OBJECTIVE:Sleep disturbances after pediatric traumatic brain injury (TBI) occur in more than 50% of survivors and portend worse cognitive and psychosocial outcomes. We aimed to determine feasibility and acceptability of an early melatonin and sleep education intervention study after TBI. PATIENTS AND METHODS:We conducted a pilot randomized, double-blinded placebo-controlled trial of melatonin for 30 days vs placebo in children aged more than 6 to 18 years started within 72 hours of TBI admission. All participants received sleep education handouts with access to short videos. Covariate adaptive randomization was used to balance groups by age and TBI severity. Primary outcomes were feasibility and acceptability. Secondary effectiveness sleep outcomes were explored with the Sleep Disturbances Scale for Children (SDSC) T-scores and actigraphy. RESULTS:Twenty-one (40%) of 53 approached patients consented (median age, 10.7 years), and 19 (91%) completed the study. Fifteen (79%) reported adherence (defined ≥5 of 7 days per week for medication), and 15 provided usable actigraphy data. We found high acceptability with no safety concerns identified. Randomization procedures were successful with no between-group differences observed. A higher frequency of clinically important SDSC scores (T-score ≥60, indicating moderate or greater risk for sleep disorder) at 30 days were found with placebo vs melatonin. Actigraphy showed nonsignificant differences. CONCLUSION:Melatonin paired with sleep education early during hospitalization and continued for 30 days is feasible and acceptable. Although not powered for effectiveness, results suggest melatonin may reduce sleep disturbances by clinically meaningful margins after TBI hospitalization, and results can be used as effect size estimates for a larger study.
OBJECTIVES:Literature from Medicare beneficiaries suggests that hospital readmission metrics limited to inpatient encounters, omitting observation-status data, may not fully capture hospital performance and affect rankings. The impact of omitting observation-status data on this metric at the pediatric population level has not been fully assessed. STUDY DESIGN:This retrospective cohort study analyzed hospital stays for pediatric patients younger than 18 years old, using Healthcare Cost and Utilization Project state-specific databases from 5 states (Georgia, Iowa, Maryland, Nebraska, and Wisconsin) spanning 2016-2019. The primary outcome was the percentile change in hospital ranks based on 30-day risk-adjusted hospital readmission rates with and without observation-status data. We assessed correlations of the percentile change in hospital ranks with hospital-level percentage of observation-status use and with hospital pediatric care capability, reflecting diversity and complexity of pediatric care offered by a hospital. RESULTS:There were a total of 288 149 and 205 107 eligible initial inpatient and observation stays, respectively. The 30-day unadjusted readmission rate was significantly different between the 2 groups of initial stays: 5.10% and 7.55% after initial observation and inpatient stays, respectively (P value <0.001). Hospitals with higher observation-status use tended to shift toward worse ranking positions after including observation-status data, whereas hospitals with lower observation-status use tended to shift toward better ranking positions. This pattern was particularly evident among tertiary children's hospitals, which had a median improvement of 11.9 percentile points. CONCLUSIONS:Hospitals with lower observation-status use were ranked lower for pediatric care when using the inpatient-only metric, with a disproportionately negative impact on tertiary children's hospitals.
BACKGROUND:Large language model (LLM)-generated hospital courses are increasingly integrated into electronic health records (EHRs), yet their accuracy and safety in pediatric populations remain poorly characterized. OBJECTIVE:To evaluate the accuracy, text quality, and perceived potential harm of EHR-integrated and LLM-generated hospital courses in pediatric inpatient care during early clinical implementation. METHODS:We conducted a descriptive evaluation from June 10 to August 8, 2025, at an academic freestanding children's hospital using an Epic EHR with an integrated LLM tool (GPT-4o and GPT-4.1). Clinicians across multiple roles, including attending physicians, residents, and advanced practice providers, reviewed LLM-generated hospital courses for their own patients. Clinicians identified and categorized errors (hallucinations, inaccuracies, or omissions). They also rated text quality (comprehensiveness, conciseness, coherence) on a 5-point scale and perceived harm on an 8-point scale. RESULTS:A total of 129 LLM-generated hospital courses were reviewed (median length of stay, 3 days; IQR, 2-7) by 50 involved clinicians. Hallucinations occurred in 21% (95% CI, 14%-29%) of the hospital courses, inaccuracies in 41% (53/129; 95% CI, 33%-50%), and omissions in 24% (31/129; 95% CI, 17%-32%). Overall, perceived harm ratings were low (median, 0; IQR, 0-1). Text quality ratings were high (median [IQR]: comprehensiveness, 4 [3-5]; conciseness, 4 [4-5]; coherence, 4 [4-5]) and comparable with prior literature. CONCLUSION:In this pediatric evaluation of LLM-generated hospital courses reviewed by frontline clinicians, errors were common, but perceived potential harm was low, even assuming use without clinician correction. These findings support the use of LLM-generated hospital courses as starting drafts when paired with clinician review and institutional safeguards.
BACKGROUND AND OBJECTIVES:As survival after pediatric critical illness improves, attention has shifted to post-intensive care syndrome and the long-term mental health of pediatric intensive care unit (PICU) survivors, who have high rates of posttraumatic stress, anxiety, and depression. The objective of this study is to examine the rates of new mental health follow-up and psychopharmacology use among publicly insured children following PICU hospitalization, compared with those hospitalized on acute care wards. METHODS:We performed a retrospective cohort study using 2016-2021 multistate Medicaid claims. The cohort comprised children aged 3 to 18 years discharged home after an index hospitalization. The primary exposure was PICU admission. The primary outcome was new mental health visits within 1 year after discharge. Secondary outcomes included visit clinician type, visit diagnoses category, and new psychiatric prescriptions. RESULTS:Among 144 763 Medicaid-insured pediatric hospitalizations (20.7% with PICU stays), only 5.2% initiated new mental health care. When compared with hospitalizations without PICU exposure, those with PICU exposure were more likely to complete new mental health visits (n = 1697 [6.1%] of PICU hospitalizations vs 5252 [4.9%] of non-PICU hospitalizations). PICU exposure was independently associated with a new mental health visit (odds ratio 1.07; 95% CI 1-1.14; P = .042). Older age, complex chronic conditions, and longer length of stay were associated with new mental health visits. CONCLUSIONS:New mental health follow-up after pediatric hospitalization is rare and independently associated with PICU exposure during hospitalization. Future studies should investigate barriers to care and identify effective methods for systematic screening and proactive referral.
OBJECTIVE:Most US children receive care at nonchildren's hospitals. Trends over the past 2 decades have revealed decreasing pediatric inpatient capabilities. This study aimed to describe the hospital characteristics associated with loss of pediatric inpatient capabilities among a national sample of US nonchildren's hospitals between 2013 and 2021. METHODS:A secondary analysis was conducted using National Pediatric Readiness Project Assessments from 2013 to 2021. Hospitals with 1 or more reported pediatric inpatient unit capability (pediatric ward, pediatric intensive care unit [PICU], nursery/neonatal intensive care unit [NICU]) in 2013 and assessment responses in 2013 and 2021 were included. Multivariable logistic regression models were used to assess associations between hospital characteristics and loss of pediatric inpatient capabilities. RESULTS:Of the 1570 included hospitals, 33.4% were urban high volume, 42.8% were nontrauma designated, and 40.9% had loss of 1 or more pediatric inpatient capability between 2013 and 2021. Multivariable analysis showed nonmetro status was associated with increased adjusted odds of pediatric ward loss (adjusted OR [aOR] 3.45; 95% CI, 2.42-4.94) and nursery/NICU loss (aOR, 2.93; 95% CI, 1.76-5.00) compared with urban high-volume hospitals. Trauma-designated hospitals had decreased adjusted odds of pediatric ward loss (aOR, 0.63; 95% CI, 0.47-0.83) and nursery/NICU loss (aOR, 0.60; 95% CI, 0.40-0.88). CONCLUSIONS:Two in 5 hospitals with pediatric inpatient capability lost 1 or more capability between 2013 and 2021. Nonmetro hospitals had higher odds of capability loss, whereas trauma-designated hospitals had lower odds, highlighting geographic and structural disparities in pediatric inpatient service sustainability. Identifying impacts of these changes is critical to ensuring equitable access.
BACKGROUND:High-risk infants with significant neonatal-perinatal morbidities often require opioids, but prolonged exposures can impair neurodevelopment. We evaluated the effect of cumulative opioid exposures in the first year of life, measured by morphine milligrams equivalents (MME), on neurodevelopment. METHODS:A retrospective cohort of high-risk infants younger than 1 year admitted to a tertiary children's hospital from 2010 to 2020 was identified. International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/ICD-10) codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and thoracoabdominal surgery identified high-risk infants. Cumulative MME received over all hospitalizations in the first year of life were calculated alongside benzodiazepine dosing and neurodevelopmental scores at 18 months or older. Neurodevelopmental impairment was defined as a score more than 1 SD from the standardized mean. Multivariable linear regressions adjusted for demographics and comorbidities. RESULTS:Overall, 330 high-risk infants were identified, and 70.6% demonstrated neurodevelopmental impairment. Cumulative MME negatively correlated with cognitive (P < .001), motor (P < .001), and language (P = .004) scores. On multivariable linear regression, increasing MME was significantly associated with decreasing cognitive (P < .001) scores but not motor or language scores. CONCLUSION:Higher cumulative opioid exposure in the first year of life was associated with reduced cognitive scores at 18 months or older, independent of comorbidities. Opioid stewardship initiatives extended to high-risk infants may further optimize long-term neurodevelopment.
Clustered data, in which observations are grouped within higher-level units, arise frequently in pediatric research. Common examples include repeated measures within patients and patients nested within hospitals. Observations within the same cluster tend to be correlated, and standard analytic methods that assume independence produce invalid SEs and misleading inference. Mixed-effects models account for this correlation by incorporating random effects that quantify variation between clusters. This article introduces mixed-effects models as a practical tool for clinician-researchers analyzing clustered data. Two examples using simulated neonatal intensive care data illustrate a linear mixed-effects model for a continuous outcome and a generalized linear mixed model for a binary outcome. Each example demonstrates model specification and interpretation using R, compares results with a naive analysis that ignores clustering, and illustrates how ignoring clustering can bias conclusions in opposite directions depending on the data structure. Supplemental material includes the complete R code, simulated data sets, output interpretation, and a guide for reporting clustered data analyses in manuscripts.
BACKGROUND:Intermittent vital sign (VS) documentation is the standard of care in pediatric wards and pediatric intensive care units (PICUs). However, intermittent capture of VS values may miss important trajectories and extreme values, particularly for patients at risk of organ dysfunction. OBJECTIVE:Determine the agreement between intermittently charted and high-frequency (continuous) bedside monitor VS measurements, as well as the performance of the 2 types of VS measurements to predict cardiorespiratory dysfunction. METHODS:This was a single-center, retrospective study of children admitted to the PICU. We examined agreement by comparing the range of high-frequency VS measurements with the corresponding intermittently charted VS measurements. To assess the performance for predicting cardiorespiratory dysfunction, both sets of VS measurements were summarized as the worst values at an hourly level. The dataset was temporally divided into training and test sets, and XGBoost models were trained using either the intermittent or high-frequency values. The area under the receiver operating characteristic (AUROC) curve of both models was compared using the DeLong methods. RESULTS:There were 12 189 PICU encounters, with over 1.5 million paired VS observations. Agreement varied based on the VS, with 21% to 33% of all intermittently charted VS measurements out of range from the high-frequency VS measurements. Cardiorespiratory dysfunction occurred in 36.4% of encounters. High-frequency VS measurements had a small but significantly higher performance at predicting cardiorespiratory dysfunction compared with intermittently charted VS measurements (AUROC, 0.64 vs 0.63; P < .001). CONCLUSIONS:About 20% to 30% of intermittently charted VS measurements do not fall into the expected high-frequency, bedside monitor range. High-frequency VS measurements are weakly but significantly better than intermittently charted VS measurements in predicting cardiorespiratory dysfunction.
BACKGROUND:Clinical deterioration with late escalation, termed emergency transfer (ET), is a key safety metric. However, national benchmarking is limited by variable definitions. We sought to estimate pooled ET rates and assess variation across pediatric hospitals. METHODS:We performed a cross-sectional analysis of ET events (2020-2022) at 7 pediatric tertiary care hospitals. ET was defined as unplanned transfer to the pediatric intensive care unit with intubation, vasopressors, and/or at least 60 mL/kg fluid resuscitation within 1 hour before or after transfer. We calculated ET rates per 10 000 patient-days and as a percentage of total unplanned transfers. RESULTS:Across 1 582 794 patient-days and 11 100 unplanned transfers, we identified 448 ET events. The most common qualifying intervention categories were endotracheal intubation in 236 ETs (53%) and vasopressor initiation in 204 ETs (46%). The pooled ET rate was 2.83 per 10 000 patient-days (95% CI, 2.57-3.11), with significant variation across sites (range, 1.2-5.1; P < .01). The pooled proportion of unplanned transfers meeting ET criteria was 4.04% (95% CI, 3.68%-4.42%), which also varied significantly (P < .01). Variation persisted when restricted to sites already institutionally tracking ETs. Metric definitions varied most regarding fluid thresholds and which medications were included in vasoactive infusion definitions. CONCLUSION:ET rates vary significantly across pediatric hospitals regardless of the denominator used. Variation may be related to the observed differences in ET metric definitions (eg, fluid thresholds) and hospital characteristics (eg, intensive care unit criteria). These pooled estimates provide initial benchmarks, and standardization of the ET metric definition is required to enable reliable interinstitutional comparison.
BACKGROUND:Pott's puffy tumor is a rare complication of sinusitis characterized by osteomyelitis of the frontal bone with subperiosteal abscess, often with intracranial sequelae. Although complications of sinusitis increased after the pandemic, it is unclear whether rates of Pott's puffy tumor increased. OBJECTIVE:To investigate the rate of Pott's puffy tumor hospitalizations in US children and assess trends in clinical characteristics during 2017-2025. METHODS:We performed a cross-sectional epidemiological study using Epic Cosmos. We included hospitalizations of pediatric patients (aged 0-21 years) at continuously contributing US hospitals during 2017-2025 with a Pott's puffy tumor diagnosis and receipt of systemic antibiotics. We calculated annual Pott's puffy tumor hospitalization rates per 100 000 hospitalizations. We identified patient-level demographic and clinical characteristics and compared these between 2017-2019 and 2022-2025. RESULTS:We identified 601 pediatric patients hospitalized for Pott's puffy tumor during 2017-2025 from 170 hospitals. The hospitalization rate increased from 2.8 per 100 000 hospitalizations in 2017 to 6.0 in 2025. The median age was 12 years, the median length of stay was 7 days, and 33% of patients received care in the intensive care unit, which was similar across time periods. The proportion of patients who underwent surgical procedures increased from 37% in 2017-2019 to 60% in 2022-2025 (P < .001). CONCLUSION:Our findings suggest that, although still a rare diagnosis, Pott's puffy tumor hospitalizations among children have increased, with an increase in surgical intervention. Further investigation into the incidence and the cause of observed increases is warranted.
BACKGROUND AND OBJECTIVES:Early identification of children with Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) at risk of a complicated course may optimize management. The neutrophil-to-lymphocyte ratio (NLR) is a simple, widely available marker of inflammatory imbalance with prognostic value in several diseases; however, its prognostic performance in children with STEC-HUS remains unexplored. METHODS:In this retrospective observational prognostic study, we reviewed the medical records of patients hospitalized with STEC-HUS at a tertiary hospital in Argentina between 2000 and 2024. Demographic, clinical, and laboratory variables were compared between patients with complicated (dialysis >10 days and/or extrarenal complications and/or death) and uncomplicated disease. The prognostic performance of laboratory variables was calculated using receiver operating characteristic (ROC) curve analysis. RESULTS:Of 214 patients, 70 (32.7%) had complicated disease. Patients who developed complicated disease had significantly higher NLR values than those who did not (4.8 vs 1.4, P < .001). In multivariable analysis, NLR (odds ratio [OR], 2.7, 95% CI, 2.03-3.58; P < .001) and C-reactive protein (OR, 1.01, 95% CI, 1.0006-1.02; P = .04) remained independent predictors of a complicated episode. The prognostic performance of NLR assessed by ROC curve analysis was 0.91 (95% CI, 0.87-0.96). At a cutoff value of at least 3.7, sensitivity was 88.6% (95% CI, 78.7%-94.9%) and specificity was 94.4% (95% CI, 89.3%-97.6%). Posttest probability of complications was 88.6% for NLR greater than or equal to 3.7 and 5.5% for NLR less than 3.7. CONCLUSION:The NLR demonstrated strong predictive value for a complicated disease course in children with STEC-HUS. External validation in independent cohorts is required before routine clinical implementation.
OBJECTIVE:To evaluate postoperative disposition and resource use among patients admitted to the inpatient unit or pediatric intensive care unit (PICU) following tonsillectomy, adenoidectomy, and tonsillectomy/adenoidectomy (T/A). PATIENTS AND METHODS:This retrospective cohort study featured patients aged 18 years or less after T/A procedures in 38 children's hospitals in the Pediatric Health Information System database (2016-2023). Patients were categorized by postoperative disposition: ambulatory, inpatient unit, inpatient unit with subsequent PICU transfer, or PICU; inpatient admissions were analyzed. Primary outcomes were the frequency of urgent interventions (racemic epinephrine administration and noninvasive ventilation) and emergent interventions or outcomes (invasive mechanical ventilation, cardiopulmonary resuscitation, hemorrhage, blood transfusion, or return to operating room). The secondary outcome was median daily hospital cost. RESULTS:A total of 388 071 T/A procedures were identified, including 316 323 ambulatory and 71 748 inpatient. Among the patients in the inpatient unit and PICU, 2% and 16% received an urgent intervention, and, in both locations, 2% received an emergent intervention or outcome. For patients without interventions, the median daily cost difference between PICU and inpatient unit admissions was $1774. Based on the difference between PICU and inpatient costs for patients with no interventions, we estimate that $2.6 million could be saved if 50% of these patients in the PICU were admitted to the inpatient unit. CONCLUSIONS:A minority of PICU admissions following T/A procedures require urgent or emergent interventions. This suggests that deimplementation of routine T/A PICU admissions may facilitate transitioning patients to the inpatient unit, reducing costs and optimizing PICU use.
OBJECTIVE:Respiratory viral panels (RVP) are common, expensive tests that often do not change treatment, especially in children with suspected urinary tract infections. In children with abnormal urinalysis (UA) results, we hypothesize that RVP overuse existed before the COVID-19 pandemic and has risen further after. METHODS:We conducted a single-center retrospective cohort study of children aged 0 to 24 months who presented to a quaternary care children's emergency department (ED) from March 2018 to May 2025 with abnormal UA results. Children with complex chronic conditions, required intensive care or respiratory support, or sepsis were excluded. The primary outcome was the proportion of children with RVP testing within periods of prepandemic (March 2018-February 2020), pandemic (March 2020-May 2023), and postpandemic (July 2023-May 2025). Secondary outcomes included ED revisits, antiviral use, and cost of testing. We assessed trends in RVP use across the periods using interrupted time series analysis. Cost was measured using Medicaid reimbursement fees. RESULTS:Our cohort included 7496 patients. The proportion of all children who received an RVP was 25.0% (95% CI, 23.1-27.0), 68.1% (95% CI, 66.5-69.7), and 66.1% (95% CI, 64.1-68.0) during prepandemic, pandemic, and postpandemic periods, respectively. There was an increase in viral testing during the pandemic compared with prepandemic period (P < .001) but without change between pandemic and postpandemic (P = .14). Viral testing was associated with no differences in ED revisits (P = .41). Only 134 patients (1.8%) received antivirals. The total cost of respiratory viral testing was $1 037 978. CONCLUSIONS:RVP testing increased during the COVID-19 pandemic in children with abnormal UA results and remained elevated postpandemic. RVP testing was costly and associated with low antiviral use. These results highlight opportunities for diagnostic stewardship.
OBJECTIVES Respiratory syncytial virus (RSV) immunoprophylaxis is efficacious, yet uptake is low in comparison with other recommended newborn interventions. We aimed to identify barriers to and enablers of implementation of an intervention in the well newborn unit to increase parental confidence in newborn RSV immunoprophylaxis. PATIENTS AND METHODS We conducted individual, semi-structured interviews of purposively sampled clinicians and parents at an urban, quaternary-care hospital well newborn unit between August 13, 2025, and October 22, 2025. Interviews elicited clinicians’ and parents’ perceptions of RSV immunoprophylaxis, the counseling process, barriers and facilitators, and their perspectives on the design and implementation of an intervention to increase parental confidence. Using both deductive and inductive approaches, 4 investigators independently coded the first 2 transcripts in each stakeholder group to identify themes. Two investigators then applied codes to the remaining transcripts, resolving discrepancies by consensus. RESULTS We interviewed 18 clinicians (5 hospitalists, 3 general pediatricians, 3 obstetricians, 7 nurses/nurse managers) and 24 parents. We identified several themes related to an intervention to increase parental confidence, including barriers and facilitators: (1) trust and mistrust of information; (2) differentiation of RSV immunoprophylaxis from a vaccine; and (3) value of providing both data and personal experiences. We also identified themes related to implementation: (1) support for a tool to augment, but not replace, clinician counseling; (2) use of visuals; (3) accessibility for parents of varying health literacy and languages; and (4) importance of timing. CONCLUSIONS The identified themes can inform the design and implementation of an intervention to increase parental confidence in newborn RSV immunoprophylaxis.
Grounded theory offers rich possibilities for health-related qualitative research, yet it is frequently misunderstood. Grounded theory is not simply a coding method, but a rigorous methodological approach, with core elements impacting the entire research process, whose goal is to generate a theory that is grounded in the data. Although there is not a unified definition of grounded theory among all its proponents, constructivist grounded theory (CGT) as formulated by Kathy Charmaz is particularly well suited to investigating complex social processes in health care. In this Method/ology article we (1) explain constructivism as a foundational worldview that presumes meaning is coconstructed by individuals through their interactions, (2) outline how the CGT approach grounds both the researcher and their outcomes in the data through an iterative process of data collection and analysis, and (3) describe how the CGT researcher moves beyond descriptive themes to develop a theory or explanatory model of specific social processes. This article highlights common pitfalls in qualitative health care research and provides practical guidance for clinician-researchers interested in pursuing CGT studies.
