Top This: Articles in Pediatric Hospital Medicine Not to Miss!

Michele Long & Michael Koster

July 30th, 2016

PHM 2016

Acknowledgements

•  All Top Articles presenters from prior years •  All the tireless researchers •  Lauren Cerio and administrative support •  Shared practice-changing articles •  AAP SOHM listserv

Disclosure

•  Mike and Michele (aka M&M) – No financial relationships to disclose – We have no conflicts of interest to resolve

•  This presentation will not endorse the use of unapproved, off-label, or experimental interventions or medications

All (169,915)

JUST A FEW ARTICLES!

(Infant* OR newborn* OR new-born* OR perinat* OR neonat* OR baby OR baby* OR babies OR toddler* OR minors OR minors* OR boy OR boys OR boyfriend OR boyhood OR girl* OR kid OR kids OR child OR child* OR children* OR schoolchild* OR schoolchild OR school child[tiab] OR school child*[tiab] OR adolescent* OR juvenil* OR youth* OR teen* OR under*age* OR pubescent* OR pediatrics[mh] OR pediatric* OR paediatric* OR peadiatric* OR school[tiab] OR school*[tiab] OR premature* OR preterm*)

JOURNALS & # OF ARTICLES

Academic Medicine 538 J of Pediatrics 967

Academic Peds 162 JAMA* 164

Ann of Emerg Med 67 JAMA Pediatrics 328

Arch of Dis in Child 407 J of Hospital Medicine 206

Clinical Pediatrics 372 NEJM* 164

Curr Opinions in Peds 110 Pediatrics 715

Hospital Pediatrics 108 Pediatric Critical Care 341

Selection of Articles

•  Ranked articles, enerated topic areas •  Sorted based on independent title and

abstract review •  Selection included relevance to pediatric

hospitalist medicine practice •  Further narrowed with input from external

reviewers

Vitamin D: Give those Babies a Break!

High-dose vitamin D supplementation for moms instead of infants

Background

•  Breast milk lacks Vit D, it’s recommended that infants take supplemental Vit D

•  1-13% compliance with recs for Vit D supplementation for BF babies

•  Small studies have shown that maternal Vit D gets into BM

•  Could maternal only supplementation work?

Methods

•  RC-DB-CET 2-sites, exclus. BF dyads x 7 mo •  334 Mom/infants randomized:

400 IU Vit D/d mom + 400 IU/d infant (110➔47) 6400 IU Vit D/d mom + placebo infant (106➔48)

•  Vit D & Cr/Ca/phos baseline, Qmo in moms •  Vit D baseline, 4 mo, 7 mo infants •  Stopping exclusive BF, moving ➔ attrition

➔➔ p<0.0001

Tota

l 25(

OH

)D (n

Mol

/L)

Goal

Results

Final Visit (p<0.0001)

Mom Vit D Infant Vit D level

Impact to practice

•  Limitation: loss of patients due to lack of exclusive BF status

•  Maternal supplementation an option (especially if compliance concern with infant supplementation, parent preference)

•  6400 IU/day sounds high, but there’s evidence for safety

–  Look for more on supplementation dose

Choose Wisely for Babies!

The things we do that we just simply shouldn’t

Anti-reflux meds for GERD, preemie A’s&D’s

Antibiotics beyond 48 hours for rule-outs

Pneumograms at D/C even for AOP, A’s&D’s

Daily CXRs for intubation

MRIs on D/C for preemies

Avoid routine:

Babies Prefer Mom Over Morphine!

Opioid addiction is at all time high NAS is a downstream problem

Background

•  NAS 5-fold increase 2000-2012 •  22,000 neonates per year

5.8/1000 births •  Infants use up to 20% of NICU days •  NAS with increase costs: $93,000

Methods

•  Single site multidisciplinary QI project – consecutive PDSA cycles

•  Trained nurses on modified scoring •  Standardized MD interpretation of scores •  Prenatal education, family engagement,

non-pharm treatment, avoid NICU •  Outcomes via statistical process controls

Results

•  Decrease in morphine: 46 to 27% –  cumulative dose: 13.7 to 6.6 mg

•  Decrease in phenobarb: 13 to 2% •  Decrease LOS: 17 to 12 days •  Decreased cost/infant: $19,737 to $8,755 •  No adverse events or 30-day readmits

Results

See Figure 3. from Article

Impact to practice

•  Multiple studies showing improvement in LOS with adoption of protocols

•  Rooming-in >> NICU •  Watch out: ondansetron NAS preventative

study (NCT01965704)

Hold that Opioid Rx!

From use to misuse: how opioid prescriptions can lead to harm

Background

•  Medical use of opioids is associated with misuse in adults

•  Guidelines suggest risk too high in conditions such as back pain

•  Little is known on the risk of opioid misuse in adolescents exposed prior to high school completion

Methods

•  Prospective cohort from “Monitoring the Future” study

•  A nationally representative sample of 6220 surveyed in 12th grade and again at 23yrs

•  Main outcome is non-medical use of opioid at 19-23 yrs

•  Predictors were hx of drug use and attitude toward illegal drug use

Results

•  Medical use of opioid independent risk factor of future opioid misuse – 33% increase

•  Association highest with kids with – NO drug use – STRONG disapproval of illegal drug use

Impact to practice

•  Clinicians need to weigh risk and benefits of opioid prescriptions in adolescents

•  Non-medical opioid use associated with highest rates of heroinuse– Cerda,et al. J Pediatr 2015;167:605-12

Sleep-Scratch-Sleep-Scratch: Disruption of the Cycle

Melatonin for atopic dermatitis improved sleep and clinical outcomes

Background

•  Sleep disturbance 55% in AD •  Diphenhydramine at night for sleep in AD •  Nocturnal melatonin levels low in AD •  Melatonin also anti-inflammatory

Methods

•  RCT-DB-PC-CO design over 6 mos •  Single tertiary hospital in Taiwan, 2012 •  1-18yo, with >5% BSA, 3d/wk of sleep

disturbance in last 3 mos •  3mg QHS of melatonin x 4wks •  SCORAD – Scoring AD Index by single

blinded physician (0-103)

Results

•  48 children randomized •  38 (79%) completed the cross-over (2wk

washout period) •  SCORAD decreased by 9.1 in tx group •  Sleep onset decreased by 21.4 min •  NO ADVERSE EVENTS

Results: ↓eczema ↑sleep

See Figure 2. from Article

Impact to practice

•  Melatonin safe and effective •  Decreases disease severity •  Improves sleep-latency onset •  Limitation: homogenous population •  Bringing wrist-worn actigraphic devices to

future research on sleep and wake cycles

PEGing in Pediatrics!

Thickened oral feeds vs. GT feeds in kids with aspiration

Background

•  GT vs. GT+ fundo vs. transpyloric vs. thickened oral feeding

•  Pts w/ neurological conditions could have less respiratory complications

•  GTs once placed are fraught with issues •  Multidisciplinary “aerodigestive” teams

moved away from GT to avoid feeding aversion, and complications of GTs

Methods

•  Single site retrospective review 2006-13 •  All had some aspiration; excluded those

with aspiration of all types of textures •  Compared hospitalization rates of

aspirators with GT vs. thickened oral feeds – 1 year of data – Number of secondary outcomes

Results

•  Subject characteristics – Oral: Pulmonary, ENT comorbidities – GT: Cardiac, neuro, metabolic, renal

comorbidities •  114 enrolled, 49 oral, 65 GT •  Repeat flouro-swallow study in 80 pts

– Oral 6/32, 19% normal – GT 21/49, 43% normal

Results

•  Readmissions: 1 in oral vs. 2 in GT group •  Inpatient days: 2 in oral vs. 24 in GT group •  No difference in urgent admits

– Among pulm causes: 69% vs.100% in GT group (Pulm comorbidity equal b/t groups)

Results

See Figure 2. from Article

Impact to practice

•  Feed ’em first, twice as few admissions •  No difference in pneumonia admits •  Better quality of life

–  less GERD –  less feeding aversion

•  Limitation: difference in age, dissimilar comorbidities

Juice…it’s What’s for Gastro!

Dilute juice vs. oral rehydration solution for mild acute dehydration

Stephen B. Freedman, Andrew R. Willan, Kathy Boutis, Suzanne Schuh

Background

•  For AGE, e-lyte solutions recommended to treat dehydration, high-sugar drinks discouraged

•  Problem: e-lyte solutions expensive, may be may be unfamiliar, over-recommended

•  Could dilute apple juice/preferred fluids work in mild gastroenteritis?

Methods

•  RC-SB-Noninferiority: Peds ED 2010-15 •  6-60 months: gastroenteritis, minimal

dehydration, access to follow-up •  PO ½-strength AJ/preferred vs. e-lyte

solution in ED, then at home •  Outcome: 7-d failure to stay well

•  644: AJ less IV 17% vs 25% •  No difference hospitalizations, V/D •  Older Age favors ½ strength AJ/preferred

Results

Impact to practice

•  ½ strength AJ/preferred cheaper, better tasting, works in the right patients

•  Let ’em drink juice! •  Limit: single-center study in high-SES

Trimming the Fat: Butcher or Hospitalist?

Opportunities for inpatient identification and treatment of obesity

Summary: Hospital Obesity

•  Background: Obesity ID and prevention an outpatient quality focus (not inpatient)

•  Methods: Single center retrospective, BMI calculator for OW/OB and chart review

•  Results: 300 charts (2-18 yo), obesity identified only 8% of the time; addressed in plan 4% (mostly by attendings)

Impact

•  Need to think more about obesity •  Burden…or opportunity?

–  Scholarship anyone? –  QI for obesity identification, intervention –  Education targeting trainees, physicians, patients and families

Nothing’s Risk Free!

General anesthesia (GA) and the

developing brain

Summary: GA and Children

•  Anesthesia: animal effects, adult concerns •  Question: GA <4yo and measurable deficits •  Method: CC, 5-18 yo MRI & neurocognitive •  Results: 53 C/C, age 12 (surgery age 1.5)

See Figure 1. from Article

Impact to practice

•  Consider when counseling, especially for elective surgery (expect parent questions)

•  More data needed to prove/disprove causation, to look at later GA effects

No Need to Flush Twice!

Intermittent NS IV flushes once a day better than twice a day

Summary slide

•  Background: intermittent saline as good as intermittent heparin, no pediatric data

•  Methods: Randomized, open label non-inferiority, comparing 1x vs 2x day flush

•  Results: 198 in 2x/d; 199 1x/d NS flush – Occlusions in twice daily (7.6%) once (4.5%) – No difference in adverse events

Results

See Figure 2. from Article

Impact to practice

•  1x/d day maintains patency of PIVs •  Decreases costs (material and RN time) •  Reduce unnecessary manipulation that

can stress patients and parents •  Solutions for Patient Safety

–  Hospital acquired condition: IV infiltrates

From the Ivory Tower to the Surrounding Fortresses of Care!

Intermountain QI program results in sustained improvement of asthma care

Background

•  680,000 pediatric asthma admits in 2009 •  Gaps in best asthma care practices •  Inpatient QI haven’t shown (+) impact on

asthma outcomes •  Implementation at the Primary Children’s

Hospital (PCH) – Roll-out to 7 community partner sites

Methods

•  Intermountain Healthcare System •  Baseline asthma care quality •  Multidisciplinary implementation

– Leadership buy-in – Champions – Education and training –  Integration of tools into workflow

Methods

•  EB-CPM: Evidence Based Care Process Model was developed to standardize – Assessment tool for acute and chronic – Treatment recs for acute and chronic – Algorithms for escalating albuterol and O2

– Criteria for sub-specialist consult (ICU, D/C) – Template/Checklist for transition to outpt care

–  WAAP, parent competency education – Algorithm-based adjustment of controllers

Results

•  3510 from the Primary Children’s Hospital •  1721 Community Hospitals •  Compliance with EB-CPM

–  >90% 5yrs at PCH –  80-90% within 6mos at CH

Results: Process reliability

See Figure 1. from Article

Results

PCH pre vs post

implementation

Community Hospital pre vs post

implementation

Readmits (%)

16.4 vs 13.6 (p=0.026)

13.8 vs 11.5 (p=0.119)

LOS (hours)

49 vs 45 (p<0.001)

44 vs 35 (p<0.001)

Costs (2013 dollars)

1817 vs 1704 (p=0.94)

1569 vs 1485 (p=0.53)

Relative resource use

22.6 vs 22.6 (p=0.218)

22.3 vs 22.9 (p=0.032)

Impact to practice

•  Importance of disseminating QI initiatives –  Key to AAP Value In Pediatrics success

•  Intermountain shows us not just a WAAP but a process improvement will = better, sustainable outcomes in asthma

Our Care is Better Than Yours?!

Quality measures in pediatrics not yet able to distinguish centers of excellence

Background

•  Hospital QC measures reported to consumers, drive: - Accountability - QI - Competition

•  Unclear which hospitals/states have enough discharges per diagnosis and overall to distinguish high/low performers

Methods

•  RA of DC’s 2009 Kids’ Inpatient Database •  ~20% CH, ~70% Non-CH, ~9 undetermined •  3974 hospitals, 44 states, 0-to-17 yo •  Looked at common quality measures

–  All-condition (2) –  Condition-specific (9)

•  # hospitals, # states with DC volume that met “power standard” to detect outliers unrelated to chance

Results

CONDITION MEASURE Powered to detect 20% variance

All ADEs Care not “excellent”

95% 87%

Mental health Asthma

Birth

MH unjustified meds No Asthma AP

Birth trauma

90% 56% 52%

SCD 30-day readmit 5%

APPY, AGE Seizure

Shunt surg Heart surg

(-) Appy rate, meds given 30-day readmit

Shunt malfunction Heart surgery mortality

NONE

Impact to practice

•  One size/measure doesn’t fit all! •  Be wary of single-diagnosis measures •  Reporting should focus on all-condition

measures (i.e. ADEs, family experiences) •  Think about ‘power’ when designing

incentives in pediatrics

Bronchiolitis and HS: Another Med Bites the Dust!

Hypertonic saline not the key for inpatient bronchiolitis

Background

•  Keep ‘losing’ things: Steroids, albuterol, racemic epinephrine

•  Common path: Promising small trials ➔ Larger trials ➔ Hospital outcomes ➔ Meta/Cochrane/cost •  Bronchiolitis CPG 14: HS Consider for LOS •  MA: Zhang (Oct 2015), Badgett •  RCT: Silver (Dec 2015), others

Methods, Results

•  Re-analysis: Zhang and Badgett cohorts, repeat lit search

•  18 RCTs, outcome measure LOS •  Specifically looked for heterogeneity (bold)

– Study level: LOS (2 studies from China) – Patient factors: age, severity, DOI – Treatment arm: age, severity, DOI (later HS)

•  Adjusting for heterogeneity: no HS benefit

Impact to practice

•  Don’t expect HS to shorten LOS •  Don’t forget practical HS concerns:

cost, time, energy •  What’s our “what’s next” for bronchiolitis?

Expert-Schmexpert, Show Me the Data!

Support for recommendations on permissive O2 sats & intermittent monitoring

SteveCunningham,AryellyRodriguez,TimAdams,KathleenABoyd,IsabellaButcher,BethEnderby,MoragMacLean,JonathanMcCormick,JamesYPaton,FionaWee,HuwThomas,KayRiding,SteveWTurner,ChrisWilliams,EmmaMcIntosh,SteffCLewis,fortheBronchioliOsofInfancyDischargeStudy(BIDS)group

Summary: BIDS Sat 90 vs 94%

•  Methods: RC-MC-DB equivalence <12mo Standard pulse OX (94% = 94%): 308 vs Modified (90-93% displayed 94%): 307 •  Results: Standard on O2 longer (significant),

modified D/C a day sooner, no⬆ readmits or post-discharge anxiety

•  Impact: BIDS: Trust the 90!

Summary: Cont. vs Intermittent

•  RCT MC trial superiority, age ≤ 2, 2009-14

•  CPO: 80 vs. Intermittent: 81

•  Results: Mean LOS similar, intermittent didn’t have more testing, care needs, escalation

•  Impact: Don’t fixate on pulse OX if sats OK: turn monitor off

It Vill Cost You Your Blood, Vahhhahhhaaa!!!

Costs of blood cultures in pediatric community acquired pneumonia

Background

•  178,000 admission annually for CAP •  2011 CAP CPG: Blood culture-strong

recommendation, low-quality evidence •  Bacteremia rates 1.4 to 7% in studies •  Recent studies question utility •  Nothing known about cost-effectiveness

Methods

•  Compare universal blood cultures to a targeted approach

•  6 studies used for assumptions (4,900pts) •  High Risk

– <6 mos, central line, immunocompromised, toxic/ICU, chronic dz, effusion/empyema

Methods: Cost analysis

•  Laboratory charges – $51 for (-) culture, $87 for (+) culture

($36 for sensitivities) •  Hospital charges

– 1.2 days for no culture, 2 days if culture drawn

– 2 day admission for missed bacteremia, treatment failure

Methods

•  Outcomes – # w/bacteremia leading to ABX change/100 – # w/missed bacteremia and tx failure/100

•  Primary outcome – Cost/100pts: Universal vs targeted

•  Secondary – # of cultures to identify 1 case of

bacteremia leading to ABX change

Results

•  Targeted = $3,186 cost savings/100 pts – 0.07 missed bacteremia with tx failure/100

•  Universal no missed bacteremia – 0.8 w/ true bacteremia = ABX change/100

•  Population – Lab costs savings = $5,668,778 annually – All costs savings = $187,669,983 annually

Impact to practice

•  Targeted approach results in significant population savings

•  Missed cases…perfect enemy of good? •  Importance of highly immunized

population = much lower invasive pneumococcal disease

ID-ing the bug: Today or tomorrow?!

UK study of film array detection for bloodstream pathogens

Summary slide

•  Background: –  Current time to ID is 24-72 hrs –  Multi-plex PCR ID’s 24 bugs in 1 hour

•  Methods: Prospective cohort, 6mos

•  Outcome: Change in clinical management – Secondary length of stay

Results

•  117 blood cultures tested – 74 pathogens (63%) – 43 contaminates (37%)

•  ABX started or changed in 23 (19%) •  ABX stopped or tailored in 29 (25%) •  Meaningful changes in 63 (54%) •  10% of pts with decreased LOS

Impact to practice

•  Rapid diagnostics will continue to provide more efficient and quality care

•  Some institutions using a staph PCR that can tell you MRSA/MSSA from CoNS

•  Watch for: Multi-plex for AGE, and RVPs for viruses and bacteria!

Dex for Flex!

Adjuvant steroid use in septic arthritis improves outcomes

Summary slide

•  Background: Steroids used in infections: Meningitis, pharyngitis; 2 previous RCT show improvement in SA

•  Methods: Retrospective cohort, followed to final clinic appointment

•  Outcomes: Fever, CRP, LOS, IV duration, full recovery

Results: better, Better, BETTER!

116 pts: 90 ABX, 26 ABX +dex

See Table 4. from Article

Impact to practice

•  What the heck are we waiting for?! •  Dex ‘em up! •  Limitations:

– Do pathogens matter: Kingella vs MRSA? – Does the joint size/location matter?

UTI’m Not Sure How Long to Treat ’em!

Opportunities for shortening therapy in bacteremic infants

Background and Methods

•  Bacteremic UTI (B-UTI) significant black box: No guidelines

•  Methods: Retrospective cohort, 11 centers •  Infants <3 mos, 1998-2013, with B-UTI

(same pathogen in blood and urine)

•  Outcomes: IV antibiotic duration and predictors, UTI 30-day relapse

Results

See Figure 1. from Article

Impact to practice

•  Bacteraemic UTIs: OK to treat with sequential IV ➔ PO ABX

•  STOP treating entirely parenteral •  Bonus: Schroeder et al

•  Same group, different focus: UAs •  UAs: high sensitivity/specificity for B-UTI •  Use to target treatment to severity?

Thesilent“e”

Development

•  Background: near-miss SIDS, ALTE, ICD9 •  Broad committee representation:

– University/Ch, community hospitalists – Gen peds, ED – Cards, ID, GI, pulm, genetics, neuro,

abuse, epidemiology, policy •  Comprehensive review 1970-2014 •  Guidelines with level of evidence support •  Include a great table to learn, digest, teach

STEP 1: Confirm well now, event was brief, included ≥ 1 change in breathing, color, tone, responsiveness.

H and P doesn’t identify a diagnosis... It’s A BRUE!

STEP 2: Low risk (> 60d, no CPR, <1min, 1st time, ≥32 wk/adj GA ≥45 wk, no social/subtle concerns)...

It’s IN SCOPE!

SHOULD: Teaching CPR training

MAY: Pertussis, ECG, brief obs

SHOULD NOT: Most labs, CRM, AED, ANTACID

NEED NOT: Some labs, admit JUST for CRM

Impact to practice

•  Limitation: no repeats, no very young •  Will help us to reduce unnecessary

testing, improve outcomes, unify approach •  No more ALTE- call it BRUE!

Hollis, B.W., et al., Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial. Pediatrics, 2015. 136(4): p. 625-34.

Ho, T., et al., Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value. Pediatrics, 2015. 136(2): p. e482-9.

Holmes, A.V., et al., Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. Pediatrics, 2016. 137(6).

Miech, R., et al., Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 2015. 136(5): p. e1169-77.

Chang, Y.S., et al., Melatonin Supplementation for Children With Atopic Dermatitis and Sleep Disturbance: A RCT. JAMA Pediatr, 2016. 170(1): p. 35-42.

McSweeney, M.E., et al., Oral Feeding Reduces Hospitalizations Compared with Gastrostomy Feeding in Infants and Children Who Aspirate. J Pediatr, 2016. 170: p. 79-84.

Freedman, S.B., et al., Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. Jama, 2016. 315(18): p. 1966-74.

King, M.A., et al., Physicians and Physician Trainees Rarely Identify or Address Overweight/Obesity in Hospitalized Children. J Pediatr, 2015. 167(4): p. 816-820.e1.

Backeljauw, B., et al., Cognition and Brain Structure Following Early Childhood Surgery With Anesthesia. Pediatrics, 2015. 136(1): p. e1-12.

Schreiber, S., et al., Normal saline flushes performed once daily maintain peripheral intravenous catheter patency: a randomised controlled trial. Arch Dis Child, 2015. 100(7): p. 700-3. .

ArOcles

ArOclesNkoy, F., et al., Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals. Pediatrics, 2015. 136(6): p. e1602-10.

Berry, J.G., et al., Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care. Pediatrics, 2015. 136(2): p. 251-62.

Brooks, C.G., W.N. Harrison, and S.L. Ralston, Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses. JAMA Pediatr, 2016. 170(6): p. 577-84.

Cunningham, S., et al., Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet, 2015. 386(9998): p. 1041-8.

McCulloh, R., et al., Use of Intermittent vs Continuous Pulse Oximetry for Nonhypoxemic Infants and Young Children Hospitalized for Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr, 2015. 169(10): p. 898-904.

Andrews, A.L., et al., A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia. J Pediatr, 2015. 167(6): p. 1280-6.

Ray, S.T., et al., Rapid Identification of Microorganisms by FilmArray Blood Culture Identification Panel Improves Clinical Management in Children. Pediatr Infect Dis J, 2016. 35(5): p. e134-8.

Fogel, I., et al., Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics, 2015. 136(4): p. e776-82.

Schroeder, A.R., et al., Bacteraemic urinary tract infection: management and outcomes in young infants. Arch Dis Child, 2016. 101(2): p. 125-30.

Tieder, J.S., et al., Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics, 2016. 137(5).