis optica spectrum disorders, and other demyelinating disorders, or acute transverse myelitis and other myelitis were included. Charges were converted to costs using hospital-level annual average cost-to-charge ratios and then inflated to 2023 costs. Statistical analysis was implemented to predict the likelihood of having a high-cost or a longer length of stay (LOS) hospitalization and a hospitalization that involved intensive care. There were 2155 hospitalizations involving pediatric patients with a primary diagnosis of NIDs. The most common diagnoses were E/EM. The median total cost of these hospitalizations was $31 365.49, with a median LOS of 6days. More than half (59.1%) required intensive care unit (ICU) admission and were associated with a higher cost. After adjusting for patient and facility characteristics, the primary diagnostic group remained a significant independent predictor of whether hospitalization was classified as high-cost or long-LOS or involved an ICU stay. These findings align with clinical observations, highlighting the significant burden of NIDs, which often require longer hospital stays, intensive care, and higher costs compared with most pediatric conditions.