Asthma is a leading cause of paediatric mortality. This study aims to elucidate trends in paediatric mortality over time. Using US Centers for Disease Control (CDC) WONDER data, we conducted a cross-sectional analysis of paediatric asthma-related mortality between 1999 and 2023, overall and stratified by year, age, sex, race and region. Negative binomial regression was used to test the linear temporal trend and conduct group comparisons in asthma-related mortality rates. Over the study period, there were 5357 asthma deaths. The mortality rate was 3 per 1 000 000 children and rates remained stable over this period. Asthma mortality was higher in males, children 10-19 years (compared to children 5-9 years) and black (relative to white) children. Advances in the treatment of paediatric asthma should be aimed at reducing mortality and addressing differential health outcomes among black children.

PURPOSE OF REVIEW:Artificial intelligence has been integrated in nearly all aspects of clinical care to improve patient outcomes, augment human capabilities and improve efficiency. Particularly in the field of radiology and medical imaging, artificial intelligence could revolutionize how care is delivered. In this review, we review the recent literature and provide an assessment of the advantages (pros) and limitations (cons) of artificial intelligence in point-of-care ultrasonography (POCUS). RECENT FINDINGS:Emerging literature suggests that artificial intelligence assisted diagnostic models offer a performance advantage over standard imaging modalities with regards to image acquisition and diagnostic accuracy particularly with less experienced users. In pediatric POCUS, artificial intelligence has been shown to improve image acquisition and augment education, which is remarkably helpful in areas where ultrasound experts are limited. Nevertheless, integration of artificial intelligence in the growing field of POCUS requires careful assessment of its drawbacks, biases and limitations. Models that are trained primarily on adult populations should be assessed and validated before utilization in the pediatric population to ensure generalizability. Furthermore, the use of artificial intelligence should integrate with and not replace existing educational models and credentialing processes to preserve ultrasound skills. Finally, at the institutional and global levels, hospitals and organizations will need to weigh in on policies, data governance and oversight in this vulnerable population. SUMMARY:The use of artificial intelligence in POCUS in the fields of emergency medicine and critical care is promising but should be viewed with a lens of caution. It holds promise for improving accessibility, reducing variability in care and transforming care in resource-limited settings, but integration of this evolving technology should be thoughtful to address its potential limitations.

BACKGROUND AND OBJECTIVE:Chest radiographs (CXRs) are often obtained among children presenting to the emergency department (ED) with an asthma exacerbation, despite guidelines recommending against their routine use. The clinical consequences and hospital-level variation of this practice remain unclear. This study's objective was to assess trends, interhospital variation, and factors associated with CXR utilization for asthma exacerbations across US pediatric EDs. METHODS:Using the Pediatric Health Information System (PHIS), we identified ED encounters for children aged 2 to 18 years with asthma between 2016 and 2024. Asthma exacerbations were identified using a combination of a discharge diagnosis code for asthma and receipt of albuterol during the ED encounter. We evaluated CXR trends, patient/hospital-level predictors, and downstream outcomes using multivariable logistic regression models. RESULTS:CXRs were obtained in 145 059 children (22.3%). No significant temporal trend in overall CXR use was observed; however, CXR use declined among the subset of children diagnosed with pneumonia. Rates varied widely across hospitals (13.1%-37.7%). Higher CXR use was associated with younger age, female sex, white race, private insurance, and winter presentation. Hospitals with higher imaging rates had more pneumonia diagnoses and 3-day return visits but similar admissions, length of stay, and charges. CONCLUSIONS:CXR utilization in pediatric asthma exacerbations is common, highly variable, and linked to increased pneumonia diagnoses and return visits. Persistent low-value imaging suggests hospital-level practices may influence diagnostic labeling and patient outcomes. Targeted interventions, such as decision support and benchmarking, are needed to reduce unnecessary imaging and promote equitable, evidence-based care in pediatric EDs.

OBJECTIVE:To evaluate whether reduced ventricular function identified by cardiac point-of-care ultrasound (POCUS) in children with suspected systemic infection is associated with subsequent use of IV vasoactive medications. METHODS:We conducted a retrospective cohort study of patients aged 1 month to 21 years presenting to a tertiary pediatric emergency department (ED) between 2015 and 2024. Eligible patients underwent cardiac POCUS performed by the clinical team before vasoactive therapy (if any) and received evaluation and treatment for suspected systemic infection. Global ventricular function was categorized as reduced or not reduced based on image review by an expert sonographer. Multivariable logistic regression assessed associations between reduced function and clinical outcomes. RESULTS:Of 329 included patients, 27 (8.2%) had reduced cardiac function on POCUS, and 55 (16.7%) subsequently received an IV vasoactive. Reduced function was associated with higher odds of IV vasoactive use (aOR=7.9, 95% CI: 2.7-23.0), ICU admission, and fewer ICU- and hospital-free days. Interrater agreement between bedside and expert interpretation was excellent (κ=0.90). Associations remained consistent in secondary analyses using expert interpretations. CONCLUSION:Cardiac POCUS findings of reduced ventricular function were strongly associated with subsequent IV vasoactive therapy and worse clinical outcomes. These findings suggest that reduced cardiac function identified on cardiac POCUS is associated with greater illness severity and may support early risk stratification.

Objective: We sought to characterize point-of-care lung ultrasound (LUS) findings in children with asthma exacerbations and to determine whether the presence and magnitude of findings were associated with asthma severity. Methods: We enrolled a convenience sample of patients aged 5-18 years presenting with acute asthma exacerbation to a tertiary care pediatric emergency department. Severity of an asthma exacerbation (mild, moderate, severe) was assessed within 1-hour of the LUS using the Hospital Asthma Severity Score, a validated asthma assessment tool. LUS was performed by trained pediatric emergency providers . The presence of LUS findings (any B-lines, ≥3 B-lines per view, consolidations, pleural effusion and pleural line abnormalities) was assessed using a standardized criterion. Results: A total of 111 patients with a median age of 8 years (IQR 6, 12) were enrolled. LUS was positive in 57% of patients. Pleural line abnormalities were observed in 34%, B-lines in 29%, consolidations <1cm in 24%, and consolidations ≥1cm in 7 %. Patients with moderate and severe asthma exacerbations were more likely to have any B-lines (31% and 43%, respectively) than patients with mild exacerbations (12%; p= 0.021), however the presence of ≥3 B-lines did not differ across severity groups. The presence of other findings did not differ based upon asthma severity. Conclusions: LUS findings are commonly observed in patients presenting with asthma exacerbations. While B-lines were more likely to be found in exacerbations of higher severity, LUS findings associated with pediatric pneumonia did not correlate with severity. These findings provide valuable information for the diagnostic use of LUS.

ObjectiveThe aim of the study is to assess diagnostic performance of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians in children with preexisting cardiac disease.MethodsWe evaluated the use of cardiac POCUS performed by PEM physicians among a convenience sample of children with preexisting cardiac disease presenting to a tertiary care pediatric ED. We assessed patient characteristics and the indication for POCUS. The test characteristics of the sonologist interpretation for the assessment of both pericardial effusion as well as left ventricular systolic dysfunction were compared with expert POCUS review by PEM physicians with POCUS fellowship training.ResultsA total of 104 children with preexisting cardiac disease underwent cardiac POCUS examinations between July 2015 and December 2017. Among children with preexisting cardiac disease, structural defects were present in 72%, acquired conditions in 22%, and arrhythmias in 13% of patients. Cardiac POCUS was most frequently obtained because of chest pain (55%), dyspnea (18%), tachycardia (17%), and syncope (10%). Cardiac POCUS interpretation compared with expert review had a sensitivity of 100% (95% confidence interval [CI], 85.7-100) for pericardial effusion and 100% (95% CI, 71.5-100) for left ventricular systolic dysfunction; specificity was 97.5% (95% CI, 91.3.1-99.7) for pericardial effusion and 98.9% (95% CI, 93.8-99.8) for left ventricular systolic dysfunction.ConclusionsCardiac POCUS demonstrates good sensitivity and specificity in diagnosing pericardial effusion and left ventricular systolic dysfunction in children with preexisting cardiac conditions when technically adequate studies are obtained. These findings support future studies of cardiac POCUS in children with preexisting cardiac conditions presenting to the ED.

Pediatric cardiac arrest presents an infrequent but high-stakes event for emergency clinicians, who need to maintain expertise in this area. Evidence regarding pediatric resuscitations has been accumulating substantially over the past decade and highlights the unique considerations and challenges when resuscitating children. This issue reviews resuscitation principles of children in cardiac arrest while addressing the newest evidence-based and best-practice recommendations by the American Heart Association.

To the Editor: “Where can we go to talk about this with each other?” a co-resident asked us, after a medical error was disclosed to our team. When trainees are involved in medical errors, they may find themselves in a vulnerable position, as they are tasked with confronting the complex emotional burden of making an error and analyzing the events that may have led to an adverse outcome. 1 While many training programs have traditional morbidity and mortality conferences to address these events, an internal forum for peer support and emotional reflection for trainees is often missing. Our personal experience inspired us to establish an innovative platform that empowers residents to talk about mistakes in a safe environment. We chose the framework of a resident-led morbidity and mortality conference not only to engage trainees in traditional quality and safety learning but also to prioritize trauma processing, supportive reflection, and narrative sharing. Our goal was to create a network of social support aimed at improving the culture of discussing medical errors among trainees. We launched a pilot of this framework in spring 2020. Each conference consists of a 45-minute presentation during the daily protected educational hour. Residents volunteer to present and work closely with us to design a presentation that debriefs the medical content and the grief associated with the mistake. Each presentation is followed by a discussion. The audience for these conferences comprises residents, program leadership, and faculty who were involved in the event. The reflection component focuses on error reconciliation, grief, and trauma processing. These conferences have educated individuals at every training level about how to foster a culture of openness and camaraderie. The discussions have facilitated anecdote sharing from senior faculty regarding their own errors, further inspiring a culture of shared vulnerability. The presentations have challenged residents to consider how to incorporate mistakes when they happen into their practice and how to reflect on errors without devaluing their worth as a human and a clinician. The response to our initiative has been astounding: 8 residents have presented thus far, many of them interns. The conferences have given residents an opportunity to take an active role in reflection and to reclaim their experience. By doing so, residents have paved the way for their growth as clinicians and, importantly, as advocates for a culture of emotional safety surrounding mistakes. Acknowledgments: The authors thank Joshua Nagler, MD, MHPEd, and Theodore Sectish, MD, for their guidance and support.

An 8-year-old boy presented to the emergency department for the evaluation of an adherent foreign body on the uvula. A hymenopteran had flown into the patient’s mouth while he was playing outside. The patient’s mother visualized the hymenopteran on the patient’s uvula and was unable to retrieve it. On presentation, the patient was not in respiratory distress and was breathing comfortably. An oropharyngeal examination revealed a hymenopteran attached to the patient’s uvula (Figures 1 and 2). Furthermore, mild erythema of the uvula was noted, without significant edema or swelling.Figure 2Magnified view demonstrating a hymenopteran adherent to the uvula.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Retained hymenopteran. Intraoral hymenopteran stings can be associated with significant soft tissue swelling and can lead to life-threatening complications.1Fitzgerald K.T. Flood A.A. Hymenoptera stings.Clin Tech Small Anim Pract. 2006; 21: 194-204Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar Retained hymenopteran stingers need to be removed to prevent ongoing local inflammation and swelling.2Viswanathan S. Viswanathan S. Iqbal N. et al.Odynophagia following retained bee stinger.J Venom Anim Toxins Incl Trop Dis. 2012; 18: 253-255Crossref Scopus (3) Google Scholar The removal of foreign bodies from the uvula can prove challenging and may require sedation or general anesthesia.3Shunyu N.B. Akhtar H. Karim H.M. et al.Ear, nose, and throat foreign bodies removed under general anaesthesia: a retrospective study.J Clin Diagn Res. 2017; 11: MC01PubMed Google Scholar After consultation with the otolaryngology department, the removal of the foreign body was first attempted using forceps and a suction catheter but was unsuccessful despite patient cooperation because of the patient’s gag reflex, which persisted despite local anesthesia with viscous lidocaine. A subsequent attempt with a Kelly forceps with the patient under procedural sedation with 1.5 mg/kg of intravenous ketamine was successfully performed (Figure 3). Ketamine was selected to provide analgesia while minimizing the risk of aspiration, and despite pharyngeal manipulation during the extraction procedure, no adverse events occurred. Dexamethasone was administered after the procedure to minimize uvular swelling. No signs of inflammation or infection were noted at the follow-up appointment.

Background & aims: Lean body mass loss due to critical illness in childhood could be detrimental to long term outcomes, including functional status and quality of life. We describe the feasibility of body composition assessment by bioimpedance spectroscopy (BIS) in the pediatric intensive care unit (PICU), and functional status and quality of life assessments up to 6 months following admission in a cohort of mechanically ventilated, critically ill children. Methods: We conducted a prospective, observational pilot study in a multidisciplinary PICU. Children aged 1 month to 18 years who required mechanical ventilation, with expected stay in the PICU of at least 5 days were included. We examined the feasibility of consenting, enrolling, and completing baseline and 6-month assessments of BIS variables, Functional Status Scale (FSS), and Pediatric Quality of Life (Peds QL), in eligible patients. Results: Of 32 patients approached, 23 (72%) completed baseline assessments [median (IQR) age 3.4 (1.0, 7.8) years, 14 (61%) male]; 6-month assessments were completed in 15 (65%) enrolled patients. Mean (SD) phase angle at study enrollment was 2.95 (0.93) and the impedance ratio was 0.90 (0.03). Phase angle (r(s) =-0.58, p = 0.03) and impedance ratio (r(s) = 0.61, p = 0.02) by BIS were significantly correlated with total FSS at PICU discharge. Median total FSS and FSS tech (feeding and respiratory domains of FSS) scores improved from enrollment [16 (13, 26) and 8 (7, 10)] to 6 months [6 (6, 9) and 2 (2, 4), respectively, p < 0.001]. Median Peds QL total, physical summary and psychosocial summary scores were not significantly different between PICU discharge and 6 months after PICU admission. Correlations between the total 6-month FSS and a) phase angle (-0.45, p = 0.197) and b) impedance ratio (0.56, p = 0.096) at PICU discharge were not significant. Conclusions: We have demonstrated the feasibility of obtaining bedside BIS measurements in the PICU, and functional and quality of life assessments remotely following PICU discharge. Body composition and long-term assessment of functional outcomes and quality of life must be incorporated in nutrition trials in critically ill children. (C) 2021 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

OBJECTIVES: Evaluate the reliability of ultrasound to measure quadriceps femoris muscle thickness in critically ill children and to describe serial changes in quadriceps femoris muscle thickness in relation to fluid balance and nutritional intake. DESIGN: Prospective observational study. SETTING: Tertiary care children's hospital. PATIENTS: Inpatients age 3 months to 18 years recently admitted to the ICU who were sedated and mechanically ventilated at the time of the first ultrasound scan. METHODS: Prospective observational study to examine the reliability of averaged ultrasound measurements of quadriceps femoris muscle thickness. Change in average quadriceps femoris muscle thickness over time was correlated with fluid balance and nutritional intake. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Averaged quadriceps femoris muscle thickness demonstrated good to excellent reliability when comparing pediatric critical care providers to pediatric radiologists and when comparing between different pediatric critical care providers. We found no significant association between fluid balance over 1 or 3 days and change in quadriceps femoris muscle thickness over the same time frame. However, there was a significant association between percent of goal calories (p < 0.001) or percent of goal protein (p < 0.001) over 6 days and change in quadriceps femoris muscle thickness over the same time frame. CONCLUSIONS: Averaged ultrasound measurements of quadriceps femoris muscle thickness demonstrate good to excellent reliability, are not confounded by fluid balance, and are useful for tracking changes in muscle thickness that are associated with nutritional intake. Ultrasound-based assessment of quadriceps femoris is a clinically useful tool for evaluating muscle mass and may be a proxy for nutritional status.