bims-cliped Biomed News
on Clinical pediatrics
Issue of 2026–09–27
forty-six papers selected by
Alyssa M. Portwood, Akron’s Children
  1. Off-label prescribing in pediatrics: between regulatory gaps and clinical evidence.
  2. Quality Improvement Initiative: Implementation of a Unified Pediatric Asthma Pathway Reduces Critical Care Requirements.
  3. The Conundrum of Maintaining Pediatric Readiness at Nonpediatric Designated Trauma Centers.
  4. Optimizing Nutrition in Pediatric Burn Patients: A Quality Improvement Initiative.
  5. "The resources are so far, and you need them right here": Perspectives on Emergency Care for Youth who Experience Violence.
  6. Reducing Serum Bilirubin Measurements in a Newborn Nursery Using Quality Improvement Methodology.
  7. Voices From the Community: How Inpatient Clinicians Experience Caring for Deteriorating Children.
  8. Osteonecrosis in Youth with Sickle Cell Disease-A Narrative Review.
  9. A Quality Improvement Project to Increase Discharges before Noon at a Pediatric Hospital.
  10. Accidental Toxicological Pediatric Ingestions: Disparities in the Involvement of Social Work and Child Protective Services.
  11. Increasing Rates of Health-related Social Needs Screening in a Pediatric Critical Care Setting Through Quality Improvement.
  12. Pediatric Patellar Injuries.
  13. Decreasing Ambulatory Antibiotic Treatment Duration for Acute Otitis Media and Community-Acquired Pneumonia.
  14. Trends in Regionalization of Pediatric Inpatient and Critical Care by Medical Complexity.
  15. Approach to pediatric patients with elbow injuries in the emergency department.
  16. A Scoping Review of Risk Factors for Thunderstorm Asthma in Pediatric Patients.
  17. Access to Care as Predictors of Emergency Department Utilization: A Cross-Sectional National Study.
  18. Launching Pediatric Primary Care-Based PrEP for Adolescents in a Low HIV Prevalence Setting.
  19. Promoting Optimal Pediatric Readiness at US Trauma Centers: Understanding and Addressing Barriers.
  20. The Unique Features of Pediatric Sports Injuries: The Hip.
  21. Decreasing Prescriber Errors in a Tertiary Care Pediatric Intensive Care Unit via QI Methodology.
  22. Impact on Health Disparities: Secondary Analysis of an Unplanned Extubation Quality Improvement Study.
  23. Are intensive care settings essential in the management of diabetic ketoacidosis in children?
  24. Talk to Me, Not Just My Parent: Teen and Caregiver Perspectives on Implementing Screening, Brief Intervention, and Referral to Treatment Equitably in Pediatric Inpatient Settings for Teens with Chronic Illness.
  25. Distress Screening and Pediatric Palliative Care Referral: A Retrospective Case-Control Study in Supportive Cancer Care Delivery.
  26. Patient and Clinical Characteristics Associated With Subsequent Suicide Attempt Among Youth in the Emergency Department With a Positive Suicide Risk Screen.
  27. Medical Diagnosis, ED Visits, and Hospitalizations for Substance Use in U.S. Children's Hospitals: A Retrospective Multi-Center Cohort Study.
  28. Screening for Celiac Disease in Children: Practical Guidance for Primary Care Providers.
  29. Racial and ethnic differences in hospital-based low-value pediatric care.
  30. Emergency management of extreme hyperbilirubinemia.
  31. Caregiver-Perceived Appropriateness of Discussing Firearm Storage in the Healthcare Setting.
  32. Healthcare Providers' Prescription Practices for Spacer Devices and Mask Sizes in Pediatric Asthma Care.
  33. Making the Case: Demonstrating the Value of Pediatric Hospital Medicine to Hospital Leadership.
  34. Managing Sjögren's Disease in Pediatric Patients.
  35. Mental Health Decision Making in Pediatric Primary Care: A Scoping Review.
  36. Universal Newborn Screening for Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency in a Safety-Net Well-Baby Nursery: A Quality Improvement Initiative.
  37. Red blood cell transfusion to treat or prevent complications in sickle cell disease: an overview of Cochrane reviews.
  38. Children with sickle cell disease hospitalized for acute pancreatitis have an increased disease burden.
  39. Diagnosis-related handoffs for inter-facility transfers to the pediatric intensive care unit.
  40. Caregiver Acceptability of Hospital-based Household Substance Use Screening during Pediatric Hospital Admissions.
  41. Mobile Health Interventions to Support Self-Management in Youth with Type 1 Diabetes.
  42. Health Outcomes, Healthcare Resource Use, and Economic Burden of Invasive Meningococcal Disease in the United States Among Children Aged <11 Years.
  43. Sedation/anesthesia use for inpatient pediatric brain MRIs: National trends and outcomes.
  44. Building Pediatric Readiness Across a Health System: Evaluation of a Pediatric Emergency Department Affiliation Program.
  45. Embedding Family Voices in Pediatric Campus Design: A Participatory Model for a New Children's Hospital.
  46. Sedation-Assisted, Non-sedated, and Escalated Removal of Pediatric ENT Foreign Bodies in Emergency Settings: A Systematic Review.
  1. Ital J Pediatr. 2026 09 24. pii: 142. [Epub ahead of print]52(1):
    Off-label prescribing in pediatrics: between regulatory gaps and clinical evidence.
    Federico Marchetti, Maurizio Bonati, Antonio Clavenna.
      Despite important regulatory progress, evidence supporting the use of medicines in children remains limited, and off-label prescribing continues to be common in pediatric practice. Regulatory initiatives such as the United States Pediatric Research Equity Act (PREA) and the European Pediatric Regulation were designed to increase the labelling information relevant to paediatric use, yet important gaps persist because studies are often delayed, incomplete, or absent for many conditions and formulations. This article addresses the common misconception that off-label prescribing is always inappropriate or unsupported and argues that this interpretation is not supported by the current evidence. In reality, many off-label treatments in pediatrics are supported by scientific evidence, clinical guidelines, and consolidated experience, even when formal regulatory approval is lacking. Examples involving pediatric oncology, child psychiatric disorders, and supportive care illustrate how effective therapies may remain off-label despite becoming standards of care. The Italian experience reflects these broader challenges. Studies have shown that off-label prescribing is structural rather than exceptional in pediatrics, while national initiatives such as Law 648/96 and pediatric formularies have sought to support evidence-based prescribing beyond regulatory boundaries. It is necessary to overcome the simplistic distinction between prescriptions that comply with the indications and appropriate prescriptions. A more rational framework should distinguish unsupported off-label use from evidence-based off-label prescribing. Reducing the pediatric evidence gap therefore requires not only more pediatric research, but also recognition of rational off-label prescribing as an essential component of pediatric clinical practice.
    Keywords:  Children; Medicines; Off-label; Pediatric
    DOI:  https://doi.org/10.1186/s13052-026-02348-w
  2. Pediatr Qual Saf. 2026 Sep-Oct;11(5):11(5): e915
    Quality Improvement Initiative: Implementation of a Unified Pediatric Asthma Pathway Reduces Critical Care Requirements.
    Jocelyn A Livezey, Jessica Witkowski, Kendra Grether-Jones, Moonjoo Han, Michelle Linenberger, Stephanie Mateev, Kirsten McCullough, Heather McKnight, JoAnne Natale, Kriston Reneau, Brian J Smith, Lisa Tsang, Leah Tzimenatos, Michelle Y Hamline.
       Introduction: Asthma management is a leading cause of pediatric hospitalizations, contributing to a significant economic burden and critical care resource use. Standardized asthma care pathways have been shown to improve care delivery and resource allocation. We aimed to determine whether a unified asthma clinical pathway that integrates care across multiple care settings would reduce pediatric intensive care unit (PICU) and hospital length of stay (LOS) in an academic tertiary-care hospital.
    Methods: We designed a unified asthma pathway to integrate care across the emergency department, PICU, and ward. Quality improvement interventions included the unified clinical pathway, an electronic medical record order set, a standardized discharge checklist, and clinician education. The study team evaluated patients admitted with a primary diagnosis of asthma between 24 months and 18 years of age in the "baseline" group (May 2023-March 2024) or "intervention" group (April 2024-July 2025). The primary outcome was LOS, and the secondary outcomes were assessed using statistical process control charts. Wards-to-PICU transfers, 30-day hospital readmissions, and 7-day emergency department revisits served as balancing measures.
    Results: Overall hospital and PICU LOS remained consistent between the baseline (n = 168) and intervention periods (n = 217). After pathway implementation, there was a significant reduction in the number of patients requiring PICU-level care (31% versus 13%) and a reduction in the average time on continuous albuterol (7.4-3.2 h). Balancing measures remained unchanged between groups.
    Conclusions: Implementation of the unified asthma pathway in an academic tertiary-care hospital reduced the number of patients requiring PICU-level care and the time on continuous albuterol without an increase in adverse events.
    DOI:  https://doi.org/10.1097/pq9.0000000000000915
  3. Pediatr Emerg Care. 2026 Sep 21.
    The Conundrum of Maintaining Pediatric Readiness at Nonpediatric Designated Trauma Centers.
    Steven G Schauer, Mark Piehl, Julie A Rizzo, Michael D April.
       INTRODUCTION: The American College of Surgeons (ACS) has recently highlighted the need for emergency departments to maintain pediatric readiness, regardless of pediatric trauma center verification. Since sufficient emergency department volume is often required to maintain pediatric competency, a more complete understanding of pediatric trauma volume at centers without ACS verification would help inform efforts to improve pediatric trauma readiness.
    METHODS: We conducted a retrospective descriptive analysis of public data sets from 2017 through 2023 from the Trauma Quality Improvement Program (TQIP) registry. We included encounters at non-pediatric-designated facilities with a documented age. We used deidentified facility keys to perform per-facility analyses. Based on previously published data, we used thresholds of <324, 324 to 899, 900 to 1799, and >1800 pediatric trauma encounters per year for low, medium-low, medium-high, and high volume.
    RESULTS: Among 5,805,596 trauma encounters with a documented age, 291,418 patients were younger than 15 years old and presented to a trauma center without pediatric verification. During the study period, most nondesignated centers saw at least 1 pediatric trauma patient, with a yearly median of 25 to 32 pediatric trauma encounters per non-pediatric-designated facility. The majority (97%) were in the lowest category of pediatric trauma volume (<324 cases per year). The yearly median encounters per facility with a composite injury severity score >15 were 1. For adult verified level 1, level 2, level 3, and unverified trauma centers, the median visits per year were 31, 31, 22, and 31, respectively. When assessed by age groups of younger than 4, 5 to 9 years, and 10 to 14 years, the median number of visits per year was 8, 9, and 11, respectively.
    CONCLUSIONS: Pediatric encounters at non-pediatric-designated trauma centers were very low, with few trauma centers having sufficient volume to sustain system-level readiness through patient care only. Our findings highlight ongoing challenges with maintaining pediatric readiness and point to the need for innovative methods to ensure a high level of pediatric readiness.
    Keywords:  injury; readiness; trauma; volume
    DOI:  https://doi.org/10.1097/PEC.0000000000003694
  4. Pediatr Qual Saf. 2026 Sep-Oct;11(5):11(5): e918
    Optimizing Nutrition in Pediatric Burn Patients: A Quality Improvement Initiative.
    Tamara O Sharf, Mary S Kim, Dylan W Arkowitz, Elizabeth M Waibel, Jonathan M Teets, Samantha Schug, Elizabeth C Elliott, Matthew P Sharron, Randall S Burd.
       Introduction: Pediatric burn patients require up to twice their basal nutritional needs for healing and growth. Perioperative fasting is a modifiable source of nutritional interruption. Recent investigations show that liberalized feeding protocols do not increase aspiration risk. This study aimed to identify and mitigate nutritional barriers in operative pediatric burn patients.
    Methods: A multidisciplinary team identified key drivers of prolonged fasting. A standardized protocol was implemented using concentrated feeding formulas, continuing enteral feeds through procedures in intubated patients, and allowing high-protein clear liquids for up to two hours preoperatively in nonintubated patients. Primary outcomes included preoperative fasting duration and caloric and protein intake. Secondary outcomes included length of stay and perioperative complications.
    Results: Thirty patients were included (15 baseline and 15 intervention). Statistical process control analysis showed sustained reduction in preoperative fasting duration following protocol implementation. Among patients receiving tube feeding, median nil per os duration decreased from 11-hour baseline to 5.6 hours (P < 0.001), whereas caloric and protein intake increased (both P < 0.001). When adjusted for surgical start time and feeding modality, intervention status was associated with shorter fasting duration and increased caloric and protein delivery. No aspiration events occurred.
    Conclusions: Perioperative fasting is a contributor to nutritional outcomes in pediatric burn patients. A quality improvement initiative reduced fasting durations and improved perioperative caloric and protein delivery without increasing aspiration risk, impacting length of stay, or increasing perioperative complications. This approach is feasible in centers with varying resources and may be adapted to other pediatric surgical populations.
    DOI:  https://doi.org/10.1097/pq9.0000000000000918
  5. Acad Pediatr. 2026 Sep 23. pii: S1876-2859(26)00247-0. [Epub ahead of print] 103465
    "The resources are so far, and you need them right here": Perspectives on Emergency Care for Youth who Experience Violence.
    Samaa Kemal, Jennifer A Hoffmann, Stephanie Loo, Diana Madden, Elizabeth R Alpern, Margaret Samuels-Kalow.
       OBJECTIVE: In caring for youth who experience violence, variability in available emergency department (ED) resources and conditions that impact comprehensive care delivery (i.e., care coordination, connection to community resources) is not well understood. This study explored conditions that impact care delivery in pediatric and general EDs for youth who experience self-directed or interpersonal violence.
    METHODS: Semi-structured interviews with pediatric and general ED physicians and nurses were conducted to understand conditions that impact comprehensive care delivery in the ED for youth who experience violence. Participants were recruited from the National ED Inventory database from October 2023-May 2024. Recurring themes were identified using a constant comparative analytical approach.
    RESULTS: 13 interviews were conducted (8 participants from pediatric EDs and 5 from general EDs). Five major themes were found: 1) imbalance of perceived needs and available resources; 2) consequences of this mismatch negatively affecting both patients and providers; 3) challenges to care provision from the legal system and sociopolitical environments; 4) negative impact of provider implicit biases on care provision; 5) lack of consensus among providers on the appropriate role of the ED in injury prevention efforts and post-discharge care coordination.
    CONCLUSIONS: Pediatric and general EDs perceive many challenges when caring for youth who experience violence with particular emphasis on the mismatch between needs and resources and non-clinical influences on providers' care provision. To improve comprehensive care for these youth, EDs may consider increasing pediatric-specific training, building awareness of clinical and community-based resources, and advocacy to expand specialized pediatric care in all settings.
    Keywords:  emergency department; firearms; suicide; violence
    DOI:  https://doi.org/10.1016/j.acap.2026.103465
  6. Hosp Pediatr. 2026 Sep 24. pii: e2026009508. [Epub ahead of print]
    Reducing Serum Bilirubin Measurements in a Newborn Nursery Using Quality Improvement Methodology.
    Juniper L Burch, Regina Joseph, Tamra Ouellette, Elena Luo, Leela Sarathy.
       BACKGROUND: Transcutaneous bilirubin (TcB) screening in the newborn nursery (NBN) is noninvasive and appropriate for most infants; however, reported rates of total serum bilirubin (TSB) measurement remain at 17% to 30%.
    OBJECTIVE: From January to December 2024, 17.2% of infants solely admitted to our NBN received any TSB test, but only 45.3% of TSB measurements were concordant with the American Academy of Pediatrics guidelines. Our aim was to decrease the percentage of infants receiving any TSB measurement from 17% to 12% within 6 months by increasing the percentage of guideline-concordant TSB measurements from 45% to 75%.
    METHODS: Interventions included the following: (1) updated nursing protocol for bilirubin screening, (2) NBN physician manual chart review, (3) nursing education sessions, (4) NBN physician meeting to discuss ongoing barriers and potential practice changes, and (5) ongoing reinforcement of TSB indications. The outcome measure was the percentage of infants receiving any TSB test. Process measures included percentage of guideline-concordant TSB tests and TSB tests without a preceding TcB screen (unless on/post phototherapy). Balancing measures included readmissions for phototherapy and escalation of care on readmission. Data were analyzed using statistical process control.
    RESULTS: The percentage of infants receiving any TSB test decreased from 17.2% to 11.2%. The percentage of guideline-concordant TSB tests increased from 45.3% to 85.1%, and TSB tests without a TcB screen decreased from 24.4% to 7.1%. There was no significant change in readmission rate.
    CONCLUSION: Using quality improvement methodology to increase guideline-concordant TSB tests decreased the percentage of infants receiving any TSB test. This outcome is beneficial for patient-centered care, with decreased painful procedures, and for resource use.
    DOI:  https://doi.org/10.1542/hpeds.2026-009508
  7. Hosp Pediatr. 2026 Sep 21. pii: e2026009288. [Epub ahead of print]
    Voices From the Community: How Inpatient Clinicians Experience Caring for Deteriorating Children.
    Daniela Hochreiter, Jordan Silberg, Lara Batey, Alanah Armstead, Magna Dias, Corrie E McDaniel.
       BACKGROUND: National initiatives to improve care for children in community emergency department settings have demonstrated improved quality with decreased pediatric mortality. In contrast, pediatric readiness for inpatient care in community hospitals remains poorly defined. Caring for a child whose condition deteriorates unexpectedly requires timely recognition, communication, escalation, stabilization, and transfer when needed. As such, we aimed to understand the experience of inpatient clinicians caring for clinically deteriorating children with evolving acute care needs in community hospitals.
    METHODS: We conducted a qualitative study, utilizing an inductive approach, from November 2023 to May 2024. Using purposive sampling, we conducted semi-structured interviews with pediatric hospitalists, nurses, and respiratory therapists from 16 community hospitals in the Northeastern United States. Data were analyzed using thematic analysis.
    RESULTS: Twenty-three clinicians participated. We identified 4 themes: (1) Trust-based collaborative decision-making; (2) Adaptive clinical decision-making strategies; (3) Building pediatric-specific capability; (4) The invisible labor of isolated pediatric expertise and its emotional toll. A framework linking clinician experiences to individual and hospital-level consequences was derived, and 14 components for a future pediatric inpatient readiness toolbox were identified.
    CONCLUSION: Community clinicians caring for deteriorating children rely on trusted relationships, ongoing decision-making under resource constraints, and locally developed preparedness systems. Future pediatric inpatient readiness frameworks should incorporate these contextual factors alongside traditional measures of staffing, equipment, medications, and clinical capability.
    DOI:  https://doi.org/10.1542/hpeds.2026-009288
  8. Children (Basel). 2026 Aug 26. pii: 1143. [Epub ahead of print]13(9):
    Osteonecrosis in Youth with Sickle Cell Disease-A Narrative Review.
    Melissa Fiscaletti.
      Osteonecrosis can cause significant and chronic musculoskeletal morbidity in children and adolescents with sickle cell disease (SCD). Although the femoral head is most frequently affected, lesions can also occur in the humeral head, vertebral bodies, knees, and other joints. Progressive joint damage can result in chronic pain, impaired mobility, loss of function, and the need for surgical intervention at a young age. As survival continues to improve in SCD, the long-term burden of osteonecrosis is becoming increasingly important. This narrative review summarizes the current understanding of osteonecrosis in pediatric and adolescent SCD. We review its epidemiology, pathophysiology, clinical presentation, imaging findings, and management. Disease burden increases with age and is closely linked to markers of severe SCD, including frequent vaso-occlusive crises and acute chest syndrome.
    Keywords:  avascular necrosis; bone infarcts; children; osteonecrosis; sickle cell disease
    DOI:  https://doi.org/10.3390/children13091143
  9. Pediatr Qual Saf. 2026 Sep-Oct;11(5):11(5): e910
    A Quality Improvement Project to Increase Discharges before Noon at a Pediatric Hospital.
    Karen C Willis, Samantha M Gunkelman, Brittany K Potts, Kerwyn C Jones, Angela M Contant, Karan R Johnson, Prabi Rajbhandari.
       Introduction: Delays in patient discharges lead to inefficient hospital throughput and reduced access to care. The aim of this quality improvement (QI) project was to increase the percentage of discharge orders placed before noon (DOBN) by the pediatric hospital medicine (PHM) service from 27% to 32% between January 1, 2021, and December 31, 2022.
    Methods: We convened a multidisciplinary team of hospitalists, residents, nurses, and bed management staff and surveyed key stakeholders to identify the most important barriers. Key interventions included the implementation of a multidisciplinary huddle, earlier preparation of the electronic health record for discharges, and prioritizing rounding on discharge-ready patients. The outcome measure was the monthly percentage of DOBN. Balancing measures were 7-day readmission rates and average length of stay (LOS). The primary measure was analyzed using a statistical process control chart (p-chart), and the balancing measures were analyzed using run charts.
    Results: The baseline rate of DOBN on the PHM service was 27%. After interventions, this increased to 32%. The LOS was 2.5 days, and the average 7-day readmission rate was 2.4%. Run chart analysis showed no special cause variation in the balancing measures. These results were sustained for 16 months without increasing LOS or 7-day readmission rates.
    Conclusions: The QI team successfully increased the DOBN rate for a PHM service by applying QI methods and adopting a multidisciplinary approach to discharge planning and preparation.
    DOI:  https://doi.org/10.1097/pq9.0000000000000910
  10. Pediatr Emerg Care. 2026 Sep 23.
    Accidental Toxicological Pediatric Ingestions: Disparities in the Involvement of Social Work and Child Protective Services.
    Henry Nguyen, Joshua Kim, Priya Spencer, Laura Sansoterra, Kelly Levasseur, Amy M DeLaroche.
       OBJECTIVES: To examine sociodemographic and clinical factors associated with social work consultation and child protective services (CPS) referrals among children presenting to the pediatric emergency department (ED) after an accidental toxicological ingestion.
    METHODS: This retrospective study included children ≤5 years of age presenting to the ED between January 1, 2021, and December 31, 2023, with a diagnostic code for poisonings. Demographic and clinical variables were recorded, and clinical severity was quantified using 2 complementary scores. Predictor variables include race, ethnicity, language, insurance, serum drug screen and urine drug screen (UDS) results, prior CPS involvement, clinical severity on presentation, and critical interventions. The primary outcome was social work involvement, while the secondary outcome was a CPS referral. Unadjusted odds ratios (OR) with 95% CI were calculated.
    RESULTS: Among 569 patients, social work was involved in 26.5% (n=151) of cases, and CPS was contacted for 17.8% (n=101). Children who were Black (OR: 2.08, 95% CI: 1.38-3.13, P=0.0005), had public insurance (OR: 2.87, 95% CI: 1.59-5.22, P=0.0003), a positive UDS (OR: 17.79, 95% CI: 7.49-42.22, P<0.0001), or critical/fatal clinical severity (OR: 24.92, 95% CI: 9.55-65.05, P<0.0001) were more likely to have social work consultation. These children were also more likely to have a CPS referral.
    CONCLUSIONS: Race, insurance status, a positive UDS, and clinical severity were associated with social work consultation and CPS referrals among young children presenting to the ED following an accidental ingestion. Evidence-based referral guidelines are needed to promote consistent and equitable decision-making.
    Keywords:  child protective services; disparities; emergency medicine; marijuana; pediatric accidental ingestion; poisonings; social work; unintentional ingestion
    DOI:  https://doi.org/10.1097/PEC.0000000000003712
  11. Pediatr Qual Saf. 2026 Sep-Oct;11(5):11(5): e932
    Increasing Rates of Health-related Social Needs Screening in a Pediatric Critical Care Setting Through Quality Improvement.
    Hemen Muleta, Camilo Pardo, Amanda Klafter, Susan Velasco, Renee Whiskey-LaLanne, Henry M Ushay, Patricia Hametz, Kevin P Fiori, Gina Cassel-Choudhury.
       Introduction: Prior research has linked health-related social needs (HRSNs) with poor pediatric health outcomes. Studies have demonstrated the implementation of HRSN screening in lower-acuity settings, but few have been conducted in pediatric intensive care units (PICUs). Our primary aim was to increase HRSN screening from 4% to 75% between February 2024 and May 2025. Our secondary aim was to increase referral rates for community health workers (CHW) from 0% to 75% for those with unmet HRSNs.
    Methods: A multidisciplinary team used quality improvement (QI) methodology to implement interventions in a 26-bed PICU at an urban, tertiary-care children's hospital. The study included all patients admitted to the PICU. We implemented six interventions over multiple plan-do-study-act cycles to optimize screening and CHW resource navigation workflow.
    Results: Data collection included sociodemographic characteristics and monthly HRSN screening completion, positive screens, and CHW referral rates. During our intervention period, there were 1,256 direct admits to the PICU. By the end of the study period, an average of 76% of patients had a completed HRSN screen, just over our anticipated goal. The mean HRSN screening increased from a baseline of 17.9% to 76.5. Among screened patients, 27.7% reported ≥1 unmet HRSN, with a mean CHW referral rate of 64%.
    Conclusions: A multidisciplinary team approach and use of QI methodology led to an increase in monthly HRSN screenings in our PICU. Next steps will focus on increasing CHW referral rates and connecting patients with resources for unmet HRSNs.
    DOI:  https://doi.org/10.1097/pq9.0000000000000932
  12. J Emerg Med. 2026 Sep 01. pii: S0736-4679(26)00257-X. [Epub ahead of print]90 46-60
    Pediatric Patellar Injuries.
    Victor N Oboli, Chibuike D Onyejesi, Corinna Franklin, Lawrence Siew.
       BACKGROUND: Pediatric patellar injuries are common causes of anterior knee pain in children and adolescents and are frequently encountered in emergency and acute care settings. These conditions range from load-related overuse syndromes to acute traumatic injuries requiring timely recognition and referral. Unique features of the skeletally immature knee, including evolving ossification centers, open physes, and cartilaginous structures, may complicate diagnosis and contribute to missed or delayed recognition.
    OBJECTIVE: This review provides an evidence-informed, emergency medicine-oriented approach to the evaluation and management of pediatric patellar injuries, with emphasis on key history and examination findings, imaging selection, initial treatment, and indications for orthopedic referral.
    DISCUSSION: Pediatric patellar conditions include patellofemoral pain syndrome, patellar subluxation and dislocation, prepatellar bursitis, patellar tendinopathy, Sinding-Larsen-Johansson syndrome, chondromalacia patellae, and patellar fractures. Most load-related conditions are diagnosed clinically and managed nonoperatively with symptom control, activity modification, and rehabilitation. In contrast, acute patellar dislocation and fractures require careful assessment for osteochondral injury, loose bodies, and extensor mechanism disruption. Radiographs are the first-line imaging study for traumatic presentations; magnetic resonance imaging or ultrasonography may be necessary when clinically important cartilaginous, osteochondral, or extensor mechanism injury is suspected despite nondiagnostic radiographs. Computed tomography (CT) has a selective role when detailed characterization of an osseous or osteochondral fragment would alter management.
    CONCLUSION: A systematic approach to pediatric anterior knee pain can help emergency clinicians distinguish low-risk load-related syndromes from injuries requiring immobilization, advanced imaging, or urgent orthopedic consultation. Attention to mechanism of injury, effusion, focal tenderness, patellar instability, and active knee extension is central to appropriate diagnosis and disposition.
    Keywords:  anterior knee pain; emergency medicine; patellar dislocation; patellar fracture; patellofemoral pain syndrome; pediatric emergency medicine; pediatrics; sleeve fracture
    DOI:  https://doi.org/10.1016/j.jemermed.2026.08.034
  13. Acad Pediatr. 2026 Sep 22. pii: S1876-2859(26)00237-8. [Epub ahead of print] 103455
    Decreasing Ambulatory Antibiotic Treatment Duration for Acute Otitis Media and Community-Acquired Pneumonia.
    Elysha L Pifko, Andrea Rivera-Sepulveda, Jonathan M Miller, Eddie Geagea, Magdy W Attia, Neil Rellosa, Scott O'Connor, Paul Simons, Tara Rao, Arianna Phillips, Arezoo Zomorrodi.
       BACKGROUND AND OBJECTIVE: Despite evidence supporting short treatment duration for acute otitis media and community-acquired pneumonia, many patients receive longer courses. The aim was to increase the proportion of short duration antibiotic therapy from 40% to 80% within 9 months in primary care, emergency department, and urgent care settings spanning three states.
    METHODS: This quality improvement initiative was conducted from June 2022 to March 2025. Interventions were implemented through seven plan-do-study-act cycles, including creation of a clinical pathway and electronic health record tools with subsequent enhancements, education, organizational support via physician incentivization and alignment with organizational goals, data sharing, gemba walks, and positive reinforcement. Change in the outcome (percentage of encounters receiving short duration therapy and the mean duration of therapy), process (percentage of encounters utilizing order panels) and balancing (treatment failure) measures over time were analyzed using statistical process control charts.
    RESULTS: 51,056 patients were included, with 18,040 patients in the baseline and 33,016 in the implementation phase. Short duration antibiotic therapy increased from 40% to 88% and improved across all race, ethnicity, and child opportunity indices (p<0.001). Minimal baseline disparities were further attenuated. Mean antibiotic duration decreased from 8 to 5.9 days, saving 42,141 cumulative antibiotic days. Treatment failure remained unchanged (5%, range 2.5%-7.8%).
    CONCLUSION: Quality improvement methodology led to system-wide decrease in antibiotic duration across demographics in two common pediatric diagnoses. Aligning with organizational goals and data sharing proved to be effective strategies to promote large-scale practice change.
    CLINICAL TRIAL REGISTRATION: N/A.
    Keywords:  acute otitis media; community-acquired pneumonia; quality improvement
    DOI:  https://doi.org/10.1016/j.acap.2026.103455
  14. Hosp Pediatr. 2026 Sep 24. pii: e2026009661. [Epub ahead of print]
    Trends in Regionalization of Pediatric Inpatient and Critical Care by Medical Complexity.
    Allan M Joseph, Manzilat Y Akande, Nadine Straka, Elizabeth C Lendrum, Robert J Graham, Elizabeth Y Killien, Mary E Hartman, Matthew Keller, Karen Segar, Julia A Heneghan.
       BACKGROUND AND OBJECTIVES: Pediatric inpatient and critical care services are increasingly regionalizing: shifting from smaller hospitals to larger specialty centers. Children with medical complexity (CMC) and with technology dependence (TD) account for a disproportionate share of these services, but it is unknown whether regionalization has evolved differently for these groups compared with children without medical complexity.
    METHODS: We conducted a retrospective cohort study of all pediatric inpatient and non-cardiac/neonatal intensive care unit encounters in 6 states from 2001 to 2022. We calculated the proportion of hospitals providing these services, the distribution of encounters across hospital types, the distance traveled for admission, and the concentration of encounters among hospitals.
    RESULTS: We identified 1 427 565 hospitalizations, of which 210 398 involved critical care. Over time, fewer hospitals provided pediatric inpatient or critical care, and encounters became more concentrated in specialty hospitals. Median travel distance for inpatient care rose from 4.9 miles in 2001 to 8.3 miles in 2022 (an increase of 69.4%), with CMC and children with TD traveling farthest in all years. Critical care travel distances were generally stable over time. Concentration of encounters for children without medical complexity increased more rapidly than for CMC and children with TD.
    CONCLUSIONS: Between 2001 and 2022, regionalization most affected care for noncritical care inpatient encounters and for children without medical complexity. Care patterns for children without complexity converged with those for CMC and children with TD. These trends have important implications for family travel burden and efforts to maintain pediatric readiness outside of specialty centers.
    DOI:  https://doi.org/10.1542/hpeds.2026-009661
  15. Pediatr Emerg Med Pract. 2026 Oct;23(10): 1-28
    Approach to pediatric patients with elbow injuries in the emergency department.
    Chad McCalla, Crick Watkins, Nicole J Prendergast, Adam B Johnson.
      Pediatric elbow injuries are a common complaint presenting to emergency departments. The unique anatomy and skeletal immaturity in children can make the elbow particularly difficult to evaluate and manage. Additionally, many healthcare institutions have limited or no access to pediatric orthopedic specialists, leaving management decisions to the clinician at the bedside. This review highlights the nuances of the pediatric elbow examination, addressing both acute and subacute (overuse) injuries. Common fracture types are reviewed, and key principles of x-ray interpretation are demonstrated, including recognition of normal variants and ossification centers. Management strategies are outlined, with an emphasis on identifying which patients can be safely managed without orthopedic consultation and which require more urgent care at a pediatric center with access to pediatric orthopedic specialists.
  16. Cureus. 2026 Aug;18(8): e115107
    A Scoping Review of Risk Factors for Thunderstorm Asthma in Pediatric Patients.
    Suraya Foster, Nora Antova, Adam Usher.
      Thunderstorm weather conditions are known to trigger asthma-like symptoms in susceptible patients, causing spikes in the use of paramedical, primary care, and hospital services. While risk factors for thunderstorm asthma (TSA) in adults have been studied in both original research and systematic reviews, there has been less focus on the risk profile of pediatric patients. With epidemic TSA (ETSA) events predicted to increase in frequency and severity as climate change progresses, it is more crucial than ever to identify those children most at risk so that appropriate public health education, parent and family education, and conservative management can be initiated. This scoping review followed the PRISMA-ScR checklist. We searched Embase, Ovid MEDLINE, and Scopus for primary research that assessed risk factors or strong predictive associations for TSA in patient cohorts that included children. A total of 39 studies met our inclusion criteria; of these, just five focused exclusively on pediatric populations. We found that ETSA events may trigger a first-time asthma presentation in a large proportion of pediatric patients, especially those with atopic conditions such as allergic rhinitis or eczema. In some studies that included both children and adults, younger age groups were among those most affected by TSA; however, analysis was not routinely age-stratified. These findings highlight a critical gap in the literature, limiting the ability to define a pediatric-specific risk profile. Further research is needed to inform targeted prevention strategies, clinical management, and public health preparedness.
    Keywords:  climate change; pediatrics; public health; risk factors; thunderstorm asthma
    DOI:  https://doi.org/10.7759/cureus.115107
  17. Pediatr Emerg Care. 2026 Sep 25.
    Access to Care as Predictors of Emergency Department Utilization: A Cross-Sectional National Study.
    Catherine G Coughlin, Michael C Monuteaux, Rebekah Mannix.
       OBJECTIVE: To examine the association between caregiver-reported access to care and children's emergency department (ED) utilization using the 2023 National Survey of Children's Health (NSCH).
    METHODS: We conducted a cross-sectional study using the 2023 NSCH. Access-to-care measures included having a personal doctor or nurse, a usual place for sick care, difficulty seeing specialists, caregiver frustration obtaining services, presence of a medical home, receipt of family-centered care, effective care coordination, and care in a well-functioning system. The primary outcome was number of ED visits in 1 year. Multivariable Poisson regression models were estimated for each access measure, adjusted for child age, race and ethnicity, sex, insurance type, poverty level, household language, and presence of special health care needs.
    RESULTS: The sample included 55,162 participants representing 72 million US children. ED visits were higher among American Indian or Alaska Native; Black, non-Hispanic; and Hispanic children compared with White children, and among those with public insurance, lower income, or special health care needs. Among access-to-care measures, the strongest associations were seen for unmet care-coordination needs: children requiring care coordination had roughly double the rate of ED visits compared with those who did not. Increased ED use was also associated with caregiver frustration obtaining services, lack of a medical home, and fragmented systems of care.
    CONCLUSIONS: Caregiver-reported barriers to coordinated, family-centered care are strongly associated with higher pediatric ED utilization.
    Keywords:  access to care; care coordination; emergency department
    DOI:  https://doi.org/10.1097/PEC.0000000000003704
  18. Acad Pediatr. 2026 Sep 22. pii: S1876-2859(26)00235-4. [Epub ahead of print] 103453
    Launching Pediatric Primary Care-Based PrEP for Adolescents in a Low HIV Prevalence Setting.
    Claudia P Vicetti Miguel, Lia Mojica, Charlotte Formeller, Margaret Thew, Kevin Hartz, Wendi Ehrman.
       OBJECTIVE: The objective of this Quality Improvement (QI) initiative was to increase the provision of HIV pre-exposure prophylaxis (PrEP) care in pediatric primary care clinics, among adolescents at risk for HIV.
    METHODS: We conducted a qualitive improvement initiative in 22 pediatric primary care clinics in southeast Wisconsin. After identifying barriers via provider survey, we implemented a multicomponent intervention bundle in 2023, including PrEP clinical guidance, provider education, long-acting injectable PrEP availability, best practice alerts and infectious disease electronic consultation for all PrEP-eligible adolescents. For the primary outcome we utilized PrEP prescription rates among adolescents diagnosed with a bacterial sexually transmitted infection (STI) from 2021-2025 as this was the only reliable risk factor trackable in the electronic medical record, using a statistical process control chart.
    RESULTS: Among surveyed pediatric primary care providers, 93% had never prescribed PrEP, with lack of awareness and discomfort being major barriers; a targeted educational intervention significantly increased provider comfort discussing and offering PrEP (from 36% to 100%, p<0.01). Following implementation of a multicomponent QI bundle, PrEP initiation among adolescents with a bacterial STI rose from <1% to 5%. 96% of patients who started PrEP received guideline-concordant care. Injectable cabotegravir was selected by 43% of new PrEP users, and most care remained within primary care.
    CONCLUSION: This QI initiative successfully launched adolescent PrEP care in primary care through provider education, clinical guidance, and multidisciplinary support, demonstrating feasibility of improving HIV prevention even in low prevalence settings.
    Keywords:  HIV; Quality improvement; STI; pre-exposure prophylaxis
    DOI:  https://doi.org/10.1016/j.acap.2026.103453
  19. J Am Coll Surg. 2026 Sep 21.
    Promoting Optimal Pediatric Readiness at US Trauma Centers: Understanding and Addressing Barriers.
    Jill Knepprath, Ashley Stoeckel, Megan Chiu, Bhavin Patel, Brian Yorkgitis, Aaron Jensen, Michael Dingeldein.
      Children treated at facilities prepared to provide emergency pediatric care have improved outcomes, but access to pediatric-ready care remains inconsistent. A multidisciplinary spotlight session at the 2026 American College of Surgeons Committee on Trauma Annual Meeting examined barriers to pediatric readiness across US trauma systems and practical strategies to address them. Participants identified limited dedicated personnel, financial and equipment constraints, fragmented regional coordination, inconsistent requirements, and barriers to completing and acting on pediatric readiness assessments, particularly among rural, resource-limited, and non-verified facilities. Proposed strategies emphasized regional shared accountability, including engagement of higher-level trauma centers and regional pediatric emergency care coordinators to support smaller facilities, targeted outreach through existing trauma networks, shared or rotated resources, improved access to guidelines and tools, and local champions to facilitate readiness assessments. Although these recommendations reflect expert opinion from a single, self-selected multidisciplinary session rather than formal consensus, they provide a practical framework for translating national pediatric readiness standards into regional action. Improving pediatric readiness will require collaboration across trauma centers regardless of level or verification status, with shared responsibility for ensuring that every facility caring for injured children can provide appropriate initial stabilization and emergency care.
    Keywords:  Pediatric readiness; pediatric trauma
    DOI:  https://doi.org/10.1097/XCS.0000000000002213
  20. Children (Basel). 2026 Sep 11. pii: 1229. [Epub ahead of print]13(9):
    The Unique Features of Pediatric Sports Injuries: The Hip.
    Leah Henry, Karli Funk, Yi-Meng Yen, Joshua Abzug.
      Sports-related injuries of the hip and groin have demonstrated increasing prevalence in pediatric and adolescent athletes. Pediatric injuries require specific consideration of unique factors such as skeletal maturity, apophyseal vulnerability, physeal closure status, and growth-related changes in injury pattern. These injuries include a variety of conditions, including apophyseal injuries, hip dislocations, coxa saltans (snapping hip), femoroacetabular impingement syndrome (FAIS), and stress fractures. Injuries such as hip dislocation and high-risk femoral neck stress fracture require urgent diagnosis and management; however, timely diagnosis and appropriate management is necessary for all pediatric hip injuries to prevent delays in return to sport and long-term complications. The literature synthesized in this narrative review includes randomized controlled trials, systematic reviews, prospective and retrospective studies, and consensus statements to provide a summary of each injury. An overview of pediatric sports injuries of the hip, with emphasis on the epidemiology, presentation, diagnosis, management, and complications, is presented.
    Keywords:  adolescents; femoroacetabular impingement syndrome; hip; lower extremity; orthopaedics; overuse injuries; pediatrics; sports injuries; stress fractures
    DOI:  https://doi.org/10.3390/children13091229
  21. Pediatr Qual Saf. 2026 Sep-Oct;11(5):11(5): e909
    Decreasing Prescriber Errors in a Tertiary Care Pediatric Intensive Care Unit via QI Methodology.
    Timothy Brandt, Dhara D Shah, Gina Cassel-Choudhury.
       Introduction: Medication errors are a significant source of preventable adverse drug events for pediatric patients, particularly those with a complex chronic condition (CCC). In our pediatric intensive care unit (PICU), medication errors often occurred during admission or as medication regimens were adjusted throughout hospitalization. Our primary aim was to reduce the rate of reported prescriber medication errors per 1,000 medication orders by 40% between August 2022 and June 2024.
    Methods: Key drivers contributing to prescriber medication errors included the lack of a standardized medication reconciliation process, high-risk medications unintentionally expiring, and the difficulty of reconciling the home medication list for patients with a CCC. Five plan-do-study-act interventions were completed. A retrospective chart review was used for all baseline data. The primary outcome was the rate of reported monthly prescriber medication errors per 1,000 medication orders placed. This project took place in a 26-bed PICU within an urban, tertiary care children's hospital.
    Results: The rate of reported prescriber medication errors remained stable throughout the intervention period without evidence of special cause variation. However, admission medication reconciliation errors among children with CCCs decreased by a mean of 43% over time, with a downward centerline shift.
    Conclusions: A multidisciplinary quality improvement approach was associated with improvement in medication reconciliation processes for children with CCCs. Pharmacy-supported medication reconciliation and standardized workflows were associated with fewer admission medication reconciliation errors in this high-risk population.
    DOI:  https://doi.org/10.1097/pq9.0000000000000909
  22. Pediatr Qual Saf. 2026 Sep-Oct;11(5):11(5): e922
    Impact on Health Disparities: Secondary Analysis of an Unplanned Extubation Quality Improvement Study.
    Gayathri Sreenivasan, Parvathy Krishnan, Lance A Parton, Meenakshi Singh.
       Introduction: Quality improvement (QI) initiatives have reduced unplanned extubation (UE) rates in neonatal intensive care units, but few studies have examined the equity of these improvements. An explicit equity focus in QI can reveal disparities that may otherwise remain unrecognized. This secondary analysis of a previously published UE prevention QI initiative aimed to identify baseline disparities in UE rates and determine whether these disparities narrowed following the implementation of a standardized best-practice bundle (BPB).
    Methods: We reviewed 6 months of preintervention medical record data and stratified UE rates by race/ethnicity, preferred primary language, and socioeconomic status (insurance as a proxy). Using the Model for Improvement, the QI team implemented the BPB components sequentially and uniformly across the neonatal intensive care unit. Data collection continued throughout implementation. Statistical process control (U) charts were used to examine baseline disparities and assess changes over time.
    Results: At baseline, non-Hispanic Black infants, patients from English-speaking families, and Medicaid-insured patients had higher UE rates. Following the implementation of the BPB, UE rates decreased across all subgroups. Control charts showed special-cause variation beginning in December 2022. Differences in UE rates across racial/ethnic, language, and socioeconomic groups narrowed.
    Conclusions: UE rates were higher among racial minority and lower socioeconomic status populations at baseline. A standardized QI approach was associated with lower UE rates across all subgroups and reduced baseline disparities.
    DOI:  https://doi.org/10.1097/pq9.0000000000000922
  23. Ann Pediatr Endocrinol Metab. 2026 Sep 18.
    Are intensive care settings essential in the management of diabetic ketoacidosis in children?
    Fatma Akgul, Emel Ulusoy, An Er, Fikriye Baki, Tar K, İlker Günay, Behzat Özkan, Hurşit Apa.
       Purpose: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes in children and is frequently managed in pediatric intensive care units (PICUs). This study aimed to evaluate the feasibility and safety of managing DKA in the pediatric emergency department (PED).
    Methods: A retrospective analysis was conducted of pediatric patients presenting with DKA between 2017 and 2024 at a tertiary care hospital. Patients were categorized according to DKA severity and evaluated for demographic characteristics, risk factors, clinical findings, laboratory parameters, complications, and outcomes. All patients were managed using a standardized institutional treatment protocol. Clinical characteristics of patients admitted to the PICU were compared with those managed in the PED.
    Results: A total of 169 patients were included (mean age, 10.3 ± 4.4 years). Most patients were managed in the PED until resolution of DKA (95.3%). Moderate and severe DKA accounted for 71% of cases. Complications occurred in 27 patients (15.9%). Although tachycardia, respiratory abnormalities, decreased Glasgow Coma Scale scores (≤14), and electrolyte abnormalities were more frequent among patients admitted to the PICU, most patients with these findings were successfully managed in the PED. Patients requiring PICU admission had significantly lower pH levels, lower bicarbonate concentrations, more frequent neurologic impairment, and a higher rate of electrolyte abnormalities.
    Conclusion: Most pediatric patients with DKA can be safely managed outside the PICU when standardized protocols and close clinical monitoring are implemented. A selective PICU admission strategy based on clinical indicators of deterioration may therefore help optimize the use of limited intensive care resources while maintaining patient safety.
    Keywords:  Child; Diabetes mellitus; Diabetic ketoacidosis; Emergency treatment
    DOI:  https://doi.org/10.6065/apem.2652036.018
  24. Children (Basel). 2026 Sep 02. pii: 1184. [Epub ahead of print]13(9):
    Talk to Me, Not Just My Parent: Teen and Caregiver Perspectives on Implementing Screening, Brief Intervention, and Referral to Treatment Equitably in Pediatric Inpatient Settings for Teens with Chronic Illness.
    Faith Summersett Williams, Sarah Welch, Ella Kuffour, Emily Lynott, Sheridan Grettenberger, Kennedy Curtis, Yiyang Liu, Ruth Debono, Maria H Rahmandar, Sara Becker.
      Background/Objectives: While screening, brief intervention, and referral to treatment (SBIRT) is a widely recommended evidence-based approach for early detection and intervention for alcohol and other drug (AOD) use, limited guidance exists for implementing SBIRT among hospitalized adolescents with chronic medical conditions (A-CMCs). This exploratory qualitative study examined A-CMC and caregiver perspectives on factors that may shape the acceptability, feasibility, and equitable implementation of a proposed inpatient SBIRT approach for A-CMCs. Methods: Two separate focus groups were conducted in an urban pediatric hospital in 2023 with A-CMCs aged 13-18 (n = 7), who had a history of hospitalization for their medical condition, and their caregivers (n = 6). Data were coded using thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR) and the Health Equity Implementation Framework (HEIF), which captured implementation and equity-relevant determinants, respectively. Results: Although A-CMCs and caregivers recognized the importance of SBIRT within hospital settings, its acceptability hinged on the conditions of its delivery. The timing, relevance to current health needs, and modality of screening shaped an A-CMC's willingness to disclose AOD use. Clinician communication style, including the use of a nonjudgmental tone and clear parameters for confidentiality, were also indicated as crucial for SBIRT delivery. Broadly, participants noted the significant impact that the sociopolitical context (e.g., stigma) and structural factors (e.g., financial burden) had on a family's ability to benefit from SBIRT. Conclusions: In this exploratory qualitative study, participants identified confidentiality-forward, patient-centered workflows, and accessible follow-up supports as potentially important considerations for inpatient SBIRT among A-CMCs. These findings generate hypotheses for future co-design and implementation research across diverse pediatric inpatient settings.
    Keywords:  SBIRT; adolescents with chronic medical conditions; alcohol and other drug use; caregivers; inpatient hospitalization; pediatric hospitals
    DOI:  https://doi.org/10.3390/children13091184
  25. J Palliat Med. 2026 Sep 20. 10966218261486531
    Distress Screening and Pediatric Palliative Care Referral: A Retrospective Case-Control Study in Supportive Cancer Care Delivery.
    Jonathan Ebelhar, Katherine Yeager, Jordan Gilleland-Marchak, Dio Kavalieratos, Zhulin He, Rebecca Williamson Lewis, Katharine E Brock.
       BACKGROUND/OBJECTIVES: Pediatric palliative care (PPC) reduces distressing symptoms and improves quality of life for children with cancer and their caregivers. This study assesses whether patient and caregiver distress is associated with PPC referral. Utilizing screening tools to identify families experiencing high distress could lead to earlier access to PPC.
    METHODS: A retrospective case-control study compared children with cancer referred to a PPC clinic at a large pediatric cancer center in the United States from 2019 to 2021 to a matched sample of nonreferred patients. Distress scores and emotional, practical, family/social, and spiritual concerns were routinely measured for patients and caregivers using the Pediatric Distress Thermometer (Peds DT). Conditional logistic regression was utilized to assess the association between PPC referral and (1) high Peds DT scores and (2) Peds DT domains. Van Elteren test was used to compare overall Peds DT scores between the cohorts.
    RESULTS: PPC-referred patients (n = 135) were matched to 257 nonreferred patients. Patients ever reporting high distress had higher odds of PPC referral (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.05-3.39). Median Peds DT scores did not differ for patients (1.36 vs. 1.44; p = 0.29) or caregivers (2.52 vs. 2.48; p = 0.30). Caregivers reporting family/social concerns had lower odds of PPC referral (OR 0.56, 95% CI 0.33-0.97).
    CONCLUSION: Patients reporting high distress had higher odds of PPC referral. Caregiver DT scores were not associated with PPC referral. High patient distress scores could serve as a screening criterion for PPC referral. Further research could evaluate the impact PPC has on patient and caregiver distress.
    Keywords:  childhood cancer; distress thermometer; outpatient care; pediatric oncology; pediatric palliative care
    DOI:  https://doi.org/10.1177/10966218261486531
  26. Ann Emerg Med. 2026 Sep 24. pii: S0196-0644(26)00478-6. [Epub ahead of print]
    Patient and Clinical Characteristics Associated With Subsequent Suicide Attempt Among Youth in the Emergency Department With a Positive Suicide Risk Screen.
    Ashley A Foster, Jennifer A Hoffmann, Newton Addo, David Brent, Jeffrey A Bridge, T Charles Casper, Lisa M Horowitz, Cheryl A King, Jacqueline Grupp-Phelan.
       STUDY OBJECTIVE: To evaluate sociodemographic and clinical characteristics associated with a subsequent suicide attempt among youth with a positive suicide risk screen in the emergency department (ED).
    METHODS: This secondary data analysis used the 2015 to 2019 Pediatric Emergency Care Applied Research Network ED Screen for Teens at Risk for Suicide data set, a prospective cohort of adolescents aged 12 to 17 years in the ED. Adolescents with positive Ask Suicide-Screening Questions, a validated suicide risk screen, were included. Multivariable regression models assessed sociodemographic and clinical characteristics associated with suicide attempt, and mental health-related ED revisit/hospitalization, within 3 months after index ED visit.
    RESULTS: Among 2,085 adolescents with a positive Ask Suicide-Screening Questions (40.7% age 14 to 15 years; 65.5% female, 49.0% Non-Hispanic White), 11.6% attempted suicide and 19.9% had an ED revisit/hospitalization within 3 months. Risk factors of suicide attempt included suicide attempt in the past month (adjusted odds ratio [aOR] 2.52, 95% confidence interval [CI] 1.84 to 3.45), prior mental health hospitalization (aOR 1.39, 95% CI 1.02 to 1.90), past nonsuicidal self-injury (aOR 2.06, 95% CI 1.41 to 3.01), and hopelessness (aOR 1.30, 95% CI 1.04 to 1.63). Risk factors of ED revisit/hospitalization within 3 months included prior mental health hospitalization (aOR 2.23, 95% CI 1.74 to 2.84), suicide attempt in the past month (aOR 1.63, 95% CI 1.24 to 2.14), and hopelessness (aOR 1.44, 95% CI 1.21 to 1.72).
    CONCLUSION: Among youth with positive suicide risk screens in the ED, multiple sociodemographic and clinical factors were associated with subsequent suicide attempt and mental health-related ED revisits/hospitalizations. Following a positive suicide risk screen, these factors may be important for consideration when assessing risk and determining next steps in care.
    Keywords:  Mental health; Suicide attempt; Suicide prevention; Suicide screening
    DOI:  https://doi.org/10.1016/j.annemergmed.2026.07.011
  27. Children (Basel). 2026 Sep 20. pii: 1277. [Epub ahead of print]13(9):
    Medical Diagnosis, ED Visits, and Hospitalizations for Substance Use in U.S. Children's Hospitals: A Retrospective Multi-Center Cohort Study.
    Faith Summersett Williams, Isabella Zaniletti, Sharon Levy, Hayley Centola, Natalie Larez, Colleen Stiles-Shields, Ashley Dominguez, Sarah Sauerteig, Maria H Rahmandar, Robert Garofalo, Lisa M Kuhns.
       BACKGROUND/OBJECTIVES: Adolescents with chronic medical conditions (A-CMCs) are at increased risk for alcohol and other drug (AOD) use and adverse health outcomes. However, little is known about patterns of AOD-related emergency department (ED) visits and hospitalization among A-CMCs. This study investigates ED patterns and associations between AOD use, chronic medical complexity, and race-ethnicity with hospitalization following ED visits. AOD use was categorized into three groups: mainstream substances (e.g., cannabis), illicit/other psychoactive substances (e.g., opioids), and no documented AOD diagnosis. A-CMCs were divided into two groups: chronic conditions (CC) or complex chronic conditions (CCC).
    METHODS: A retrospective cohort of ED encounters among A-CMCs was analyzed. Data were derived from 45 U.S. children's hospitals participating in the Pediatric Health Information System from 2021 to 2023. Associations were examined using logistic regression, adjusting for covariates.
    RESULTS: The cohort included 1,098,496 ED visits among A-CMCs (encounter-level counts, which may include repeat visits by the same A-CMC); 72.9% of encounters involved adolescents with CCs (27.1% with CCCs).4.2% of those visits were AOD-related, with most involving mainstream substances in CCs and CCCs groups (78.0% and 76.3%, respectively; p = 0.002). Compared with encounters with no documented AOD diagnosis, AOD-related ED encounters were associated with significantly higher adjusted odds of hospitalization for both mainstream substances (aOR 2.8, 95% CI 2.68-2.94 for CC; aOR 3.7, 95% CI 3.19-4.28 for CCC) and illicit/other psychoactive substances (aOR 2.2, 95% CI 2.03-2.4 for CC; aOR 3.18, 95% CI 2.47-4.09 for CCC; all p < 0.001)There were significant interactions between AOD use type and race/ethnicity within each A-CMC subgroup (p = 0.002), indicating differing patterns of hospitalization across groups.
    DISCUSSION/CONCLUSIONS: Among A-CMCs, AOD-related ED visits-involving either mainstream or illicit/other psychoactive substances-were associated with increased adjusted odds of hospitalization relative to visits with no documented AOD diagnosis, with mainstream substances accounting for the majority of AOD-related encounters overall. Racial-ethnic differences in hospitalization were observed and may reflect a range of clinical and contextual factors not measured in this study, underscoring the need for standardized AOD screening and evaluation in pediatric settings.
    Keywords:  adolescents; chronic disease; emergency department; hospitalizations; substance use
    DOI:  https://doi.org/10.3390/children13091277
  28. R I Med J (2013). 2026 Oct 01. 109(10): 47-49
    Screening for Celiac Disease in Children: Practical Guidance for Primary Care Providers.
    Prerana Baranwal.
      Celiac disease is prevalent in the pediatric population. However, screening for celiac disease can be confusing given the variety of tests available and current guidelines are not always widely known in the medical community. As most children with celiac disease will initially present to their primary care providers (PCPs), PCPs play an integral role in identifying patients at risk for celiac disease. This review provides practical guidance for PCPs screening pediatric patients for celiac disease.
    Keywords:  Celiac disease; gastroenterology; gluten; pediatrics; screening
  29. J Hosp Med. 2026 Sep 22.
    Racial and ethnic differences in hospital-based low-value pediatric care.
    Elisha McCoy, Megan E Collins, Jillian M Cotter, Natalie Grills, Matt Hall, Jessica Markham, Matthew J Molloy, Michelle Polich, Michael J Steiner, John R Stephens, Michael J Tchou, Ronald Teufel, Irma Ugalde, Andrew Yu, Samantha A House.
       BACKGROUND: Low-value care (LVC), or care in which potential risk outweighs perceived benefits, continues to impact pediatric populations. While pediatric healthcare delivery is known to vary across racial and ethnic groups, little is known about the relationship between race and ethnicity and LVC. We sought to evaluate this relationship among hospitalized children.
    METHODS: This cross-sectional study applied the Pediatric Health Information System LVC Calculator to encounters from July 1, 2022 to June 30, 2024. We used generalized estimating equation models to analyze differences in LVC across seven groups (Non-Hispanic White, Non-Hispanic Black, Hispanic, Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and Other or Multiracial). For measures with across-group differences, we performed pairwise comparisons to assess differential odds of LVC receipt with the Non-Hispanic White group as a referent. We then performed a subanalysis applying these methods to only the largest groups.
    RESULTS: Of 14 eligible measures, LVC varied across racial and ethnic groups for seven. Patterns varied by measure, with no group demonstrating consistently high or low LVC. Measures with the greatest variation across groups included head computed tomography for first seizure, concurrent use of antipsychotics, and broad-spectrum antibiotics for uncomplicated community-acquired pneumonia. Our subanalysis demonstrated similar findings, with across-group differences noted for eight measures.
    CONCLUSIONS: We identified differences in LVC receipt by race and ethnicity for some services among hospitalized patients, without consistency in patterns across measures. Further evaluation of drivers and outcomes associated with these patterns is needed; our findings may assist in prioritizing deimplementation efforts.
    DOI:  https://doi.org/10.1002/jhm.70486
  30. Semin Perinatol. 2026 Sep 19. pii: S0146-0005(26)00096-0. [Epub ahead of print] 152307
    Emergency management of extreme hyperbilirubinemia.
    Daniele De Luca, Roberta Centorrino.
      Extreme hyperbilirubinemia is rare and considered a medical emergency. The American Academy of Pediatrics (AAP) recommends shortening any delay in the diagnosis and treatment of these cases. However, the critical care monitoring and management of these cases have not been described in detail. This may contribute to significant treatment delays (e.g., failure to recognize signs of bilirubin neurotoxicity or provide an efficient vascular access). Here, we offer guidance to provide accurate monitoring to recognize bilirubin neurotoxicity and prompt interventions by using modern techniques such as amplitude-integrated electroencephalography (aEEG) and point-of-care ultrasound to guide vascular access. We also review the literature regarding exchange-transfusions (EXT) in light of recently accumulated evidence and offer a classification of EXT based on the involved vessels, the type of catheter, and techniques, describing their advantages and disadvantages.
    Keywords:  Critical care; Exchange transfusion; Jaundice; Monitoring; NICU; Neonate
    DOI:  https://doi.org/10.1016/j.semperi.2026.152307
  31. Acad Pediatr. 2026 Sep 23. pii: S1876-2859(26)00242-1. [Epub ahead of print] 103460
    Caregiver-Perceived Appropriateness of Discussing Firearm Storage in the Healthcare Setting.
    Erica K Sheline, Rachel L Johnson, Erin Wright-Kelly, Maya Haasz.
       OBJECTIVE: Firearms are the leading cause of death for children in the US - secure storage decreases morbidity and mortality. Though effective at improving storage, healthcare providers (HCPs) seldom discuss secure storage, partly due to concern that it will damage the caregiver-provider relationship. We sought to1) Describe caregiver-perceived appropriateness of HCP firearm storage counseling, and 2) Identify variables associated with perceived appropriateness.
    METHODS: This cross-sectional study used data from the 2025 Colorado Firearm Injury Prevention Survey (COFIPS), administered online in English and Spanish by Ipsos (June-July 2025). Adults with children <18 years old living, visiting, or staying in their home were eligible (herein caregivers). The primary outcome, perceived appropriateness of HCP discussing firearm storage, was dichotomized as "at least sometimes" versus "never" appropriate; responses of "unsure" were excluded. Weighted logistic regression models examined associations between perceived appropriateness and prior HCP firearm counseling, firearm access, storage practices, and beliefs. Poststratification weights were applied to produce state-representative estimates.
    RESULTS: Of 627 caregivers, 586 were included in the analysis. Overall, 82.7% (95% CI: 79.3-85.6%) reported discussions were at least sometimes appropriate. Prior firearm counseling during a healthcare visit was strongly associated with perceived appropriateness (OR 7.34, 95% CI: 2.73-19.74). Among caregivers reporting an unlocked and loaded firearm in the home (least secure storage), 72.5% found these discussions appropriate.
    CONCLUSIONS: Most caregivers were receptive to HCP firearm storage counseling. Prior counseling was associated with increased receptivity, highlighting the benefit of repeated messaging. HCPs should consider capitalizing on clinical visits to discuss firearm safety.
    Keywords:  anticipatory guidance; firearm counseling; injury prevention; safe storage
    DOI:  https://doi.org/10.1016/j.acap.2026.103460
  32. J Asthma. 2026 Sep 21. 1-26
    Healthcare Providers' Prescription Practices for Spacer Devices and Mask Sizes in Pediatric Asthma Care.
    Marina Reznik, Chirinda Witness.
       BACKGROUND: Asthma guidelines recommend that children use a valve-holding chamber or spacer with inhalers for optimal delivery of asthma medications. Spacers with correct-fitting face masks should be used to deliver the full dose of medication.
    OBJECTIVE: To evaluate healthcare providers' prescription practices regarding spacer devices for children, focusing on factors influencing mask size specification.
    METHODS: We conducted a cross-sectional survey with pediatric and family medicine providers across 18 Bronx, NY clinics. The survey assessed providers' preferences for prescribing spacers, frequency of mask size specification, barriers to prescribing and possible solutions. Data were analyzed using descriptive statistics, chi-square tests, and multivariable logistic regression.
    RESULTS: 149 providers participated (response rate: 71.0%). Providers who assessed inhaler-spacer technique during visits were more likely to specify mask sizes than providers who do not assess the technique (54.0% vs 33.3%, p = 0.017). Pediatricians specified mask sizes more often than family providers (52.5% vs. 21.4%, p = 0.003). Providers who frequently saw children with asthma had significantly higher odds of specifying mask sizes (OR = 2.64, 95% CI: 1.20-5.98, p = 0.017), as did those who reported patients bringing spacers to visits (OR = 2.59, 95% CI: 1.26-5.47, p = 0.011). Barriers cited included insurance coverage issues, pharmacies not having spacers with masks in stock, and challenges in ordering spacers via Electronic Health Records. Suggested solutions included having models of spacers in the office and guidelines on what size mask to order.
    CONCLUSION: Our findings highlight the variability in providers' prescription practices for spacers. Future interventions should target provider education and addressing barriers to optimize asthma care.
    Keywords:  asthma; face masks; mask size specification; pediatrics; prescription practices; spacer devices; urban settings
    DOI:  https://doi.org/10.1080/02770903.2026.2734968
  33. Hosp Pediatr. 2026 Sep 21. pii: e2026009296. [Epub ahead of print]
    Making the Case: Demonstrating the Value of Pediatric Hospital Medicine to Hospital Leadership.
    Hunaid Gurji, Elizabeth C Kuhn, Magna Dias.
      Pediatric hospital medicine (PHM) has become a foundational component of inpatient pediatric care; however, its value is frequently evaluated through a narrow financial lens. This C-suite series piece examines how PHM's contribution to "value" encompasses not only professional revenue but also quality, safety, and access. We describe PHM's impact across 3 domains: financial performance, operational throughput, and its role as a force multiplier for other clinical service lines. Key contributions include revenue enablement, cost avoidance through reduced length of stay and transfers, and continuous pediatric expertise. We contend that PHM should be regarded as a strategic institutional investment rather than a standalone cost center when aligning clinical services with health system priorities. For PHM leaders navigating conversations with hospital administrators, understanding how to frame these contributions in terms of institutional priorities is an essential advocacy skill.
    DOI:  https://doi.org/10.1542/hpeds.2026-009296
  34. Paediatr Drugs. 2026 Sep 21.
    Managing Sjögren's Disease in Pediatric Patients.
    Sara M Stern, Ludovic Trinquart, Hermine I Brunner, Marisha E Palm, Nora G Singer.
      Over the past decade, therapeutic development in adult Sjögren's disease (SjD) has accelerated substantially. Multiple targeted agents directed at B-cell survival, co-stimulation, autoantibody recycling, and immune regulation are advancing through late-phase clinical development. As of August 2026, there are no US Food and Drug Administration-approved disease-modifying or immunomodulatory therapies specifically indicated to treat the underlying autoimmunity of SjD. US Food and Drug Administration approvals in adults are limited to symptomatic treatment of sicca (dryness) symptoms, particularly xerostomia (dry mouth). Treatment of childhood SjD remains off-label and is supported by a limited evidence base consisting largely of case reports, case series, registry abstracts, and clinician survey data. B-cell-targeted medicines and conventional disease-modifying anti-rheumatic drugs have been used off-label in SjD, including childhood SjD. In this review, we compare the clinical phenotype of childhood SjD with adult SjD, summarize the therapies currently used in children and the evidence supporting them, and propose a framework for prioritizing adult SjD therapeutics for pediatric development. The inflammatory phenotype of childhood SjD provides a strong biologic rationale for the study of selected targeted therapies, while underscoring the need for staged pediatric development, phenotype-enriched trials, and outcome measures suited to glandular and systemic disease in children. The highest-priority candidates for pediatric study are discussed based on available adult data and current approval in children for other pediatric diseases.
    DOI:  https://doi.org/10.1007/s40272-026-00772-3
  35. Acad Pediatr. 2026 Sep 22. pii: S1876-2859(26)00240-8. [Epub ahead of print] 103458
    Mental Health Decision Making in Pediatric Primary Care: A Scoping Review.
    John Parkhurst, Jinann Shoshara, Julia Rabin, Andrea Fawcett, Tara Von Mach, Marilyn L Sampilo, John V Lavigne.
       BACKGROUND: Pediatric primary care providers (PCPs) play a central and growing role in identifying and addressing mental health problems (MHPs), yet the clinical-decision making processes are poorly understood. We reviewed the literature on PCP recognition, referral, and management of pediatric MHP to identify opportunities for future research related to diagnostic accuracy and mental health service delivery in primary care.
    METHODS: Scoping review methodology was used to examine the published research on PCP recognition, referral, and management decisions for pediatric MHPs. Data was organized by decision type and factors that influence decision making, including child characteristics, family characteristics, and clinician or practice context variables.
    RESULTS: Forty-five peer-reviewed studies were included. Compared to gold standard assessments and parent-reported questionnaires, PCPs consistently under-recognized MHPs. The decision to refer patients varied by disorder and was largely influenced by problem severity and parental disclosure. Management decisions were primarily shaped by disorder and clinician comfort level. Across decision domains, problem severity, parental engagement, clinician training, and practice context emerged as consistent determinants of PCP decision making.
    CONCLUSIONS: PCPs face persistent challenges in addressing pediatric mental health concerns. This review underscores many opportunities to improve outcomes and reduce inequities in primary care mental health service delivery. There is a need to improve accurate identification, clarify thresholds for referral, and strengthen PCP knowledge and confidence in addressing internalizing disorders and higher acuity concerns. Future research should explore sequential screening, targeted training, and integrated behavioral health approaches to support clinicians and improve systems.
    Keywords:  Pediatrics; decision making; mental health; primary care
    DOI:  https://doi.org/10.1016/j.acap.2026.103458
  36. Children (Basel). 2026 Sep 09. pii: 1219. [Epub ahead of print]13(9):
    Universal Newborn Screening for Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency in a Safety-Net Well-Baby Nursery: A Quality Improvement Initiative.
    Sheetal Sriraman, Charlotte Banayan, Sana Usmani, Saema Khandakar, Ivan Hand.
      Background: G6PD deficiency is among the leading causes of neonatal hyperbilirubinemia and kernicterus. Following a 2022 New York State Department of Health recommendation to test high-risk neonates, we implemented universal G6PD deficiency screening in the well-baby nursery. Objectives: We aimed to increase the proportion of infants screened from 0% to more than 75% within 6 months and to describe the prevalence of G6PD deficiency and the early outcomes of affected neonates. Methods: This quality improvement (QI) initiative, guided by the Model for Improvement, included a cross-sectional analysis of screening yield and early neonatal outcomes. A statistical process control p-chart tracked monthly screening. Outcomes were compared between screen-positive and screen-negative infants using the Fisher exact test. Results: Screening rose from 0% to a sustained mean of 81.1%, exceeding the 75% aim. Of 580 screened neonates, 52 (9.0%) screened positive for G6PD deficiency. Screen-positive infants were more likely than screen-negative infants to undergo repeat serum bilirubin testing (38.5% vs. 19.3%; p = 0.002) and to reach a peak bilirubin above 10 mg/dL (30.8% vs. 10.2%; p < 0.001). A higher rate of readmission for phototherapy was also observed (5.8% vs. 0.9%; p = 0.028), though based on few events. Phototherapy during the birth hospitalization, IVIG, and exchange transfusion did not differ. Conclusions: Universal G6PD screening was feasibly implemented and sustained in a high-risk well-baby nursery through routine workflow changes, without additional phlebotomy. Nearly 1 in 11 screened neonates tested positive for G6PD deficiency.
    Keywords:  bilirubin metabolism; glucose-6-phosphate dehydrogenase; hematology; kernicterus; neonatology; newborn medicine; newborn screening; quality improvement; screening
    DOI:  https://doi.org/10.3390/children13091219
  37. Cochrane Database Syst Rev. 2026 Sep 24. 9 CD012082
    Red blood cell transfusion to treat or prevent complications in sickle cell disease: an overview of Cochrane reviews.
    Alvin M Katumba, Carolyn Dorée, Lise J Estcourt.
       BACKGROUND: Sickle cell disease (SCD) is one of the most common severe monogenic disorders globally. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Red blood cell (RBC) transfusions are used to treat complications of SCD, e.g. acute chest syndrome (ACS), or they can be part of a regular long-term transfusion programme to prevent SCD complications.
    OBJECTIVES: To summarise the evidence from Cochrane reviews of the benefits and harms of RBC transfusions versus no transfusion, or restrictive transfusion (to increase the total haemoglobin) versus liberal transfusion (to decrease the haemoglobin S level below a specified percentage), for treating or preventing complications experienced by people with SCD.
    METHODS: We searched the Cochrane Database of Systematic Reviews on 3 June 2026. We included Cochrane reviews of randomised or quasi-randomised controlled trials that addressed various SCD complications and had RBC transfusion as an intervention or comparator. We assessed the methodological quality of included reviews according to the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) quality assessment. The primary outcomes of the overview were: mortality from any cause; SCD-related serious adverse events; and transfusion-related adverse events. We extracted GRADE assessments from included reviews.
    MAIN RESULTS: We included 17 reviews, 11 had no included studies with an RBC transfusion intervention. Six reviews included trials with participants randomised to RBC transfusion; in one of these reviews, with no usable data, only 10 participants were randomised. This overview focuses on the five remaining reviews. Five reviews (containing nine trials with 1502 participants) reported data comparing short- or long-term RBC transfusions versus standard care; disease-modifying agents; a restrictive versus a liberal transfusion strategy; and long-term RBC transfusions versus transfusions to treat complications. All reviews were high-quality according to AMSTAR, however, the certainty of the evidence was variable across outcomes, with most being very-low certainty. Trials were downgraded according to GRADE methodology for risk of bias, indirectness (most trials were conducted in children with the HbSS phenotype), and imprecision (outcomes had wide confidence intervals). In all five reviews and all comparisons there may be little or no difference in the risk of death (low or very low-certainty evidence). There were either no deaths or death was a rare event. In all five reviews and all comparisons, evidence for several outcomes was of very-low certainty. These were: transfusion reactions, development of alloantibodies and serious infections. Short-term RBC transfusion versus standard care (one review: two trials, 434 participants) All reported outcomes were very-low certainty evidence. Long-term RBC transfusion versus standard care (two reviews: three trials, 405 participants) In children and adolescents at high risk of stroke, long-term RBC transfusions probably decrease the risk of stroke (RR 0.12, 95% CI 0.03 to 0.49; 2 trials, 326 participants; moderate-certainty evidence) and may decrease the risk of ACS (RR 0.24, 95% CI 0.12 to 0.48; 2 trials, 326 participants, low-certainty evidence) and painful crisis (RR 0.62, 95% CI 0.46 to 0.84; 2 trials, 326 participants; low-certainty evidence) compared to standard care. Long-term RBC transfusions may also decrease the risk of silent cerebral infarcts (SCI) in children with abnormal transcranial doppler (TCD) velocities (RR 0.11, 95% CI 0.02 to 0.86; 1 trial, 124 participants; low-certainty evidence), but there may be little or no difference in the risk of SCI in children with normal TCD velocities and previous SCI (RR 0.70, 95% CI 0.23 to 2.13; 1 trial, 196 participants; low-certainty evidence). In children and adolescents already receiving long-term RBC transfusions for preventing stroke, compared to standard care, continuing long-term RBC transfusions may reduce the risk of SCI (RR 0.29, 95% CI 0.09 to 0.97; 1 trial 77 participants; low-certainty evidence). In children with normal TCD velocities and SCI, RBC transfusions may increase the risk of iron overload (incidence rate ratio 14.42, 95% CI 5.41 to 875.17; 1 trial, 121 participants; low-certainty evidence). Long-term RBC transfusion versus RBC transfusion to treat complications (one review: one trial, 72 participants) In pregnant women, long-term RBC transfusions may decrease the risk of painful crisis compared to transfusion for complications (RR 0.28, 95% CI 0.12 to 0.67; 1 trial, 72 participants, low-certainty evidence). RBC transfusion versus disease-modifying agents (hydroxyurea) (two reviews: two trials; 254 participants) For primary prevention of stroke in children with abnormal TCD and no severe vasculopathy on magnetic resonance imaging or magnetic resonance angiography, who have received at least one year of RBC transfusions, there may be little or no difference in the risk of iron overload between RBC transfusion and disease-modifying agents (mean difference (MD) -1.80, 95% CI -5.16 to 1.56; 1 trial, 121 participants; low-certainty evidence); all SCD-related outcomes were very-low certainty evidence. For secondary prevention of stroke in children and adolescents, hydroxyurea with phlebotomy may increase the risk of painful crisis (RR 3.15, 95% CI 1.23 to 8.11; 1 trial, 133 participants; low-certainty evidence) and global SCD serious adverse events compared to RBC transfusion (RR 3.10, 95% CI 1.42 to 6.75; 1 trial, 133 participants; low-certainty evidence). There may be little or no difference in the risk of iron overload (low-certainty evidence). Restrictive versus liberal RBC transfusion strategy (one review: one trial; 230 participants) All reported outcomes were very-low certainty evidence.
    AUTHORS' CONCLUSIONS: This overview provides support from two high-quality Cochrane reviews for the use of RBC transfusions in preventing stroke in children and adolescents at high risk of stroke (abnormal TCDs or SCI) and evidence that it may decrease the risk of SCI in children with abnormal TCD velocities. In addition, RBC transfusions may reduce the risk of ACS and painful crisis in this population. This overview highlights the lack of high-quality evidence in adults with SCD and the number of reviews that have no evidence for the use of RBC transfusions across a spectrum of SCD complications. The variable and often incomplete reporting of patient-relevant outcomes in the included trials, such as SCD-related serious adverse events and quality of life, is also concerning.
    FUNDING: This review update had no funding.
    REGISTRATION: Protocol (2016) DOI: 10.1002/14651858.CD012082 Original review (2018) DOI: 10.1002/14651858.CD012082.pub2.
    DOI:  https://doi.org/10.1002/14651858.CD012082.pub3
  38. J Pediatr Gastroenterol Nutr. 2026 Sep 22.
    Children with sickle cell disease hospitalized for acute pancreatitis have an increased disease burden.
    Olawale Oduru, Akm Fazlur Rahman, Kyanam Kabir Baig Kr, Ali Ahmed, Saskia D'Sa, Shaundra Blakemore, Chinenye R Dike.
       OBJECTIVES: Children with sickle cell disease (SCD) are at increased risk of developing gallstones, a common etiology of acute pancreatitis (AP). We aimed to determine if children with SCD admitted to children's hospitals for AP will have an increased burden of AP compared to non-SCD.
    METHODS: Retrospective study of children 0-21 years admitted with a diagnosis of AP in the Pediatric Health Information System (PHIS) database from 2012 to 2023. Descriptive statistics were used to describe baseline demographics. Categorical variables including readmissions, complications, transfusions, and procedure rates were compared between groups (SCD vs. non-SCD) using χ2 or Fisher's exact test. Wilcoxon rank sum test was used to compare the median age and length of stay (LOS) between groups.
    RESULTS: We analyzed 18,213 distinct participants (17,927 [non-SCD] and 286 [SCD]). Children with SCD were older; p = 0.0004 compared to non-SCD. Children with SCD had increased LOS compared to those without SCD; 4 versus 3 days, p = <0.001. Further, children with SCD received more transfusions compared to those without SCD (31% vs. 3%; p = <0.0001). Need for endoscopic interventions in SCD was 21% versus 8% in non-SCD (p < 0.0001), and cholecystectomy rates were higher in SCD, 33% compared to 11% in non-SCD (p < 0.0001).
    CONCLUSIONS: Children with SCD hospitalized with AP at children's hospitals are older, need more red blood cell transfusions, have an increased LOS, and need more procedures compared to children without SCD. Further studies aimed at reducing the burden of AP in children with SCD are needed.
    Keywords:  blood disorder; hemoglobinopathy; pancreatic disease; pediatrics
    DOI:  https://doi.org/10.1002/jpn3.70590
  39. Diagnosis (Berl). 2026 Sep 21.
    Diagnosis-related handoffs for inter-facility transfers to the pediatric intensive care unit.
    Irene Pantekidis, Poornima Pandiyan, Hardeep Singh, Christopher P Landrigan, Christina L Cifra.
       OBJECTIVES: Inter-facility transfers to the pediatric intensive care unit (PICU) increase the risk of patient harm from communication breakdowns. We previously developed I-PASS-to-PICU, a structured inter-facility handoff program to improve information exchange during these transitions. However, it was not designed to optimize communication related to diagnosis (diagnostic handoff). This exploratory study evaluated how well I-PASS-to-PICU facilitated inter-facility diagnostic handoffs.
    METHODS: Using mixed methods, we analyzed audio-recorded referral calls to a single PICU to characterize inter-facility diagnostic handoff communication before and after I-PASS-to-PICU implementation. Two pediatric intensivists trained to review calls indicated whether diagnosis-relevant information or activities were discussed. Discrepancies in review were resolved via consensus. Reviewers also provided qualitative observations on diagnosis-related discussions.
    RESULTS: Forty-four referral calls were reviewed (16 pre-and 28 post-I-PASS-to-PICU implementation). Compared with unstructured handoffs, I-PASS-to-PICU use did not result in statistically significant differences in the communication of diagnosis-related information in inter-facility handoffs. However, we observed some absolute differences; there were more calls using I-PASS-to-PICU in which illness severity was discussed (75 % vs. 50 %) and the primary diagnosis was stated by the referring clinician (68 % vs. 44 %) or receiving PICU physician (39 % vs. 25 %). Qualitative analysis revealed that shared mental models were more effectively created when primary diagnoses and diagnostic uncertainty were discussed.
    CONCLUSIONS: I-PASS-to-PICU may support aspects of the inter-facility diagnostic handoff but needs further revision to facilitate consistent discussion of diagnoses and diagnostic uncertainty. Future work will focus on redesigning and evaluating I-PASS-to-PICU for improving the diagnostic handoff during inter-facility PICU transfers.
    Keywords:  communication; critical care; diagnostic errors; patient handoff; patient safety; pediatrics
    DOI:  https://doi.org/10.1515/dx-2026-0083
  40. Acad Pediatr. 2026 Sep 22. pii: S1876-2859(26)00228-7. [Epub ahead of print] 103446
    Caregiver Acceptability of Hospital-based Household Substance Use Screening during Pediatric Hospital Admissions.
    Samara Jinks-Chang, Hoover Adger, Emily Murphy, Maria Trent, Jacqueline Toppins, Ashlé Barfield, Steven Huettner, Abigail Bunting, Pamela A Matson.
       OBJECTIVE: Exposure to household substance use (SU) is an adverse childhood experience linked to poor long-term health outcomes. Despite guidelines, pediatricians infrequently screen for household SU, often citing concerns about offending parents. Prior outpatient studies suggest caregivers support universal outpatient screening, but acceptability in inpatient settings remains unclear. This study assessed caregiver acceptance of household SU screening during pediatric hospitalizations, differences by reported household SU, and the association between screening acceptability and caregiver trust in inpatient pediatricians.
    METHODS: English-speaking adult caregivers of pediatric patients admitted to a community hospital's newborn or pediatric floor (October 2023-June 2024) completed an anonymous computer-based survey. Measures included items on screening acceptability, provider trust, demographics, and household SU. Chi-squared tests and multivariable logistic regression were used to assess associations.
    RESULTS: Of 278 respondents, 58% were mothers, 44% were Black, and 42% were insured with Medicaid. Forty percent reported current household SU, most commonly alcohol (70%), marijuana (43%), and tobacco (28%). Most caregivers supported screening for household SU (89% to 96%), with no differences by SU in the home. Caregivers with education beyond high school (aOR 4.15) and those on the newborn floor (aOR 2.45) were more likely to find screening acceptable. Trust in inpatient pediatricians was strongly associated with acceptability (aOR 14.19, p=0.001) CONCLUSIONS: Caregivers broadly support inpatient screening for household SU, even when SU is present. Trust in providers significantly influences acceptance, highlighting the importance of building trusting relationships to support families and address intergenerational SU risk.
    Keywords:  Caregiver Trust; Intergenerational Risk; Pediatric Inpatient Care; Screening Acceptability; adverse childhood experiences; substance use
    DOI:  https://doi.org/10.1016/j.acap.2026.103446
  41. Curr Diab Rep. 2026 Sep 25. pii: 31. [Epub ahead of print]26(1):
    Mobile Health Interventions to Support Self-Management in Youth with Type 1 Diabetes.
    Isa Granados, David A Fedele, Susana R Patton.
       PURPOSE OF REVIEW: Youth with type 1 diabetes face demanding daily self-management requirements. Mobile health interventions are a promising approach for supporting diabetes self-management both within clinical care and in everyday contexts. This review synthesizes recent evidence published between 2018 and 2024 on mobile health interventions designed to support self-management in children and adolescents with type 1 diabetes.
    RECENT FINDINGS: Forty-four studies met inclusion criteria. Most were early-phase evaluations emphasizing feasibility, usability, and engagement. Across modalities, mHealth interventions were most successful at lowering hemoglobin A1c when they provided real-time, actionable support during insulin dosing or carbohydrate estimation. Engagement trajectory emerged as an important determinant of clinical benefit, suggesting that initial usability alone are insufficient to produce meaningful clinical impact. Mobile health interventions for youth with type 1 diabetes are feasible, acceptable, and effective for improving self-management processes and psychosocial outcomes. Glycemic improvements occur selectively when interventions provide point-of-need decision support and when engagement is sustained. Future research should prioritize mechanisms of action, strategies to support long-term engagement, and rigorous effectiveness-implementation trials to support scalable clinical impact.
    Keywords:  Type 1 diabetes; glycemic control; mobile health; pediatric diabetes; self-management
    DOI:  https://doi.org/10.1007/s11892-026-01645-2
  42. Pharmacoecon Open. 2026 Sep 21.
    Health Outcomes, Healthcare Resource Use, and Economic Burden of Invasive Meningococcal Disease in the United States Among Children Aged <11 Years.
    Oscar Herrera-Restrepo, Elizabeth Packnett, Megan Richards, Elise Kuylen, Tosin O Olaiya, Thatiana Pinto, Lindsay Landgrave, Ryan Ross, Andrew G Allmon.
       BACKGROUND/OBJECTIVE: Although uncommon, invasive meningococcal disease (IMD) is a serious and life-threatening illness. In the United States (US), incidence is highest among infants aged <1 year, but research characterizing pediatric IMD burden is limited. This study aimed to evaluate health outcomes and economic burden (healthcare resource utilization [HCRU] and costs [associated with health outcomes and HCRU]) in US individuals aged <11 years with IMD and without IMD, and their caregivers, from the patient and payer (commercial and Medicaid insurance) perspective.
    METHODS: Retrospective claims analysis utilizing real-world data (1/1/2005-12/31/2022) from the MarketScan® Commercial and Multi-State Medicaid Databases compared health outcomes, HCRU (e.g., inpatient and outpatient admissions, surgical procedures, pharmacy claims), and costs (associated with health outcomes and HCRU) in commercially and Medicaid-insured infants (aged <1 year), toddlers (aged 1-4 years), and children (aged 5-10 years) with IMD versus those without IMD (matched 1:5), and their caregivers. Length of follow-up was variable, divided into acute/post-acute phases for individuals with IMD.
    RESULTS: Infants, toddlers, and children with IMD versus without IMD generally experienced more negative health outcomes and HCRU, and higher associated costs. Common health outcomes among infants with IMD included neurological, physical, and neurodevelopmental/mental health disorders. In the commercially insured cohort, infants with IMD had more inpatient admissions, specialist office visits, and surgical procedures than those without IMD. In the Medicaid-insured cohort, HCRU was higher for infants with IMD versus without IMD. Costs associated with health outcomes and HCRU were higher for infants with IMD versus those without IMD, regardless of insurance cohort. Health outcomes, HCRU, and HCRU-associated costs did not differ for caregivers to individuals with IMD versus without IMD.
    CONCLUSION: In this retrospective claims analysis from a dual US patient and payer perspective, infants, toddlers, and children with IMD experienced substantial negative health outcomes and economic burden, regardless of insurance status. Preventive interventions in childhood may lessen the impact of IMD on individuals, families, and healthcare systems.
    DOI:  https://doi.org/10.1007/s41669-026-00676-5
  43. J Hosp Med. 2026 Sep 22.
    Sedation/anesthesia use for inpatient pediatric brain MRIs: National trends and outcomes.
    Kristen H Calhoun, Matthew Hall, Stephanie Arar, Whitney Cameron, W Caleb Hancock, Chloë E Nunneley, Andrew G Yu.
       BACKGROUND: Minimizing unnecessary sedation/anesthesia for pediatric brain MRI has been identified as an area for improvement. However, data on its use across a national sample of children's hospitals is lacking.
    OBJECTIVE: To understand patient demographics, clinical outcomes, hospital variation, and trends over time associated with sedation/anesthesia use for pediatric brain MRIs.
    METHODS: This retrospective cohort study utilized Pediatric Health Information System (PHIS) data for children < 18 years old who received an inpatient brain MRI from 2014 to 2024 (N = 215,377). Outcomes included the need for a repeat brain MRI, length of stay (LOS, in days), cost, and mortality. The likelihood of receiving sedation/anesthesia was modeled using Generalized Estimating Equations (GEE), clustered on hospital and adjusted for clinical and demographic factors. Outcomes were also modeled using GEEs.
    RESULTS: Sedation/anesthesia was used for 36% of children with no significant change over time. There was significant hospital variation in sedation/anesthesia use, ranging from 4.8% to 54.9%. Age, mental health diagnoses, and MRI type (contrast, limited) were associated with the likelihood of receiving sedation/anesthesia. Compared to no sedation/anesthesia, sedation/anesthesia use was associated with a lower likelihood of repeat MRI (1.7% vs. 5.6%, aOR 0.29, 95% CI: 0.25-0.34) and higher cost ($12,819 vs. $10,122, aRR 1.27, 95% CI: 1.13-1.42). There were no meaningful differences in LOS or mortality.
    CONCLUSION: There is currently wide variability in the use of sedation/anesthesia across children's hospitals, and its use was associated with lower repeat MRIs but higher costs. Identification of appropriate patients and MRI techniques may be strategies to reduce unnecessary sedation/anesthesia.
    DOI:  https://doi.org/10.1002/jhm.70495
  44. J Emerg Nurs. 2026 Sep 21. pii: S0099-1767(26)00309-0. [Epub ahead of print]
    Building Pediatric Readiness Across a Health System: Evaluation of a Pediatric Emergency Department Affiliation Program.
    Melony Murray.
       INTRODUCTION: Pediatric readiness in emergency departments is associated with improved patient outcomes; however, variability in preparedness persists across health care settings. This quality improvement project evaluated baseline pediatric readiness across a network of affiliated emergency departments and assessed the impact of a systemwide Pediatric Emergency Department Affiliation Program.
    METHODS: A pre-post design compared National Pediatric Readness Project (NPRP) assessment scores collected during site onboarding (2021-2023) with scores from the 2026 national assessment. To promote consistency, baseline and follow-up assessments were each completed by a single program coordinator. Interventions included implementation of Pediatric Emergency Care Champions (PECCs), standardized clinical pathways, simulation-based education, and ongoing quality improvement and operational support. Twenty-five emergency departments were included. A paired-samples t test was used to compare scores.
    RESULTS: Baseline NPRP scores averaged 66.3 (SD = 6.63) and varied across sites. At follow-up, all participating emergency departments achieved an NPRP score of 100, indicating full alignment with national pediatric readiness standards. Mean scores increased by 33.7 points. The improvement was statistically significant, t(24) = 25.41, p < .001. Gains were observed across all NPRP domains, with the largest improvements in Coordination of Care and Equipment and Supplies.
    DISCUSSION: A structured, systemwide affiliation program was associated with substantial improvements in pediatric readiness across diverse emergency care settings. Programs that incorporate pediatric leadership, standardized pathways, simulation-based education, and continuous quality improvement support may strengthen emergency nurses' preparedness and promote consistent, high-quality pediatric emergency care.
    Keywords:  Emergency nursing; Pediatric Emergency Care Champion (PECC); Pediatric emergency Care; Pediatric readiness; Quality improvement; Simulation-based education
    DOI:  https://doi.org/10.1016/j.jen.2026.08.013
  45. HERD. 2026 Sep 22. 19375867261486799
    Embedding Family Voices in Pediatric Campus Design: A Participatory Model for a New Children's Hospital.
    Caitlin Potter, Vianey Romo.
      ObjectiveTo describe a practice-based, participatory engagement model that embedded patient, family, and youth voices during planning for a new pediatric campus within a quaternary children's health system.BackgroundFamily-centered care is widely endorsed, yet engagement in capital projects is often late, limited in reach, or disconnected from early design decisions. Practical guidance for large-scale, equitable engagement with clear linkage from input to decisions remains limited.MethodsA multidisciplinary Engagement Core Team partnered with an established Patient and Family Advisory Network (PFAN) to ensure patient and family centered input. Over 8 months, the team hosted more than 50 engagement sessions, including town halls, pop-ups, virtual focus groups, and full-scale mock-up reviews. Input was captured, organized into consistent planning and design categories, translated into actionable recommendations, and linked to resulting design decisions through decision logs.ResultsThe process engaged more than 1,000 participants and captured over 5,000 comments. Town Halls reached approximately 30% of the inpatient census on event days. PFAN input informed campus identity and wayfinding, public realm features (including outdoor access and key landmarks), and multiple inpatient room elements including layouts, storage strategies, and bedside environmental controls.ConclusionsA structured, multi-modal engagement model can scale patient and family participation in large capital projects and translate lived experience into specific, evidence-aligned design decisions. The team has a post-occupancy learning plan focused on patient/family experience, operational performance and safety, and equity.
    Keywords:  co-design; experience-based design; patient and family engagement; pediatric environments
    DOI:  https://doi.org/10.1177/19375867261486799
  46. Cureus. 2026 Aug;18(8): e114951
    Sedation-Assisted, Non-sedated, and Escalated Removal of Pediatric ENT Foreign Bodies in Emergency Settings: A Systematic Review.
    Hassan H Al Bader, Hassan A Alalawi, Rahaf K Alhajji, Taif K H Aka Mi, Ahmed F Alluwaim, Muath H Alqesair, Liyan A Alwadai, Hussain M Reda, Sulaiman A Darbashi, Abdullah F Aljoudi, Yousef M Bajhzer.
      Pediatric ear, nose, and throat (ENT) foreign bodies are among the most common procedural challenges in emergency medicine. Substantial uncertainty exists regarding the optimal approach to removal, including sedation-assisted versus non-sedated techniques, and the appropriate thresholds for escalation to otolaryngology or the operating room. A systematic literature search was conducted in PubMed, the Cochrane Library, Web of Science, and Scopus (search date: June 2026). Studies were included if they reported outcomes of ENT foreign body removal in pediatric or predominantly pediatric emergency and acute care settings. Risk of bias was assessed using domain-specific methodological appraisal. Meta-analysis was not performed because of substantial clinical and methodological heterogeneity. Eight studies published between 2004 and 2022 were included from the United States, Singapore, Australia, and Israel, representing 2,332 patients and 2,336 removal attempts or study-level encounters. The difference reflects one study that reported 254 removal attempts involving 250 children. Removal success varied according to clinical setting and case complexity. In one pediatric ED cohort, successful removal was achieved in 204/254 (80.3%) ear foreign body attempts, while another study reported first-attempt success of 82.4% for pediatric emergency physicians and 96.1% for ENT physicians. Sedation was used in 1/254 (0.4%) to 71/312 (22.8%) of cases and was generally reserved for difficult or uncooperative patients or after failed non-sedated attempts, precluding causal comparison between strategies. Reported complication rates varied substantially because of differences in definitions and patient selection; one study reported complications in 30/254 (11.8%) cases, whereas another reported complications in 40/380 (10.5%), including tympanic membrane perforation in 1/380 (0.3%). Referral and escalation also varied according to clinical setting and case complexity. In one study, 38/275 (13.8%) patients were referred to ENT after previous removal attempts, while in another study, 44.8% were referred to an ENT clinic for further assessment. In one study, operative intervention was required in 2/44 (4.6%) patients initially managed by ENT and 13/38 (34.2%) patients referred to ENT after previous unsuccessful attempts; whereas in another study, 51/380 (13.4%) underwent removal in the operating theatre under general anaesthesia. ED procedural sedation demonstrated a safety profile comparable to operating-room management while substantially reducing costs. Repeated removal attempts and difficult foreign body characteristics were consistently associated with failure, complications, or escalation of care. Overall, emergency physicians can successfully remove most pediatric ear and nasal foreign bodies, although success varies substantially according to clinical setting and case complexity. Sedation appears to be a useful escalation strategy for uncooperative children or after failed initial attempts, although current evidence does not support a causal comparison with non-sedated approaches. Early otolaryngology referral is appropriate after failed attempts, for difficult foreign bodies, suspected tympanic membrane involvement, or button battery exposure. High-quality prospective comparative studies using standardized outcome definitions are needed to strengthen the evidence base.
    Keywords:  ear foreign body; emergency department; foreign body removal; nasal foreign body; non-sedated removal; pediatric emergency medicine; procedural sedation; sedation-assisted removal; throat foreign body
    DOI:  https://doi.org/10.7759/cureus.114951
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