Top This: Articles in Pediatric Hospital Medicine Not to Miss!
Michele Long & Michael Koster
July 30th, 2016
PHM 2016
Acknowledgements
• All Top Articles presenters from prior years • All the tireless researchers • Lauren Cerio and administrative support • Shared practice-changing articles • AAP SOHM listserv
Disclosure
• Mike and Michele (aka M&M) – No financial relationships to disclose – We have no conflicts of interest to resolve
• This presentation will not endorse the use of unapproved, off-label, or experimental interventions or medications
All (169,915)
JUST A FEW ARTICLES!
(Infant* OR newborn* OR new-born* OR perinat* OR neonat* OR baby OR baby* OR babies OR toddler* OR minors OR minors* OR boy OR boys OR boyfriend OR boyhood OR girl* OR kid OR kids OR child OR child* OR children* OR schoolchild* OR schoolchild OR school child[tiab] OR school child*[tiab] OR adolescent* OR juvenil* OR youth* OR teen* OR under*age* OR pubescent* OR pediatrics[mh] OR pediatric* OR paediatric* OR peadiatric* OR school[tiab] OR school*[tiab] OR premature* OR preterm*)
JOURNALS & # OF ARTICLES
Academic Medicine 538 J of Pediatrics 967
Academic Peds 162 JAMA* 164
Ann of Emerg Med 67 JAMA Pediatrics 328
Arch of Dis in Child 407 J of Hospital Medicine 206
Clinical Pediatrics 372 NEJM* 164
Curr Opinions in Peds 110 Pediatrics 715
Hospital Pediatrics 108 Pediatric Critical Care 341
Selection of Articles
• Ranked articles, enerated topic areas • Sorted based on independent title and
abstract review • Selection included relevance to pediatric
hospitalist medicine practice • Further narrowed with input from external
reviewers
Vitamin D: Give those Babies a Break!
High-dose vitamin D supplementation for moms instead of infants
Background
• Breast milk lacks Vit D, it’s recommended that infants take supplemental Vit D
• 1-13% compliance with recs for Vit D supplementation for BF babies
• Small studies have shown that maternal Vit D gets into BM
• Could maternal only supplementation work?
Methods
• RC-DB-CET 2-sites, exclus. BF dyads x 7 mo • 334 Mom/infants randomized:
400 IU Vit D/d mom + 400 IU/d infant (110➔47) 6400 IU Vit D/d mom + placebo infant (106➔48)
• Vit D & Cr/Ca/phos baseline, Qmo in moms • Vit D baseline, 4 mo, 7 mo infants • Stopping exclusive BF, moving ➔ attrition
➔➔ p<0.0001
Tota
l 25(
OH
)D (n
Mol
/L)
Goal
Results
Final Visit (p<0.0001)
Mom Vit D Infant Vit D level
Impact to practice
• Limitation: loss of patients due to lack of exclusive BF status
• Maternal supplementation an option (especially if compliance concern with infant supplementation, parent preference)
• 6400 IU/day sounds high, but there’s evidence for safety
– Look for more on supplementation dose
Choose Wisely for Babies!
The things we do that we just simply shouldn’t
Anti-reflux meds for GERD, preemie A’s&D’s
Antibiotics beyond 48 hours for rule-outs
Pneumograms at D/C even for AOP, A’s&D’s
Daily CXRs for intubation
MRIs on D/C for preemies
Avoid routine:
Babies Prefer Mom Over Morphine!
Opioid addiction is at all time high NAS is a downstream problem
Background
• NAS 5-fold increase 2000-2012 • 22,000 neonates per year
5.8/1000 births • Infants use up to 20% of NICU days • NAS with increase costs: $93,000
Methods
• Single site multidisciplinary QI project – consecutive PDSA cycles
• Trained nurses on modified scoring • Standardized MD interpretation of scores • Prenatal education, family engagement,
non-pharm treatment, avoid NICU • Outcomes via statistical process controls
Results
• Decrease in morphine: 46 to 27% – cumulative dose: 13.7 to 6.6 mg
• Decrease in phenobarb: 13 to 2% • Decrease LOS: 17 to 12 days • Decreased cost/infant: $19,737 to $8,755 • No adverse events or 30-day readmits
Results
See Figure 3. from Article
Impact to practice
• Multiple studies showing improvement in LOS with adoption of protocols
• Rooming-in >> NICU • Watch out: ondansetron NAS preventative
study (NCT01965704)
Hold that Opioid Rx!
From use to misuse: how opioid prescriptions can lead to harm
Background
• Medical use of opioids is associated with misuse in adults
• Guidelines suggest risk too high in conditions such as back pain
• Little is known on the risk of opioid misuse in adolescents exposed prior to high school completion
Methods
• Prospective cohort from “Monitoring the Future” study
• A nationally representative sample of 6220 surveyed in 12th grade and again at 23yrs
• Main outcome is non-medical use of opioid at 19-23 yrs
• Predictors were hx of drug use and attitude toward illegal drug use
Results
• Medical use of opioid independent risk factor of future opioid misuse – 33% increase
• Association highest with kids with – NO drug use – STRONG disapproval of illegal drug use
Impact to practice
• Clinicians need to weigh risk and benefits of opioid prescriptions in adolescents
• Non-medical opioid use associated with highest rates of heroinuse– Cerda,et al. J Pediatr 2015;167:605-12
Sleep-Scratch-Sleep-Scratch: Disruption of the Cycle
Melatonin for atopic dermatitis improved sleep and clinical outcomes
Background
• Sleep disturbance 55% in AD • Diphenhydramine at night for sleep in AD • Nocturnal melatonin levels low in AD • Melatonin also anti-inflammatory
Methods
• RCT-DB-PC-CO design over 6 mos • Single tertiary hospital in Taiwan, 2012 • 1-18yo, with >5% BSA, 3d/wk of sleep
disturbance in last 3 mos • 3mg QHS of melatonin x 4wks • SCORAD – Scoring AD Index by single
blinded physician (0-103)
Results
• 48 children randomized • 38 (79%) completed the cross-over (2wk
washout period) • SCORAD decreased by 9.1 in tx group • Sleep onset decreased by 21.4 min • NO ADVERSE EVENTS
Results: ↓eczema ↑sleep
See Figure 2. from Article
Impact to practice
• Melatonin safe and effective • Decreases disease severity • Improves sleep-latency onset • Limitation: homogenous population • Bringing wrist-worn actigraphic devices to
future research on sleep and wake cycles
PEGing in Pediatrics!
Thickened oral feeds vs. GT feeds in kids with aspiration
Background
• GT vs. GT+ fundo vs. transpyloric vs. thickened oral feeding
• Pts w/ neurological conditions could have less respiratory complications
• GTs once placed are fraught with issues • Multidisciplinary “aerodigestive” teams
moved away from GT to avoid feeding aversion, and complications of GTs
Methods
• Single site retrospective review 2006-13 • All had some aspiration; excluded those
with aspiration of all types of textures • Compared hospitalization rates of
aspirators with GT vs. thickened oral feeds – 1 year of data – Number of secondary outcomes
Results
• Subject characteristics – Oral: Pulmonary, ENT comorbidities – GT: Cardiac, neuro, metabolic, renal
comorbidities • 114 enrolled, 49 oral, 65 GT • Repeat flouro-swallow study in 80 pts
– Oral 6/32, 19% normal – GT 21/49, 43% normal
Results
• Readmissions: 1 in oral vs. 2 in GT group • Inpatient days: 2 in oral vs. 24 in GT group • No difference in urgent admits
– Among pulm causes: 69% vs.100% in GT group (Pulm comorbidity equal b/t groups)
Results
See Figure 2. from Article
Impact to practice
• Feed ’em first, twice as few admissions • No difference in pneumonia admits • Better quality of life
– less GERD – less feeding aversion
• Limitation: difference in age, dissimilar comorbidities
Juice…it’s What’s for Gastro!
Dilute juice vs. oral rehydration solution for mild acute dehydration
Stephen B. Freedman, Andrew R. Willan, Kathy Boutis, Suzanne Schuh
Background
• For AGE, e-lyte solutions recommended to treat dehydration, high-sugar drinks discouraged
• Problem: e-lyte solutions expensive, may be may be unfamiliar, over-recommended
• Could dilute apple juice/preferred fluids work in mild gastroenteritis?
Methods
• RC-SB-Noninferiority: Peds ED 2010-15 • 6-60 months: gastroenteritis, minimal
dehydration, access to follow-up • PO ½-strength AJ/preferred vs. e-lyte
solution in ED, then at home • Outcome: 7-d failure to stay well
• 644: AJ less IV 17% vs 25% • No difference hospitalizations, V/D • Older Age favors ½ strength AJ/preferred
Results
Impact to practice
• ½ strength AJ/preferred cheaper, better tasting, works in the right patients
• Let ’em drink juice! • Limit: single-center study in high-SES
Trimming the Fat: Butcher or Hospitalist?
Opportunities for inpatient identification and treatment of obesity
Summary: Hospital Obesity
• Background: Obesity ID and prevention an outpatient quality focus (not inpatient)
• Methods: Single center retrospective, BMI calculator for OW/OB and chart review
• Results: 300 charts (2-18 yo), obesity identified only 8% of the time; addressed in plan 4% (mostly by attendings)
Impact
• Need to think more about obesity • Burden…or opportunity?
– Scholarship anyone? – QI for obesity identification, intervention – Education targeting trainees, physicians, patients and families
Nothing’s Risk Free!
General anesthesia (GA) and the
developing brain
Summary: GA and Children
• Anesthesia: animal effects, adult concerns • Question: GA <4yo and measurable deficits • Method: CC, 5-18 yo MRI & neurocognitive • Results: 53 C/C, age 12 (surgery age 1.5)
See Figure 1. from Article
Impact to practice
• Consider when counseling, especially for elective surgery (expect parent questions)
• More data needed to prove/disprove causation, to look at later GA effects
No Need to Flush Twice!
Intermittent NS IV flushes once a day better than twice a day
Summary slide
• Background: intermittent saline as good as intermittent heparin, no pediatric data
• Methods: Randomized, open label non-inferiority, comparing 1x vs 2x day flush
• Results: 198 in 2x/d; 199 1x/d NS flush – Occlusions in twice daily (7.6%) once (4.5%) – No difference in adverse events
Results
See Figure 2. from Article
Impact to practice
• 1x/d day maintains patency of PIVs • Decreases costs (material and RN time) • Reduce unnecessary manipulation that
can stress patients and parents • Solutions for Patient Safety
– Hospital acquired condition: IV infiltrates
From the Ivory Tower to the Surrounding Fortresses of Care!
Intermountain QI program results in sustained improvement of asthma care
Background
• 680,000 pediatric asthma admits in 2009 • Gaps in best asthma care practices • Inpatient QI haven’t shown (+) impact on
asthma outcomes • Implementation at the Primary Children’s
Hospital (PCH) – Roll-out to 7 community partner sites
Methods
• Intermountain Healthcare System • Baseline asthma care quality • Multidisciplinary implementation
– Leadership buy-in – Champions – Education and training – Integration of tools into workflow
Methods
• EB-CPM: Evidence Based Care Process Model was developed to standardize – Assessment tool for acute and chronic – Treatment recs for acute and chronic – Algorithms for escalating albuterol and O2
– Criteria for sub-specialist consult (ICU, D/C) – Template/Checklist for transition to outpt care
– WAAP, parent competency education – Algorithm-based adjustment of controllers
Results
• 3510 from the Primary Children’s Hospital • 1721 Community Hospitals • Compliance with EB-CPM
– >90% 5yrs at PCH – 80-90% within 6mos at CH
Results: Process reliability
See Figure 1. from Article
Results
PCH pre vs post
implementation
Community Hospital pre vs post
implementation
Readmits (%)
16.4 vs 13.6 (p=0.026)
13.8 vs 11.5 (p=0.119)
LOS (hours)
49 vs 45 (p<0.001)
44 vs 35 (p<0.001)
Costs (2013 dollars)
1817 vs 1704 (p=0.94)
1569 vs 1485 (p=0.53)
Relative resource use
22.6 vs 22.6 (p=0.218)
22.3 vs 22.9 (p=0.032)
Impact to practice
• Importance of disseminating QI initiatives – Key to AAP Value In Pediatrics success
• Intermountain shows us not just a WAAP but a process improvement will = better, sustainable outcomes in asthma
Our Care is Better Than Yours?!
Quality measures in pediatrics not yet able to distinguish centers of excellence
Background
• Hospital QC measures reported to consumers, drive: - Accountability - QI - Competition
• Unclear which hospitals/states have enough discharges per diagnosis and overall to distinguish high/low performers
Methods
• RA of DC’s 2009 Kids’ Inpatient Database • ~20% CH, ~70% Non-CH, ~9 undetermined • 3974 hospitals, 44 states, 0-to-17 yo • Looked at common quality measures
– All-condition (2) – Condition-specific (9)
• # hospitals, # states with DC volume that met “power standard” to detect outliers unrelated to chance
Results
CONDITION MEASURE Powered to detect 20% variance
All ADEs Care not “excellent”
95% 87%
Mental health Asthma
Birth
MH unjustified meds No Asthma AP
Birth trauma
90% 56% 52%
SCD 30-day readmit 5%
APPY, AGE Seizure
Shunt surg Heart surg
(-) Appy rate, meds given 30-day readmit
Shunt malfunction Heart surgery mortality
NONE
Impact to practice
• One size/measure doesn’t fit all! • Be wary of single-diagnosis measures • Reporting should focus on all-condition
measures (i.e. ADEs, family experiences) • Think about ‘power’ when designing
incentives in pediatrics
Bronchiolitis and HS: Another Med Bites the Dust!
Hypertonic saline not the key for inpatient bronchiolitis
Background
• Keep ‘losing’ things: Steroids, albuterol, racemic epinephrine
• Common path: Promising small trials ➔ Larger trials ➔ Hospital outcomes ➔ Meta/Cochrane/cost • Bronchiolitis CPG 14: HS Consider for LOS • MA: Zhang (Oct 2015), Badgett • RCT: Silver (Dec 2015), others
Methods, Results
• Re-analysis: Zhang and Badgett cohorts, repeat lit search
• 18 RCTs, outcome measure LOS • Specifically looked for heterogeneity (bold)
– Study level: LOS (2 studies from China) – Patient factors: age, severity, DOI – Treatment arm: age, severity, DOI (later HS)
• Adjusting for heterogeneity: no HS benefit
Impact to practice
• Don’t expect HS to shorten LOS • Don’t forget practical HS concerns:
cost, time, energy • What’s our “what’s next” for bronchiolitis?
Expert-Schmexpert, Show Me the Data!
Support for recommendations on permissive O2 sats & intermittent monitoring
SteveCunningham,AryellyRodriguez,TimAdams,KathleenABoyd,IsabellaButcher,BethEnderby,MoragMacLean,JonathanMcCormick,JamesYPaton,FionaWee,HuwThomas,KayRiding,SteveWTurner,ChrisWilliams,EmmaMcIntosh,SteffCLewis,fortheBronchioliOsofInfancyDischargeStudy(BIDS)group
Summary: BIDS Sat 90 vs 94%
• Methods: RC-MC-DB equivalence <12mo Standard pulse OX (94% = 94%): 308 vs Modified (90-93% displayed 94%): 307 • Results: Standard on O2 longer (significant),
modified D/C a day sooner, no⬆ readmits or post-discharge anxiety
• Impact: BIDS: Trust the 90!
Summary: Cont. vs Intermittent
• RCT MC trial superiority, age ≤ 2, 2009-14
• CPO: 80 vs. Intermittent: 81
• Results: Mean LOS similar, intermittent didn’t have more testing, care needs, escalation
• Impact: Don’t fixate on pulse OX if sats OK: turn monitor off
It Vill Cost You Your Blood, Vahhhahhhaaa!!!
Costs of blood cultures in pediatric community acquired pneumonia
Background
• 178,000 admission annually for CAP • 2011 CAP CPG: Blood culture-strong
recommendation, low-quality evidence • Bacteremia rates 1.4 to 7% in studies • Recent studies question utility • Nothing known about cost-effectiveness
Methods
• Compare universal blood cultures to a targeted approach
• 6 studies used for assumptions (4,900pts) • High Risk
– <6 mos, central line, immunocompromised, toxic/ICU, chronic dz, effusion/empyema
Methods: Cost analysis
• Laboratory charges – $51 for (-) culture, $87 for (+) culture
($36 for sensitivities) • Hospital charges
– 1.2 days for no culture, 2 days if culture drawn
– 2 day admission for missed bacteremia, treatment failure
Methods
• Outcomes – # w/bacteremia leading to ABX change/100 – # w/missed bacteremia and tx failure/100
• Primary outcome – Cost/100pts: Universal vs targeted
• Secondary – # of cultures to identify 1 case of
bacteremia leading to ABX change
Results
• Targeted = $3,186 cost savings/100 pts – 0.07 missed bacteremia with tx failure/100
• Universal no missed bacteremia – 0.8 w/ true bacteremia = ABX change/100
• Population – Lab costs savings = $5,668,778 annually – All costs savings = $187,669,983 annually
Impact to practice
• Targeted approach results in significant population savings
• Missed cases…perfect enemy of good? • Importance of highly immunized
population = much lower invasive pneumococcal disease
ID-ing the bug: Today or tomorrow?!
UK study of film array detection for bloodstream pathogens
Summary slide
• Background: – Current time to ID is 24-72 hrs – Multi-plex PCR ID’s 24 bugs in 1 hour
• Methods: Prospective cohort, 6mos
• Outcome: Change in clinical management – Secondary length of stay
Results
• 117 blood cultures tested – 74 pathogens (63%) – 43 contaminates (37%)
• ABX started or changed in 23 (19%) • ABX stopped or tailored in 29 (25%) • Meaningful changes in 63 (54%) • 10% of pts with decreased LOS
Impact to practice
• Rapid diagnostics will continue to provide more efficient and quality care
• Some institutions using a staph PCR that can tell you MRSA/MSSA from CoNS
• Watch for: Multi-plex for AGE, and RVPs for viruses and bacteria!
Dex for Flex!
Adjuvant steroid use in septic arthritis improves outcomes
Summary slide
• Background: Steroids used in infections: Meningitis, pharyngitis; 2 previous RCT show improvement in SA
• Methods: Retrospective cohort, followed to final clinic appointment
• Outcomes: Fever, CRP, LOS, IV duration, full recovery
Results: better, Better, BETTER!
116 pts: 90 ABX, 26 ABX +dex
See Table 4. from Article
Impact to practice
• What the heck are we waiting for?! • Dex ‘em up! • Limitations:
– Do pathogens matter: Kingella vs MRSA? – Does the joint size/location matter?
UTI’m Not Sure How Long to Treat ’em!
Opportunities for shortening therapy in bacteremic infants
Background and Methods
• Bacteremic UTI (B-UTI) significant black box: No guidelines
• Methods: Retrospective cohort, 11 centers • Infants <3 mos, 1998-2013, with B-UTI
(same pathogen in blood and urine)
• Outcomes: IV antibiotic duration and predictors, UTI 30-day relapse
Results
See Figure 1. from Article
Impact to practice
• Bacteraemic UTIs: OK to treat with sequential IV ➔ PO ABX
• STOP treating entirely parenteral • Bonus: Schroeder et al
• Same group, different focus: UAs • UAs: high sensitivity/specificity for B-UTI • Use to target treatment to severity?
Thesilent“e”
Development
• Background: near-miss SIDS, ALTE, ICD9 • Broad committee representation:
– University/Ch, community hospitalists – Gen peds, ED – Cards, ID, GI, pulm, genetics, neuro,
abuse, epidemiology, policy • Comprehensive review 1970-2014 • Guidelines with level of evidence support • Include a great table to learn, digest, teach
STEP 1: Confirm well now, event was brief, included ≥ 1 change in breathing, color, tone, responsiveness.
H and P doesn’t identify a diagnosis... It’s A BRUE!
STEP 2: Low risk (> 60d, no CPR, <1min, 1st time, ≥32 wk/adj GA ≥45 wk, no social/subtle concerns)...
It’s IN SCOPE!
SHOULD: Teaching CPR training
MAY: Pertussis, ECG, brief obs
SHOULD NOT: Most labs, CRM, AED, ANTACID
NEED NOT: Some labs, admit JUST for CRM
Impact to practice
• Limitation: no repeats, no very young • Will help us to reduce unnecessary
testing, improve outcomes, unify approach • No more ALTE- call it BRUE!
Hollis, B.W., et al., Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial. Pediatrics, 2015. 136(4): p. 625-34.
Ho, T., et al., Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value. Pediatrics, 2015. 136(2): p. e482-9.
Holmes, A.V., et al., Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. Pediatrics, 2016. 137(6).
Miech, R., et al., Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 2015. 136(5): p. e1169-77.
Chang, Y.S., et al., Melatonin Supplementation for Children With Atopic Dermatitis and Sleep Disturbance: A RCT. JAMA Pediatr, 2016. 170(1): p. 35-42.
McSweeney, M.E., et al., Oral Feeding Reduces Hospitalizations Compared with Gastrostomy Feeding in Infants and Children Who Aspirate. J Pediatr, 2016. 170: p. 79-84.
Freedman, S.B., et al., Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. Jama, 2016. 315(18): p. 1966-74.
King, M.A., et al., Physicians and Physician Trainees Rarely Identify or Address Overweight/Obesity in Hospitalized Children. J Pediatr, 2015. 167(4): p. 816-820.e1.
Backeljauw, B., et al., Cognition and Brain Structure Following Early Childhood Surgery With Anesthesia. Pediatrics, 2015. 136(1): p. e1-12.
Schreiber, S., et al., Normal saline flushes performed once daily maintain peripheral intravenous catheter patency: a randomised controlled trial. Arch Dis Child, 2015. 100(7): p. 700-3. .
ArOcles
ArOclesNkoy, F., et al., Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals. Pediatrics, 2015. 136(6): p. e1602-10.
Berry, J.G., et al., Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care. Pediatrics, 2015. 136(2): p. 251-62.
Brooks, C.G., W.N. Harrison, and S.L. Ralston, Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses. JAMA Pediatr, 2016. 170(6): p. 577-84.
Cunningham, S., et al., Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet, 2015. 386(9998): p. 1041-8.
McCulloh, R., et al., Use of Intermittent vs Continuous Pulse Oximetry for Nonhypoxemic Infants and Young Children Hospitalized for Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr, 2015. 169(10): p. 898-904.
Andrews, A.L., et al., A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia. J Pediatr, 2015. 167(6): p. 1280-6.
Ray, S.T., et al., Rapid Identification of Microorganisms by FilmArray Blood Culture Identification Panel Improves Clinical Management in Children. Pediatr Infect Dis J, 2016. 35(5): p. e134-8.
Fogel, I., et al., Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics, 2015. 136(4): p. e776-82.
Schroeder, A.R., et al., Bacteraemic urinary tract infection: management and outcomes in young infants. Arch Dis Child, 2016. 101(2): p. 125-30.
Tieder, J.S., et al., Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics, 2016. 137(5).