BACKGROUND:Initial respiratory management is critical during drowning resuscitation. We studied the effect of prehospital airway adjuncts and supplemental oxygen on pediatric drowning outcomes. METHODS:This cross-sectional study was a sub-analysis of children 0-18 years old who presented post-drowning to one of 32 pediatric emergency departments from 2010 to 2017. Submersion and clinical data were obtained from prehospital and medical records. Patients were categorized based on presence of out-of-hospital cardiac arrest (OHCA). Airway adjuncts included prehospital bag-valve mask (BVM) or endotracheal intubation for OHCA patients and supplemental oxygen or room air in non-OHCA patients. Primary outcomes were survival or favorable neurological outcomes at hospital discharge using Cerebral Performance Category. Covariates included demographics, body of water, bystander CPR, submersion duration, and witnessed drowning. Outcomes were compared by cardiac arrest status and respiratory intervention using logistic regression. RESULTS:There were 3188 patients (No OHCA: 2975 (93%); OHCA: 213 (7%)). Median age was 3.3 years (IQR: 2.0, 5.6); 61% were male. Among OHCA patients, intubation did not have significantly different odds of favorable neurological outcome [aOR: 0.6 (95%CI: 0.1, 3.5)] or survival [aOR: 2.0 (95%CI: 0.6, 7.2)] at hospital discharge compared to BVM. No significant difference in outcomes occurred in non-cardiac arrest patients based on provision of prehospital supplemental oxygen. CONCLUSION:In pediatric patients in OHCA following drowning, endotracheal intubation was not associated with significantly different odds of favorable neurological outcome or survival at hospital discharge compared to BVM. No differences in outcomes also occurred in non-OHCA patients based on provision of prehospital supplemental oxygen.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may impact immune-related micro ribonucleic acids (miRNAs). The role of salivary miRNAs as predictors of severe infection in children is unknown. This study sought to examine the relationship between SARS-CoV-2 severity and salivary miRNA levels in children. A convenience sample of 400 children with SARS-CoV-2 infection was prospectively evaluated between March 2021 and February 2022 at two U.S. children's hospitals. Saliva swabs were obtained. Levels of 3 miRNAs previously implicated in SARS-CoV-2 pathophysiology were measured with quantitative polymerase chain reaction (miR-1273c, miR-296-5p, and miR-4495). The primary outcome measure was the occurrence of severe illness, including respiratory failure, shock, or death from a related cause within 1 month of evaluation. Disease resolution was determined through chart review and caretaker phone calls 4 weeks after the initial visit. Saliva samples from 395 (severe = 105) participants (mean age: 7.4 ± 5.9 years, 51.7% female, 54.7% African American) were analyzed. Children with severe outcomes had lower levels of miR-296-5p (fold difference: 0.361, d = 0.111, p = 0.046). Multivariable adjusted logistic regression analysis demonstrated an inverse association between severe outcomes and levels of miR-296-5p (adjusted odds ratio = 0.89; 95% confidence interval [0.81, 0.98], p = 0.021) while controlling for age, sex, race, weight, insurance, diabetes, asthma, fever, and symptom duration. The model had an area under curve of 0.744 (sensitivity = 0.71, specificity = 0.66). Measurement of saliva miRNA in conjunction with demographic and clinical characteristics may aid in the prediction of severe illness. Larger, longitudinal studies to assess the utility of salivary miRNAs in SARS-CoV-2 and other viral infections are needed.

Most children with SARS-CoV-2 have mild or asymptomatic symptoms, but some develop severe complications. Early identification of high-risk cases is crucial for timely intervention. Alterations in salivary microRNA (miRNA) levels serve as biomarkers for severity prediction. However, a rapid, non-invasive method is needed to quantify miRNA level changes as an alternative to sequencing. Here, we developed a highly specific and sensitive ligation-recombinase polymerase amplification (RPA) assay for quantifying severe and non-severe miRNAs on a portable platform. The assay begins with a miRNA-templated annealing and ligation-RPA reaction of miR-1273, miR-296, and miR-29. We quantified 100 pM to 1 fM, resolving 1 fM, with 100% specificity. Next, we validated portable extraction against benchtop extraction, achieving R-square > 0.85 and r > 0.92 in clinical samples. Finally, testing 154 clinical samples revealed severe miRNA downregulation compared to non-severe cases. The assay achieved high diagnostic accuracy with an AUC of 0.98. This platform enables informed clinical decisions and optimizes resources, especially in resource-limited settings.

Recent toxicosurveillance trends indicate an increase in intentional pediatric diphenhydramine ingestions, raising concerns about accessibility, toxicity, social media influence, and the need for appropriate harm reduction. This study analyzes US national poison center data on intentional diphenhydramine ingestions to assess trends, clinical severity, and outcomes over the past decade. A retrospective review of the National Poison Data System (NPDS) identified intentional single-substance diphenhydramine ingestions in patients aged 19 years or younger from January 1, 2014, to December 31, 2023. Demographics, clinical severity, and outcomes were analyzed. To evaluate the pandemic’s impact on diphenhydramine-related call frequency, an interrupted time series analysis was performed. Over the 10-year period, 45 085 pediatric diphenhydramine ingestions were reported to the NPDS, representing an 87.2% increase from 3183 cases in 2014 to 5960 cases in 2023. Ingestions were more common among females and adolescents, with suicidal intent as the leading cause, more than doubling from 2248 to 4688 cases. Cardiovascular and neurologic symptoms were most frequent. Most cases (90%) required treatment at a health care facility, with 20% admitted to a critical care unit. Post-pandemic onset monthly diphenhydramine-related calls increased significantly after April 2020, driven largely by a rise in ingestions associated with suicidal intent. Intentional pediatric diphenhydramine ingestions reported to US poison centers increased significantly over the study period, particularly among adolescents engaging in self-harm. These findings highlight the continued need for targeted harm-reduction strategies and enhanced regulatory measures to mitigate the growing toxicity burden.

BACKGROUND:Large language models (LLMs) have demonstrated powerful capabilities in natural language tasks and are increasingly being integrated into health care for tasks like disease risk assessment. Traditional machine learning methods rely on structured data and coding, limiting their flexibility in dynamic clinical environments. This study presents a novel approach to disease risk assessment using generative LLMs through conversational artificial intelligence (AI), eliminating the need for programming. OBJECTIVE:This study evaluates the use of pretrained generative LLMs, including LLaMA2-7b and Flan-T5-xl, for COVID-19 severity prediction with the goal of enabling a real-time, no-code, risk assessment solution through chatbot-based, question-answering interactions. To contextualize their performance, we compare LLMs with traditional machine learning classifiers, such as logistic regression, extreme gradient boosting (XGBoost), and random forest, which rely on tabular data. METHODS:We fine-tuned LLMs using few-shot natural language examples from a dataset of 393 pediatric patients, developing a mobile app that integrates these models to provide real-time, no-code, COVID-19 severity risk assessment through clinician-patient interaction. The LLMs were compared with traditional classifiers across different experimental settings, using the area under the curve (AUC) as the primary evaluation metric. Feature importance derived from LLM attention layers was also analyzed to enhance interpretability. RESULTS:Generative LLMs demonstrated strong performance in low-data settings. In zero-shot scenarios, the T0-3b-T model achieved an AUC of 0.75, while other LLMs, such as T0pp(8bit)-T and Flan-T5-xl-T, reached 0.67 and 0.69, respectively. At 2-shot settings, logistic regression and random forest achieved an AUC of 0.57, while Flan-T5-xl-T and T0-3b-T obtained 0.69 and 0.65, respectively. By 32-shot settings, Flan-T5-xl-T reached 0.70, similar to logistic regression (0.69) and random forest (0.68), while XGBoost improved to 0.65. These results illustrate the differences in how generative LLMs and traditional models handle the increasing data availability. LLMs perform well in low-data scenarios, whereas traditional models rely more on structured tabular data and labeled training examples. Furthermore, the mobile app provides real-time, COVID-19 severity assessments and personalized insights through attention-based feature importance, adding value to the clinical interpretation of the results. CONCLUSIONS:Generative LLMs provide a robust alternative to traditional classifiers, particularly in scenarios with limited labeled data. Their ability to handle unstructured inputs and deliver personalized, real-time assessments without coding makes them highly adaptable to clinical settings. This study underscores the potential of LLM-powered conversational artificial intelligence (AI) in health care and encourages further exploration of its use for real-time, disease risk assessment and decision-making support.

While most children with COVID-19 experience mild symptoms or remain asymptomatic, some may develop severe complications. Early identification of children at risk for severe outcomes is essential to ensuring timely and effective intervention. Recent studies have identified alterations in salivary microRNA (miRNA) expression levels as promising biomarkers for predicting severe complications in children. However, there remains a need for a rapid, noninvasive, and quantitative method to detect miRNA expression level changes, as their upregulation or downregulation serves as a hallmark of various diseases, providing an alternative to sequencing-based methods. Here, we developed a highly specific and sensitive ligation-coupled recombinase polymerase amplification (RPA) assay for quantitatively detecting multiplex severe and nonsevere miRNAs on a portable platform. The assay begins with an miRNA-templated annealing and ligation reaction of miR-1273, miR-296, and miR-29, followed by an RPA reaction. We quantified 100 pM to 1 fM, resolving 1 fM, with 100% specificity. Next, we validated portable extraction against benchtop extraction, achieving R- 2 > 0.85 and r > 0.92 in clinical samples. Finally, testing 154 clinical samples revealed severe miRNA downregulation compared to nonsevere cases. The assay achieved high diagnostic accuracy with an area under the curve (AUC) of 0.98. This platform would empower clinicians to make informed decisions, optimize resource allocation, and improve outcomes, particularly in point-of-care (POC) settings.

Background/Objectives: Research on the association of adverse social determinants of health (SDOH) with severe pediatric coronavirus disease (COVID-19) is limited. We examined associations between SDOH patterns and COVID-19 severity in children. Methods: We conducted a prospective, observational study of children (<18 years) with symptomatic SARS-CoV-2 infection evaluated in an urban pediatric emergency department (March 2021–April 2022) in Detroit, Michigan. Caregivers completed a 34-item survey based on the Healthy People 2030 framework. Severe disease was defined as the occurrence of respiratory/cardiac failure or death within four weeks of diagnosis. Continuous and categorical variables were described using medians and percentages, respectively. Associations between disease severity and risk factors were determined using chi-square tests. Association rule mining was used for feature selection, followed by multivariate logistic regression. Results: We analyzed data from 354 children [6–12 years: 31.1%, Female: 51.1%, Black: 59%, not Hispanic: 84.7%, public insurance: 77.1%, chronic condition: 27.4%]. Of the total, 113 children had severe disease. Most caregivers were 30–44 years old (53.1%), had less than a college degree (70.4%), and income < USD 50,000 (75.2%). Adverse SDOH reported included food/housing insecurity (24.6%), no support (64.7%), unmet childcare needs (35.9%), and lack of transportation (12.7%). After controlling for age, sex, medical history, income, and obesity, severe disease was associated with caregiver use of drugs/alcohol (OR:5.92, p < 0.001) and social discrimination/lack of support (OR: 1.74, p = 0.030). Conclusions: Two SDOH patterns (caregiver use of drugs/alcohol and social discrimination/lack of support) were associated with severe COVID-19. Further studies are needed to confirm findings and develop interventions.

Large language models (LLMs) have shown remarkable capabilities in various natural language tasks and are increasingly being applied in healthcare domains. This work demonstrates a new LLM-powered disease risk assessment approach via streaming human-AI conversation, eliminating the need for programming required by traditional machine learning approaches. In a COVID-19 severity risk assessment case study, we fine-tune pre-trained generative LLMs (e.g., Llama2-7b and Flan-t5-xl) using a few shots of natural language examples, comparing their performance with traditional classifiers (i.e., Logistic Regression, XGBoost, Random Forest) that are trained de novo using tabular data across various experimental settings. We develop a mobile application that uses these fine-tuned LLMs as its generative AI (GenAI) core to facilitate real-time interaction between clinicians and patients, providing no-code risk assessment through conversational interfaces. This integration not only allows for the use of streaming Questions and Answers (QA) as inputs but also offers personalized feature importance analysis derived from the LLM's attention layers, enhancing the interpretability of risk assessments. By achieving high Area Under the Curve (AUC) scores with a limited number of fine-tuning samples, our results demonstrate the potential of generative LLMs to outperform discriminative classification methods in low-data regimes, highlighting their real-world adaptability and effectiveness. This work aims to fill the existing gap in leveraging generative LLMs for interactive no-code risk assessment and to encourage further research in this emerging field.

14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.

OBJECTIVE:To identify risk factors for clinically-important drowning-associated lung injury (ciDALI) in children. STUDY DESIGN:This was a cross-sectional study of children (0 through 18 years) who presented to 32 pediatric emergency departments (EDs) from 2010 through 2017. We reviewed demographics, comorbidities, prehospital data, chest radiographs reports, and ED course from emergency medical services, medical, and fatality records. We defined ciDALI as presence of any of the following: (1) drowning deaths without cerebral/cervical spine injuries; (2) supplemental oxygen >8 hours postdrowning; (3) invasive/noninvasive ventilatory support in first 24 hours; or (4) abnormal chest radiographic findings in the first 24 hours without resolution within 8 hours postdrowning. We used mixed-methods logistic regression with site as random effect to identify risk factors and bootstrapping to reduce overfitting. RESULTS:We enrolled 4213 patients (no ciDALI = 3045 [72%]; ciDALI = 1168 [28%]). The median age was 3 years (IQR: 1, 5). The risk factors for patients with ciDALI were age >5 years old (aOR: 2.4 [95% CI: 2.0-3.0]); submersion >5 minutes (aOR: 6.0 [95% CI: 3.5-10.2]); any scene resuscitation (aOR: 3.3 [95% CI: 2.5-4.5]) and at presentation to the ED abnormal mentation (aOR: 6.4 [95% CI: 4.1-10.0]), abnormal heart rate (aOR: 1.8 [95% CI: 1.6-2.1]), abnormal respiratory rate (aOR: 1.8 [95% CI: 1.4-2.3]), hypotension (aOR: 2.8 [95% CI: 1.0-7.4]), and abnormal lung auscultation (OR: 3.9 [95% CI: 2.9-5.4]). CONCLUSIONS:Pediatric ciDALI risk factors include older age, scene resuscitation, prolonged submersion, and abnormal pulmonary, hemodynamic, and neurological findings at ED presentation. Prospective research to stratify risks based on submersion-related lung injury is needed to help determine short-term outcome and optimize patient disposition.

In their letter, Auger et al. [ [1] Kang-Auger G. Ayoub A. Côté-Corriveau G. Letter to the editor regarding: comparison of trauma and burn evaluations in a pediatric emergency department during pre, early and late COVID-19 pandemic. J Pediatr Surg. 2023; https://doi.org/10.1016/j.jpedsurg.2023.03.008 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ] suggested that a possible explanation for an increase in burn injuries noted in our study during the pandemic periods could be secondary to undetected child maltreatment especially in children 0–4 years of age. In an age stratified analysis, we noted that a higher proportion of children in the 0–4 age group sustained burns when compared to the older age groups during both the pre-pandemic and pandemic periods. There was no significant difference in the median total body surface area (TBSA) between the three age groups or in proportion of children with severe burns (>15% TBSA) between the pre-pandemic and pandemic periods. There were no significant differences in the proportion of children with burns secondary to child maltreatment during the pre-pandemic and pandemic periods (Table 1). We categorized injury mechanism as secondary to child maltreatment in only those patients classified as such by our institution's Child At Risk Evaluation (CARE) team. Hence, we could have underestimated the incidence of burns secondary to maltreatment. Table 1Comparison of burn injuries during the pre-pandemic, early and late pandemic periods by age stratification. Variable Pre-Pandemic n = 494 Early Pandemic n = 307 Late Pandemic n = 484 p value Burn injuries 0–4 years 301 (60.9%) 171 (55.7%) 261 (53.9%) 5–11 years 138 (27.9%) 103 (33.6%) 172 (35.5%) 0.14 12–16 years 55 (11.2%) 33 (10.7%) 51 (10.5%) Median TBSA (IQR)a TBSA: Total Body Surface Area. 0–4 years 1.00 (0.5,3.00) 1.50 (0.5,3.00) 1.25 (0.50,2.50) 5–11 years 1.00 (0.5, 2.00) 1.00 (0.5,3.00) 1.50 (0.50,3.00) 0.16 12–16 years 1.00 (0.25,2.00) 1.00 (0.25, 2.00) 1.00 (0.50,2.25) Severe burns (TBSA>15%) 0–4 years 8 (66.6%) 0 (0.0%) 5 (50.0%) 0.17 5–11 years 2 (16.7%) 3 (60.0%) 3 (30.0%) 12–16 years 2 (16.7%) 2 (40.0%) 2 (20.0%) Burns secondary to child maltreatment 0–4 years 22 (73.3%) 10 (90.9%) 8 (50.0%) 5–11 years 8 (26.7%) 1 (9.1%) 7 (43.8%) 0.13 12–16 years 0 (0.0%) 0 (0.0%) 1 (6.25%) a TBSA: Total Body Surface Area. Open table in a new tab

Background Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. To date, there are no published data on epidemiology of pediatric anaphylaxis in Michigan. Our objective was to describe and compare the time trends in incidence of anaphylaxis in urban and suburban populations of Metro Detroit. Methods We performed a retrospective study of Pediatric Emergency Department (ED) anaphylaxis visits from January 1, 2010, to December 1, 2017. The study was conducted at 1 suburban ED (SED) and 1 urban ED (UED). We identified cases using an International Classification of Diseases (ICD) 9 and 10 query of the electronic medical record. Patients were included if they aged 0–17 years and met the 2006 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network diagnostic criteria for anaphylaxis. The anaphylaxis rate was calculated as the number of detected cases divided by the total number of pediatric emergency room visits for that month. Anaphylaxis rates were compared between the two EDs using Poisson regression. Results A total of 8,627 patient encounters had ICD codes for anaphylaxis, of which 703 visits fulfilled the inclusion criteria and were used in subsequent analyses. Overall, the incidence of anaphylaxis was more common in males and in children < 4 years of age in both centers. Although the total number of anaphylaxis related visits was higher at UED over the eight-year time frame for this study, the anaphylaxis rate (cases per 100,000 ED visits) throughout the study was higher at the SED. While the observed anaphylaxis rate at UED was 10.47 – 162.05 cases per 100,000 ED visits, the observed anaphylaxis rate at SED was 0 – 556.24 cases per 100,000 ED visits. Conclusion Pediatric anaphylaxis rates differ significantly between urban and suburban populations in metro Detroit EDs. The rate of anaphylaxis related visits to the ED has significantly increased over the past 8 years in the metro Detroit area, with significantly higher rise in suburban compared to urban ED. More studies are needed to explore the reasons for this observed difference in increase rates.

Purpose of Review Pediatric hypertension has been on the rise over the past four decades. While most cases are evaluated and managed in the primary healthcare setting, some children may be referred to the emergency department (ED) for an expedited workup of elevated blood pressure or for management of hypertensive crisis. Recent Findings Acute severe hypertension without end-organ damage and hypertensive emergency are life-threatening conditions that healthcare providers must be prepared to accurately recognize and treat as pediatric hypertension increases in prevalence. Summary In this article, we review the most recent definitions of elevated blood pressure and hypertension and discuss the updated literature on the evaluation and management of hypertension and hypertensive crisis of children in the ED.

Background: Pediatric trauma epidemiology altered during early COVID-19 pandemic period but the impact of the ongoing pandemic is unknown.Objectives: To compare pediatric trauma epidemiology between the pre, early and late pandemic periods and to evaluate the association of race and ethnicity on injury severity during the pandemic.Methods: We performed a retrospective study of trauma consults for an injury/burn in children <= 16 years between January 1, 2019 and December 31, 2021. Study period was categorized into pre (January 1, 2019-February 28, 2020), early (March 1, 2020-December 31, 2020), and late (January 1, 2021-December 31, 2021) pandemic. Demographics, etiology, injury/burn severity, interventions and outcomes were noted.Results: A total of 4940 patients underwent trauma evaluation. Compared to pre-pandemic, trauma evaluations for injuries and burns increased during both the early (RR: 2.13, 95% CI: 1.6-2.82 and RR: 2.24, 95% CI: 1.39-3.63, respectively) and late pandemic periods (RR: 1.42, 95% CI: 1.09-1.86 and RR: 2.44, 95% CI: 1.55-3.83, respectively). Severe injuries, hospital admissions, operations and death were higher in the early pandemic but reverted to pre-pandemic levels during late pandemic. Non-Hispanic Blacks had an approximately 40% increase in mean ISS during both pandemic periods though they had lower odds of severe injury during both pandemic periods. Conclusions: Trauma evaluations for injuries and burns increased during the pandemic periods. There was a significant association of race and ethnicity with injury severity which varied with pandemic periods.

Cardiac involvement in multisystem inflammatory syndrome in children (MIS-C) is common and contributes to significant morbidity and mortality. We evaluated the efficacy of cardiac biomarkers in detection of an abnormal echocardiogram in MIS-C patients. A retrospective chart review of children ≤18 years diagnosed with MIS-C at our hospital was performed. Sensitivity and specificity of high-sensitivity troponin I (hs-TnI) and B-type natriuretic peptide (BNP) were estimated for an abnormal echocardiogram. Of the 83 patients with MIS-C, 33 (39.8%) had an abnormal echocardiogram. While BNP was more sensitive, hs-TnI >50 ng/L was more specific for detecting an abnormal echocardiogram. Compared with children who had normal hs-TnI levels (<17 ng/L), those with hs-TnI >50 ng/L were more likely to have an echocardiographic abnormality (relative risk: 4.9; 95% CI, 2.9-10.9). Children with abnormal BNP and/or troponin (especially greater than 3-fold the upper limit of normal) would benefit from an urgent echocardiogram in the emergency department.

Introduction The COVID-19 pandemic increased demand for alcohol-based hand sanitizers. We aimed to describe the epidemiological trends in pediatric alcohol-based hand sanitizer cases reported to United States poison centers. We characterized clinically significant pediatric reports involving alcohol-based hand sanitizer products before and during the pandemic and methanol-containing hand sanitizers during the pandemic. Methods We included all single-substance cases involving alcohol-based hand sanitizers reported to the National Poison Data System among children & LE; 19 years from 1 January 2017 to 31 December 2021, and methanol-containing hand sanitizers from 23 June 2020 to 31 December 2021. Multiple product exposures and non-human exposures were excluded. Clinically significant outcomes included moderate or major effects or death. Results There were 95,718 alcohol-based hand sanitizer pediatric cases during the study period. Most (n = 89,521; 94%) were unintentional, occurred by ingestion (n = 89,879; 93.9%), occurred at home, and were managed at the exposure site (n = 89,774; 93.8%). Common symptoms were vomiting (n = 2,969; 3.1%), coughing (n = 1,102; 1.2%), ocular irritation (n = 1,244; 1.3%), and drowsiness (n = 981; 1.0%). Most children (n = 3,937; 66.2%) managed at a health care facility were treated and released; a minority were admitted (n = 527; 9.0%). Few children (n = 81; 1.4%) were admitted to the intensive care unit. The prevalence of clinically significant cases increased in 2020 and 2021, compared to 2017. Population-adjusted rates, by state, of alcohol-based hand sanitizer cases ranged from 280 to 2,700 per million children. Of the 540 reported cases involving methanol-containing hand sanitizers, the majority (n = 255) occurred in July 2020. Thirteen cases (2.4%) had clinically significant outcomes. The prevalence of clinically significant cases remained similar in 2020 and 2021 and exhibited lower prevalence compared to alcohol-based products. Population-adjusted rates, by state, ranged from fewer than 0.9 to 40 per million children. Conclusions Clinically significant pediatric cases involving alcohol-based hand sanitizers increased during the pandemic and remained elevated in 2021. Cases involving methanol-containing products were less frequent. Our findings may inform heightened product quality control and regulatory oversight.

Area deprivation index (ADI) is associated with the risk of severe COVID-19 in adults. However, this association has not been established in children. Information on ADI, demographics, clinical features, disease severity, and outcomes was analyzed for 3434 children with COVID-19. A multivariate logistic regression revealed that non-Hispanic Asians, extremes of weight, and higher ADI were associated with severe disease.