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Objectives: Rhabdomyolysis in children is a highly variable condition with presentations ranging from myalgias to more severe complications like acute renal failure. We sought to explore demographics and incidence of pediatric rhabdomyolysis hospitalizations and rates of associated renal failure, as our current understanding is limited., Methods: This was a retrospective analysis using the Healthcare Cost and Utilization Project Kids' Inpatient Database to identify children hospitalized with a primary diagnosis of rhabdomyolysis. Data were analyzed for demographic characteristics, as well as geographic and temporal trends. Multivariable logistic regression was used to identify characteristics associated with rhabdomyolysis-associated acute renal failure., Results: From 2006 to 2016, there were 8599 hospitalized children with a primary diagnosis of rhabdomyolysis. Overall, hospitalizations for pediatric rhabdomyolysis are increasing over time, with geographic peaks in the South and Northeast regions, and seasonal peaks in March and August. Though renal morbidity was diagnosed in 8.5% of children requiring hospitalization for rhabdomyolysis, very few of these patients required renal replacement therapy (0.41%), and death was rare (0.03%). Characteristics associated with renal failure included male sex, age greater than 15 years, and non-Hispanic Black race., Conclusions: Though renal failure occurs at a significant rate in children hospitalized with rhabdomyolysis, severe complications, including death, are rare. The number of children hospitalized with rhabdomyolysis varies by geographic region and month of the year. Future studies are needed to explore etiologies of rhabdomyolysis and laboratory values that predict higher risk of morbidity and mortality in children with rhabdomyolysis., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup., Methods: This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs >1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS., Results: Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving >1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, >1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, >1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation., Conclusions: We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, >1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objective: To describe challenges in inpatient pediatric quality and safety during the coronavirus disease 2019 (COVID-19) pandemic., Methods: In a previous qualitative study, our team sought to broadly describe changes in pediatric inpatient care during the pandemic. For both that study and this ancillary analysis, we purposefully sampled participants from community and children's hospitals in the 6 US states with the highest COVID-19 hospitalization rates from March to May 2020. We recruited 2 to 3 participants from each hospital (administrators, front-line physicians, nurses, caregivers) for semistructured interviews. We used constant comparative methods to identify themes regarding quality and safety challenges during the pandemic., Results: We interviewed 30 participants from 12 hospitals. Participants described several impacts to clinical workflows, including decreased direct clinician-patient interactions and challenges to communication, partly addressed through innovative use of telehealth technology. Participants reported changes in the discharge and transfer process (eg, discharges, difficulties accessing specialized facilities). Participants also described impacts to hospital operations, including changes in quality monitoring and operations (eg, decreased staff, data collection), increased health risks for clinicians and staff (eg, COVID-19 exposure, testing delays), and staff and supply shortages. Participants voiced concerns that negative quality and safety impacts could include increased risk of preventable safety events and hospital readmissions, and decreased patient engagement, education, and satisfaction., Conclusions: We identified several impacts to clinical workflows and hospital operations during the pandemic that may have affected inpatient pediatric care quality and safety. Our findings highlight potentially important areas of focus for planning pandemic recovery, preparing for future pandemics, and conducting future research on inpatient pediatric quality and safety., Competing Interests: CONFLICT OF INTEREST: The authors have indicated they have no potential conflict of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: The number of hospitalized coronavirus disease 2019 patients in March 2020 to April 2020 in our New York City hospital required increased physician staffing, including deployment of pediatricians to adult care. To improve the deployment process, we sought to understand the mindset, preparations for, and experience during deployment of pediatric faculty in our institution., Methods: Faculty members of the Department of Pediatrics completed pre- and postsurveys evaluating perspectives, fears, and preparations relevant to deployment. Demographic characteristics of the faculty members were collected. Survey questions included Likert scale, multiple choice, and free-text responses. Descriptive statistics, Fisher's exact test, and χ 2 test were used to compare groups. Free-text responses were categorized by topic. Survey responses were shared with leadership in real time and adjustments to the deployment process made., Results: The predeployment survey was sent to 202 pediatric faculty members, with a 29% ( n = 59) completion rate. Of the 36 deployed faculty, 29 (81%) completed all items of the postsurvey. The majority (74%, n = 42) expressed discomfort with care of adults and fear and/or nervousness about deployment (61%, n = 35). Most faculty (88%, n = 52) prepared for deployment and cited local guidelines and published literature as helpful preparation materials (55%, n = 16). Dissemination of details about schedules and role clarification before deployment were areas for improvement., Conclusions: Pediatric faculty facing deployment to adult care have concerns about the process of deployment as well as the work itself. Specific information distributed in advance, along with consistent and frequent communication, may help mitigate these fears., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: To determine practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children., Methods: An electronic survey was distributed to 249 members of the Pediatric Research in Inpatient Settings Network over 6 weeks in 2017 (83 responses [33%]). Questions explored beliefs regarding the impact of tobacco smoke exposure (TSE) and practices in TSE screening, provision of counseling, resources, and pharmacotherapy. Nonparametric tests were used to compare groups on numeric variables, χ 2 tests were used to compare groups on nominal variables, and McNemar's test was used to compare dichotomous responses within subjects., Results: All respondents were familiar with the term "secondhand smoke," and >75% were familiar with "thirdhand smoke" (THS). Familiarity with THS was associated with more recent completion of training ( P = .04). Former smokers (7%) were less likely to agree that THS has a significant impact on a child's health ( P = .04). Hospitalists ask about TSE more often than they provide counseling, resources, or pharmacotherapy to caregivers who want to quit smoking. Hospitalists are more likely to ask about TSE and provide cessation counseling when patients have asthma as opposed to other diseases. Time was identified by 41% of respondents as a barrier for providing counseling and by 26% of respondents as a barrier for providing resources. Most respondents never prescribe pharmacotherapy (72%), nor do they follow-up with caregivers after hospitalization regarding cessation (87%)., Conclusions: Although most respondents ask about TSE, opportunities are missed for counseling and providing support to caregivers who want to quit smoking. Providers should be educated about THS, and systems should be streamlined to facilitate brief counseling sessions., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Wilson is deputy editor of Hospital Pediatrics; and Drs Dickinson, Thompson, and Gracely have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: Understanding patterns of parental tobacco use and their association with child exposure can help us target interventions more appropriately. We aimed to examine the association between parental smoking practices and cotinine levels of hospitalized children., Methods: This is a secondary analysis of data collected from parents of hospitalized children, recruited for a cessation intervention randomized controlled trial. Smoking parents were identified by using a medical record screening question. Parent-reported demographics and smoking habits were compared to child urine cotinine by using geometric means and log-transformed cotinine levels in multivariable linear regression analyses., Results: A total of 213 patients had complete baseline parent-interview and urine cotinine data. The median age was 4 (interquartile range: 1-9); 57% were boys; 56% were white, 12% were Black, and 23% were multiracial; 36% identified as Hispanic. Most families (54%) had 1 smoker in the home; 36% had 2, and 9% had ≥3. Many (77%) reported having a ban on smoking in the home, and 86% reported smoking only outside. The geometric mean cotinine level of the cohort was 0.98 ng/mL. Higher cotinine levels were associated with more smokers in the home (ratio of 2.99) and smoking inside the house (ratio of 4.11)., Conclusions: Having more smokers in the home and parents who smoke inside are associated with increased smoke exposure; however, even children whose families who smoke only outside the home have significant levels of cotinine, a marker for toxin exposure., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors are the Associate Editor (Dr Schroeder), Deputy Editor (Dr Wilson), and Editor-in-Chief (Dr Ralston) for Hospital Pediatrics.

Background and Objective: To determine if cigarette smoke exposure, marijuana smoke exposure, or cytokine levels at admission to the hospital for bronchiolitis are associated with follow-up visits for asthma., Methods: We enrolled a cohort of children aged 31 days to 2 years who were hospitalized with bronchiolitis from January 2013 to April 2014. Data included the results of a baseline survey about children's health and demographics, nasal wash samples, the results of a 6-month postdischarge follow-up survey, and a chart review. Nasal wash samples were tested for interleukin (IL)-6, IL-13, and tumor necrosis factor α (TNF-α); values were categorized for analysis. χ 2 , Fisher's exact, and Wilcoxon rank tests were done to test bivariable differences; all analyses were done using SAS., Results: We approached 180 families for enrollment; 99 consented to participate, and 74% of these completed follow-up surveys. Half of those with high levels of IL-13 had follow-up visits for asthma, whereas only 4.2% of those with low levels had follow-up visits for asthma ( P = .02). Marijuana exposure was reported for 12.5% ( n = 7) of study participants. There was a significant association between marijuana exposure and TNF-α levels ( P = .03)., Conclusions: Our study revealed an association between IL-13 and follow-up visits for asthma in children who were hospitalized with bronchiolitis. We found an association between family-reported marijuana smoke exposure and detectable but lower levels of TNF-α. Further research is needed to study these relationships., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objectives: Psychogenic nonepileptic seizures (PNES) are a manifestation of conversion disorder among children but can be difficult to distinguish from epilepsy. We sought to identify characteristics that differentiate children with PNES from those with epilepsy., Methods: We conducted a retrospective cohort study of children admitted with epilepsy or PNES to 45 children's hospitals from 2004 to 2014. Children with PNES ( n = 399) versus those with epilepsy ( n = 13 241) were compared on demographic and clinical characteristics, testing, treatment, and health care use. Hierarchical multivariable logistic regression was used to identify characteristics associated with PNES diagnosis., Results: Children with PNES were more likely to be female (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.8-3.0), older (aOR 3.8; 95% CI 2.7-5.3 for 14-16 years old), African American (aOR 2.0; 95% CI 1.5-2.7), and have diagnosis codes for psychiatric disorders (aOR 7.1; 95% CI 5.6-9.1) and pain (aOR 2.6; 95% CI 1.9-3.4). They were also more likely to be admitted in the fall (aOR 2.0; 95% CI 1.4-2.8) or spring (aOR 1.9; 95% CI 1.4-2.6) versus summer. Total adjusted hospitalization costs were greater for children with epilepsy ($4724, 95% CI $4413-$5057 vs $5326, 95% CI $5259-$5393; P = .001); length of stay was similar., Conclusions: Demographic and clinical characteristics differed among children with PNES versus those with epilepsy, including significantly increased odds of psychiatric and pain diagnoses among children with PNES. To better inform treatment and prognostication for children with PNES, research is needed to understand reasons for these differences, seasonal admission patterns, and the relationship between PNES and other psychiatric disorders., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objectives: To identify the extent and characteristics of missed opportunities for influenza vaccination among children hospitalized with influenza at a tertiary children's hospital., Methods: We conducted a retrospective cohort study of hospitalized patients with polymerase chain reaction-confirmed influenza admitted to Children's Hospital Colorado from 2010 to 2014. We reviewed medical records for vaccination status and previous visits. The primary outcome was the proportion of underimmunized patients hospitalized with influenza with at least 1 missed opportunity visit (visit before influenza diagnosis in which an eligible patient did not receive the influenza vaccine). The relationship between sociodemographic characteristics and the primary outcome were examined using χ(2) tests and nonparametric tests, and variables with P < .2 were entered into a multivariate logistic regression model., Results: Among 322 patients hospitalized with influenza, 199 (61%) were undervaccinated; 83 of 199 (42%) had at least 1 missed opportunity for influenza vaccination. Multivariate analysis demonstrated that high-risk status (adjusted odds ratio 6.9, 95% confidence interval 3.8-12.4) was associated with increased odds of having a missed opportunity visit. Most missed opportunity visits were to subspecialty clinics (42%), and most visits (71%) occurred from September to November., Conclusions: More than 40% of hospitalizations for influenza in children are associated with at least 1 missed opportunity visit at a tertiary center. Our findings highlight the potential role of tertiary care institutions in increasing influenza vaccination rates among children., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: Oseltamivir prescribing among pediatric inpatients with influenza varied from 2% to 48% prior to the 2009 H1N1 pandemic. After the pandemic, prescribing guidelines were expanded, and studies reported benefits for hospitalized children. Post-pandemic prescribing practices among children are unclear., Objectives: To report the rate of oseltamivir use and to identify factors associated with its use among inpatients with confirmed influenza infection from 2010 to 2014 at a tertiary children's hospital., Methods: We conducted a retrospective cohort study of inpatients with polymerase chain reaction-confirmed influenza from December 2010 to April 2014 at Children's Hospital Colorado. The primary outcome was oseltamivir use. Variables regarding demographics, underlying medical conditions, diagnoses, and hospital course were also explored. Univariate and multivariate logistic regression analyses were performed., Results: Among 395 inpatients with influenza, 323 (82%) received oseltamivir. In univariate analyses, oseltamivir use was associated with admission within 48 hours of symptom onset (89% vs 77%), ICU admission (88% vs 79%), longer length of stay (90% for >6 days vs 77% for ≤2 days), and influenza A H1N1 infection (P < .05 for all). In multivariate logistic regression analysis, longer length of stay, illness during the 2013-2014 season, and admission within 48 hours of symptom onset were associated with higher odds of oseltamivir use., Conclusions: Oseltamivir use for children with influenza in the postpandemic era is increasing at our institution, aligning with official recommendations and reported benefits. We report highest use for patients in the 2013-2014 season, those who present early in their illness, and those requiring a prolonged hospital stay., (Copyright © 2016 by the American Academy of Pediatrics.)

Background and Objective: Community-acquired pneumonia (CAP) is a common and expensive cause of hospitalization among US children, many of whom receive a codiagnosis of acute asthma. The objective of this study was to describe demographic characteristics, cost, length of stay (LOS), and adherence to clinical guidelines among these groups and to compare health care utilization and guideline adherence between them., Methods: This was a multicenter retrospective cohort study using data from the Pediatric Health Information System. Children aged 2 to 18 who were hospitalized with uncomplicated CAP from July 1, 2007, to June 30, 2012 were included. Demographics, LOS, total standardized cost, and clinical guideline adherence were compared between patients with CAP only and CAP plus acute asthma., Results: Among the 25,124 admissions, 57% were diagnosed with CAP only; 43% had a codiagnosis of acute asthma. The geometric mean for standardized cost was $4830; for LOS, it was 2.01 days. Eighty-four percent of patients had chest radiographs; CAP+acute asthma patients were less likely to have a blood culture performed (36% vs 62%, respectively) and more likely not to have a complete blood count performed (49% vs 27%, respectively). Greater guideline adherence was associated with higher cost at the patient-level but lower average cost per hospitalization at the hospital level. CAP+acute asthma patients had higher relative costs (11.8%) and LOS (5.6%) within hospitals and had more cost variation across hospitals, compared with patients with CAP only., Conclusions: A codiagnosis of acute asthma is common for children with CAP. This could be from misdiagnosis or co-occurrence. Diagnostic and/or management variability appears to be greater in patients with CAP+asthma, which may increase resource utilization and LOS for these patients., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: To determine the association between secondhand smoke (SHS) exposure and length of stay (LOS) and other exacerbation severity indicators in children hospitalized for asthma., Methods: We conducted a retrospective chart review at 2 children's hospitals. Patients aged 2 to 18 hospitalized for asthma in 2012 were included. Outcome variables included LOS, PICU, magnesium, and intravenous (IV) steroids. Bivariate analysis determined differences between SHS-exposed and non-SHS-exposed groups. Geometric means were used for LOS to account for skewed distribution. Logistic and zero-truncated negative binomial regression models were used to determine the independent association between SHS exposure and hospitalization severity indicators., Results: A total of 623 patients were included; 41% reported SHS exposure. Mean LOS was 47.5 hours. In the SHS-exposed group, LOS was 50.0 (95% confidence interval [CI] 46.7-54.0) and in the nonexposed group it was 45.8 (95% CI 43.4-48.4) (P = .02). In regression analysis, institution modified the effect of SHS exposure on LOS. At Children's Hospital Colorado, SHS exposure was associated with a 20% increase in LOS (incidence rate ratio 1.2, 95% CI 1.1-1.3). At the Medical University of South Carolina, there was no significant association. SHS-exposed patients were more likely to receive IV steroids (odds ratio 1.6, 95% CI 1.1-2.3) CONCLUSIONS: Among children hospitalized for asthma, we identified a significant association at 1 institution between SHS exposure and LOS and found that IV steroid use was significantly associated with LOS at both institutions. Eliminating SHS exposure among children with asthma is important., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: Family-centered rounds (FCR) are becoming the status quo for inpatient pediatric medical care; however, barriers still exist. The use of facilitators in FCR is gaining popularity. Although facilitators can increase comfort with FCR, the choice of preferred facilitator has not been studied by using rigorous methodology. In this study, we performed a randomized trial of facilitated FCR with bunnies and clowns, 2 commonly mentioned facilitators, and compared their results with the usual care condition., Methods: The 3 floor teams were randomized to have rounds facilitated with bunnies and clowns or the usual care model facilitated by distracted residents and overbearing attending physicians. Infection control procedures were instituted. Outcome measures were parent satisfaction scores, use of anxiolytic agents during examinations as part of FCR, resident satisfaction, and the number of times presenters were interrupted by their attending. Differences between the experimental and control groups were analyzed by using ttests, chi2 statistics, and multiple regression analysis. Qualitative analyses were also performed by using participant-observers., Results: Bunnies had the best overall improvement in parent satisfaction, anxiety, and resident satisfaction. Both intervention groups were successful at reducing attending interruptions. The clown arm was suspended by the Data Safety Monitoring Board before study completion due to adverse events., Discussion: Facilitated FCR has the potential to improve satisfaction among parents, patients, and residents, and to decrease attending interruptions. Care needs to be taken, however, to avoid unanticipated adverse effects from potentially emotionally damaging interventions. Tularemia was not identified in any of our treatment conditions.

Objectives: Secondhand smoke (SHS) exposure is an important and preventable cause of mortality and morbidity among children; hospitalization represents a sentinel event that may offer opportunities for intervention. The goal of this study was to determine the frequency and validity of SHS exposure screenings by emergency department (ED) providers, residents, and nurses., Methods: A total of 140 inpatient pediatric families consented to a salivary cotinine measurement, in-person SHS exposure interview, and chart review to assess ED provider, pediatric resident, and nurse SHS exposure screenings and documentation validity., Results: ED providers documented screening for SHS exposure 46% of the time, pediatric residents 42% of the time, and nurses 79% of the time. ED providers, pediatric residents, and nurses reported 18%, 38%, and 12% of patients exposed to SHS, respectively, whereas 46% of patients were identified as smoke-exposed according to cotinine level and/or parent report. Those with SHS exposure outside the home were least likely to be identified as exposed., Conclusions: The majority of smoke-exposed children were not identified as exposed based on documentation of admission screenings. Future research is important to identify accurate and efficient methods of screening for and identifying SHS exposure among children admitted to the hospital.

Objective: To assess the current state of research productivity, goals, obstacles, and needs of pediatric hospitalists., Methods: The American Academy of Pediatrics Section on Hospital Medicine performed a cross-sectional online survey of pediatric hospitalists. Questions assessed demographics, research productivity, system-level factors, research interests, goals and obstacles, and the perceived need for research training and support., Results: Two hundred twenty pediatric hospitalists in the United States completed the survey. Of these, 56% had presented at a national meeting, 24% were first authors of an article in a peer-reviewed journal, 8% had more than publications, and 12% had secured external grant support. While 90% of respondents had spent 10% or less time in research, 64% had an academic appointment at the assistant professor level or above. Nearly 40% felt that their institution expected them to do research, and 56% were interested and another 27% were very interested in conducting research. The main research interest was quality improvement (QI) evaluation. Common obstacles to research were lack of time, mentorship, and resources., Conclusions: Pediatric hospitalists want to conduct research to improve the quality of inpatient care but face significant obstacles including lack of dedicated time for research and mentorship. Coordinated efforts to improve access to academic resources are important for career development and academic growth of the field. National organizations and hospital programs interested in improving the quality of care for hospitalized children can provide support to meet the field's professional needs for research.