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OBJECTIVES A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season. METHODS We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018–March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates. RESULTS We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P < .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P < .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P < .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures. CONCLUSIONS The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences.

CONTEXT Bronchiolitis is the leading cause of pediatric hospital admissions. Hospital-at-Home (HAH) delivers hospital-level care at home, relieving pressure on the hospital system. OBJECTIVES We aimed to review the feasibility, acceptability, and safety of HAH for bronchiolitis, and assess the cost-impact to hospitals and society. DATA SOURCES Ovid Medline, Embase, Pubmed, Cochrane Library, CINAHL, and Web of Science. STUDY SELECTION Studies (randomized control trials, retrospective audits, prospective observational trials) of infants with bronchiolitis receiving HAH (oxygen, nasogastric feeding, remote monitoring). Studies were limited to English language since 2000. DATA EXTRACTION We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias. RESULTS Ten studies met inclusion criteria, all for home oxygen therapy (HOT). One abstract on nasogastric feeding did not meet full inclusion criteria. No studies on remote monitoring were found. HOT appears feasible in terms of uptake (70%–82%) and successful completion, both at altitude and sea-level. Caregiver acceptability was reported in 2 qualitative studies. There were 7 reported adverse events (0.6%) with 0 mortality in 1257 patients. Cost studies showed evidence of savings, although included costs to hospitals only. LIMITATIONS Small number of studies with heterogenous study design and quality. No adequately powered randomized control studies. CONCLUSIONS Evidence exists to support HOT as feasible, acceptable, and safe. Evidence of cost-effectiveness remains limited. Further research is needed to understand the relevant impact of HAH versus alternative interventions to reduce oxygen prescribing. Other models of care looking at nasogastric feeding support and remote monitoring should be explored.

BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15–1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15–1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11–1.29; P < .0001). CONCLUSIONS Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.

BACKGROUND AND OBJECTIVES Evidence suggests that average performance on quality measures for bronchiolitis has been improving over time, but it is unknown whether optimal performance, as defined by Achievable Benchmarks of Care (ABCs), has also changed. Thus, we aimed to compare ABCs for established bronchiolitis quality measures between 2 consecutive time periods. As a secondary aim, we evaluated performance gaps, defined as the difference between median performance and ABCs, to identify measures that may benefit most from targeted quality initiatives. METHODS We used hospital administrative data from the Pediatric Health Information System database to calculate ABCs and performance gaps for nonrecommended bronchiolitis tests and treatments in 2 groups (patients discharged from the emergency department [ED] and those hospitalized) over 2 time periods (2006–2014 and 2014–2019) corresponding to publication of national bronchiolitis guidelines. RESULTS Substantial improvements were identified in ABCs for chest radiography (ED −8.8% [confidence interval (CI) −8.3% to −9.4%]; hospitalized −17.5% [CI −16.3% to −18.7%]), viral testing (hospitalized −14.6% [CI −13.5% to −15.7%]), antibiotic use (hospitalized −10.4% [CI −8.9% to −11.1%]), and bronchodilator use (ED −9.0% [CI −8.4% to −9.6%]). Viral testing (ED 11.5% [CI 10.9% to 12.1%]; hospitalized 21.5% [CI 19.6% to 23.4%]) and bronchodilator use (ED 13.8% [CI 12.8% to 14.8%]; hospitalized 22.8% [CI 20.6% to 25.1%]) demonstrated the largest performance gaps. CONCLUSIONS Marked changes in ABCs over time for some bronchiolitis quality measures highlight the need to reevaluate improvement targets as practice patterns evolve. Measures with large performance gaps, such as bronchodilator use and viral testing, are recommended as targets for ongoing quality improvement initiatives.

BACKGROUND AND OBJECTIVESThere are no effective interventions to prevent hospital admissions in infants with bronchiolitis. The American Academy of Pediatrics recommends against routine bronchodilator use for bronchiolitis. The objective of this study was to characterize trends in and outcomes associated with the use of bronchodilators for bronchiolitis.METHODSThis is a multicenter retrospective study of infants RESULTSA total of 446 696 ED visits of infants with bronchiolitis were included. Bronchodilator use, hospital admissions, and ED return visits decreased between 2010 and 2018 (all P < .001). ICU admissions and invasive and noninvasive ventilation increased over the study period (all P < .001). Hospital-level early bronchodilator use (hospitals with high versus low use) was not associated with differences in patient-level hospital admissions, ICU admissions, ED return visits, noninvasive ventilation, or invasive ventilation (all P > .05).CONCLUSIONSIn a large study of infants at children’s hospitals, bronchodilator therapy decreased significantly from 2010 to 2018. Hospital-level early bronchodilator use was not associated with a reduction in any outcomes. This study supports the current American Academy of Pediatrics recommendation to limit routine use of bronchodilators in infants with bronchiolitis.

* Abbreviations: HFNC — : high-flow nasal cannula therapy NIV — : noninvasive ventilation PHIS — : Pediatric Health Information System database Health care expenditures make up a large and increasing proportion of the US gross domestic product. Pediatrics is not immune to the problem, because expenditures on child health services are now equivalent to half of the US defense budget.1 Trends in our most common pediatric inpatient diagnoses, such as bronchiolitis, provide insight into the problem. Despite an apparent decrease in hospitalizations for bronchiolitis, overall costs continue to rise.2 In this month’s issue of Pediatrics , Pelletier et al3 provide further information on the phenomenon of rising resource use for bronchiolitis. These investigators demonstrated a dramatic increase in ICU use for bronchiolitis over 10 years, without clear evidence for an increase in severity of the illness itself. Indeed, there is some evidence to the contrary, with stable to declining length of stay and frequency of invasive ventilation. In the last year of the study, 2019, nearly a quarter of bronchiolitis patients in these Pediatric Health Information System database (PHIS) hospitals were cared for in an ICU. Another notable trend was … Address correspondence to Brian Alverson, MD, Department of Pediatrics, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. E-mail: balverson{at}lifespan.org

OBJECTIVES: To determine the changes in ICU admissions, ventilatory support, length of stay, and cost for patients with bronchiolitis in the United States. METHODS: Retrospective cross-sectional study of the Pediatric Health Information Systems database. All patients age RESULTS: Of 203 859 admissions for bronchiolitis, 39 442 (19.3%) were admitted to an ICU, 6751 (3.3%) received IMV, and 9983 (4.9%) received NIV. ICU admissions for bronchiolitis doubled from 11.7% in 2010 to 24.5% in 2019 (P < .001 for trend), whereas ICU admissions for all children in Pediatric Health Information Systems CONCLUSIONS: The proportions of children with bronchiolitis admitted to an ICU and receiving NIV have substantially increased, whereas the proportion receiving IMV is unchanged over the past decade. Further study is needed to better understand the factors underlying these temporal patterns.

OBJECTIVES: To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis. METHODS: We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts. RESULTS: We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8–21.4) to 0% (IQR 0–1.9) in the ED and from 14.1% (IQR 5.8–21.6) to 5% (IQR 2.7–8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2–11.1) to 4.6% (95% CI, 3.4–6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2–5.4) to 1.1% (95% CI, 0.4–2.3) (P =.007) and from 9.5% (95% CI; 7.3–12.3) to 1.7% (95% CI, 0.9–7.3) (P CONCLUSIONS: An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.

* Abbreviations: ABC — : achievable benchmark of care ED — : emergency department PHIS — : Pediatric Health Information System Achievable benchmarks of care (ABCs) provide a goal for deimplementation initiatives by defining attainable performance. ABCs have previously been defined for bronchiolitis.1 It is unclear, however, whether these previously defined ABCs have an expiration date. Are ABCs a static benchmark, or do they require modification over time? Bronchiolitis is an ideal target for deimplementation initiatives to reduce the use of low-value tests and treatments because no interventions improve its course.2,3 In this issue of Pediatrics , Ralston et al4 examine the evolution of ABCs for bronchiolitis over time using data from the Pediatric Health Information System (PHIS). Ralston et al4 calculated both ABCs and performance gaps for 6 nonrecommended tests and treatments for 2 cohorts of patients diagnosed with bronchiolitis: those evaluated in and discharged from the emergency department (ED) and those admitted as either inpatient or observation status. Children evaluated between 2006 and 2019 were included and divided into 2 time periods separated by the updated 2014 American Academy of Pediatrics bronchiolitis guideline. In the ED cohort, they found improvements in ABCs … Address correspondence to Dr Samir S. Shah, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 9016, Cincinnati, OH 45229. E-mail: Samir.Shah{at}cchmc.org

In rare instances, severe respiratory syncytial virus (RSV) infections of the lower respiratory tract can cause life-threatening extrapulmonary complications. In this report, we describe 4 previously healthy, term and late-preterm infants admitted to the PICU with respiratory failure due to RSV bronchiolitis who developed necrotizing enterocolitis shortly after admission. All infants exhibited progressive abdominal distention, had typical radiographic findings, and developed simple or complex ascites. In addition to being managed with broad-spectrum antibiotics and bowel rest, 1 infant was treated with colon resection and ileostomy, 2 had peritoneal drainage procedures for ascites, and one of those later developed small bowel strictures treated with delayed resection and anastomosis. Three were discharged from the hospital without further complications; 1 died of septic shock. In this case series, we describe development of necrotizing enterocolitis in otherwise healthy neonates with severe RSV disease in the absence of traditional risk factors. We hypothesize that a dysregulated proinflammatory response associated with severe RSV disease may alter intestinal blood flow and compromise barriers to bacterial translocation. Enteral feeding intolerance, septic ileus, and/or complex ascites may represent important clinical corollaries in these patients.

CONTEXT: Uncertainty exists as to which treatments are most effective for bronchiolitis, with considerable practice variation within and across health care sites. OBJECTIVE: A network meta-analysis to compare the effectiveness of common treatments for bronchiolitis in children aged ≤2 years. DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to September 1, 2019. STUDY SELECTION: A total 150 randomized controlled trials comparing a placebo or active comparator with any bronchodilator, glucocorticoid steroid, hypertonic saline solution, antibiotic, helium-oxygen therapy, or high-flow oxygen therapy were included. DATA EXTRACTION: Data were extracted by 1 reviewer and independently verified. Primary outcomes were admission rate on day 1 and by day 7 and hospital length of stay. Strength of evidence was assessed by using Confidence in Network Meta-Analysis . RESULTS: Nebulized epinephrine (odds ratio: 0.64, 95% confidence interval [CI]: 0.44 to 0.93, low confidence) and nebulized hypertonic saline plus salbutamol (odds ratio: 0.44, 95% CI: 0.23 to 0.84, low confidence) reduced the admission rate on day 1. No treatment significantly reduced the admission rate on day 7. Nebulized hypertonic saline (mean difference: −0.64 days, 95% CI: −1.01 to −0.26, low confidence) and nebulized hypertonic saline plus epinephrine (mean difference: −0.91 days, 95% CI: −1.14 to −0.40, low confidence) reduced hospital length of stay. LIMITATIONS: Because we did not report adverse events in this analysis, we cannot make inferences about the safety of these treatments. CONCLUSIONS: Although hypertonic saline alone, or combined with epinephrine, may reduce an infant’s stay in the hospital, poor strength of evidence necessitates additional rigorous trials.

BACKGROUND AND OBJECTIVES:The coronavirus disease 2019 (COVID-19) pandemic has led to changes in health care use, including decreased emergency department visits for children. In this study, we sought to describe the impact of the COVID-19 pandemic on inpatient use within children’s hospitals.METHODS:We performed a retrospective study using the Pediatric Health Information System. We compared inpatient use and clinical outcomes for children 0 to 18 years of age during the COVID-19 period (March 15 to August 29, 2020) to the same time frame in the previous 3 years (pre-COVID-19 period). Adjusted generalized linear mixed models were used to examine the association of the pandemic period with inpatient use. We assessed trends overall and for a subgroup of 15 medical All Patient Refined Diagnosis Related Groups (APR-DRGs).RESULTS:We identified 424 856 hospitalizations (mean: 141 619 hospitalizations per year) in the pre-COVID-19 period and 91 532 in the COVID-19 period. Compared with the median number of hospitalizations in the pre-COVID-19 period, we observed declines in hospitalizations overall (35.1%), and by APR-DRG (range: 8.5%–81.3%) with asthma (81.3%), bronchiolitis (80.1%), and pneumonia (71.4%) experiencing the greatest declines. Overall readmission rates were lower during the COVID-19 period; however, other outcomes, including length of stay, cost, ICU use, and mortality remained similar to the pre-COVID-19 period with some variability by APR-DRGs.CONCLUSIONS:US children’s hospitals observed substantial reductions in inpatient admissions with largely unchanged hospital-level outcomes during the COVID-19 pandemic. Although the impact on use varied by condition, the most notable declines were related to inpatient admissions for respiratory conditions, including asthma, bronchiolitis, and pneumonia.

Pediatric patients with respiratory signs and symptoms who are found to be wheezing present a diagnostic dilemma to pediatricians. The majority of these cases are diagnosed as some degree of reactive airway disease, either as viral bronchiolitis or asthma. In this scenario, a patient with wheezing was initially given 2 courses of appropriate antibiotics on the basis of the duration and concurrence of other symptoms. However, he was subsequently referred to a pediatric pulmonologist for further workup after failure to improve and persistent oxygen saturations in the low-to-mid 90s. More extensive testing was completed by the pediatric pulmonologist, in addition to a short hospital admission. A rigid bronchoscopy was eventually completed, which revealed small pieces of partially digested material. Although his persistent cough resolved, his saturations continued to be suboptimal. A chest computed tomography scan with contrast was then completed, which eventually led to his diagnosis and appropriate treatment and resolution of his symptoms.

* Abbreviations: HS — : hypertonic saline LOS — : length of stay NMA — : network meta-analysis Viral bronchiolitis is one of the most common reasons for infant hospitalization in the United States. Despite the morbidity attributable to the disease, there are no generally recommended therapeutic strategies for bronchiolitis other than supportive care.1 The pull of the therapeutic vacuum surrounding this disease has been noted in the pages of this journal for at least 50 years, with Wright and Beem2 writing in 1965 that “energies should not be frittered away by the annoyance of unnecessary or futile medications and procedures” for the child with bronchiolitis. Pairwise meta-analyses, the pinnacle of the traditional evidence pyramid, have been controversial in settling the question of which, if any, therapies are effective for bronchiolitis. For example, multiple meta-analyses examining the benefit of nebulized hypertonic saline (HS) on hospital length of stay (LOS) have revealed disparate conclusions.3 Brooks et al4 suggested that the beneficial effect of HS on LOS noted in previous meta-analyses was likely due to heterogeneity and imbalance of baseline patient characteristics.5 Using newer statistical techniques, such as trial sequential analysis, researchers have attempted to … Address correspondence to Matthew J. Lipshaw, MD, MS, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45229. E-mail: matthew.lipshaw{at}cchmc.org

* Abbreviations: COVID-19 — : coronavirus disease 2019 SARS-CoV-2 — : severe acute respiratory syndrome coronavirus 2 Social distancing measures, defined as closures of schools and public places, physical distancing, and cancellation of mass gatherings,1 were implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the coronavirus disease 2019 (COVID-19) pandemic. Although children have been relatively spared from severe SARS-CoV-2 infections requiring hospitalization,2,3 it remains unknown if social distancing measures are related to pediatric inpatient use for conditions caused by other respiratory viruses. To address this knowledge gap, we examined the effect … Address correspondence to Jayme L. Wilder, MD, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: jayme.wilder{at}childrens.harvard.edu

* Abbreviations: CPG — : clinical practice guideline HFNC — : high-flow nasal cannula Bronchiolitis is one of the most common reasons for pediatric hospitalization in the United States, incurring costs of $734 million each year.1 Supportive care is the mainstay of treatment, with numerous studies demonstrating the futility of adjunct therapies including corticosteroids, β-agonists, epinephrine, and hypertonic saline. In this issue of Pediatrics , Kalburgi and Halley2 describe patterns of adoption of high-flow nasal cannula (HFNC) therapy in general pediatric units in the United States and Canada, illustrating wide uptake of another intervention for bronchiolitis that is not supported by evidence. Surveying 114 hospitals that participate in the Pediatric Research in Inpatient Settings Network, Kalburgi and Halley2 found that 48% of hospitals use HFNC therapy for bronchiolitis on the general pediatric ward. At three-quarters of hospitals using HFNC therapy, locally developed protocols guided its use. These guidelines are heterogeneous and vary in their scope, with only 68% including criteria for HFNC initiation, 57% including criteria for HFNC discontinuation, and less than one-quarter including guidelines for feeding and/or nutritional support concurrent with HFNC administration. A salient concept … Address correspondence to JoAnna K. Leyenaar, MD, PhD, MPH, Department of Pediatrics and The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Building and Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756. E-mail: joanna.k.leyenaar{at}hitchcock.org

OBJECTIVES: To describe the practice of high-flow nasal cannula (HFNC) use in the pediatric ward setting across North America. METHODS: A survey was distributed through the Pediatric Research in Inpatient Settings Network, which represents 114 hospital sites. Questions included indication for HFNC use, flow and oxygen parameters, guideline availability, and use of outcomes measures. RESULTS: There was a response rate of 68% to the survey from sites representing all regions from the United States. Thirty-seven sites (48%) used HFNC in the pediatric ward setting. All 37 sites used HFNC for patients with bronchiolitis. All children’s hospital sites providing HFNC on the wards had an on-site ICU, compared with only 60% of non–children’s hospital sites (P = .003). Seventy-six percent of sites used local protocols, including parameters for patient assessment, initiation, weaning, and feeding practices. CONCLUSIONS: HFNC is used outside the ICU in nearly 50% of responding hospitals, with variation related to flow rate, feeding, and protocol use. HFNC is used for management of acute respiratory distress due to bronchiolitis, asthma, and pneumonia. Study findings suggest that HFNC is often used by pediatric hospitalists, but its use across North American hospitals remains variable and based on local consensus.

BACKGROUND: Bronchiolitis is often described to follow an expected clinical trajectory, with a peak in severity between days 3 and 5. This predicted trajectory may influence anticipatory guidance and clinical decision-making. We aimed to determine the association between day of illness at admission and outcomes, including hospital length of stay, receipt of positive-pressure ventilation, and total cough duration. METHODS: We compiled data from 2 multicenter prospective studies involving bronchiolitis hospitalizations in patients RESULTS: The median (interquartile range) day of illness at admission for 746 patients was 4 (2–5) days. Day of illness at admission was not associated with length of stay (coefficient 0.01 days, 95% confidence interval [CI]: −0.05 to 0.08 days), positive-pressure ventilation (adjusted odds ratio: 1.0, 95% CI: 0.9 to 1.1), or total cough duration (coefficient 0.33 days, 95% CI: −0.01 to 0.67 days). Additionally, there was no significant difference in day of illness at discharge in readmitted versus nonreadmitted patients (5.9 vs 6.4 days, P = .54). The median cough duration postdischarge was 6 days, with 65 (14.3%) patients experiencing cough for 14+ days. CONCLUSIONS: We found no associations between day of illness at admission and outcomes in bronchiolitis hospitalizations. Practitioners should exercise caution when making clinical decisions or providing anticipatory guidance based on symptom duration.

BACKGROUND:Because of the impact of continuous pulse oximetry (CPOX) on the overdiagnosis of hypoxemia in bronchiolitis, the American Academy of Pediatrics and the Choosing Wisely campaign have issued recommendations for intermittent monitoring. Parental preferences for monitoring may impact adoption of these recommendations, but these perspectives are poorly understood.METHODS:Using this cross-sectional survey, we explored parental perspectives on CPOX monitoring before discharge and 1 week after bronchiolitis hospitalizations. During the 1-week call, half of the participants were randomly assigned to receive a verbal statement on the potential harms of CPOX to determine if conveying the concept of overdiagnosis can change parental preferences on monitoring frequency. An aggregate variable measuring favorable perceptions of CPOX was created to determine CPOX affinity predictors.RESULTS:In-hospital interviews were completed on 357 patients, of which 306 (86%) completed the 1-week follow-up. Although 25% of parents agreed or strongly agreed that hospital monitors made them feel anxious, 98% agreed that the monitors were helpful. Compared to other vital signs, respiratory rate (87%) and oxygen saturation (84%) were commonly rated as “extremely important.” Providing an educational statement on CPOX comparatively decreased parental desire for continuous monitoring (40% vs 20%; P < .001). Although there were no significant predictors of CPOX affinity, the effect size of the educational intervention was higher in college-educated parents.CONCLUSIONS:Parents find security in CPOX. A brief statement on the potential harms of CPOX use had an impact on stated monitoring preferences. Parental perspectives are important to consider because they may influence the adoption of intermittent monitoring.

BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS: We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6–3.2), apnea (aOR 2.2; 1.1–3.5), and fever (aOR 2.4; 1.7–3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24–14.76), United States 4.14 (1.70–10.10), Australia and New Zealand 2.25 (0.86–5.74), and Spain and Portugal 3.96 (0.96–16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30–2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS: The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

* Abbreviations: CI — : confidence interval COVID-19 — : coronavirus disease 2019 Ct — : cycle threshold MARC-30 — : 30th Multicenter Airway Research Collaboration MARC-35 — : 35th Multicenter Airway Research Collaboration RSV — : respiratory syncytial virus SARS-CoV-2 — : severe acute respiratory syndrome coronavirus 2 The first human coronaviruses, OC43 and 229E, were discovered in the 1960s, but NL63 and HKU1 were discovered in 2004 and 2005, respectively. These 4 endemic coronaviruses cause respiratory illness in hospitalized children,1 as does the newest coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19).2–4 Despite many SARS-CoV-2 publications, there remains limited information about viral coinfections and the importance of viral load to acute severity. Given the potential for useful insights into SARS-CoV-2 childhood infections, we analyzed data from 2 prospective multicenter cohorts of children hospitalized with bronchiolitis in the … Address correspondence to Jonathan M. Mansbach, MD, MPH, Boston Children’s Hospital, Main Clinical Building, #9157, 300 Longwood Ave, Boston, MA 02115. E-mail: jonathan.mansbach{at}childrens.harvard.edu

BACKGROUND: Due to the impact of continuous pulse oximetry (CPOX) on the overdiagnosis of hypoxemia in bronchiolitis, the AAP and the Choosing Wisely Campaign have issued recommendations for intermittent monitoring. Parental preferences for monitoring may impact adoption of these recommendations, but these perspectives are poorly understood. METHODS: This cross-sectional survey examining parental perspectives on CPOX monitoring surveyed parents prior to and 1 week after bronchiolitis hospitalizations. During the 1-week call, half of the participants were randomized to receive a verbal statement on the potential harms of CPOX to determine whether conveying the concept of overdiagnosis can change parental preferences on monitoring frequency. An aggregate variable measuring favorable perceptions of CPOX was created to determine CPOX affinity predictors. RESULTS: In-hospital interviews were completed on 357 patients, of which 306 (86%) completed the 1-week follow-up. Though 25% of parents “agreed or strongly agreed” that hospital monitors made them feel anxious, 98% agreed that the monitors were helpful. Compared to other vital signs, respiratory rate (87%) and oxygen saturation (84%) were commonly rated as “extremely important”. Providing an educational statement on CPOX decreased parental desire for continuous monitoring (40 vs. 20%, p

The parents of a child recently hospitalized for 3 days for bronchiolitis receive the bill in the mail for their child’s hospital stay. They are stunned by the total amount of the bill. They notice that the hospital room charge accounts for nearly three-fourths of the billed amount. The bill provides no information about the room charge. The parents wonder, “What is this charge? What goes into it? Why is it so expensive?” They are grateful that the bill is covered almost fully by their child’s health insurance. In the current issue of Pediatrics , Synhorst et al1 assessed variation across children’s hospitals in the cost of care for pediatric patients hospitalized with asthma, bronchiolitis, and other common pediatric illnesses. Patients’ hospital rooms accounted for the majority of total hospital costs, whereas nonroom costs (eg, medications, laboratory testing) contributed much less. The authors concluded that initiatives to improve the quality of hospital care for common pediatric illnesses have limited opportunity to meaningfully reduce costs without addressing hospital room costs. Synhorst et al1 highlight the difficulty of conducting research on hospital cost of care using administrative data that provide little information about the biggest expense on the bill: the patient’s room. Although Synhorst et al1 suggest that room costs broadly include overhead and staffing expenses, there are neither established definitions nor … Address correspondence to Jay Berry, MD, MPH, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02130. E-mail: jay.berry{at}childrens.harvard.edu

BACKGROUND: Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses. METHODS: This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children’s hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation. RESULTS: For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%–81% for seizure, 12%–51% for bronchiolitis, 19%–63% for asthma, 19%–62% for pneumonia, 21%–78% for acute gastroenteritis, 21%–63% for upper respiratory tract infection, 28%–69% for other gastrointestinal diagnoses, and 21%–71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed. CONCLUSIONS: Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.

The advent of pulse oximetry as a widely adopted technology has transformed the overall clinical assessment of children with acute respiratory illness. One result of this transformation is a stronger clinical focus on treating hypoxemia in young children hospitalized with common respiratory illnesses, such as bronchiolitis, asthma, and pneumonia. For example, in acute viral bronchiolitis, international guidelines provide lower-limit oxygen saturation thresholds despite a weak evidence base and lack of consensus on the specific values. Nonetheless, advice to keep oxygen saturations above a precise threshold can be found in almost every bronchiolitis order set or hospital pathway. On the other hand, there has not been much debate about the opposite end of the spectrum: an upper saturation boundary once supplemental oxygen is administered for these common pediatric conditions. Pulse oximetry readings of 100% are not generally treated as abnormal, but they can represent a wide variety of Pao2 values and tissue oxygen delivery; thus, some readings of 100% while on supplemental oxygen will likely constitute tissue hyperoxia. Furthermore, nebulized therapies given in the hospital setting are typically driven by the flow of 100% oxygen from centralized supply lines, thus providing another source of exposure, which can be substantial for patients on continuously nebulized treatments. Nevertheless, there is a dearth of pediatric research on the scope of the exposure and the potential for harm from excess oxygen … Address correspondence to Shawn L. Ralston, MD, MS, Division of Quality and Safety, Johns Hopkins Children’s Center, 1800 N Orleans St, Baltimore, MD 21287. E-mail: sralsto3{at}jhmi.edu

Background: High flow nasal cannula (HFNC) therapy for bronchiolitis has become increasingly popular,however early initiation did not impact patient outcomes in the two randomized trials and is reported to be15x more costly than standard low flow nasal cannula (LFNC) We hypothesized that lack of initiation criteriafor use of HFNC was resulting in overutilization Objective: We sought to increase trials of LFNC in acute viralbronchiolitis in order to decrease the use of HFNC Our primary aim is to increase the percent of LFNCutilization prior to HFNC initiation by 50% by April 2020 Design/Methods: We undertook a multidisciplinaryquality improvement project involving Hospital Medicine, Emergency Medicine and Critical Care physicians,along with respiratory therapy and nursing We revised our existing bronchiolitis protocol to include LFNCfailure defined as no improvement in oxygen saturation, heart rate or respiratory rate within 30-60 minutes ofinitiation and protocolized LFNC treatment failure to precede HFNC initiation Our pathway change took effectDecember 1st, 2019 Inclusion criteria were: < 2 years admitted to PHM with a primary diagnosis of any ICD-10 code for bronchiolitis PICU transfer rates serve as the balancing measure and statistical process controlgrouping data in two-week increments is the primary method of analysis Results: Baseline data for the seasonpreceding our intervention (2018-2019) revealed HFNC usage in floor patients with bronchiolitis to be 62%(61/98), with 39% (24/61) undergoing a trial of LFNC prior to initiation of HFNC Post-intervention datademonstrate an increase in LFNC trials to 73% (29/40) and a concomitant decrease in HFNC utilization to 48%(40/84) (Figure 1 a/b) Rules for special cause were satisfied for the LFNC measure (2 out 3 consecutivemeasures above 2 sigma) but not for the HFNC measure when the project had to be stopped due to the SARS-CoV2 epidemic which was an external pressure against the use of HFNC (an aerosolizing procedure) Ourbalancing measure appears stable with a pre-intervention PICU transfer rate of 6 1% (n=98) and a post-intervention rate of 2 9% (n=68) Conclusion: Preliminary data suggests a simple intervention consisting ofestablishing LFNC treatment failure criteria in patients with moderate bronchiolitis may reduce HFNC usewithout adverse effects

Background: Understanding disparities in pediatric quality of care may reveal opportunities for targeted improvement. Objective: To examine associations between social disadvantage (SD) markers and performance on the Pediatric Respiratory Illness Measurement System (PRIMES) quality indicators during hospitalization for acute respiratory illness. Methods: This study was nested within a prospective cohort study of children aged 2 weeks-16 years who received emergency department or inpatient care at 5 tertiary children’s hospitals from 7/1/14-6/30/16 for one of four respiratory illnesses: asthma, bronchiolitis, croup, or pneumonia. We collected four parent-reported SD markers (minority race/ethnicity, limited English proficiency, …

Background Mechanical ventilation (MV) is often used for bronchiolitis in the Pediatric Intensive Care Unit (PICU), and typically requires analgesic and sedative medications to treat pain and agitation and to prevent dislodgement of life-sustaining equipment. Sedative side effects include bradycardia, hypotension, decreased respiratory drive, and withdrawal, but it is unknown if cumulative dosages of these medications within the first 36hrs of MV are associated with unfavorable outcomes. Methods With IRB approval, charts of PICU patients

Background The AAP recommends targeting oxygen saturation (SpO2) ≥90% for bronchiolitis. High flow nasal cannula (HFNC) is an effective therapy for bronchiolitis, but the effect of applying a specific SpO2 target to infants and children receiving HFNC for bronchiolitis is not known. We conducted a retrospective cohort study of a quality improvement initiative that instituted a standardized SpO2 goal (90-95%) to a non-standardized SpO2 goal to determine the impact on outcomes among critically ill children with bronchiolitis. Methodology A standardized protocol of HFNC with SpO2 targets for management of bronchiolitis was implemented at UC Davis Children’s Hospital in March 2019. We retrospectively studied patients hospitalized 1/1/18-12/31/18 as the “non-standardized SpO2” …

E Fishma, G Crawfor, A DeVries. Ann Allergy Asthma Immunol. 2019;123(2):186–192.e9 To evaluate the association between antibiotic exposure in the first 2 years of life and incidence of asthma later in childhood among children insured by Medicaid. Children with continuous medical and pharmacy coverage from birth to 2.5 years of age whose claims were linked to their mothers’ claims. Children were excluded if they had complex chronic medical conditions, a diagnosis of asthma, a diagnosis of bronchiolitis, or another respiratory condition in the first 2.5 years of life. Medical and pharmacy claims from 13 …

E Bergroth, M Aakula, V Elenius. J Allergy Clin Immunol Pract. 2020;8(2):588–595.e4 Respiratory syncytial virus (RSV) and rhinovirus (RV)-induced bronchiolitis are associated with increased asthma risk in children. Whether virus types have different risks associated with later development of asthma is not known. RV-A and RV-C cause more severe respiratory illness than RV-B. Cadherin-related family member 3, a receptor for RV-C, and atopy are risk factors for development of early-onset asthma. The current study investigates whether RSV or RV types are differentially associated with use of asthma medications in the 4 years following severe bronchiolitis in infancy. Children less than 24 months of age, hospitalized for bronchiolitis over consecutive winter …