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Importance: Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission., Objectives: To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care., Design, Setting, and Participants: Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity., Exposures: Live birth at GA of 34 weeks or more., Main Outcomes and Measures: Inborn NICU admission rate., Results: Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41)., Conclusions and Relevance: Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

Background and Objectives: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay., Methods: In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles., Results: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile., Conclusions: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: We used live telemedicine consultations to assist remote providers in the examination of sexually assaulted children presenting to rural, underserved hospitals. We hypothesized that telemedicine would increase the ability of the rural provider to perform a complete and accurate sexual assault examination., Patients and Methods: Child abuse experts from a university children's hospital provided 24/7 live telemedicine consultations to clinicians at 2 rural, underserved hospitals. Consultations consisted of videoconferencing to assist in the examination and interpretation of findings during live examinations. Consecutive female patients <18 years of age presenting to the 2 participating hospitals were included. We developed and used an instrument to assess the quality of care and the interventions provided via telemedicine as it related to patient history, physical examination, colposcopic and manual manipulation techniques, interpretation of findings, and treatment plans for victims of child sexual abuse., Results: Data from 42 live telemedicine consultations were analyzed. The mean duration of the consultations was 71 minutes (range: 25-210 minutes). The consultations resulted in changes in interview methods (47%), the use of the multimethod examination technique (86%), and the use of adjunct techniques (40%). There were 9 acute sexual assault telemedicine consults that resulted in changes to the collection of forensic evidence (89%). Rankings of practitioners' skills and the telemedicine consult effectiveness were high, with the majority of cases scoring > or =5 on a 7-point Likert scale., Conclusions: The use of telemedicine to assist in the examination of sexually assaulted children presenting to underserved, rural communities results in significant changes in the methods of examination and evidence collection. It is possible that this model of care results in increased quality of care and appropriate forensic evidence collection.

Objective: To report a novel application of telemedicine and to assess the resulting quality and satisfaction of care. Study design An existing telemedicine program was evaluated through the use of a nonconcurrent cohort design. Cohorts of patients were compared by means of the Pediatric Risk of Mortality, version III (PRISM III), to adjust for severity of illness and assess risk-adjusted mortality rates. Satisfaction and quality of care surveys administered to the pediatric patient's parents and providers were also analyzed., Results: Telemedicine consultations (n=70) were conducted on 47 patients during a 2-year period. Patients receiving telemedicine consultations were sicker than the average pediatric patient cared for in the adult intensive care unit (ICU) (n=180) and compared with historic control pediatric patients (n=116) (mean PRISM III score of 9.6 versus 7.7 and 7.5, respectively). PRISM III-standardized mortality ratios were consistent among the same cohorts of patients (0.24, 0.36, and 0.37, respectively). Overall satisfaction and perception of quality of care was high among parents and rural health care providers., Conclusions: This study demonstrates that a regional pediatric ICU-based telemedicine program providing live interactive consultations to a rural adult ICU can provide quality care that is considered highly satisfactory to a select group of critically ill pediatric patients.

The objective of this research was to examine the fiscal impact of telemedicine consultations for acutely ill and injured children in a rural setting using pediatric intensive care unit (ICU) telemedicine. One hundred seventy-nine acutely ill and injured infants and children were cared for in the Mercy Redding ICU from April 2000 to April 2002. Data were gathered from these patients, including 47 patients who received 70 pediatric ICU telemedicine consultations during the same time period. Transport and hospital costs avoided were calculated for patients who received telemedicine consultations (Group 1) and for those not transferred due to the availability telemedicine consultations (Group 2), estimated to be one-half of the 179 patients (Group 2). The revenue generated in the rural ICU based on the ability to keep these patients was also determined. An estimated annual cost savings of $172,000 and $300,000 for transport and inpatient care was demonstrated for Group 1 and Group 2, respectively. Additionally, this program resulted in generating $186,000 and $279,000 of inpatient revenue annually for the two groups at the rural hospital. The cost of this program was approximately $120,000 per year. Given the substantial financial savings, support for underserved rural programs, and significant funds kept in the rural community, this may serve as a viable model for providing care to acutely ill and injured infants and children.

Objective: For children with special health care needs (CSHCN) that live in rural, medically underserved communities, obtaining subspecialty care is a challenge. Telemedicine is a means of improving access to these children by addressing rural physician shortages and geographic barriers. This article reports a medical-needs assessment of parents/guardians with CSHCN and the status of a telemedicine program for CSHCN as well as the results of parent/guardian and local provider satisfaction with the telemedicine program., Design: We report the results of a pretelemedicine medical-needs survey conducted in March 1999 by using a convenience sample of CSHCN living in a rural, medically underserved community located 90 miles north of the University of California Davis Children's Hospital (Davis, CA). In April 1999, a telemedicine program was initiated to provide consultations to CSHCN and has continued since. We also report the parent/guardian's perceptions of the appropriateness and quality of telemedicine consultations and the local provider's satisfaction with telemedicine consultations completed from April 1999 to April 2002., Results: The pretelemedicine medical-needs assessment demonstrated several barriers in access to subspecialty care including traveling >1 hour for appointments (86% of parents/guardians), missing work for appointments (96% of working parents/guardians), and frequently relying on emergency department services and/or self-regulation of their child's medications. From April 1999 to April 2002, 130 telemedicine consultations were completed on 55 CSHCN. Overall, satisfaction was very high. All the parents/guardians rated satisfaction with telemedicine care as either "excellent" or "very good," and all but 2 of the rural providers' surveys reported satisfaction with telemedicine as "excellent" or "very good." The frequency of telemedicine consultations has increased with time., Conclusions: Pediatric subspecialty telemedicine consultations can be provided to CSHCN living in a rural, medically underserved community with high satisfaction among local providers and parents/guardians. Telemedicine should be considered as a means of facilitating care to CSHCN that, relative to the customary delivery of health care, is more accessible, family-centered, and coordinated among patients and their health care providers.

Background: Hepatic and neurologic injury developed in two infants after ingestion of mint tea. Examination of the mint plants, from which the teas were brewed, indicated that they contained the toxic agent pennyroyal oil., Methods: Sera from each infant were analyzed for the toxic constituents of pennyroyal oil, including pulegone and its metabolite menthofuran., Results: Fulminant liver failure with cerebral edema and necrosis developed in the first infant, who died. This infant was positive only for menthofuran (10 ng/mL). In the other infant, who was positive for both pulegone (25 ng/mL) and menthofuran (41 ng/mL), hepatic dysfunction and a severe epileptic encephalopathy developed., Conclusion: Pennyroyal oil is a highly toxic agent that may cause both hepatic and neurologic injury if ingested. A potential source of pennyroyal oil is certain mint teas mistakenly used as home remedies to treat minor ailments and colic in infants. Physicians should consider pennyroyal oil poisoning as a possible cause of hepatic and neurologic injury in infants, particularly if the infants may have been given home-brewed mint teas.

The effects of ranitidine, an H(2)-receptor antagonist, on gastric pH, incidence of upper gastrointestinal hemorrhage and postoperative metabolic alkalosis were evaluated in 23 pediatric liver transplant recipients. Intragastric pH probes were inserted postoperatively and pH was monitored for 48 h. Ranitidine was infused for 48 h at 0.2 mg kg(minus sign1) h(minus sign1) (0.15 with renal impairment) and increased once by 0.05 mg kg(minus sign1) if the pH was less than 4.0 for 4 h. The pretreatment gastric pH was 2.1 plus minus 0.7; ranitidine infusion raised the pH to 6.8 plus minus 0.6 (p greater-than-or-equal 0.05). An intragastric pH > 4 was achieved in 64 plus minus 36 min, with a median ED(50) (50% of maximum response) of 0.24 mg kg(minus sign1). The pH was < 4 for 5.3 plus minus 4.8% of the time after the initial response. Loss of pH control occurred in three patients, two of whom had bacterial sepsis. The incidence of upper gastrointestinal bleeding and metabolic alkalosis was evaluated by comparing the study patients to age- and weight-matched historic controls from our center. Bleeding occurred in 1 of 23 (4%) study patients compared to 7 of 23 (30%) controls (p greater-than-or-equal 0.05). Metabolic alkalosis did not develop in the study patients at 24 or 48 h postoperatively (p greater-than-or-equal 0.05 versus controls). Whole blood cyclosporine levels and hepatocellular enzymes were similar in the two groups. We conclude that continuous intravenous infusion of ranitidine in the postoperative pediatric liver transplant recipient raises intragastric pH, decreases the incidence of upper gastrointestinal hemorrhage and prevents the development of metabolic alkalosis.

Study Objectives: This study was undertaken to determine the incidence of endotracheal intubation after the use of diazepam compared with phenobarbital or phenytoin in emergency treatment of seizures in children., Design: The records of all children (98) were reviewed in a case-control fashion. A logistic regression model was used to determine whether there was an association between diazepam administration and intubation, adjusting for all other covariates (age, weight, convulsion time before first anticonvulsant was given, response latency, diagnosis, and therapy)., Setting: All children were treated in an emergency department and then transported to a tertiary pediatric center by a pediatric transport team., Type of Participants: All patients were children, with a median age of 2.7 years (range 0.17 to 15.3 years)., Interventions: None., Measurements and Main Results: Only the use of diazepam was found to be significantly associated with intubation after adjusting for all other covariates (adjusted odds ratio, 49.4; P less than .001). In the comparison of diazepam versus phenobarbital or phenytoin used as the first anticonvulsant, median response latency did not differ (27.0 vs 32.5 minutes, P greater than .83)., Conclusion: A significant association was found between diazepam use and intubation. Response latency was not shorter when diazepam was used as the initial anticonvulsant compared with phenobarbital or phenytoin.

H2-receptor antagonists (H2RAs) have evolved into the mainstay of anti-acid therapy for pediatric patients, replacing antacids and other modes of therapy. Much of the experience and data used for therapeutic decisions in children, however, have been extrapolated from adult studies. Ranitidine and cimetidine have been studied most extensively in the adult and pediatric populations. Both raise gastric pH and achieve other therapeutic endpoints; however, cimetidine appears to have a greater frequency of both adversed effects and drug interactions. H2RAs are the preferred agents for prevention of stress ulcers, ulcer disease, and reflux esophagitis in the pediatric population.

A new method to assess noninvasively the proportionate storage of poly- and mono-unsaturated fatty acids in human adipose tissue is described. The method is based on in vivo natural abundance 13C NMR at 1.9 T using a TMR 32/200. Data were acquired with a concentric coil system placed below subcutaneous adipose tissue of the calf or the lower arm. Continuous single-frequency decoupling was used to optimize the signal in the spectral region of interest and minimize potential heating effects. Only adipose triglycerides contributed significantly to the resonance intensities. Typical linewidths for the in vivo 13C resonances were 10-14 Hz resulting in excellent resolution in the region of the unsaturated carbons. Signal-to-noise ratios for the resonance at 128.4 ppm (due to carbon atoms of polyunsaturated fatty acids) were typically 50-90 in 8 min using 0.25s repetition time. The relative storage of polyunsaturated fatty acids was determined by comparing the peak intensity at 128.4 ppm with the intensities of the peaks due to the carbonyl, the glycerol, or the main methyl carbons. High-resolution in vitro NMR of adipose biopsies and various mixtures of triglycerides studied with the in vivo NMR protocols provided further evidence that the described in vivo NMR methods allowed precise information on the relative storage of linoleic acid, the main constituent of the pool of polyunsaturated fatty acids. Conventional gas chromatography was performed on adipose biopsies of two volunteers and resulted in close agreement with the in vivo NMR methods. The average polyunsaturated fatty acid concentration in adipose tissue in seven healthy volunteers was 19.83 mol% +/- 1.74 (SD) as determined by in vivo NMR, consistent with conventional studies based on gas chromatography of biopsied material. Preliminary data on three cystic fibrosis patients showed a decreased polyunsaturated fatty acid concentration of 13.12 mol% +/- 2.73 (SD). The high accuracy of this method and its noninvasive character should be especially valuable in clinical research and diagnosis as repetitive adipose biopsies can be avoided.

Natural abundance in vivo carbon-13 topical magnetic resonance (TMR) spectroscopy was used to assess human adipose tissue stores of essential (polyunsaturated) fatty acids. TMR spectra were obtained from 17 normal volunteers and nine cystic fibrosis patients using an Oxford TMR-32 with a surface coil that sampled tissue less than 1 cm below the surface of an extremity. Spectra were taken of lower leg adipose tissue. Polyunsaturated fatty acid content was determined by comparing peak heights of the polyunsaturated peak (internal unsaturated carbons, 128 ppm) to C-1 carboxyl groups (173 ppm). Monounsaturated fatty acid content was determined by subtracting the polyunsaturated peak from the peak observed for all unsaturated carbons (external unsaturated carbon, 130 ppm) and dividing this ratio by the carboxyl peak. In vivo TMR of normal volunteers resulted in observed polyunsaturated fatty acid content of 17.8 +/- 2.1% and a monounsaturated content of 44.8 +/- 3.8%. The polyunsaturated and monounsaturated fatty acid content of adipose tissue from the cystic fibrosis patients was 15.0 +/- 2.0% (p less than 0.005 versus normal volunteers) and 47.8 +/- 6.5% (NS), respectively. One cystic fibrosis patient without fat malabsorption had decreased adipose polyunsaturates, whereas another patient on high calorie gastrostomy feeds had normal levels. Carbon-13 TMR spectroscopy is a sensitive, noninvasive technique for determining essential fatty acid status in subcutaneous adipose tissue of patients with cystic fibrosis.

Triacylglycerol lipase activity was studied using glycerol [1-13C]trioctanoate mixed with postheparin rat plasma. 13C NMR spectroscopy demonstrated triacylglycerol hydrolysis into free fatty acids with no difference at the 1,3 or 2 glycerol positions. There was no inhibition by high sodium concentration, consistent with lipase of hepatic origin.