INTRODUCTION:Socioeconomic disadvantage is associated with increased disease severity and worse clinical outcomes among children with acute appendicitis. We sought to evaluate the association between neighborhood-level child opportunity and complicated appendicitis (CA) among a retrospective pediatric cohort. We hypothesized that lower neighborhood-level opportunity, measured by the Child Opportunity Index (COI), is associated with higher incidence of CA and hospital length of stay (LOS). METHODS:We performed a retrospective review of children (<18 y) with appendicitis in the North Carolina Discharge Database, from 2019 to 2021. Patients were categorized as having simple appendicitis or CA, based on the presence of perforation, gangrene, or abscess. Multivariate regression analysis was used to identify independent predictors of CA and LOS. RESULTS:A total of 876 children with acute appendicitis and available zip code data were identified. Most children had public (n = 463, 52.9%) health insurance coverage. Compared to children with simple appendicitis, those with CA were significantly younger (9.9 ± 4.4 versus 11.9 ± 3.8 y; P < 0.0001), and with a higher proportion from very low (15.3% versus 12.2%) and low (23.1% versus 15.9%) COI neighborhoods. Hospital LOS was significantly longer for children with CA (3.7 ± 5.2 versus 1.6 ± 2.1 d; P < 0.001). On multivariate regression analysis, COI was not independently associated with odds of CA (adjusted odds ratio: 1.003; 95% confidence interval: 1.00-1.01) or hospital LOS (adjusted relative risk: 0.001; 95% confidence interval: -0.001 to 0.003). CONCLUSIONS:In a statewide cohort of pediatric patients, COI was not independently associated with CA. Our findings suggest that high insurance coverage improves access to acute pediatric surgical care and may mitigate disparities linked to child neighborhood level opportunity.

Background Enhanced recovery pathways (ERPs) after pediatric colorectal surgery have been shown to improve patient experience without compromising outcomes. ERPs for this population are also associated with reduced admission costs, but their economic impact in large populations is unclear. We present the first formal cost-effectiveness analysis of a pediatric colorectal surgery ERP from the payer perspective. Methods We compared the cost-effectiveness of an ERP versus standard care in a pediatric patient requiring colorectal surgery without additional comorbid conditions, using a Markov microsimulation model to estimate the incremental cost-effectiveness ratio for each intervention. We sourced costs and health utilities from the peer-reviewed literature and transition-state probabilities from institutional primary data. We modeled our analysis from a US payer perspective over a 30-day time horizon and a willingness-to-pay ratio of $100,000/quality-adjusted life-year (QALY) gained by either intervention. Results We simulated individual patient outcomes using published clinical outcomes for patients managed with and without an ERP (microsimulation). The statistical software evaluates the variability across 10,000 microsimulations and repeats the modeling 1,000 times (iterations). The software then reports the most likely outcome based on the summarized results. We found that our ERP was a cost-effective alternative to standard care in over 86% of iterations. On average, an admission with ERP costs $5,625 less and provides a health utility benefit of 0.002 QALY over 30 days compared to standard care. Our model was sensitive to the costs of acute-care hospital stays, celecoxib costs, and time to solid oral (PO) intake. Conclusions In a first-of-its-kind cost-effectiveness analysis of ERPs for pediatric surgery, ERPs were both less costly and better for quality of life than standard care. These findings support the continued development and implementation of ERPs for pediatric patients requiring colorectal surgery, as well as the referral of such patients to centers with ERP programs.

Pediatric chest wall deformities, such as pectus excavatum (PE), carinatum (PC), and arcuatum (PA), may result in psychosocial and cardiorespiratory morbidity. Pediatric radiologists play a key role in imaging-based characterization, preoperative assessment, and the evaluation of postoperative complications. This pictorial essay highlights key imaging characteristics, indices for surgical planning, and common postoperative findings for pectus deformities.

INTRODUCTION:Previous studies have demonstrated improvements in length of stay and opioid utilization after implementing Enhanced Recovery After Surgery Pathways (ERPs) for pediatric colorectal surgery. However, the long-term impact of ERPs on postoperative outcomes following the implementation of specific ERP components has not been examined. METHODS:In this single-institution retrospective and longitudinal cohort review of pediatric patients undergoing colorectal surgery before (Pre-ERP - 4/2014-8/2015) and after an ERP implementation (ERP - 9/2015-1/2024). Poisson regression was performed to determine the role of pathway implementation on length of stay (LOS), opioid utilization total (OU) (morphine milliequivalents/kilogram), indwelling urinary catheter use, total intravenous fluid (IVF) use, and time to PO intake. Secondary analysis compared patients during implementation (9/2015-4/2020) and sustainment periods (5/2020-1/2024) to report long-term ERP impacts. RESULTS:On multivariable regression, LOS for ERP patients was lower than for pre-ERP patients, and OU was almost half the pre-ERP OU (p ≤ 0.01). The ERP cohort also had shorter indwelling urinary catheter duration, less IVF volume, and shorter time to PO intake. Secondary analysis found that these effects improved further in the post-ERP sustainment phase. CONCLUSION:To our knowledge, this represents the largest single-institution study to date of children ≤18 years old who underwent colorectal surgery before and after ERP implementation. There were significant improvements in LOS, OU, urinary catheter duration, time to PO intake, and IVF use. This is the first study to report the impact of ERPs after implementation during sustainment and emphasizes the importance of ERPs in optimizing pediatric surgical outcomes for children undergoing colorectal surgery. TYPE OF STUDY:Retrospective cohort study. LEVEL OF EVIDENCE:Level III.

BackgroundEnhanced recovery pathways (ERP) have been shown to decrease length of stay and opioid utilization for pediatric patients undergoing colorectal surgery without compromising outcomes. However, the cost benefits of ERP implementation have not been quantified. We sought to describe, for the first time, the resulting fiscal benefits of ERP implementation at a single-center academic hospital, aiming to highlight the financial benefits to hospitals and payers of ERP utilization.MethodsWe conducted a single-institution retrospective cohort study of patients aged 2-18 who underwent planned colorectal surgery before and after our institution implemented a colorectal ERP. Our primary outcome was total hospital admission costs based on hospital length of stay, narcotic use, crystalloid infusion, and multimodal pain medication use. We sourced our cost data from peer-reviewed literature and publicly available cost data. To account for potential confounding, we created a multivariable Gamma regression for cost using the Akaike Information Criterion selection method.ResultsOur retrospective review identified 345 eligible patients who underwent planned colorectal surgery between 2014 and 2024, with a median cost savings of $5689 per case. After adjusting for cofounders and employing our AIC model selection, we found that ERP implementation was associated with an overall 9% reduction in total admission costs compared to patients managed before the ERP (IRR 0.91, 95% CI 0.84-0.99, P = 0.038).ConclusionsThis is the first study to quantify cost savings after ERP implementation for pediatric colorectal surgery, and savings are independently associated with pathway exposure. To determine whether these single-institution savings are generalizable to other children's hospitals a formal additional ERP data from other institutions and a formal cost-effectiveness analysis are needed.

The Child Opportunity Index (COI) is a measure of neighborhood conditions associated with healthy child development. Inguinal hernia repair (IHR) is a common pediatric procedure. We sought to evaluate the association between COI and complicated inguinal hernia (IH), incarcerated or strangulated IH, among children with employer-based insurance coverage. We performed a retrospective cohort study of children who underwent IHR in the IBM Watson Health MarketScan® Research Database from 2015 to 2019. Claims data were merged with the COI at the metropolitan statistical area (MSA) level. We performed a multivariate regression analysis to determine the association between COI and complicated IH. A total of 12,084 eligible pediatric patients were identified, of which 3.7

Over the past decade, several multi-institutional research consortia have formed within the North American pediatric surgical community. In this article, we describe our experience with the creation and implementation of the Eastern Pediatric Surgery Network, a large and comprehensive research consortium designed to produce a wide array of high-quality clinical studies within our subspecialty. In 2020, a vision statement and rules of governance were established at thirteen academic pediatric surgery divisions in the eastern United States. The research consortium was organized based on four major pillars, namely legal ownership of aggregate data, horizontal leadership structure, mandatory participation in adopted studies, and a broad research portfolio that encompasses the full breath of the specialty. Over the past five years, the number of research projects has dramatically expanded over time and includes participation from 24 different medical centers. Despite a lack of dedicated sponsored extramural support for most projects, there have been 28 abstracts presented at national conferences and 12 manuscripts published in peer-reviewed journals. It is our hope that sharing our experience with creating this organization can help to inform others interested in establishing the academic infrastructure to engage in multi-institutional, evidence-based clinical research in other medical specialties and beyond.

OBJECTIVE:To describe experiences of expectant mothers in gaining information and knowledge about diagnoses and surgical management, following prenatal diagnosis of a surgically correctable congenital anomaly (SCCA). METHOD:Using semi-structured interviews, we studied women with pregnancies associated with SCCA, including congenital diaphragmatic hernia (CDH), congenital pulmonary airway malformation (CPAM), gastroschisis (GS), omphalocele (OM), and myelomeningocele (MMC), from 2018-2023 that resulted in infant live birth and survival until discharge at a tertiary care center. Interviews were coded and analyzed using thematic analysis. RESULTS:Interviews with 22 participants were included. Diagnoses included CDH (n = 8), CPAM (n = 4), GS (n = 4), OM (n = 1), and MMC (n = 5). Four thematic categories emerged: (i) prenatal care prior to fetal care center evaluation, (ii) maternal knowledge, (iii) information-gathering, and (iv) social networks. Prenatally, most participants had limited knowledge about SCCA and comfort with completing healthcare-related tasks. Multi-disciplinary fetal care was vital to their understanding of SCCA diagnosis and surgical management plan. CONCLUSION:Following prenatal diagnosis of SCCA, expectant mothers struggle with obtaining information that is at their literacy level and specific to their informational needs. Studies are needed to develop literacy-informed approaches to counseling after prenatal diagnosis of SCCA to meet parents' unique informational needs and prepare them for their infants' postnatal care.

BACKGROUND:Historically, methods for quantifying the severity of pectus excavatum (PE) have involved cross-sectional imaging. An external caliper-based metric, the Modified Percent Depth (MPD), has been described as a viable alternative to radiographic-based measurements such as the Pectus and Correction Indices for identifying severe PE in the clinic setting. The purpose of this study was to evaluate the reproducibility of the MPD among PE patients evaluated within a regional multicenter consortium of children's hospitals. METHODS:This was a prospective observational study of PE patients aged 6-25 years who underwent 2 sets of preoperative caliper measurements by independent raters during the same clinical encounter at one of eight member institutions between April 2021 and December 2023. Three caliper measurements were obtained: the deepest point of sternum to posterior midline and posterior midline to maximal point of the anterior chest protrusion bilaterally. These caliper measurements were used to calculate the MPD. Severe PE was defined as an MPD of ≥14 %. Interrater reliability for severe vs. non-severe PE was assessed by Gwet's chance-corrected agreement coefficient (AC1). RESULTS:Among 202 patients, the mean (standard deviation) age was 15 ± 2 years and the majority were male (82 %). Both raters' measurements led to agreement in 174/202 (86 %) in categorizing severe vs. non-severe PE with an overall AC1 of 0.80 (95 % CI 0.72-0.91). Stratified by gender, the raters' measurements agreed in 146/65 (88 %) of males with an AC1 of 0.83 (0.75-0.91), and in 28/37 (76 %) of females with an AC1 of 0.62 (0.37-0.88). CONCLUSION:This multicenter prospective study demonstrated excellent interrater reliability in the classification of severe vs. non-severe PE in male patients with the use of external chest calipers to calculate MPD. Females had lower interrater reliability compared to males but still showed good agreement. While further study of gender-based differences will be needed, the MPD can be considered a reliable, radiation-free alternative to routine cross-sectional imaging in the preoperative work-up of PE.

Background: There is a lack of consensus on the optimal antibiotic regimen for pediatric appendicitis, and conflicting data exist regarding the need for extended-spectrum use in this population. We implemented an antibiotic stewardship program with a standard, preferred antibiotic regimen for both uncomplicated and complicated appendicitis and hypothesized that clinical outcomes would be equivalent. Methods: This is a single-institution, retrospective study of pediatric patients (≤18 y) who underwent appendectomy for acute appendicitis between October 2015 and May 2022. We used institutional data from our stewardship program supplemented by manual chart review. Patients were assigned to pre- and post-pathway cohorts on the basis of appendectomy date. Patients were further stratified on the basis of whether they met criteria for complicated appendicitis on the basis of intra-operative findings. Results: There were 752 patients that were included: 346 (46.0%) in the pre-pathway cohort and 406 (54.0%) in the post-pathway cohort. The pre-pathway cohort had a higher rate of complicated appendicitis (40.2 vs. 25.6%). However, pre- and post-pathway cohorts had similar rates of post-operative infections, readmissions, and reoperations. When separated by complicated operative findings, patients with uncomplicated appendicitis had a shorter length of stay post-pathway implementation (p < 0.001). After controlling for complicated operative findings and pertinent covariates, the preferred antibiotic regimen was independently associated with decreased odds of post-operative organ space surgical site infections (SSI) (adjusted odds ratio 0.22, 95% CI: 0.05-0.99). Discussion: Antibiotic stewardship to increase the use of a standardized, preferred antibiotic regimen did not result in worse clinical outcomes. The preferred regimen was significantly associated with a decreased rate of organ space SSI, even when controlling for complicated operative findings. The mechanism of this finding requires additional study.

BACKGROUND:Pulmonary hypertension (PHTN) causes significant morbidity and mortality in patients with congenital diaphragmatic hernia (CDH). Currently, there is no routinely obtained prenatal prognostic marker to reliably predict postnatal CDH-associated PHTN severity. METHODS:The CDH Study Group (CDHSG) registry was queried for infants born from 2015 to 2021 with a graded (1-4) PHTN diagnosis. Fetal observed-to-expected lung volume to head circumference ratio (o/e LHR), percent predicted lung volume (PPLV), and total lung volume (TLV) were classified by severity. RESULTS:Of 4056 patients, 1047 and 785 infants had prenatal ultrasound or magnetic resonance imaging, respectively. Both moderate and severe o/e LHR were associated with increased odds of postnatal development of moderate (OR 2.913) and severe PHTN (OR 4.924). CONCLUSIONS:In infants with CDH, prenatal predictor severity was associated with higher severity of PHTN and increased ECLS usage. Overall, patients with worse prenatal prognostic indicators were less likely to receive pulmonary vasodilator treatment.

Importance Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. Objective To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. Design, Setting, and Participants This was a retrospective cohort study using American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP)–Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Exposure Continuation of antibiotics after appendectomy. Main Outcomes and Measures Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. Results A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = −0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = −0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Conclusions and Relevance Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

OBJECTIVE:To develop a severity-adjusted, hospital-level benchmarking comparative performance report for postoperative organ space infection (OSI) and antibiotic utilization in children with complicated appendicitis. BACKGROUND:No benchmarking data exist to aid hospitals in identifying and prioritizing opportunities for infection prevention or antimicrobial stewardship in children with complicated appendicitis. METHODS:This was a multicenter cohort study using National Surgical Quality Improvement Program-Pediatric data from 16 hospitals participating in a regional research consortium, augmented with antibiotic utilization data obtained through supplemental chart review. Children with complicated appendicitis who underwent appendectomy from July 1, 2015 to June 30, 2020 were included. Thirty-day postoperative OSI rates and cumulative antibiotic utilization were compared between hospitals using observed-to-expected (O/E) ratios after adjusting for disease severity using mixed-effect models. Hospitals were considered outliers if the 95% CI for O/E ratios did not include 1.0. RESULTS:A total of 1790 patients were included. Overall, the OSI rate was 15.6% (hospital range: 2.6% to 39.4%) and median cumulative antibiotic utilization was 9.0 days (range: 3.0 to 13.0). Across hospitals, adjusted O/E ratios ranged 5.7-fold for OSI (0.49 to 2.80, P = 0.03) and 2.4-fold for antibiotic utilization (0.59 to 1.45, P < 0.01). Three (19%) hospitals were outliers for OSI (1 high and 2 low performers), and 8 (50%) were outliers for antibiotic utilization (5 high and 3 low utilizers). Ten (63%) hospitals were identified as outliers in one or both measures. CONCLUSIONS:A comparative performance benchmarking report may help hospitals identify and prioritize quality improvement opportunities for infection prevention and antimicrobial stewardship, as well as identify exemplar performers for dissemination of best practices.

Introduction Patients with pectus excavatum (PE) often undergo cross-sectional imaging (CSI) to quantify severity for insurance authorization before surgical repair. The modified percent depth (MPD), an external caliper-based metric, was previously validated to be similar to the pectus index and correction index. This study explored family perceptions of CSI and MPD with respect to value and costs. Methods This is a cross-sectional survey study including families of patients enrolled in an ongoing prospective multicenter study evaluating the use of MPD as an alternative to CSI for quantifying PE severity. Families of PE patients who underwent both MPD and CSI completed a survey to determine their perceptions of MPD and costs of CSI. Responses were described and associations were evaluated using chi squared, Wilcoxon rank-sum test and logistic regression as appropriate. Statistical significance was set to 0.05. Results There were 136 surveys completed for a response rate of 88%. Respondents were confident in MPD (86%) and confident in its similarity to CSI (76%). Families of females were less confident in the measurements than males (55% versus 80%, P = 0.02; odds ratio 0.30 (0.11, 0.83). Obtaining CSI required time off work/school in 90% and a copay in 60%. Nearly half (49%) of respondents reported CSI was a time/financial hardship. Increasing copay led to decreased reassurance in CSI (55%: copay > $100 versus 77%: lower copay/75%: no copay; P = 0.04). Conclusions From the family perspective, MPD is valuable in assessing the severity of PE. Obtaining CSI was financially burdensome, particularly for those with higher copays. MPD measurements provide high value at low cost in assessing the severity of PE.

IntroductionParental health literacy and neighborhood socioeconomic disadvantage are associated with adverse health outcomes and increased health-care resource utilization in children. We sought to evaluate the association between community-level health literacy and neighborhood socioeconomic disadvantage and their relationships with outcomes of pediatric patients undergoing gastrostomy tube (GT) placement.MethodsPediatric patients who underwent GT placement from 2000 to 2019 were identified using the IBM MarketScan Research database. Claims data were merged with the health literacy index (HLI) and area deprivation index (ADI), measures of community-level health literacy and neighborhood socioeconomic disadvantage, respectively. We used multivariate logistic regression to estimate factors associated with postoperative 30- and 90-day ED visits (EVs) and 30-day readmissions.ResultsA total of 4374 pediatric patients underwent GT placement. In this cohort, 6.1% and 11.4% had 30-day and 90-day EV; and 30-day readmissions in 19.75%. HLI was lower in those with 30-(244.6 ± 6.1 versus 245.4 ± 6.1; P = 0.0482) and 90-(244.5 ± 5.8 versus 245.5 ± 6.1; P = 0.001) day EV, and 30-day readmission (244.5 ± 5.56 versus 245.4 ± 6.1; P = 0.001) related to GT. ADI was lower in those with 90-day EV (55.1 ± 13.1 versus 55.9 ± 14.6; P = 0.0244). HLI was associated with decreased odds of 30- (adjusted odds ratio: 0.968; 95% confidence interval: 0.941-0.997) and 90-day (adjusted odds ratio: 0.975; 95% confidence interval: 0.954-0.998) EV following GT placement. ADI was also significantly associated with 30 and 90-day EV following GT placement.ConclusionsIn pediatric patients undergoing GT placement, higher ecologically-measured health literacy and neighborhood socioeconomic disadvantage are associated with decreased health-care resource utilization, as evidenced by decreased ED visits. Future studies should focus on the role of individual parental health literacy in outcomes of pediatric surgical patients.

Objective:To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the 2 most common antibiotic regimens with and without antipseudomonal activity [piperacillin-tazobactam (PT) and ceftriaxone with metronidazole (CM)].Background:Variation in the use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes.Methods:A retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed-effects regression to adjust for clustering after propensity matching on measures of disease severity.Results:In all, 1002 children met the criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall [PT: 11.8%, CM: 12.1%; odds ratio (OR): 1.44 (OR: 0.71-2.94)] and higher rates of drainage associated with the growth of any organism [PT: 7.7%, CM: 4.6%; OR: 2.41 (95% CI: 1.08-5.39)] and Escherichia coli [PT: 4.6%, CM: 1.8%; OR: 3.42 (95% CI: 1.07-10.92)] compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms [PT: 2.6%, CM: 1.5%; OR: 3.81 (95% CI: 0.96-15.08)] and Pseudomonas [PT: 1.0%, CM: 1.3%; OR: 3.42 (95% CI: 0.55-21.28)].Conclusions and Relevance:The use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis.

Introduction: Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI ) is a well -validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. Methods: We performed a single -institution retrospective review of pediatric (< 16 years ) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. Results: 2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 % ) and low (n = 566, 29.2 % ) COI neighborhoods. The proportion of non -Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 % ) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 % ) (p < 0.01 ). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 +/- 4.1 vs. 3.2 +/- 4.9 vs. 3.3 +/- 4.8 vs. 2.8 +/- 3.5 vs. 3.2 +/- 8.1 ) (p = 0.02 ). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56 ). Conclusion: Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. Type of study: Retrospective study Level of evidence: Level III (c) 2024 Elsevier Ltd and ISBI. All rights reserved.

Background Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC. Methods A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint. Results Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different. Discussion African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

The addition of trauma to burn injuries may result in higher morbidity and mortality. The purpose of this study was to evaluate the outcomes of pediatric patients with a combination of burn and trauma injuries, and included all pediatric Burn only, Trauma only, and combined Burn-Trauma patients admitted between 2011 and 2020. Mean length of stay, ICU length of stay, and ventilator days were highest for the Burn-Trauma group. The odds of mortality were almost 13 times higher for the Burn-Trauma group when compared to the Burn only group ( P = .1299). After using inverse probability of treatment weighting, the odds of mortality were almost 10 times higher for the Burn-Trauma group in comparison to the Burn only group ( P < .0066). Thus, the addition of trauma to burn injuries was associated with increased odds of mortality, as well as longer ICU and overall hospital length of stay in this patient population.