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

As the number and complexity of hospitalized children increase, pediatric clinicians regularly address neurosurgical issues. Pediatric clinicians need to be familiar with the clinical presentation, diagnostic evaluation, and management of common pediatric neurosurgical issues, including cerebrospinal fluid (CSF) shunt issues, baclofen pumps, and epilepsy surgery. The care of these children represents the exciting intersection of hospital-based pediatric clinicians and neurosurgeons and an opportunity for collaboration in clinical care, quality improvement, and research to advance care.

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

OBJECTIVE:To examine whether necrotizing enterocolitis (NEC) is associated with time to shunt failure (revision or infection) in infants born premature who have posthemorrhagic hydrocephalus (PHH) and cerebrospinal fluid ventriculoperitoneal shunting. STUDY DESIGN:In this retrospective, case-control study using the Hydrocephalus Clinical Research Network Core Data Project registry, we identified children <6 months of age who underwent shunt placement for PHH. The outcomes were time to shunt failure, frequency of shunt failure at 6, 12, and 24 months, and reasons for failure. RESULTS:Among the 412 patients identified, 76 were diagnosed with NEC (18%). NEC was not associated with time to shunt failure (P = .353) and was not an independent predictor of shunt failure (P = .68). Similar percentages of children experienced shunt failure at 6 (P = .12), 12 (P = .26), and 24 (P = .35) months. The reasons for shunt failure did not differ between cohorts. CONCLUSIONS:Our study did not demonstrate differences in shunt survival between children <6 months of age requiring cerebrospinal fluid diversion secondary to PHH who had NEC and those who did not. Thus, peritoneal shunt placement may be suitable for children with NEC despite having abdominal interventions.

OBJECTIVE Infection is a significant complication of CSF shunt surgery, with most infections occurring early in the postoperative course. While standardized perioperative protocols have successfully reduced early infections, the epidemiology, risk factors, and clinical patterns of late shunt infections are poorly characterized. This study aimed to determine the incidence, risk factors, clinical features, and outcomes of late shunt infections in a large, multicenter pediatric cohort. METHODS The Hydrocephalus Clinical Research Network (HCRN) Core Data Project was queried for all CSF shunt procedures performed between November 2016 and June 2023 in patients younger than 18 years. Each shunt surgery was treated as an index surgery, defined as the starting point for subsequent infection surveillance. Shunt surgeries were assigned to one of the following categories: no infection, early infection (≤ 6 months after the surgery), or late infection (> 6 months after the surgery). Demographic, operative, and clinical features of early versus late infections were compared, and Cox proportional hazards models were developed to assess shunt survival following early versus late infections. RESULTS Of 6698 shunt procedures, 285 (4.3%) were followed by early infections and 58 (0.9%) by late infections. Late infections accounted for 16.9% of all shunt infections. Late infections were significantly more likely than early infections to be associated with abdominal pseudocysts (24.1% vs 3.5%, p < 0.001) and less likely to be diagnosed via CSF culture (53.4% vs 78.6%, p < 0.001). Clinical events that took place between the shunt surgery and the late infection included abdominal surgeries (21.4%), shunt taps (23.2%), bacteremia (9.1%), and nonoperative abdominal processes requiring hospitalization (19.6%). Vancomycin was administered less frequently in the late infection group (62.1% vs 85.3%, p < 0.001), and shunts were less likely to be initially treated with complete shunt removal (65.5% vs 88.4%, p < 0.001) and more likely to be initially managed with externalization of the distal catheter alone (34.5% vs 11.6%, p < 0.001). Shunt survival after infection did not differ significantly between early and late infections. CONCLUSIONS Late CSF shunt infections are uncommon but clinically distinct from early infections and are often associated with heterogeneous secondary exposures not addressed by perioperative protocols. These findings highlight the need for long-term surveillance in patients with shunts, tailored diagnostic strategies, and expanded infection tracking efforts.

BACKGROUND:Ventricular reservoir infections and cerebrospinal fluid (CSF) shunt infections are diagnosed when bacteria are recovered from microbiological cultures of CSF samples from these devices. We applied high throughput sequencing (HTS) to understand the course of changes in ventricular reservoir and shunt infection microbiota. OBJECTIVES:Evaluate the utility of monitoring microbiota in CSF (1) from ventricular reservoirs to detect development of an infection and (2) during treatment of CSF shunt infections to assess treatment response. METHODS:Study populations included (1) neonates with temporizing ventricular reservoirs who developed reservoir infection and (2) children undergoing treatment for conventional culture-confirmed CSF shunt infection. The V4 region of the 16S ribosomal RNA gene was amplified and sequenced. Comparison of taxonomic results of HTS with standard microbiological culture results (when available) was described for each CSF sample. A robust HTS signal was defined by a microbial load of ≥1e5 microbial genome equivalents/mL. RESULTS:In none of the five ventricular reservoir infection cases was there a robust HTS signal for the responsible bacteria immediately prior to infection. In six of the seven CSF shunt infection cases, there was a robust HTS signal for the genus of the responsible bacteria in the sample at the time of positive CSF culture. The proportion of sequences from the genus associated with the responsible bacteria decreased during infection treatment. CONCLUSIONS:These pilot data suggest limited utility in using HTS for surveillance for ventricular reservoir infections, as they emerge abruptly. In CSF shunt infection, HTS demonstrates a return to heterogeneous microbiota when bacterial cultures become negative.

BACKGROUND AND OBJECTIVES Injured children and youth with special health care needs (CYSHCN) can present competing priorities for prehospital and hospital care. Clinicians must balance the potential impact of chronic conditions-such as attention-deficit/hyperactivity disorder, autism, diabetes, or depression-with concerns about acute injury treatment for CYSHCN. The objective of this study is to identify the organizational and macro-level challenges and opportunities that clinicians face when caring for injured CYSHCN in acute care settings.METHODS We conducted qualitative interviews (N = 36) with prehospital and hospital clinicians that serve the level 1 trauma centers in 1 metropolitan region in the Northeastern United States and treat patients aged younger than 19 years. The interviews were recorded, transcribed, and analyzed through rapid analysis to identify themes as well as suggestions for recommendations to improve care.RESULTS We identified 4 themes that corresponded with organization-level factors: multidisciplinary care coordination; staffing and skill alignment; protocols, policies, and practices in conflict with patient care; and competing organizational needs. Additionally, clinicians listed myriad inter-organizational, regulatory, and societal factors that varied based on the specific context.CONCLUSIONS Five recommendations are presented based on the identified themes, grounded in improving care quality for CYSHCN: developing protocols to enable coordination and follow-up across disciplines; ensuring that staff are trained to handle dual priorities; engaging trained staff and resources; reviewing organizational protocols, policies, and practices to better accommodate CYSHCN and their families; and galvanizing organizational buy-in for change. In a future study, we will engage family caregivers to inform these recommendations.

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

Surgical site infection is an uncommon postoperative complication of surgery, occurring in 1% to 2% of all pediatric surgical patients. Rates vary widely between procedure types, but in general, children with medical complexity (CMC) tend to have more surgical site infections (SSIs) than their otherwise healthy peers. Reasons for this phenomenon are unclear and likely multifactorial. Optimal prevention efforts involve pediatric and surgical providers collaborating to balance all aspects of care of CMC during the perioperative period to prevent an SSI.

BACKGROUND:Infectious Diseases Society of America guidelines recommend vancomycin plus an antipseudomonal beta-lactam (cefepime, ceftazidime or meropenem) in most cases, with adjustments based on local susceptibility patterns. The objective of this study was to determine patterns of inpatient antibiotic use in children undergoing empiric treatment of cerebrospinal (CSF) shunt infection. METHODS:Retrospective, observational cohort study at 6 tertiary care children's hospitals among children who developed first shunt infection following initial CSF shunt placement surgery between 2007 and 2012. Primary outcome was use of antimicrobials as empiric therapy, defined as any antibiotic order on the day prior, day of and day after the neurosurgical procedure to treat the infection (ie, occurring before culture results typically guide antibiotic selection). We conducted analyses at the infection and hospital levels from 2007 to 2015. RESULTS:The 181 children who received empiric antibiotics most received vancomycin (n = 155, 85.6%), cefazolin (n = 65, 35.9%), ceftriaxone (n = 55, 30.4%), cefotaxime (n = 43, 23.8%) and cefepime (n = 36, 19.9%). Few children received combinations of empiric antibiotic combinations recommended by the Infectious Diseases Society of America guidelines: vancomycin and cefepime (n = 7, 3.6%), vancomycin and ceftazidime (n = 0, 0%) or vancomycin and meropenem (n = 1, 0.5%). There was no evidence indicating a change in antimicrobial coverage over the study period. CONCLUSIONS:Empiric therapy for CSF shunt infections represents a key opportunity for antimicrobial stewardship programs to ensure guideline concordance and promote appropriate antibiotic use.

Objectives/Goals: To explore the caregivers’ lived experiences related to facilitators of and barriers to effective primary care or neurology follow-up for children discharged from the pediatric emergency department (PED) with headaches. Methods/Study Population: We used the descriptive phenomenology qualitative study design to ascertain caregivers’ lived experiences with making follow-up appointments after their child’s PED visit. We conducted semi-structured interviews with caregivers of children with headaches from 4 large urban PEDs over HIPAA-compliant Zoom conferencing platform. A facilitator/co-facilitator team (JH and SL) guided all interviews, and the audio of which was transcribed using the TRINT software. Conventional content analysis was performed by two coders (JH and AS) to generate new themes, and coding disputes were resolved by team members using Atlas TI (version 24). Results/Anticipated Results: We interviewed a total of 11 caregivers (9 mothers, 1 grandmother, and 1 father). Among interviewees, 45% identified as White non-Hispanic, 45% Hispanic, 9% as African-American, and 37% were publicly insured. Participants described similar experiences in obtaining follow-up care that included long waits to obtain neurology appointments. Participants also described opportunities to overcome wait times that included offering alternative healthcare provider types as well as telehealth options. Last, participants described desired action while awaiting neurology appointments such as obtaining testing and setting treatment plans. Discussion/Significance of Impact: Caregivers perceived time to appointment as too long and identified practical solutions to ease frustrations while waiting. Future research should explore sharing caregiver experiences with primary care providers, PED physicians, and neurologists while developing plans to implement caregiver-informed interventions.

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

Objective Children and youth with special health care needs (CYSHCN) are those who have one or more chronic conditions necessitating medical, educational, and/or social services use. Of the 15 million CYSHCN, a quarter report accessing emergency care annually, some of whom have physical injuries. This study examines the perspectives, challenges, and opportunities identified by prehospital and hospital clinicians delivering injury care to CYSHCN. Methods Qualitative interviews were conducted with 23 hospital and 13 prehospital clinicians in one geographic region. All interviews were recorded and transcribed; interviews were analyzed using multiple coders and rapid analysis procedures to identify themes. Results One intrapersonal theme pertaining to clinicians’ prior experiences and 6 interpersonal themes capture the factors characterized by the participating Emergency Medical Services and hospital-level clinicians. Identified interpersonal themes include 1) how prior experiences of injured CYSHCN shape future encounters with emergency care, 2) communication challenges specific to CYSHCN, 3) parental expertise and guidance during care, 4) emotional support, 5) trust building, and 6) the need to balance accommodations pertaining to the child’s special health care need in the emergent care context. Conclusions In prehospital and hospital settings, injured CYSHCN may need care for both their physical injury and their special health care need. Prehospital and hospital clinicians, who likely have not previously provided care for the child, are mindful of the opportunities and challenges this situation presents. These results inform an understanding of how clinicians approach care of injured CYSHCN in the emergency setting and indicate opportunities for future exploration, such as how to effectively leverage family strengths in this context.

Rationale: Children hospitalized with suspected bacterial tracheostomy-associated infections (bTRAINs) with a positive rapid respiratory viral PCR (RV-PCR) testing often receive antibiotics. Our objective was to test the association between antibiotic treatment and outcomes for this population. Methods: We conducted a multicenter cohort study between 9/1/21 and 8/31/23 of children with pre-existing tracheostomy hospitalized for suspected bTRAIN at six quaternary children's hospitals who: (1) had a positive RV-PCR test, (2) were not pre-treated with antibiotics; and (3) without prolonged LOS (>37 days, extreme outlier). Suspected bTRAIN was defined by a respiratory culture sent within 48 hours of admission and receipt of empiric antibiotic treatment. We used negative binomial multiple regression with generalized estimating equations (to account for repeated patient visits) to identify independent associations between bTRAIN treatment (a complete course of bTRAIN antibiotics) and our primary outcome of LOS (in days), adjusting for potential confounders (Table). We also explored the association between antibiotic treatment and other clinical outcomes, such as unplanned ICU transfer, in-hospital mortality, and 30-day bTRAIN rehospitalization rates. Results: Of 357 hospitalizations in 274 children meeting inclusion criteria, 60% (n=213) were associated with male gender, and 77% (n=273) had public insurance. Median age for all admissions was 4 years [interquartile range (IQR): 2-8 years]. For comorbidities, 55% (n=197) were associated with chronic MV, 42% (n=148) with prematurity <37 weeks gestational age, and 67% (n=240) with neuromuscular comorbidity. Common viruses included rhinovirus (n=184; 52%), SARS-CoV-2 (n=52; 15%), and RSV (n=39; 11%). Over 64% (n=230) of hospitalizations among children with a positive RV-PCR test received bTRAIN treatment. The median LOS was 7 days (IQR: 5-11 days), with longer LOS for those receiving bTRAIN (8, IQR: 5-12 versus untreated 6, IQR: 4-10; p=0.02). bTRAIN treatment was independently associated with a 25% (95% CI: 6%-47%) longer LOS. Unplanned ICU transfer was uncommon (8.4%; n=30) and independently associated with a 67% (95% CI: 28%-118%) longer LOS. 30-day bTRAIN rehospitalization was rare (3.1%, n=11) and not different in treated (3.9%, n=9) versus untreated (1.6%; n=2; p=0.34) children. Conclusions: In children with tracheostomy hospitalized for suspected bTRAINs with a positive RV-PCR test, bTRAIN treatment was independently associated with an 25% increase in LOS. Unplanned ICU transfer, in-hospital mortality and bTRAIN-related rehospitalization were uncommon and not associated with bTRAIN treatment. Given this, as well as cumulative antibiotic exposure, clinicians should reconsider antibiotic treatment in children with suspected bTRAINs who have a positive rapid RV-PCR test.

Rationale: Bacterial tracheostomy-associated infections (bTRAINs) are a leading cause of hospitalization among children who are tracheostomy dependent, and patients are sometimes discharged on higher respiratory support. Our objective is to determine how different factors affect discharge respiratory settings. We hypothesized that home health nursing (HHN) is associated with increased odds of discharge with higher respiratory settings compared to those without HHN. Methods: We conducted a multi-center, prospective cohort study that included children ≤21 years old with tracheostomy hospitalized for a bTRAIN from one of six freestanding children's hospitals between 2020-2022. We excluded children who received pre-hospitalization antibiotic treatment or who died during the hospitalization. Our primary outcome was a binary outcome defined as higher respiratory settings at discharge (higher oxygen or ventilator needs). Demographic and clinical factors were summarized by higher respiratory support at discharge groups (median (IQR) for continuous variables; count (%) for categorical variables). Bivariate associations of each factor with the outcome variable were analyzed using logistic regression with generalized estimating equations (GEE) to account for correlated patient visits. Multivariable logistic regression with GEE was used to look at associations between factors that were significantly associated in bivariate models or confounders. Results: We included 378 children representing 560 hospitalizations. The median age at admission was 5 years (IQR 2-12 years) and 71.3% had public insurance only. Most (59.1%) lived at home with HHN. The median length of stay (LOS) for the entire group was 8 days (IQR 5-14 days). For our primary outcome, 21.7% (n=122) were discharged on higher respiratory settings than their baseline. In our multivariable model (Table), there was no association between pre-admission HHN and higher respiratory support at discharge. Higher oxygen requirements (p=0.02), acute ventilatory support (p=0.007), and acute on chronic ventilatory support (p=0.001) during hospitalization were associated with higher odds of discharge on higher support when compared to those on their chronic (baseline) support. The 30-day bTRAIN readmission rates were 3.2% (n=18) in the total sample; 4.9% (n=6) of those discharged on higher respiratory settings readmitted compared to 2.7% (n=12) discharged on baseline settings (p=0.34). Conclusions: Children admitted for bTRAINs who required higher oxygen or ventilator support during hospitalization were more likely to be discharged on higher respiratory settings. Readmission rates were rare whether discharged on baseline or higher respiratory settings, though we may have been underpowered to detect statistically significant differences.

OBJECTIVE:To assess how medical complexity and neighborhood opportunity jointly affect cognitive, motor, and language Bayley Scales of Infant Development. Secondary objectives involved identifying the factors contributing to developmental disparities across diverse racial and ethnic groups. STUDY DESIGN:Electronic health records from a Southern California high-risk infant follow-up clinic were analyzed for 440 infants from 2014 through 2023 who had either had neonatal intensive care unit stays, prematurity, very low birth weight, or developmental delay risk. Medical complexity was categorized using the Pediatric Medical Complexity Algorithm into complex chronic (CC), noncomplex chronic, or nonchronic (NC). Neighborhood opportunity was assessed using the Child Opportunity Index 2.0. Developmental progress was tracked from ages 4 to 35.6 months. RESULTS:Of the cohort, 56% were male, and 67% were born prematurely, with 143 NC, 115 noncomplex chronic, and 182 CC cases. Developmental scores showed a progressive decline with increased medical complexity. Infants who were CC had lower cognitive (β = -15.20, P < .001, 95% CI -18.75, -11.7), motor (β = -20.50, P < .001, 95% CI -24.25, -16.8), and language scores (β = -11.88, P < .001, 95% CI = -15.13 to -8.6) compared with infants who were NC. Lower Child Opportunity Index score was linked with decreased language scores (β = -0.07, P = .005, 95% CI 0.01-0.12) but not cognitive or motor scores. CONCLUSIONS:In high-risk infants, the adverse effects of medical complexities on developmental outcomes exceeded those of prematurity and additionally varied according to child neighborhood opportunity.

OBJECTIVE The objective of this study was to describe trends in the utilization of infection prevention techniques (standard care, intrathecal [IT] antibiotics, antibiotic -impregnated catheters [AICs], and combination of IT antibiotics and AICs) among participating hospitals over time. METHODS This retrospective cohort study at six large children's hospitals between 2007 and 2015 included children <= 18 years of age who underwent initial shunt placement between 2007 and 2012. Pediatric Health Information System + (PHIS+) data were augmented with chart review data for all shunt surgeries that occurred prior to the first shunt infection. The Pearson chi-square test was used to test for differences in outcomes. RESULTS In total, 1723 eligible children had initial shunt placement between 2007 and 2012, with 3094 shunt surgeries through 2015. Differences were noted between hospitals in gestational age, etiology of hydrocephalus, and race and ethnicity, but not sex, weight at surgery, and previous surgeries. Utilization of infection prevention techniques varied across participating hospitals. Hydrocephalus Clinical Research Network hospitals used more IT antibiotics in 2007-2011; after 2012, increasing adoption of AICs was observed in most hospitals. CONCLUSIONS A consistent trend of decreasing IT antibiotic use and increased AIC utilization was observed after 2012, except for hospital B, which consistently used AICs.

BACKGROUND AND OBJECTIVESChildren with medical complexity (CMC) may be at a high risk of neurodevelopmental and mental health conditions given disease comorbidities and lived experiences. Little is known about the prevalence of these conditions at a population level. In this study, we estimated the prevalence of neurodevelopmental and mental health diagnoses in CMC relative to children without medical complexity and measured associations between these diagnoses in CMC and subsequent health care utilization and in-hospital mortality.METHODSWe applied the Child and Adolescent Mental Health Disorders Classification System to identify neurodevelopmental and mental health diagnoses using all-payer claims data from three states (2012–2017). Poisson regression was used to compare outcomes in CMC with neurodevelopmental and mental health diagnoses to CMC without these diagnoses, adjusting for sociodemographic and clinical characteristics.RESULTSAmong 85 581 CMC, 39 065 (45.6%) had ≥1 neurodevelopmental diagnoses, and 31 703 (37.0%) had ≥1 mental health diagnoses, reflecting adjusted relative risks of 3.46 (3.42–3.50) for neurodevelopmental diagnoses and 2.22 (2.19–2.24) for mental health diagnoses compared with children without medical complexity. CMC with both neurodevelopmental and mental health diagnoses had 3.00 (95% confidence interval [CI]: 2.98–3.01) times the number of ambulatory visits, 69% more emergency department visits (rate ratio = 1.69, 95% CI: 1.66–1.72), 58% greater risk of hospitalization (rate ratio = 1.58, 95% CI: 1.50–1.67), and 2.32 times (95% CI: 2.28–2.36) the number of hospital days than CMC without these diagnoses.CONCLUSIONSNeurodevelopmental and mental health diagnoses are prevalent among CMC and associated with increased health care utilization across the continuum of care. These findings illustrate the importance of recognizing and treating neurodevelopmental and mental health conditions in this population.

OBJECTIVE When the peritoneal cavity cannot serve as the distal shunt terminus, nonperitoneal shunts, typically terminating in the atrium or pleural space, are used. The comparative effectiveness of these two terminus options has not been evaluated. The authors directly compared shunt survival and complication rates for ventriculoatrial (VA) and ventriculopleural (VPl) shunts in a pediatric cohort. METHODS The Hydrocephalus Clinical Research Network Core Data Project was used to identify children ≤ 18 years of age who underwent either VA or VPl shunt insertion. The primary outcome was time to shunt failure. Secondary outcomes included distal site complications and frequency of shunt failure at 6, 12, and 24 months. RESULTS The search criteria yielded 416 children from 14 centers with either a VA (n = 318) or VPl (n = 98) shunt, including those converted from ventriculoperitoneal shunts. Children with VA shunts had a lower median age at insertion (6.1 years vs 12.4 years, p < 0.001). Among those children with VA shunts, a hydrocephalus etiology of intraventricular hemorrhage (IVH) secondary to prematurity comprised a higher proportion (47.0% vs 31.2%) and myelomeningocele comprised a lower proportion (17.8% vs 27.3%) (p = 0.024) compared with those with VPl shunts. At 24 months, there was a higher cumulative number of revisions for VA shunts (48.6% vs 38.9%, p = 0.038). When stratified by patient age at shunt insertion, VA shunts in children < 6 years had the lowest shunt survival rate (p < 0.001, log-rank test). After controlling for age and etiology, multivariable analysis did not find that shunt type (VA vs VPl) was predictive of time to shunt failure. No differences were found in the cumulative frequency of complications (VA 6.0% vs VPl 9.2%, p = 0.257), but there was a higher rate of pneumothorax in the VPl cohort (3.1% vs 0%, p = 0.013). CONCLUSIONS Shunt survival was similar between VA and VPl shunts, although VA shunts are used more often, particularly in younger patients. Children < 6 years with VA shunts appeared to have the shortest shunt survival, which may be a result of the VA group having more cases of IVH secondary to prematurity; however, when age and etiology were included in a multivariable model, shunt location (atrium vs pleural space) was not associated with time to failure. The baseline differences between children treated with a VA versus a VPl shunt likely explain current practice patterns.

Cerebrospinal fluid (CSF) shunt infections are a particularly challenging clinical problem. This review article addresses epidemiology and microbiology of CSF shunt infections. Clinical care is reviewed in detail, including recent guidelines and systematic review articles. Finally, current research into prevention and treatment is highlighted, with a discussion on the mechanisms of infection.