OBJECTIVES:To describe common pulmonary vasodilators (PV), exposure timing, and characteristics associated with their use in very preterm (VP) infants. STUDY DESIGN:Observational study of VP infants discharged from U.S. children's hospitals (2011-2021). PV exposures during hospitalization were identified, and multivariable modeling determined characteristics associated with exposure. RESULTS:Among 37,428 infants, 6.3% received PV. Early inhaled nitric oxide (iNO) and late sildenafil were most common. Early exposure was associated with lower gestational age, aOR: 9.2 (7.3-11.7), 22-25 vs. 29-31 weeks) and small for gestational age (SGA), 2.3 (2.0-2.7). Late exposure was associated with bronchopulmonary dysplasia (BPD) grade, 26.2 (16.8-40.9), grade 3 vs. no BPD) and early PV exposure, 3.7 (2.9-4.8). CONCLUSIONS:Early iNO and late sildenafil are used in VP infants despite limited evidence. Prospective early studies enrolling extremely preterm and SGA infants and late studies enrolling infants with early PV exposure and high-grade BPD would target current evidence gaps.

Platelet transfusions are frequently given to preterm infants to prevent bleeding, but randomized trials demonstrated harmful effects from current practices. Many platelet transfusions were administered in 15–20 mL/kg doses. We sought to decrease platelet exposure among neonates by standardizing 10 mL/kg transfusions for non-bleeding thrombocytopenic infants in a level IV NICU. We created evidence-based platelet dosing guidelines and changed practices in 3 plan-do-study-act cycles focused on education, reinforcement and electronic clinical decision support. We reviewed 240 transfusions over 3 years. The percentage of 10 mL/kg transfusions improved from 17.6% to 100%, without increasing major bleeding and repeat transfusion rates. Monthly transfused platelet volumes decreased from 2269 ± 334 mL to 857 ± 181 mL (p < 0.001), conserving limited platelet resources and saving $2746–$4942 per month in platelets. This study improved our platelet transfusion practices and can facilitate similar transfusion guideline adoption to benefit neonates at other institutions.

BACKGROUND:Whether postpyloric feeding reduces gastroesophageal reflux (GER) in very preterm infants with bronchopulmonary dysplasia (BPD) is uncertain. METHODS:Prospective observational study comparing GER profiles measured using 24-h esophageal pH-impedance monitoring in infants with BPD receiving clinically prescribed postpyloric (n = 21) or gastric (n = 24) tube feeding. RESULTS:Participants (median gestational age 25.0 weeks, IQR 24.1-26.9) underwent testing at a median postmenstrual age of 46.6 weeks (IQR 42.7-52.4). The number of GER episodes recorded by impedance varied widely (median 27, range 1-195). Postpyloric versus gastric feeding was associated with fewer GER episodes (median, IQR: 16, 5-41 vs. 40, 19-60; p = 0.07) and less exposure of the proximal esophagus to reflux (median duration, IQR: 0.1 min, 0.005-0.6 vs. 0.77 min, 0.16-1.8; p = 0.045), but a higher proportion of acidic (pH < 4) GER episodes (median, IQR: 91%, 70-100 vs. 31%, 16-54; p < 0.001). CONCLUSION:Postpyloric feeding may reduce total GER burden but increase the relative proportion of acidic GER in infants with BPD.

Objective:This study aimed to compare the acute diuretic effect of furosemide versus chlorothiazide in preterm infants with high-grade bronchopulmonary dysplasia (BPD). Study Design:We conducted a retrospective cohort study of infants with grade 2 or 3 BPD admitted to a level IV NICU between 36 and 60 weeks postmenstrual age. Novel diuretic exposures were defined as administration of furosemide or chlorothiazide without prior exposure to the same agent in the preceding 7 days. The primary outcome was the within-subject change in net fluid balance (mL/kg) in the 24 hours before and after diuretic initiation. Multivariable linear regression was performed adjusted for diuretic dosing, route, frequency, and clinical covariates. Results:Among 300 infants contributing 136 furosemide and 215 chlorothiazide exposures, furosemide was most often dosed every 24 hours (73%) and chlorothiazide every 12 hours (90%). After covariate adjustment, furosemide was associated with a threefold greater reduction in net fluid balance compared to chlorothiazide (-32.0 vs. -10.5 mL/kg; p < 0.001). More frequent dosing (every 12 hours) was associated with greater diuretic effect than every 24-hour dosing for both agents (-22.4 vs. -11.3 mL/kg; p = 0.032). Concomitant use of both agents was common, yet the order of administration did not significantly influence fluid balance. No other clinical or biochemical characteristics were significantly associated with diuretic response. Conclusion:Furosemide has a significantly greater acute diuretic effect than chlorothiazide in infants with high-grade BPD. These findings may inform short-term fluid management strategies and support further investigation into optimal diuretic selection and dosing in this population. Key Points:· Furosemide has a greater acute diuretic effect than chlorothiazide in infants with grade 2/3 BPD.. · More frequent dosing was associated with greater diuretic effect than daily dosing for both agents.. · Concomitant use of both agents was common; the order of administration did not impact fluid balance..

Background: Extremely premature neonates with severe BPD constitute a heterogeneous group with different endophenotypes. Severe acquired dysfunction of the lymphatic system in a subset of these babies leads to difficulties in clinical management and is associated with a high mortality rate. We sought to leverage the Center for Lymphatic Disorders and the Children's Hospital of Philadelphia CLD program to describe this rare clinical endophenotype in BPD. Who develops it? What are the outcomes after the development of lymphatic dysfunction? What are the underlying abnormalities in advanced lymphatic imaging? Objective: To characterize the clinical course and outcomes of infants with severe BPD and lymphatic dysfunction. Design/Methods:The study included infants admitted to the Children's Hospital of Philadelphia Newborn and Infant Chronic Lung Disease Program (NICU) between 2012 and 2024 with a diagnosis of severe BPD developed clinical features suggestive of lymphatic dysfunction. Patient characteristics, lymphatic imaging, intervention results, and outcomes were analyzed. Results:Between 2012-2024, 34 patients met the inclusion criteria (Table 1). The mean gestational age and birth weight were 25 6/7 ± 2 weeks and 723 ± 321 grams (mean ± SD). 21/34 (61%) were male, 16/34 (47%) were small for gestational age. 31/34 (91%) had grade 3 BPD (NRN criteria). 33/34 babies had received postnatal steroids. 32/34 patients had received a low-fat enteral formula due to their lymphatic dysfunction. Clinical presentation included head and neck swelling, anasarca, pleural effusion, and ascites. 17/33 (51.5%) received a tracheostomy, and 16/33 (48.5%) patients survived to discharge (1 baby remains in the hospital). Five babies had their thoracic duct externalized (one survived till discharge), and five underwent lipiodol/glue-based embolization. 25/34 (73.5%) underwent an MR Lymphangiogram to discern their lymphatic system abnormalities. Key findings are summarized in Table 2, and representative images are included in Figure 1. Conclusions:Lymphatic dysfunction in babies with severe BPD represents a rare endophenotype with high morbidity and mortality. This report represents the largest report of babies with severe BPD with lymphatic dysfunction. The next step is to perform a retrospective cohort analysis of this subgroup to identify risk factors and predictors of lymphatic dysfunction.

We aimed to profile the family impact, specifically parental health-related quality of life (HRQoL) and family functioning, of children discharged from a quaternary referral program with the most severe forms of bronchopulmonary dysplasia (BPD). We collected cross-sectional data through telephone interviews with 282 families of children aged 18 months to 11 years who had been discharged from a BPD referral program. Parental HRQoL and family functioning were not associated with the child’s age, despite improvements in the children’s health and respiratory morbidity with age. Many medical issues negatively impacted parental HRQOL and family functioning. The health outcome most strongly associated with decreased parental HRQoL and family functioning was an autism diagnosis, followed by use of feeding tube. Among families of children discharged from a quaternary BPD program, family impact was not associated with child age and was impacted by a wide range of health outcomes in their children.

OBJECTIVE:Identify characteristics associated with death or tracheostomy (D/T) in preterm infants with bronchopulmonary dysplasia (BPD) predominantly managed with non-invasive respiratory support prior to 36 weeks postmenstrual age (PMA). STUDY DESIGN:Retrospective cohort study at Children's Hospital of Philadelphia of 134 infants meeting inclusion criteria between 2010 and 2017. Various clinical characteristics were considered as predictor variables of the primary outcome, D/T; those associated at p < 0.10 in bivariable logistic regression were evaluated in multivariable models. RESULTS:Twenty-one (16%) infants had D/T. Treatment with pulmonary vasodilators and the presence of pulmonary hypertension (PH) on echocardiogram at 36 weeks PMA were associated with D/T in bivariable analyses. Pulmonary vasodilator use remained statistically significant in adjusted multivariable models. CONCLUSIONS:We identified a strong association between PH and D/T in this cohort. Our findings emphasize the importance of specialized BPD management that includes early identification of PH in this high-risk population.

Objective Bronchopulmonary dysplasia (BPD) remains the most common late morbidity for extremely premature infants. Care of infants with BPD requires a longitudinal approach from the neonatal intensive care unit to ambulatory care though interdisciplinary programs. Current approaches for the development of optimal programs vary among centers. Study Design We conducted a survey of 18 academic centers that are members of the BPD Collaborative, a consortium of institutions with an established interdisciplinary BPD program. We aimed to characterize the approach, composition, and current practices of the interdisciplinary teams in inpatient and outpatient domains. Results Variations exist among centers, including composition of the interdisciplinary team, whether the team is the primary or consult service, timing of the first team assessment of the patient, frequency and nature of rounds during the hospitalization, and the timing of ambulatory visits postdischarge. Conclusion Further studies to assess long-term outcomes are needed to optimize interdisciplinary care of infants with severe BPD. Key Points

ObjectiveTo measure the feasibility of early progressive mobility (EPM) in intubated infants with severe bronchopulmonary dysplasia (BPD) and compare neurodevelopmental skill acquisition of these infants before and after implementation of a clinical EPM program.Study designSingle-center pre-post intervention prospective cohort study in a level IV Neonatal Intensive Care Unit (NICU) from 2019-2022. Bivariate tests compared EPM interventions and results of serial Test of Infant Motor Performance (TIMP) assessments in 32 intubated infants with severe BPD cared for during two epochs, before and after NICU-wide EPM implementation.ResultsInfants in epoch 2 experienced significantly more EPM interventions than infants in epoch 1. Infants in epoch 2 also had more advanced motor skills on the TIMP than infants in epoch 1. There were no unplanned extubations.ConclusionsWe demonstrated successful implementation of EPM in this high-risk population with evidence of beneficial impacts on early motor development.

Objectives The primary objective of this study was to profile the childhood health, development, and health-related quality of life (HR QoL) for children with the most severe bronchopulmonary dysplasia (BPD), those discharged from a quaternary referral program.Study Design : We collected cross-sectional data through telephone interviews with 282 families of children ages 18 months to 11 years who had been discharged from a BPD referral program.Results Respiratory morbidities were near universal, with 42% of children ever having required a tracheostomy and severity of these morbidities correlated with parent-reported health and QoL. Developmental morbidities were also marked: 97% required an individualized educational plan. While respiratory morbidities and overall health improved over time, developmental morbidities were increasingly prominent, resulting in lower quality of life.Conclusions Among children referred to a quaternary BPD program, respiratory and developmental morbidities are on numerous counts more severe than any reported in the literature.

ObjectiveInhaled medications are commonly used at our single-center, Level IV neonatal intensive care unit (NICU). We lacked a standardized process for measuring efficacy of these medications to guide optimal duration of use, potentially leading to their overuse.MethodsWe utilized quality improvement methodology to reduce the length of inhaled hypertonic saline (HTS) course durations and high frequency albuterol use. Interventions included education, data sharing, and implementation of a respiratory therapy assessment tool.ResultsThe average inhaled HTS course duration decreased from 8.7 to 4.2 days. The percentage of q4 albuterol administrations per total albuterol doses administered monthly decreased from 39 to 20%.ConclusionDeveloping a shared mental model between interprofessional providers for the indication and effect of inhaled agents and standardizing assessment of these medications' efficacy can reduce their overuse.

Objective: To analyze the association of components of the Centers for Disease Control and Prevention (CDC) Environmental Justice Index (EJI) with respiratory health outcomes among infants with bronchopulmonary dysplasia (BPD) within one year after discharge from the neonatal intensive care unit. Methods: This was a retrospective cohort study of a cohort of preterm infants with BPD. Multivariable logistic regression models estimated associations of EJI and its components with medically attended acute respiratory illness, defined as an ED visit or inpatient readmission, within one year of discharge from the neonatal intensive care unit. A mediation analysis was conducted to evaluate how environmental injustice may contribute to racial disparities in acute respiratory illness. Results: Greater EJI was associated with an increased risk of medically attended respiratory illness (per EJI standard deviation increment, aOR 1.38, 95% CI: 1.12–1.69). Of the index’s components, the Environmental Burden Module’s Air pollution domain had the greatest association (aOR 1.44, 95% CI: 1.44–2.61). With respect to individual indicators within the EJI, Diesel Particulate Matter (DSLPM) and Air Toxic Cancer Risk (ATCR) demonstrated the strongest relationship (aOR 2.06, 95% CI: 1.57–2.71 and aOR 2.10, 95% CI: 1.59–2.78, respectively). Among non-Hispanic Black infants, 63% experienced a medically attended acute respiratory illness as compared to 18% of non-Hispanic White infants. DSLPM mediated 39% of the Black–White disparity in medically attended acute respiratory illness (p = 0.004). Conclusions: Environmental exposures, particularly air pollution, are associated with post-discharge respiratory health outcomes among preterm infants with BPD after adjusting for clinical, demographic, and social vulnerability risk factors. Certain types of air pollutants, namely, DSLPM, are more greatly associated with acute respiratory illness. Environmental exposures may contribute to racial disparities in medically attended acute respiratory illness among infants with BPD.

BACKGROUND:Left ventricular diastolic dysfunction indicated by elevated pulmonary capillary wedge pressure (ePCWP) may worsen cardiorespiratory status in bronchopulmonary dysplasia (BPD), but the scope of ePCWP by cardiac catheterization is not well described. METHODS:This single-center retrospective cohort study included infants with BPD without congenital heart disease, significant intracardiac shunts, or pulmonary vein stenosis who underwent cardiac catheterization from 2010 to 2021. ePCWP was defined as >10 mmHg. Quantitative measures of ventricular systolic and diastolic function were performed on existing echocardiograms. Patients with and without ePCWP were compared using the Chi-squared or Wilcoxon rank-sum tests. Associations between catheterization hemodynamics and echocardiographic parameters were assessed by simple linear regression. RESULTS:Seventy-one infants (93% Grade 2 or 3 BPD) met inclusion criteria, and 30 (42%) had ePCWP. Patients with ePCWP were older at catheterization (6.7 vs. 4.5 months, p < 0.001), more commonly underwent tracheostomy (66.7% vs. 29.3%, p = 0.003), and had higher mean systemic blood pressure [64.5 (56.0, 75.0) vs. 47.0 (43.0, 55.0) mm Hg, p < 0.001], higher systemic vascular resistance [11.9 (10.4, 15.6) vs. 8.7 (6.7, 11.2) WU*m2, p < 0.001), and lower cardiac index [3.9 (3.8, 4.9) vs. 4.7 (4.0, 6.3) L/min/m2, p = 0.03] at catheterization. Mean pulmonary artery pressure, pulmonary vascular resistance, and mortality were similar between the groups. Echocardiographic indices of left ventricular diastolic dysfunction did not correlate with PCWP. CONCLUSIONS:ePCWP was common in infants with severe BPD who underwent cardiac catheterization in this cohort. The association between ePCWP and higher systemic blood pressure supports further study of afterload reduction in this population.

ObjectivesTo examine the association of novel furosemide versus thiazide diuretic exposure with changes in serum sodium, potassium, and chloride levels among infants with grade 2/3 bronchopulmonary dysplasia (BPD).Study DesignRetrospective cohort study of infants admitted to a level IV neonatal intensive care unit (NICU) with grade 2/3 BPD. We measured within-subject change in serum sodium, potassium, and chloride before and after diuretic initiation using multivariable regression to adjust for differences in dosing and clinical covariates.ResultsWe identified 94 infants contributing 137 novel diuretic exposures. No significant difference was noted in the association between chlorothiazide versus furosemide and serum sodium, potassium, or chloride change in multivariable modeling.ConclusionsChanges in serum electrolytes were similar for chlorothiazide and furosemide, questioning the perception that chlorothiazide leads to less electrolyte derangement among preterm infants with grade 2/3 BPD.

Background Recognition of the patient and family's diverse backgrounds and language preference is critical for communicating effectively. In our hospital's electronic health record, a patient or family's identified language for communication is documented in a discrete field known as “preferred language.” This field serves as an interdepartmental method to identify patients with a non-English preferred language, creating a bolded banner for non-English speakers easily identifiable by health care professionals. Despite the importance of documenting preferred language to facilitate equitable care, this field is often blank. Objectives Using the Institute for Healthcare Improvement's Model for Improvement, our team sought to increase preferred language documentation within the neonatal intensive care unit (NICU) from a baseline of 74% in September 2021 to above 90% within 6 months. Methods A multidisciplinary team was assembled to address preferred language documentation. Our team incorporated guidance regarding preferred language documentation into a novel clinical decision support (CDS) tool aimed at addressing various safety and quality measures within the NICU. Our primary outcome metric was documentation of family's preferred language. Process measures included overall compliance with the CDS tool. A secondary outcome was the assessment of preferred language documentation accuracy. Results The average rate of preferred language documentation increased from a baseline of 74 to 92% within 6 months and is currently sustained at 96%. Moreover, our follow-up assessments found that 100% of a random sample of contacted patients (n = 88) had their language preferences documented correctly. Overall compliance with the CDS tool remained at 85% throughout the project. Conclusion Using a quality improvement framework coupled with a CDS initiative, our team was able to successfully and accurately improve preferred language documentation in our NICU. Future projects include strategies for more equitable care for patients with non-English preferences such as improved interpreter usage and discharge instructions in their preferred language.

Background Thrombocytopenia (<150,000 platelets/ul blood) is frequent among neonatal intensive care unit (NICU) patients, including 70% of extremely low birth weight infants. Severe thrombocytopenia is often treated with prophylactic transfusions of donated adult platelets in an effort to prevent bleeding. However, current transfusion practices actually increase bleeding, neurocognitive impairment, respiratory complications, and death in preterm neonates. This is likely due to physiologic differences in adult vs neonatal platelets. Thus, reducing adult platelet exposure will optimize neonatal outcomes and also conserve limited donated platelet resources. Prior clinical studies have demonstrated that 10mL/kg platelet transfusions can effectively treat thrombocytopenia. Objective We aimed to standardize 10 ml/kg prophylactic platelet transfusions in our quaternary neonatal intensive care unit (NICU) to >80% of ordered platelet transfusions in non-bleeding patients. Methods We identified 1) preconceptions about platelet safety, 2) default order sets with our electronic ordering system, and 3) cultural standards related to transfusion dosing as key drivers of current practices. Infants with procedures/surgeries within 12 hours, on anticoagulation, bleeding, or on ECMO were excluded. The primary outcome measure was compliant 10 ml/kg platelet transfusions orders. Our balancing measure were 1) repeat platelet transfusions within 36 hours and 2) frequency of major bleeding within 72 h of transfusion. Results We created a graphic dashboard based on our electronic medical record to monitor platelet ordering in real time. To define baseline practices, we tracked transfusions in the year prior to initiating our study. Our baseline compliance for 10 ml/kg platelet transfusion orders was 14%. Instead, most prophylactic transfusions were dosed at 15-20 ml/kg. Our first plan-do-study-act (PDSA) cycle targeted education through messaging at staff meetings, on NICU-wide computer screensavers, and laminated reminder cards posted at unit workstations where platelet transfusions were ordered. A second PDSA cycle reinforced platelet dosing guidelines among clinicians through newsletters and staff huddle discussions. A third PDSA cycle targeted clinical decision support within the medical record that eased ordering through defaults to recommended dosing. After consensus agreement from neonatology, cardiology, emergency medicine, oncology, and pediatric intensive care unit clinicians, we implemented electronic order set changes hospital-wide to most effectively spread practice change related to neonatal platelet transfusion dosing across all hospital units. We monitored 165 transfusions among 55 neonates (2022-2024). Following our PDSA cycle interventions, we achieved >80% dosing compliance, noting special cause variation with sustained process change that resulted in a center line shift from 14% to 88% ‘compliant’ (10 ml/kg) transfusions. There was no change in the rate of subsequent platelet transfusions within 36 hours, nor an increase in major bleeding complications within 72 hours post-transfusion. Coupled with more restrictive platelet transfusion thresholds across our network, as described in network-wide transfusion guidelines (Gilmore et al, Transfusion 2024), platelet transfusions dropped by 44% in the first 6 months after electronic order changes (p<0.05 by two tailed t test). Conclusion A standardized prophylactic platelet transfusion dose of 10mL/kg was established through hospital-wide collaborative efforts. We used clinician education and electronic medical record technologies to improve platelet transfusion practices within our NICU, reducing platelet exposures that have been linked with adverse outcomes in preterm neonates. Standardized 10ml/kg platelet transfusion dosing will optimize safety and efficacy of neonatal platelet transfusions and conserve limited donated platelet supplies in line with current literature.

Objectives: To quantify the association of ambient air pollution (particulate matter, PM2.5) exposure with medically attended acute respiratory illness among infants with bronchopulmonary dysplasia (BPD). Study Design: Single center, retrospective cohort study of preterm infants with BPD in Metropolitan Philadelphia. Multivariable logistic regression quantified associations of annual mean PM2.5 exposure (per mu g/m(3)) at the census block group level with medically attended acute respiratory illness, defined as emergency department (ED) visits or hospital readmissions within a year after first hospital discharge adjusting for age at neonatal intensive care unit (NICU) discharge, year, sex, race, insurance, BPD severity, and census tract deprivation. As a secondary analysis, we examined whether BPD severity modified the associations. Results: Of the 378 infants included in the analysis, 189 were non-Hispanic Black and 235 were publicly insured. Census block PM2.5 level was not significantly associated with medically attended acute respiratory illnesses, ED visits, or hospital readmissions in the full study cohort. We observed significant effect modification by BPD grade; each 1 mu g/m(3) higher annual PM2.5 exposure was medically attended acute respiratory illness (adjusted odds ratio [aOR] 1.65, 95% CI: 1.06-2.63) among infants with Grade 1 BPD but not among infants with grade 3 BPD (aOR 0.83, 95% CI: 0.47-1.48) (interaction p = .024). Conclusions: Cumulative PM2.5 exposure in the year after NICU discharge was not significantly associated with medically attended acute respiratory illness among infants with BPD. However, infants with Grade 1 BPD had significantly higher odds with higher exposures. If replicated, these findings could inform anticipatory guidance for families of these infants to avoid outdoor activities during high pollution days after NICU discharge.

Background: Left ventricular diastolic dysfunction (LVDD) may worsen cardiorespiratory status in bronchopulmonary dysplasia (BPD), but the scope of cardiac catheterization-confirmed LVDD is not well described. Methods: This single-center retrospective cohort study included infants with BPD without congenital heart disease or pulmonary vein stenosis who underwent cardiac catheterization from 2010-2021. LVDD was defined as pulmonary capillary wedge pressure (PCWP) > 10 mm Hg. Quantitative measures of ventricular systolic and diastolic function were performed on existing echocardiograms. Patients with and without LVDD were compared using the Chi-squared or Wilcoxon rank-sum tests. Associations between catheterization hemodynamics and echocardiographic parameters were assessed by simple linear regression. Results: Seventy-one infants (93% Grade 2 or 3 BPD) met inclusion criteria, and 30 (42%) had LVDD. Patients with LVDD were older at catheterization (6.7 vs. 4.5 months, p<0.001), more commonly underwent tracheostomy (66.7% vs. 29.3%, p=0.003), and had higher mean systemic blood pressure [64.5 (56.0, 75.0) vs. 47.0 (43.0, 55.0) mm Hg, p<0.001], higher systemic vascular resistance [11.9 (10.4, 15.6) vs. 8.7 (6.7, 11.2) WU*m2, p<0.001), and lower cardiac index [3.9 (3.8, 4.9) vs. 4.7 (4.0, 6.3) L/min/m2, p=0.03] at catheterization. Mean pulmonary artery pressure, pulmonary vascular resistance, and mortality were similar between the two groups. Echocardiographic indices of LVDD did not correlate with PCWP. Conclusions: LVDD was common in infants with severe BPD who underwent cardiac catheterization in this cohort. The association between LVDD and higher systemic blood pressure supports further study of afterload reduction in this population.

To characterize associations of the CDC Social Vulnerability Index (SVI) with medically attended acute respiratory illness among infants with bronchopulmonary dysplasia (BPD). Retrospective cohort of 378 preterm infants with BPD from a single center. Multivariable logistic regression quantified associations of SVI with medically attended acute respiratory illness, defined as emergency department (ED) visits or hospital readmissions within a year after first hospital discharge. Mediation analysis quantified the extent to which differences in SVI may explain known Black-White disparities in medically attended acute respiratory illness. SVI was associated with medically attended respiratory illness (per SVI standard deviation increment, aOR 1.44, 95% CI: 1.17–1.78). Adjustment for race and ethnicity attenuated the association (aOR 1.27, 95% CI: 0.97–1.64). SVI significantly mediated 31% of the Black-White disparity in ED visits (p = 0.04). SVI was associated with, and may partially explain racial disparities in, medically attended acute respiratory illness among infants with BPD.

Background Many students report feeling inadequately prepared for their clinical experiences in pediatrics. There is striking variability on how pediatric clinical skills are taught in pre-clerkship curricula. Methods We asked students who completed their clerkships in pediatrics, family medicine, surgery, obstetrics-gynecology and internal medicine to rate their pre-clinical training in preparing them for each clerkship, specifically asking about medical knowledge, communication, and physical exam skills. Based on these results, we surveyed pediatric clerkship and clinical skills course directors at North American medical schools to describe the competence students should have in the pediatric physical exam prior to their pediatric clerkship. Results Close to 1/3 of students reported not feeling adequately prepared for their pediatrics, obstetrics-gynecology, or surgery clerkship. Students felt less prepared to perform pediatric physical exam skills compared to physical exam skills in all other clerkships. Pediatric clerkship directors and clinical skills course directors felt students should have knowledge of and some ability to perform a wide spectrum of physical exam skills on children. There were no differences between the two groups except that clinical skills educators identified a slightly higher expected competence for development assessment skills compared to pediatric clerkship directors. Conclusions As medical schools undergo cycles of curricular reform, it may be beneficial to integrate more pre-clerkship exposure to pediatric topics and skills. Further exploration and collaboration establishing how and when to incorporate this learning could serve as a starting point for curricular improvements, with evaluation of effects on student experience and performance. A challenge is identifying infants and children for physical exam skills practice.