We conducted a multicenter prospective cohort study to identify factors associated with discharge on higher respiratory support in children with tracheostomy hospitalized for bacterial tracheostomy-associated infections (bTRAINs). We included children 0-21 years with tracheostomy hospitalized for bTRAIN at six freestanding children's hospitals between 2020 and 2024. The primary outcome was discharge on higher respiratory support compared to pre-hospital baseline. Generalized linear mixed-effects regression models accounted for patient and hospital clustering. We included 641 children representing 1180 hospitalizations, with a median age of 5 years; 45.9% were female, 35.6% Hispanic, and 20.0% Non-Hispanic Black. 24.7% were discharged on higher respiratory support. In adjusted analyses, discharge on higher respiratory support was associated with increased oxygen requirement, escalation of chronic ventilator settings, acute ventilatory support, and longer length of stay. In our study, discharge on higher respiratory support was driven by illness severity, rather than demographic or home support factors.

OBJECTIVE:Test the association between early antibiotic discontinuation and outcomes for children with a tracheostomy and positive respiratory viral PCR (RVP) hospitalized with suspected bTRAIN (bacterial TRacheostomy-Associated INfection; pneumonia/tracheitis). METHODS:We conducted a multicenter cohort study between September 1, 2021 and August 31, 2024 of children with pre-existing tracheostomy hospitalized for suspected bTRAIN (tracheal aspirate bacterial culture sent and bTRAIN antibiotics started) at six children's hospitals with: (1) a positive RVP test; (2) no antibiotic pre-treatment; and (3) length of stay (LOS) < 37 days (outlier). Mixed-effects regression models identified independent associations between early antibiotic discontinuation and our primary outcome, LOS (in days). Inverse probability treatment weighting based on propensity scoring adjusted for measured confounding. We explored the association between early antibiotic discontinuation and 3 secondary outcomes: late ICU transfer, in-hospital mortality, and 30-day bTRAIN rehospitalization rates. RESULTS:Of 542 hospitalizations in 365 children, the median admission age was 4 years (interquartile range [IQR]: 2-8 years). Common viruses included rhinovirus (n = 282; 52%), SARS-CoV-2 (n = 63; 12%), and respiratory syncytial virus (n = 61; 11%). The median LOS was 7 days (IQR: 5-11 days). Only 28% (n = 152) had early antibiotic discontinuation; full bTRAIN treatment was associated with a 23% (5%-45%) increased LOS, with estimated LOS means (95% CI) of 7.0 (5.8-8.4) days for early antibiotic discontinuation and 8.6 (7.8-9.4) days in the bTRAIN-treated group. Secondary outcome rates (late ICU transfer = 14.6%; in-hospital mortality = 0.9%; 30-day bTRAIN rehospitalization rate = 8.3%) were similar rates between both groups. CONCLUSIONS:Given similar rates of serious outcomes in both groups, clinicians could consider early discontinuation of antibiotic treatment in children with suspected bTRAINs who have a positive RVP test.

Purpose of review Children with tracheostomy frequently experience tracheostomy-associated infections (TRAINs) such as pneumonia and tracheitis. This review will summarize current evidence regarding the diagnosis, treatment, and prevention of TRAINs. Recent findings Recent evidence highlights limitations of respiratory culture testing in the face of a diverse, dynamic bacterial community within the airways of children with tracheostomy, challenging the notion that a positive bacterial culture is sufficient for diagnosing bacterial TRAIN. For this reason, recent consensus guidelines recommend against the routine obtainment of respiratory cultures for TRAIN diagnosis in the absence of specific clinical symptoms. Additional evidence for microbiome shifts and host inflammation as diagnostic tools may help identify those who will benefit from antibiotic treatment. Recent findings support selective anaerobic coverage when aspiration is suspected and suggest shorter antibiotic courses may be effective. Cycled inhaled tobramycin shows potential for reducing TRAIN frequency and related hospitalizations. Summary With recent advances in TRAIN pathobiology, diagnosis, treatment, and prevention of TRAINs is undergoing a paradigm shift. Future translational research will define the airway microbiome during TRAINs and during wellness and its impact on host inflammation. Antibiotic clinical trials are needed to optimize treatment and prevention of TRAINs.

Racial and ethnic disparities and language barriers coexist with inequities in a child’s educational, environmental, and economic opportunity. We evaluated the association between surgical outcomes and a composite child neighborhood opportunity index (COI), race and ethnicity, and language barriers among children undergoing congenital heart surgery. Utilizing the Society of Thoracic Surgeons database, we conducted a single-center retrospective cohort study of patients who underwent congenital cardiac surgery from 2010 to 2023. Patients were classified by quintile COI scores based on their reported address. Outcomes included in-hospital mortality, length of stay (LOS), and major complications. Adjusted analyses were performed using generalized linear mixed models. Among 1,568 patients, 51.2

BACKGROUND AND OBJECTIVES:Racial and ethnic disparities disproportionately impact children with medical complexity (CMC), including children with tracheostomies. Children hospitalized for bacterial tracheostomy-associated infections (bTRAINs) experience care variations that may exacerbate disparities. Our study aimed to quantify disparities in length of stay (LOS) for children hospitalized with bTRAINs. METHODS:We conducted a multicenter observational study of children aged 0 to 21 years who were hospitalized and treated for a bTRAIN at 6 children's hospitals between August 2020 and August 2024, excluding children with outlier LOS (>30 days). Our primary predictor was race and ethnicity, as documented in the electronic medical record. Our primary outcome was LOS (days). We used mixed-effects regression modeling to account for repeated encounters, nesting of patients within hospitals, and adjusting for confounders (socioeconomic factors, comorbidities and illness severity). RESULTS:We included 662 children (39% white, 35% Hispanic, 22% Black, and 4% Asian) representing 1349 unique encounters. The median age at hospitalization was 6 years (IQR 2-13) and 72% of children had public insurance. Median LOS was 8 days (IQR 5-12). When adjusting for confounders, all other racial groups had longer LOS compared with white children with ratio of means of 1.14 (95% CI: 1.03-1.28) for Black; 1.12 (95% CI: 1.01-1.25) for Hispanic; and 1.29 (95% CI: 1.07-1.54) for Asian children. CONCLUSIONS:Black, Hispanic, and Asian children hospitalized for a bTRAIN experience longer LOS than white children. Understanding is needed on how implicit bias, systemic racism, and care-team preferences lead to disparities and if standardized care can improve outcomes.

Academic coaching in graduate medical education utilizes observation and individualized goal setting to promote self-directed learning and performance improvement. Most academic coaching models are hierarchical (i.e., senior coach and junior coachee). Peer coaching is a unique growth opportunity for academic coaching. However, facilitators and barriers to implementing peer coaching, as well as which clinical and professional domains could be most helpful, remain undefined. We aimed to explore the current attitudes, promoters, and barriers of peer coaching among pediatric residents participating in academic coaching. We conducted a cross-sectional descriptive study of all pediatric and child neurology residents at a freestanding children’s hospital in 2025. Residents were anonymously surveyed on their current understanding, use of, and desire for further development of peer coaching. Residents were also allowed to indicate preference for a faculty or peer coach in thematic areas amenable to academic coaching. A total of 23/37 residents (62

BACKGROUND:The clinical features and outcomes of rhabdomyosarcoma (RMS) occurring as a secondary neoplasm are unknown. We aimed to determine the prevalence of secondary RMS (sRMS) and compare patient characteristics, treatment, and overall survival (OS) between primary RMS (pRMS) and sRMS in children, adolescents, and young adults. METHODS:We queried Surveillance, Epidemiology, and End Results data for patients 0-39 years old diagnosed with RMS from 2000 to 2021. Prevalence of sRMS was reported with 95% confidence intervals (CIs). Comparisons between pRMS and sRMS were evaluated using Chi-square or Fisher's exact test for categorical variables and Mann-Whitney U tests for continuous variables. Five-year OS from time of RMS diagnosis was calculated using Kaplan-Meier analysis. RESULTS:We identified 2676 patients with pRMS and 71 patients with sRMS (prevalence: 2.6%; 95% CI: 2.0%-3.3%). Patients with sRMS were older (p < 0.001) and more likely to have non-alveolar, non-embryonal histology (p < 0.001). Radiotherapy (63.6% vs. 32.4%, p < 0.001) and chemotherapy (93% vs. 77.5%, p < 0.001) were less frequently administered to patients with sRMS. Primary malignancies preceding sRMS included germ cell tumors (28.2%) and leukemia/lymphoma (23.1%). The 5-year OS in sRMS was inferior to pRMS (37% vs. 60%, p < 0.001). OS in sRMS was associated with age (p = 0.028) and site (p = 0.004). CONCLUSION:sRMS is rare and has distinct clinical features compared to pRMS. Treatment characteristics differed, including decreased use of chemotherapy or radiotherapy, and patients with sRMS had inferior 5-year OS. While this inferior OS is likely multifactorial, decreased use of chemotherapy and radiotherapy may be contributory.

OBJECTIVE:To evaluate the frequency of hospital-acquired venous thromboembolism (HA-VTE, including limb and neck deep venous thrombosis, pulmonary embolism, and organ-specific VTE) among critically ill children with tracheostomy and determine whether surrogate markers of impaired mobility (i.e., invasive mechanical ventilation [IMV] or a high-intensity neurologic diagnosis) are associated with HA-VTE. DESIGN:Multicenter, retrospective study of the Virtual Pediatric Systems database from January 1, 2016 to December 31, 2023. SETTING:One-hundred forty-two North American PICUs. PATIENTS:Children younger than 18 years with a preexisting tracheostomy, excluding neonatal and postoperative encounters, those with a PICU length of stay less than 1 day, and those with VTE present at admission. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Of 25,560 encounters, 181 (0.7%) developed a HA-VTE, identified at a median of 9.5 days (interquartile range: 4-19) following hospitalization. Although a larger proportion of children who developed a HA-VTE as compared with not had a high-intensity neurologic diagnosis (66.9% vs. 56.6%, p = 0.006) and greater rate of IMV exposure (92.8% vs. 81.6%, p < 0.001), these immobility surrogate markers were not associated with HA-VTE in an adjusted logistic regression model. Features independently associated with HA-VTE included: prior VTE (adjusted odds ratio [aOR]: 19.2; 95% CI, 7.1-52); central venous catheterization (CVC, aOR: 3; 95% CI, 2.1-4.2); comorbid infection (aOR: 2.2; 95% CI, 1.6-3.2); and an inherited hypercoagulability (aOR: 3.5; 95% CI, 2.6-5.7) (all p < 0.001). Among patients with CVC, concomitant high-intensity neurologic impairment diagnosis (aOR 1.7; 95% CI, 1.1-2.8) was independently associated with HA-VTE. CONCLUSIONS:In this multicenter study of critically ill children with tracheostomy, HA-VTE occurred in 0.7% of encounters and was associated with presence of a CVC, comorbid infection, prior VTE and inherited hypercoagulability. A surrogate marker of immobility (i.e., high-intensity neurologic diagnoses) was associated with HA-VTE among patients with a CVC.

OBJECTIVE:In children with urinary tract anomalies, febrile urinary tract infections (UTIs) are associated with increased risks of sepsis, hospitalization, and kidney injury. However, the best treatment strategies are unknown. We aimed to describe antibiotic treatment practices and outcomes for UTIs in children with urinary tract anomalies and evaluate whether variability in UTI treatment exists between hospitals. METHODS:We conducted a multicenter retrospective cohort study of children seen in emergency departments (EDs) in 6 free-standing US children's hospitals from January 1, 2017, through December 31, 2018. We included children aged 0-17 years with an anatomic or functional urinary tract anomaly and a physician diagnosis of febrile or hypothermic UTI. Outcomes included intravenous (IV) antibiotic administration practices, hospitalization rates, length of stay, and return ED visits. Multivariable logistic and linear regression were performed, adjusting for differences in patient and illness characteristics. RESULTS:Among the 510 children included, anomaly types, presence of home catheterization regimens, and baseline glomerular filtration rates varied between sites. In the adjusted analyses, sites differed in several treatment practices: IV antibiotic administration before ED discharge (P = .007), IV antibiotic spectrum (P = .003), IV antibiotic duration (P < .001), and hospital length of stay (P < .001). No statistically significant differences existed with bacteremia (P = .24) or intensive care stays (P = .08). Returns to the ED within 30 days did not significantly differ by site (P = .68). CONCLUSIONS:Children's hospitals vary in their treatment of UTIs in children with urinary tract anomalies, yet ED revisits are similar across sites, highlighting the opportunity to promote high-value care in treatment of UTIs in this population.

Introduction: Fever as an indicator of infection is frequently used as an aid in triggering concern for sepsis in the emergency department (ED). Adults with sepsis presenting to the ED with a normal temperature have been shown to have delays in treatment and greater mortality. The association between temperature and timeliness of sepsis-related care in the ED remains poorly characterized in children. Our objective in this study was to measure the association between body temperature at the physiologic onset of sepsis and the time to initiation of antibiotic treatment and fluid bolus among children with clinically defined sepsis. Methods: We conducted a retrospective, cohort study of pediatric patients with sepsis presenting to the ED. Data collected from an existing quality improvement database were supplemented via chart extraction. We assessed body temperature at physiologic onset of sepsis (PO-S), the date and time when a patient first met clinical criteria for sepsis as defined by Goldstein et al.1 Our primary outcomes were time from PO-S and administration of antibiotics and fluid bolus. Secondary outcomes included maximum vasoactive-inotropic scores, need for extracorporeal membrane oxygenation (ECMO) within 30 days of presentation, presence and type of organ dysfunction, 30-day hospital- and intensive care unit (ICU)-free days, and mortality. We summarized and compared data by temperature group. Multivariable quantile regression was used to evaluate adjusted associations between body temperature and time to initiation of antibiotic treatment and fluid bolus. Results: Of 928 patients screened, 385 (41%) met inclusion criteria. Median time to antibiotic treatment did not differ between temperature groups at PO-S—≤ 36.0 °C: median (IQR) 48.5, (41.3-104.8); 36.1-37.9 oC: median, 95.5, (41.3-104.8;), and ≥ 38.0 oC: median 84, 45-151; (P = .24). Median time to fluid bolus administration also did not differ between temperature groups at PO-S—≤ 36.0 °C: median 39, (20.8-65.8); 36.1-37.9 oC: median, 42.5 (21.3-86.3); and ≥ 38.0 oC: median, 54 (29-84); (P =.07). In addition, mortality differed by temperature at PO-S (≤ 36.0 °C: 1/22 (4.5%); 36.1-37.9 oC: 4/80 (5.0%); and ≥. 38.0 oC: 3/283 (1.1%), (P = .04); as did organ dysfunction at 72 hours: ≤. 36.0 °C: 15/22 (68.2%); 36.1-37.9 oC: 43/80 (53.8%), ≥ 38.0 oC: 74/283 (26.1%); (P < .001) and median (IQR) 30-day ICU- and hospital-free days—≤ 36.0 °C: median, 24, (20,-26.8); 36.1-37.9 oC: median, 28 (24.8-30), ≥ 38.0 oC: median, 30 (27-30), (P < .001); and at ≤. 36.0°C: median, 22, (17-25); 36.1-37.9 oC: median, 24 (17.8-27); ≥ 38.0 oC: median, 25 (20, 27), (P = .04), respectively. We did not observe an association between temperature and median time to antibiotic administration (β: 2.5, 95% CI, -4.2 to 9.1, P = .50) or first fluid bolus administration (β: 1.7, 95% CI, -1.4 to 4.8, P = .30). Conclusion: Time to fluid bolus administration and time to antibiotic administration did not differ statistically by temperature from physiological onset of sepsis. Children presenting with hypothermia (≤ 36.0 °C) had worse outcomes.

Rationale: Extreme premature neonates (born ≤28 weeks of gestation) have the highest risk of prolonged invasive mechanical ventilation and lung injury due to extubation failure. Current prediction models do not incorporate clinical data and biomarkers to predict the risk of extubation failure. This study explored differences in the proteome profiles of extremely premature neonates who succeeded or failed their first extubation attempt. We hypothesized that protein abundance before the extubation would differentiate neonates according to extubation success or failure. Methods: We conducted a pilot prospective cohort study in a level IV NICU. Neonates born ≤28 weeks of gestation or with birth weight ≤1000 grams intubated within the first week of life were included. Neonates with congenital anomalies were excluded. Informed parental consent was obtained for the collection of blood samples on days 0, 1, 2, 3, 7, and 14 of the intubation period. The primary outcome was extubation failure, defined as reintubation within 7 days of extubation. Plasma samples were analyzed using Tandem Mass Tag (TMT)-labeled liquid chromatography-mass spectrometry (LC-MS) proteomics. The Mass Dynamics platform was utilized to identify differentially abundant proteins with a fold change ratio > 1.5 and a False Discovery Rate threshold (adjusted P-value) < 0.05. Results: 17 participants were enrolled, with 13 completing sample collection. 7 (54%) had extubation success, 4 (31%) had extubation failure, and 2 (15%) were not extubated within the study time frame. We analyzed plasma from 4 neonates with extubation success and 2 with extubation failure, matched by gestational age and timing of extubation. The median gestational age was 27 weeks for the success group and 26 weeks in the failure group. Average birth weight was lower in the failure group at 645 grams compared to 844 grams of the success group. A total of 1041 unique proteins were observed in 24 samples from 6 subjects. We identified 43 proteins with decreased abundance and 30 with increased abundance in extubation failure compared to extubation success. Conclusions: We identified a proteomic signature differentiating between extubation failure and success that has the potential to predict extubation failure and targets for new therapies. Although this protein signature needs to be validated in a larger cohort to confirm our findings, proteins of interest were previously implicated in lung injury and bronchopulmonary dysplasia, with some (e.g. DLK1, TUBB4B, XPO1) being targets for drugs approved by the FDA.

Importance:Despite a small prevalence, children with complex chronic conditions (CCCs) use substantial inpatient resources. Objective:To assess national trends in hospital discharges, bed days, and hospital charges for children with and without CCCs in the US from 2000 to 2022. Design, Setting, and Participants:This retrospective, repeated cross-sectional study used hospital discharge data from the Kids' Inpatient Database (KID) from the years 2000, 2003, 2006, 2009, 2012, 2016, 2019, and 2022 for US children aged 0 to 18 years, excluding uncomplicated newborn discharges. Exposure:Presence of 0, 1, 2, or 3 or more CCCs. Main Outcomes and Measures:Trends in the hospital discharge rate per 100 000 children and percentage of total hospital discharges, bed days, and charges attributable to children with CCCs, identified with International Classification of Diseases, 9th Revision, Clinical Modification and International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification codes using Feudtner's diagnosis code classification system, version 3. Survey weights were applied to estimate hospital discharges, bed days, and charges. Sociodemographic (eg, primary payer) and clinical (eg, technology dependence, mental health comorbidity) characteristics for each hospital discharge were also assessed. Results:Across all years, there were an estimated 26 342 497 hospital discharges, of which 54.1% (95% CI, 54.0%-54.2%) were among males and 55.4% (95% CI, 54.4%-55.8%) were for infants. From 2000 to 2022, the discharge rate per 100 000 US children increased by 24.3% (95% CI, 22.7%-26.3%), from 779 to 968, for children with 1 or more CCCs and decreased by 9.7% (95% CI, 9.4%-10.0%), from 3831 to 3459, for children with no CCCs. From 2000 to 2022, the percentage change in the hospital discharge rate varied by number of CCCs: a 3.8% (95% CI, 0.9%-6.0%) decrease was found for 1 CCC, a 60.9% (95% CI, 57.7%-65.5%) increase for 2 CCCs, and a 340.0% (95% CI, 332.6%-351.1%) increase for 3 or more CCCs. In 2000 and 2022, children with 1 or more CCCs accounted for 16.9% (95% CI, 15.7%-17.9%) and 21.9% (95% CI, 20.7%-22.9%) of hospital discharges, 32.0% (95% CI, 30.8%-33.1%) and 44.1% (95% CI, 42.6%-45.4%) of bed days, and 44.2% (95% CI, 42.6%-45.5%) and 59.5% (95% CI, 57.8%-60.9%) of hospital charges, respectively. From 2000 to 2022, the percentage of hospital discharges in children with 1 or more CCCs increased with gastroenterologic technology dependence (7.0% [95% CI, 6.0%-8.0%] to 14.4% [95% CI, 12.4%-16.4%]), neurodevelopmental or neurocognitive disorders (5.7% [95% CI, 4.8%-6.5%] to 13.5% [95% CI, 11.7%-15.2%]), and public insurance (40.9% [95% CI, 38.8%-42.9%] to 52.1% [95% CI, 50.2%-54.1%]). Conclusions and Relevance:In this national, repeated cross-sectional study, the hospital discharge rate and the percentage of hospital resource use attributable to children with CCCs increased from 2000 to 2022, and these trends were mainly attributable to children with multiple CCCs. It is critical that health systems are equipped with the resources, staff, and payments to sustainably meet the increasing needs for inpatient care among children with CCCs.

Rationale: Variations in antibiotic treatment for bacterial tracheostomy-associated infections (TARI; e.g., pneumonia, tracheitis) have been observed with no clear benefit in clinical outcomes. A mechanistic understanding of airway and systemic physiologic response to antibiotic therapy and infection resolution may guide treatment decision making. An important first step is to characterize cytokine signaling and inflammatory signatures across multiple specimen types in children hospitalized for TARI. Methods: We performed a prospective proof-of-concept study in children <17 years of age hospitalized for TARI and treated with an antibiotic course. Blood, tracheal aspirate (TA), and urine samples were collected within 48 hours of hospital admission and 24 hours before discharge. Specimens were processed according to Olink® recommendations. The Olink Target 48 Cytokine Panel targeting 45 protein biomarkers of pathways related to cytokine signaling and inflammatory processes was used. Normalized protein expression values were uploaded into the Mass Dynamics platform for data interpretation. Results were analyzed using principle component analysis (PCA) and volcano plots to identify unique protein signatures present across groups. False discovery rate threshold was set at 0.05. Results: Forty samples from eight patients representing 12 hospitalizations were analyzed, consisting of 11 plasma, 24 TA, and five urine samples. PCA clustered plasma samples separately from TA and urine (Fig. 1A). Compared to plasma, TA specimens had a significantly higher abundance of pro-inflammatory IL-33, EGF, IL-1β, IL-6, CXCL8, IL-7, and OSM and a significantly lower abundance of LTA, CXCL12, FLT3LG, CCL11, IL-27, TSLP, CCL13, CCL19, and IL-17C (Fig. 1B). Compared to urine, TA specimens had a significantly higher abundance for 21 targets, with IL-1β, CSF3, CSCL8, and OSM comprising those with the largest difference (Fig. 1C). Compared to urine, plasma had a significantly higher abundance for 29 targets, with CCL19, MMP1, MMP12, CXCL11, and CSF3 comprising the largest difference, and a significantly lower abundance of EGF and OLR1 (Fig. 1D). Compared to admission samples, discharge samples had a decreased abundance of TNF, IFN-γ, IL-10, CCL8, and IL-17C in TA (Fig. 1E) and an increased abundance of TGFA, IL-7, CCL4, FLT3LG, and CCL11 in plasma (Fig. 1F), although these differences failed to reach statistical significance. Conclusions: Higher abundance of proinflammatory cytokines were observed in TA and plasma samples. Tracheal aspirate specimens showed a potentially meaningful decrease and plasma specimens showed an increase in inflammatory signatures from admission to discharge. This proof-of-concept study suggests inflammatory signatures may be objective markers of treatment response among TARI patients.

Background: Children admitted to the general in-patient unit for status asthmaticus may not receive the first albuterol treatment on schedule. We sought to determine if a difference in timing between the scheduled and actual first dose of albuterol is associated with care escalation to the pediatric intensive care unit (PICU). Methods: We conducted a single-center case-control study of children 2-18 years admitted from the emergency department to the general in-patient unit for status asthmaticus. Cases were defined as children who required transfer to the PICU within 24 hours of admission. Groups were compared using Fisher's exact or Mann-Whitney U tests. Firth multivariable logistic regression estimated the adjusted association between dose timing and odds of transfer to the PICU. Results: Groups did not differ by demographics, comorbidities, or asthma severity risk factors. The median (IQR) time difference between the scheduled and administered first dose of albuterol was 0 (-14 to 63) min for cases and 16 (-6 to 42) min for controls (P = .43). Fifty percent of cases received delayed treatment compared with 63% of controls (P = .26). The adjusted analyses demonstrated that as the time difference between scheduled and administered albuterol increased by 1 min, odds of care escalation to the PICU remained the same (adjusted odds ratio 1.0, 95% CI: 0.9-1.0, P = .18). Conclusions: Receiving first albuterol treatment in the general in-patient unit at a time different than scheduled was not associated with increased odds of transfer to PICU.

BACKGROUND:The American Academy of Pediatrics (AAP) 2014 clinical practice guidelines for acute viral bronchiolitis caution against systemic corticosteroid administration. We sought to estimate corticosteroid prescribing rates among critically ill children hospitalized for bronchiolitis and characterize clinical features by corticosteroid prescription. PATIENTS AND METHODS:We performed a retrospective, multicenter cohort study using the Pediatric Hospital Information System database that included children aged 1 to 23 months admitted for acute viral bronchiolitis within 48 pediatric intensive care units from 2013 to 2023. Corticosteroid prescription rates were assessed by year, season, and institution. Patient characteristics, treatments, and clinical outcomes were compared using cohorts defined by corticosteroid prescription. RESULTS:Of 81 376 encounters studied, 30 509 (37.5%) were prescribed corticosteroids. Joinpoint regression of annual prescribing rates yielded a single breakpoint model with prescribing rates decreasing by 2.9% per year before and increasing by 2.1% after 2018. Prescription rates ranged widely by center (17.8%-60.9%). Greater corticosteroid prescription was observed in summer as compared to winter months. Compared to those not prescribed corticosteroids, those prescribed corticosteroids were older (mean age: 10.1 ± 6.3 vs 6.9 ± 5.8 months), had a greater median Pediatric Medical Complexity Algorithm classification (2 [interquartile range, IQR: 1-3] vs 1 [IQR: 1-2]), experienced a longer median length of stay (5 [IQR: 3-10] vs 4 [IQR: 3-6] days), had greater invasive mechanical ventilation rates (33.3% vs 11.8%), and greater albuterol prescription rates (29.6% vs 3.9%; all P < .001). CONCLUSIONS:Corticosteroid use among critically ill children with acute viral bronchiolitis remains modest in lieu of AAP recommendations. Prospective research is needed to delineate clinical efficacy for this indication and offer insight for future guidelines.