OBJECTIVES:Hybrid closed-loop (HCL) systems improve glycemic control in type 1 diabetes mellitus (T1D), but their effectiveness in young, poorly controlled populations is not established and requires study. METHODS:A pre-post study was performed using electronic health records of patients 3-24 years with baseline HbA1c≥9 % prescribed HCL within the New York City Health+Hospitals System assessing HbA1c levels and hospitalizations before and after HCL initiation and factors associated with achieving HbA1c<9 % after HCL initiation. RESULTS:Of 47 children and adolescents who met inclusion criteria, 4.68 % female, 95.72 % non-White, and 82.22 % covered by public insurance, with a baseline average HbA1c 10.6 % (2.28 IQR). The most prevalent pump type was Omnipod 5 (70.21 %). The HbA1c was significantly lower in the postperiod than baseline (HbA1c before=median 10.6 (IQR2.28), HbA1c after=median 9.33 (IQR 2.97), difference 1.00 (IQR 1.64), p<0.05) with a decrease in median diabetes-related hospitalizations (preperiod 1.00 (IQR 1.00), postperiod 0.00 (IQR 1.00), difference -1.00, IQR 2, p<0.05). Lower baseline HbA1c levels made reaching HbA1c<9 % more likely. Multivariable analysis showed that the odds of having HbA1c of <9 % was 2.1 times less likely for every one point increase in baseline HbA1c and 12.5 times less likely for those with a pump at (p<0.05). CONCLUSIONS:HCL therapy improved glycemic control and decreased diabetes-related hospitalizations in youth with poorly controlled T1DM. Higher baseline HbA1c levels predicted less success with HCL therapy so those who stand to benefit most benefit least.

BACKGROUND Patient portals provide parents access to their child’s health information and direct communication with providers. Our study aimed to improve portal activation rates of newborns during nursery hospitalization to >70% over 6 months. Secondarily, we describe the facilitators and barriers to portal use. METHODS The study design used a mixed-methodology framework of quality improvement (QI) and cross-sectional analyses. The Model for Improvement guided QI efforts. The primary outcome was the proportion of portals activated for newborns during nursery hospitalization. Interventions included portal activation algorithm, staff huddles, and documentation templates. Telephone interviews were conducted with a randomized sample of mothers of infants who activated the portal. These mothers were divided into portal “users” and “nonusers.” We examined sociodemographic variables and health care utilization outcomes in the 2 groups. RESULTS Portal activation increased from 12.9% to 85.4% after interventions. Among 482 mothers with active portals, 127 (26.3%) were interviewed. Of those, 70% (89 of 127) reported using the portal, and 85.4% (76 of 89) found it useful. Reasons for accessing the portal included checking appointments and reviewing test results. Lack of knowledge of portal functionality was the main barrier to portal use (42.1%). Portal users were less likely to have a no-show to primary care appointments compared with nonusers (44.9% versus 78.9%, P < .001). CONCLUSIONS Portal activation rates increased after QI interventions in the nursery. Most parents accessed the portal and found it useful. Portals can improve health care delivery and patient engagement in the newborn period.

Noise exposure is a major cause of hearing loss in adults. Yet, noise affects people of all ages, and noise-induced hearing loss is also a problem for young people. Sensorineural hearing loss caused by noise and other toxic exposures is usually irreversible. Environmental noise, such as traffic noise, can affect learning, physiologic parameters, and quality of life. Children and adolescents have unique vulnerabilities to noise. Children may be exposed beginning in NICUs and well-baby nurseries, at home, at school, in their neighborhoods, and in recreational settings. Personal listening devices are increasingly used, even by small children. Infants and young children cannot remove themselves from noisy situations and must rely on adults to do so, children may not recognize hazardous noise exposures, and teenagers generally do not understand the consequences of high exposure to music from personal listening devices or attending concerts and dances. Environmental noise exposure has disproportionate effects on underserved communities. In this report and the accompanying policy statement, common sources of noise and effects on hearing at different life stages are reviewed. Noise-abatement interventions in various settings are discussed. Because noise exposure often starts in infancy and its effects result mainly from cumulative exposure to loud noise over long periods of time, more attention is needed to its presence in everyday activities starting early in life. Listening to music and attending dances, concerts, and celebratory and other events are sources of joy, pleasure, and relaxation for many people. These situations, however, often result in potentially harmful noise exposures. Pediatricians can potentially lessen exposures, including promotion of safer listening, by raising awareness in parents, children, and teenagers. Noise exposure is underrecognized as a serious public health issue in the United States, with exposure limits enforceable only in workplaces and not for the general public, including children and adolescents. Greater awareness of noise hazards is needed at a societal level.

Childhood obesity is highly prevalent among certain populations of New York. This cross-sectional pilot study examined the associations between parental attitudes about outdoor activities and body mass index (BMI). A questionnaire was distributed among parents of 1 to 13 aged children at ambulatory pediatric clinics. Of 104 children included in the study 57 were of normal weight and 47 were overweight or obese. Most parents of children with BMI <85% reported frequent playground utilization, considered longer hours to spend outside on weekdays, reported a larger total temperature range for outdoor playground utilization and a lower tolerable minimum temperature compared to parents of children with BMI ≥85%, p < .05. Only having a parent born outside of the United States remained a significant predictor of overweight and obesity in the final model. Parents of children with BMI < 85% are more willing to spend time outdoors, regardless of weather. Immigrant parents are protective against overweight.

BACKGROUND Resident-led discharge “televisits” can improve the safety of hospital-to-home transitions by increasing completed follow-up and providing patients access to their inpatient providers to troubleshoot issues. METHODS This single-center quality improvement study was set in a pediatric unit within an academically affiliated public safety-net hospital. By August 2021, the aim was to use resident-led phone call televisits within 72 hours of discharge to increase completed follow-up from 67% to 85% among patients discharged from the general pediatric unit and compare this to patients scheduled for in person visits. Patients were preferentially scheduled for televisits based on investigator-defined criteria to maximize benefit (eg, prescribed new medications). The process measure was the proportion of televisit slots filled. The balancing measures were 7-day emergency department visits and readmissions. Topics addressed during televisits were categorized to qualitatively assess potential benefits. RESULTS Three hundred and fifteen (44.5%) patients had televisits, 234 (33.1%) in person visits, and 159 (22.5%) unconfirmed follow-up. The available televisit appointments scheduled were 315 of 434 (72.5%). Completed follow-up was 88.3% for televisits and 63.3% for in person visits, compared with 67% during the baseline period. Completed follow-up was 4.4 (95% confidence interval 2.9 to 6.8) times more likely for televisits compared with in person visits after controlling for confounding variables. Common topics addressed during televisits were test results, medication issues, and appointment issues. Emergency department revisits and readmissions were similar between groups. CONCLUSIONS Resident-led discharge televisits are an innovative way to increase completeness of discharge follow-up.

BACKGROUND:Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients.METHODS:Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results.RESULTS:Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit.CONCLUSIONS:Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.

Presented here are three patients who have a common chief complaint. All three cases have discussions on presentation, the differential diagnosis, and management that collectively serve as a Review article. Following the three cases, an expert weighs in in a short commentary with 5 questions for CME credit.A previously healthy, 40-day-old girl presents with 1 day of fever (100.8°F [38.2°C]). She is sleeping more than usual and having more frequent bowel movements but normal consistency. She has no cough, congestion, eye redness, respiratory distress, emesis, rash, or change in appetite or urine output. She was born at term via normal spontaneous vaginal delivery to a mother of Japanese descent and a father of Western European descent. Maternal prenatal infection screening was negative, including group B Streptococcus. She had a routine postnatal course, is formula fed and breastfed, and is growing well.On presentation she is febrile (temperature, 100.5°F [38.1°C]). Her heart rate is 176 beats/min, respiratory rate is 48 breaths/min, and blood pressure is 93/53 mm Hg. She is well-appearing, with no dysmorphic features. The anterior fontanelle is open and flat. There is no conjunctivitis or nasal congestion. Oral mucosa appears pink and moist, without lesions. There is no rash or lymphadenopathy. Her neurologic examination findings are normal. The remainder of the examination findings are normal.Initial laboratory results are as follows: white blood cell count, 13,640/μL (13.64 × 109/L) with a normal differential count; hemoglobin level, 13.3 g/dL (133 g/L); platelet count, 349 × 103/μL (349 × 109/L); C-reactive protein level, 1.1 mg/dL (11 mg/L); procalcitonin level, 18 ng/dL (0.18 µg/L) (reference range, 0–50 ng/dL [0–0.5 µg/L]); cerebrospinal fluid (CSF) white blood cell count, 5/μL (0.05 × 109/L); glucose level, 54 mg/dL (3 mmol/L); protein level, 0.051 g/dL (0.51 g/L); and Gram-stain negative. Comprehensive metabolic panel and urinalysis findings are normal. The respiratory viral panel, including severe acute respiratory syndrome coronavirus 2, adenovirus, and enterovirus, is negative. Chest radiography is normal. She is admitted to the hospital and started on empirical antibiotics pending blood, urine, and CSF culture results. Interval development of additional physical examination findings and increasing inflammatory markers support her ultimate diagnosis.After being admitted, she continued to spike high-grade fevers (maximum temperature of 103.8°F [39.2°C]). On hospital day 2 she developed a diffuse, polymorphous maculopapular rash (Fig 1) that started on her torso and eventually expanded to the extremities, face, and inguinal area. Her palms and soles became erythematous, and she developed bilateral, nonpurulent, limbic-sparing conjunctival injection. Her lips became erythematous and cracked. Repeated laboratory studies revealed increasing inflammatory marker values, with a maximum C-reactive protein level of 14.5 mg/dL (145 mg/L) and a maximum procalcitonin level of 207 ng/dL (2.07 µg/L).Diagnostic considerations include infectious diseases (staphylococcal or streptococcal toxin-mediated disease, measles, adenovirus, Epstein-Barr virus, cytomegalovirus, parvovirus B19, enterovirus, rickettsial infections, leptospirosis), inflammatory disorders (systemic juvenile idiopathic arthritis, reactive arthritis), and dermatologic conditions (drug reactions such as Stevens-Johnson syndrome). (1) After initial blood, urine, and CSF cultures were negative, further investigation included human herpesvirus 6, parvovirus B19, Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus, a CSF meningitis encephalitis panel, and a stool gastrointestinal pathogen panel, which were all negative. Measles was less likely given maternal immunity with passive immunity to the infant. Multisystem inflammatory syndrome in children was considered but thought unlikely with negative severe acute respiratory syndrome coronavirus 2 polymerase chain reaction and nucleoprotein antibody. Drug reactions, including Stevens-Johnson syndrome, were also considered but thought unlikely given no medication exposure before symptom onset and that mucus membrane was limited to only cracked lips.The presence of high-grade fever for 5 days with 4 of 5 clinical criteria for Kawasaki disease (KD) (rash, bilateral nonpurulent conjunctivitis, cracked erythematous lips, and erythema of the palms and soles), in the absence of an alternative source and failure to improve with antibiotic drug therapy, led to the diagnosis of complete KD. (2)KD is a rare systemic inflammatory disease of unknown etiology. The leading theory involves an immune-mediated inflammatory response initiated by an unknown, likely infectious, trigger in a genetically susceptible child. (3) The highest annual incidence rates are reported in Japan, with 359 per 100,000 children younger than 5 years affected in 2018. (4) The annual number of hospitalizations for KD in the United States ranged from 1,652 to 1,796 in 2016 to 2019 and decreased to 1,382 in 2020 amid the COVID-19 pandemic. (5) In the United States, children of all racial and ethnic backgrounds are impacted. (5) Children younger than 5 years and males are predominantly affected. (3) KD in children younger than 12 months is quite rare. (6)(7)(8)(9)(10) One study of 443 patients diagnosed as having KD found that 13% were younger than 12 months and just 3% were younger than 6 months. (4)(8) A hurdle in the diagnosis of KD in young infants is that 75% present as incomplete KD with few or no classic symptoms. (8) KD should be considered in infants with prolonged fever even if there are no accompanying symptoms. (1)(2)Infants younger than 6 months with KD are at particularly high risk for coronary artery aneurysms (CAAs) and giant CAAs, with poor outcomes. (2)(4)(8) This is in part attributed to late diagnosis given atypical presentations of KD in infants with subtle or transient clinical findings aside from fever. (2)(4)(8) Timely therapy with intravenous immunoglobulin (IVIg) is recommended by illness day 10 or as soon as possible after diagnosis and improves outcomes. (2)(8) IVIg significantly decreases the risk of CAA in children with KD. (11) KD treatment also includes acetylsalicylic acid (ASA) at moderate (30–50 mg/kg per day) to high (80–100 mg/kg per day) doses for anti-inflammatory activity and at low doses (3–5 mg/kg per day) for antiplatelet activity. (2) Practices vary across institutions regarding ASA dosing and duration of treatment. (2) In addition, there is no evidence that treatment with ASA reduces CAAs. (2) Some centers treat patients with moderate- to high-dose ASA until they have been afebrile for 48 to 72 hours before transitioning to a low dose. (2) Treatment is typically continued for 6 to 8 weeks until follow-up echocardiography is performed to evaluate for CAAs. (2) If no CAAs are identified, ASA is typically discontinued, but ASA may be continued indefinitely if a CAA is identified. (2) Patients at high risk for CAAs may benefit from adjuvant therapies in addition to IVIg and ASA. (2) Options for adjuvant therapies include corticosteroids, infliximab (anti–tumor necrosis factor α monoclonal antibody), and etanercept (soluble tumor necrosis factor receptor). (2) A 2017 meta-analysis including 7 trials and 922 children with KD found that corticosteroid use during the acute phase of illness was associated with a decreased incidence of CAAs. (12) The benefits of corticosteroids were greatest for children with high risk scores and prolonged corticosteroid courses. (12) In addition, high-risk patients with CAAs seen on baseline echocardiograms had less CAA progression with treatment of corticosteroids or infliximab in addition to IVIg. (13) Patients who have persistent or recrudescent fevers at least 36 hours and less than 7 days after completion of the first IVIg infusion are considered IVIg resistant. (2) Treatment options for IVIg-resistant KD include a second IVIg infusion, IVIg plus prednisolone, infliximab, cyclosporin, anakinra, cyclophosphamide, and plasma exchange. (2)Our patient was treated with a single dose of 2 g/kg IVIg, after which she defervesced and was started on low-dose oral ASA. Although the American Heart Association KD scientific statement suggests moderate- to high-dose ASA until fever resolution, followed by low-dose ASA, moderate- to high-dose ASA was not used in this case due to the rapid improvement in clinical symptoms and resolution of fever after IVIg treatment. A baseline echocardiogram was obtained before initiating treatment and did not reveal any abnormal findings other than a small patent foramen ovale. Her inflammatory markers returned to normal levels during the following days. She was eventually discharged on ASA treatment until cardiology follow-up and was later noted to have peeling of her hands and feet. Repeated echocardiography at 2 and 6 weeks revealed no abnormalities.Pediatricians should have a high index of suspicion for Kawasaki disease when evaluating infants with unexplained fever for more than 5 days. (1)Kawasaki disease is a diagnosis of exclusion. It is important to evaluate for the infectious, inflammatory, and dermatologic etiologies that compose the differential diagnoses for Kawasaki disease. (1)

OBJECTIVES:Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence.METHODS:We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model.RESULTS:Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03).CONCLUSIONS:Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).

OBJECTIVES:Determine whether the negative impact of the COVID-19 pandemic on weight gain trajectories among children attending well-child visits in New York City persisted after the public health restrictions were reduced.STUDY DESIGN:Multicenter retrospective chart review study of 7150 children aged 3-19 years seen for well-child care between 1 January 2018 and 4 December 2021 in the NYC Health and Hospitals system. Primary outcome was the difference in annual change of modified body mass index z-score (mBMIz) between the pre-pandemic and early- and late-pandemic periods. The mBMIz allows for tracking of a greater range of BMI values than the traditional BMI z-score. The secondary outcome was odds of overweight, obesity, or severe obesity. Multivariable analyses were conducted with each outcome as the dependent variable, and year, age category, sex, race/ethnicity, insurance status, NYC borough, and baseline weight category as independent variables.RESULTS:The difference in annual mBMIz change for pre-pandemic to early-pandemic = 0.18 (95% confidence interval [CI]: 0.15, 0.20) and for pre-pandemic to late-pandemic = 0.04 (95% CI: 0.01, 0.06). There was a statistically significant interaction between period and baseline weight category. Those with severe obesity at baseline had the greatest mBMIz increase during both pandemic periods and those with underweight at baseline had the lowest mBMIz increase during both pandemic periods.CONCLUSION:In NYC, the worsening mBMIz trajectories for children associated with COVID-19 restrictions did not reverse by 2021. Decisions about continuing restrictions, such as school closures, should carefully weigh the negative health impact of these policies.

BACKGROUND AND OBJECTIVES: Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE. METHODS: This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis. RESULTS: Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients. CONCLUSIONS: Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.

BACKGROUND The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes. METHODS This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE. RESULTS Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness (P < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%. CONCLUSIONS AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.

BACKGROUND AND OBJECTIVES:Youth carry a disproportionate burden of new HIV infections. With our study, we aimed to characterize HIV testing experiences among adolescents and young adults admitted to a children's hospital that is located in a high HIV-prevalent community and implemented routine HIV testing for all patients ≥13 years of age. METHODS:A total of 120 patients aged 13 to 24 years old who were admitted to our hospital and had a documented offer of routine HIV testing on admission were invited to complete a self-administered survey that asked about sex, race and/or ethnicity, HIV risk behaviors, and attitudes toward routine HIV testing in the hospital. Date of birth, admission diagnosis, and verification of HIV testing and results were collected by chart review. RESULTS:Study participants (N = 99) were 17.4 ± 2.3 years old, 52% female, 47% Hispanic, and 29% African American. Additional characteristics include the following: 65% had previous sexual activity, 11% had a history of sexually transmitted infections, and 12% were worried about their risk for HIV. Forty-seven percent of participants accepted HIV testing, with older patients (P < .01) and those reporting previous sexual activity (P < .01) and a previous HIV test (P < .01) being more likely to accept testing. A total of 96% of participants agreed that the hospital is a good place to offer HIV testing. CONCLUSIONS:Our findings support offering routine HIV testing to youth admitted to children's hospital. Given the high incidence of new and undiagnosed HIV infections among youth, additional venues for HIV testing are essential.