Pediatric heart failure is a rare condition with significant morbidity that requires timely diagnosis and treatment. Mitral valve E-point septal separation (EPSS) may be used as an estimate of systolic function in this evaluation. Although well studied in adults, there is limited literature looking at pediatric EPSS values. The goal of this study was to establish normal pediatric EPSS values that can serve as a reference in this evaluation. This was a single-center retrospective study of 455 pediatric patients aged 17 years or younger, who had an outpatient transthoracic echocardiogram performed from January 1, 2020, until June 26, 2023. Those with reduced ejection fraction and cardiac abnormalities were excluded. EPSS measurements were taken from parasternal long-axis B-mode views. Relationships between EPSS and patient biometric and echo measurements were evaluated. Consistency of EPSS measurement between independent reviewers was also evaluated. Across all patients, the median EPSS for all measurements was 2.25mm (IQR 2.06mm). When looking specifically at the lowest 3 EPSS measurements for each patient, the median EPSS was 1.33mm (IQR 2.56mm). EPSS demonstrated statistically significant (P<0.05) but low magnitude (R <0.3) correlations with several patient biometric and echo measurements, including a negative correlation with ejection fraction and a positive correlation with age, height, weight, and body surface area. There was no significant correlation with sex. Interclass correlation by Cronbach Alpha was 0.951. EPSS measurements observed in this large pediatric patient sample are lower than those reported in both adults and children. Differences in imaging and measurement technique may explain these observed differences. Future prospective studies are needed to explore these differences and better define reference EPSS values and their clinical implications.

The objective of this study was to determine the ability of pediatric emergency medicine (PEM) physicians to use cardiac POCUS for the evaluation of cardiac standstill by obtaining cardiac POCUS images on healthy model pediatric patients in ≤10 seconds before and after a brief training video and then interpreting prerecorded cardiac POCUS images for cardiac standstill versus organized cardiac activity as quickly as possible. This was a single-center, prospective, simulation-based study. During simulated pediatric cardiac arrest scenarios, PEM physicians performed cardiac POCUS, reviewed a training video, and then reperformed cardiac POCUS. Subjects then interpreted 12 prerecorded cardiac POCUS video images as cardiac activity or standstill. The time to perform cardiac POCUS and to interpret images was recorded. Twenty PEM physicians participated. There was no change in median time, 10 seconds, to obtain cardiac POCUS images before and after the training video ( P =0.44). When data were dichotomized by ≤10 or >10 seconds, the odds of obtaining the image in ≤10 seconds were 3.5 times higher after viewing the video (95% CI=0.7, 34.5). When interpreting cardiac images, 40% (n=8) interpreted all of the images correctly; however, only 10% (n=2) did so in ≤10 seconds. The majority of PEM physicians can obtain cardiac POCUS images for the evaluation of cardiac standstill in ≤10 seconds. The ability to interpret cardiac POCUS images for cardiac activity or standstill in ≤10 seconds is variable; further research is needed to determine whether additional training could improve overall precision and timeliness.

Children with pediatric intestinal failure (PIF) on parenteral nutrition through central venous catheters are at high risk for central line-associated bloodstream infections (CLABSI), a major cause of morbidity and mortality. Current guidelines recommend prompt empiric antibiotic therapy, yet limited data exist on quality improvement initiatives in this population. To increase appropriate antibiotics ordered in the emergency department (ED) for febrile PIF patients by 50% and increase antibiotics administered within 60 minutes by 50% within 2 years. This single-center quality improvement project included PIF patients on home parenteral nutrition presenting to the ED with fever from February 2020 through August 2023. Interventions included electronic health record alerts, provider education, standardized CLABSI cards for families, antibiotic order sets, and ensuring cefepime availability in the ED. Ninety-five encounters were analyzed (43 preprotocol, 52 postprotocol). Postintervention, cefepime orders increased from 2.3% to 90.4% (P<0.0001), while ceftriaxone orders decreased from 88.4% to 23.1% (P<0.0001). Vancomycin orders increased from 76.7% to 98.1% (P<0.001). Both recommended antibiotics were ordered in 55.8% preintervention versus 80.8% postintervention (P<0.01). Median time to cephalosporin administration decreased 58%, from 94.5 to 39.5 minutes (P<0.05); vancomycin administration time decreased 56%, from 178 to 78 minutes (P<0.05). Cephalosporins were administered within 60 minutes in 30.2% preintervention versus 72.6% postintervention (P<0.05). This quality improvement initiative significantly improved appropriateness and timeliness of antibiotic delivery in children with PIF presenting with suspected CLABSI through multidisciplinary interventions targeting provider awareness, process standardization, and system-level barriers.

Traditional methods to evaluate for pediatric pneumonia include clinical examination and chest radiography (CXR). Point-of-care lung ultrasound (LUS) has emerged as a promising, noninvasive alternative for diagnosing pediatric pneumonia. This review highlights the diagnostic accuracy, benefits, and limitations of LUS compared with clinical assessment and CXR in pediatric patients with suspected pneumonia. Multiple meta-analyses demonstrate that LUS offers high sensitivity (up to 94%) and specificity (up to 96%) in diagnosing pediatric pneumonia, comparable to or exceeding CXR performance. LUS provides significant advantages, including no radiation, bedside applicability, and lower costs. However, challenges remain in standardizing LUS interpretation, particularly distinguishing bacterial pneumonia from viral illness and asthma, where overlapping ultrasound findings are common and require careful clinical correlation. Standardized protocols, clinician training, and diagnostic algorithms are essential to optimize LUS utility in pediatric respiratory care. Further research is warranted to refine differentiation between bacterial and viral etiologies and effectively integrate LUS into routine clinical pathways.

This study aimed to evaluate serum eosinophilic cationic protein (ECP) levels in young children with acute bronchiolitis compared with healthy controls and to investigate their association with clinical severity and tobacco smoke exposure. We hypothesized that ECP would not function as a diagnostic biomarker but might reflect inflammatory phenotypes associated with severe disease. In this prospective cross-sectional study, 96 children aged 1 to 24 months with acute bronchiolitis and 96 age-matched and sex-matched healthy controls were enrolled. Serum ECP levels and routine laboratory parameters were measured at presentation. Within the bronchiolitis cohort, associations between serum ECP levels and clinical severity indicators-including oxygen requirement, ICU admission, mechanical ventilation, and prenatal or passive tobacco smoke exposure-were evaluated. Correlations between ECP and systemic inflammatory markers were analyzed using Spearman correlation analysis. Multivariable binary logistic regression was performed to identify independent predictors of severe bronchiolitis. Serum ECP levels did not differ significantly between young children with bronchiolitis and healthy controls, indicating limited diagnostic utility. However, within the bronchiolitis group, significantly higher ECP levels were observed in young children requiring ICU admission or mechanical ventilation and in those with prenatal or passive tobacco smoke exposure. Serum ECP levels demonstrated significant positive correlations with total leukocyte count and leukocyte subpopulations, including neutrophils, monocytes, and eosinophils, as well as with serum glucose levels. Age-stratified analyses revealed distinct leukocyte profiles across infancy, whereas serum ECP concentrations remained comparable between age groups. In multivariable analysis adjusting for age and tobacco smoke exposure, serum ECP was not independently associated with severe disease, whereas tobacco smoke exposure emerged as a strong independent predictor of severe bronchiolitis. Although serum ECP does not seem to have independent prognostic utility, its elevation in severe and smoke-exposed cases suggests that it may reflect distinct inflammatory phenotypes in bronchiolitis rather than function as a direct clinical risk stratification tool.

Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are rare causes of pediatric out-of-hospital cardiac arrest (OHCA), especially in toddlers. Within VT, catecholaminergic polymorphic ventricular tachycardia (CPVT) is an uncommon but potentially fatal channelopathy that may present as collapse during emotional or physical stress. A previously healthy 2-year-old boy collapsed during a tantrum and became pulseless. Dispatcher-assisted CPR was limited due to a lack of bystander training, but law enforcement arrived before EMS and initiated compressions. Upon EMS arrival, the patient was found in ventricular fibrillation (VF) and promptly defibrillated with a 70-J biphasic shock (~4J/kg), achieving return of spontaneous circulation (ROSC). Intraosseous (IO) access was obtained, and 1mg/kg lidocaine was administered. En route, the patient developed seizure-like activity, treated with IO midazolam. In the ED, the child was hemodynamically stable but intermittently irritable. He had a normal baseline ECG showing sinus tachycardia. He continued to display episodes of seizure-like activity-characterized by decerebrate posturing and limb rigidity-and was treated with lorazepam. Cardiology and PICU teams were consulted. After admission to the PICU, a transthoracic echocardiogram (TTE) revealed no structural heart abnormalities. An epinephrine challenge provoked bidirectional VT, consistent with catecholaminergic polymorphic ventricular tachycardia (CPVT). Genetic testing later confirmed a likely pathogenic RYR2 variant. The patient was discharged on propranolol and flecainide, with a loaner AED and outpatient follow-up arranged. This case highlights the vital role of prehospital defibrillation, rapid IO access, and recognition of seizure-like activity as a potential recurrent arrhythmia in pediatric VF arrest. While definitive diagnosis, including echocardiography and genetic testing, occurs in the hospital, early EMS intervention-particularly rhythm recognition and timely shock delivery-was lifesaving in this rare pediatric case.

Diagnostic uncertainty is an important, yet understudied, driver of patient safety within pediatric emergency medicine. Understanding how uncertainty is experienced and communicated may reveal opportunities to optimize patient safety. This study aims to determine the frequency of physician-reported uncertainty at emergency department (ED) discharge for pediatric acute respiratory illness and to describe strategies and challenges in communicating uncertainty to caregivers. This was a cross-sectional study of children (<18y) discharged with acute respiratory illness from a tertiary care pediatric ED (April to May 2025). For each patient, the discharging attending physician completed a survey assessing diagnostic uncertainty (6-point Likert scale, dichotomized for analysis), and whether and how this was communicated to caregivers. Physicians indicated their general overall comfort communicating uncertainty. Wilson CIs were calculated around the prevalence of visits with uncertainty. Among 220 patients with acute respiratory illness, 68 (31%, 95% 25 to 37%) were discharged with diagnostic uncertainty. Uncertainty was communicated to 61 caregivers (90%) in the following ways: using terms such as "maybe," "probably," or "likely" (74%), provision of return precautions (59%), discussion of the differential diagnosis (56%), and discussion of diagnoses excluded (27%). Many (45% of 60 physicians surveyed) reported communication challenges, citing perceived caregiver expectations, anxiety, and risk communication concerns. Diagnostic uncertainty occurred in nearly one-third of ED discharges for pediatric acute respiratory illness. Communication approaches varied, and several challenges were noted. Future research engaging clinicians and families is needed to address these challenges and develop optimal methods of family-centered communication of uncertainty.

To develop and evaluate an internally validated natural language processing (NLP) model to determine guideline adherence of antibiotic decisions in the emergency department (ED) for skin and soft tissue infections (SSTIs). This cross-sectional pilot study developed and applied a random forest (RF)/NLP model to classify clinical narratives of patients with skin infections as requiring either methicillin-resistant Staphylococcus aureus (MRSA) or non-MRSA antibiotic coverage. Conducted at a quaternary care children's hospital with an annual volume of 50,000 ED visits, our study included patients aged 1 to 18 years presenting for SSTIs to the ED from July 1, 2018, through June 30, 2023. Main outcomes included the NLP model's sensitivity, specificity, and receiver operator characteristic (ROC) curve compared to gold standard manual physician review of the medical records. A total of 1588 patients were part of the training data set, with an additional 423 patients utilized for validation. The RF model achieved an area under the curve (AUC) of 0.99, 97.0% sensitivity, and 94.9% specificity. In the validation data set, the model achieved 96.6% sensitivity and 90.1% specificity. Performance remained strong despite absent/missing patient history in certain narratives. The NLP model demonstrated that automated analysis of clinical narratives for determining guideline adherence is feasible. Despite missing data in narratives, the model's high performance suggests potential for broader application. Given the rise in antibiotic-resistant infections and the role of judicious antibiotic use, developing automated systems through NLP can significantly contribute to health care delivery and patient safety. The methodology of this study provides a feasible, sustainable path for similar applications in the emergency setting.