bims-cliped 2026-05-17 papers

bims-cliped

Biomed News

on Clinical pediatrics

Issue of 2026–05–17
thirty-two papers selected by
Alyssa M. Portwood, Akron’s Children

Pediatric MRI Safety: Frequency, Types, and Severity of Zone IV MRI Safety Events at Five U.S. Children's Hospitals.
Changes in Pediatric Readiness in Critical Access Hospitals 2013-2021: An Analysis of National Pediatric Readiness Project Data.
Systematic Review of Pediatric Ketamine in Emergency Department Procedural Sedation: Frequency and Predictors of Adverse Events.
A Quality Improvement Project to Increase Nurse-initiated Care from Triage and Improve Timeliness to Care in the Pediatric Emergency Department.
Improving Documentation of Language Interpreter Use to Increase Compliance, Quality, and Safety.
Improving Influenza Vaccination in the Pediatric Emergency Department.
Beyond Medicare ACOs: Pediatric Alternative Payment Models and Financial Risk-Sharing.
A Multidisciplinary Quality Improvement Initiative to Improve Hospital Throughput in a Pediatric Tertiary Care Center.
Increasing Recommended Care for Immigrant Children in an Ambulatory Care Network.
Imaging appropriateness in pediatric emergency department using the American College of Radiology criteria: an observational study.
Rising Use of Observation Status for Pediatric Populations in Six States, 2012-2019.
Patient and staff safety implications of emergency department boarding: a systematic review.
Artificial Intelligence-Driven Triage in Pediatric Emergency Departments: Accuracy, Bias, and Impact on Clinical Outcomes: A Narrative Review.
Extracting structured clinical data from pediatric emergency records using LLMs: A multimodel retrospective study of children with medical complexity.
Evidence-based Evaluation to Promote High-value Care in Pediatric Critical Care: It Is Time to Fully Adopt.
Timeliness and Adherence to Opioid Administration Guidelines for Acute Sickle Cell Pain in Pediatric Patients: A Comparison of Pediatric and Adult Emergency Departments.
Using a Quality Improvement Initiative to Decrease Oxygen Toxicity among Mechanically Ventilated Children.
Sociodemographic Variability in Pediatric Emergency Decisions by AI.
Trends in length-of-stay per total body surface area burn in pediatric patients: A report from the pediatric injury and quality improvement collaborative.
Pediatric blast injuries: Distinguishing features and unique challenges.
Dexmedetomidine for acute respiratory conditions requiring non-invasive respiratory support in pediatric and adult patients: systematic review and meta-analysis of the literature.
Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study.
Mapping Meaningful Populations of Children With Special Health Care Needs.
Disparities in health insurance and healthcare access for immigrant children with special healthcare needs.
Trends of E-Scooter-Related Pediatric Orthopaedic Injuries: 20 Years of Nationally Representative Data.
Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial.
Clinical research in pediatric population: Scientific and ethical aspects.
Describing the Utility of Fungal Blood Cultures in Patients Hospitalized at a Large Pediatric Academic Center.
Pediatric Residents' Intubation Competency Through Simulation-Based Training: A Quality Improvement Initiative.
Interventions to reduce pharmacologic opioid exposure in neonatal opioid withdrawal syndrome: a systematic review and meta-analysis of randomized studies.
PEDIATRIC HEALTH AT THE CROSSROADS OF CLIMATE CHANGE, FOOD INSECURITY, AND MALNUTRITION.
A Pediatric Perspective on the 2025-2030 Dietary Guidelines.

J Am Coll Radiol. 2026 May 08. pii: S1546-1440(26)00244-9. [Epub ahead of print]

Pediatric MRI Safety: Frequency, Types, and Severity of Zone IV MRI Safety Events at Five U.S. Children's Hospitals.

Anna Guan, Ramesh S Iyer, Richard A Barth, Neil Lall, Nilesh K Desai, Shireen Hayatghaibi, Rama S Ayyala, Blaise V Jones, Jonathan R Dillman.

   BACKGROUND: Data on the frequency and types of MRI safety events in pediatric imaging departments are limited.
OBJECTIVE: To assess the frequency, types, and severity of MRI safety events occurring in Zone IV across five U.S. pediatric imaging departments.
METHODS: This retrospective study reviewed MRI safety events that occurred in Zone IV between 2017 and 2022 at five major U.S. children's hospital systems. The frequency, types (e.g., projectile, burn, implant-related), and severities of events were recorded using existing institutional MRI safety records. Descriptive statistical analyses were conducted.
RESULTS: Over a six-year period and approximately 540,987 MRI examinations, a total of 146 Zone IV MRI safety events were reported across the five institutions. On average, each site experienced 4.9 events per year (range across sites: 1.0-8.5) or 3.3 events per 10,000 MRI exams (range across sites: 0.9-3.7). Of the 146 events, 44 (30%) involved projectiles, 19 (13%) were burn/thermal injuries, and 14 (10%) were implant related. Ten events (6.8%) were classified as serious safety events (SSEs). MRI safety protocols were not correctly followed in 88 of 146 events (60%), and 78 of 146 events (53%) directly involved patients.
CONCLUSION: Although uncommon, MRI safety incidents do occur in Zone IV of pediatric imaging departments. While most cause no serious harm, their persistence and potential for catastrophic outcomes highlight the need for continued vigilance and ongoing safety improvements.

Keywords:  Children; MRI; Pediatric; Safety

DOI:  https://doi.org/10.1016/j.jacr.2026.05.013
Ann Emerg Med. 2026 May 14. pii: S0196-0644(26)00200-3. [Epub ahead of print]

Changes in Pediatric Readiness in Critical Access Hospitals 2013-2021: An Analysis of National Pediatric Readiness Project Data.

Jessica Katznelson, Joyce Li, Rachel Crady, Matthew Wilkinson, Katherine Remick.



Keywords:  Critical Access Hospitals; Emergency Department; Pediatric Emergency Care Coordinator; Pediatric Preparedness; Pediatrics

DOI:  https://doi.org/10.1016/j.annemergmed.2026.03.028
Ann Emerg Med. 2026 May 14. pii: S0196-0644(26)00236-2. [Epub ahead of print]

Systematic Review of Pediatric Ketamine in Emergency Department Procedural Sedation: Frequency and Predictors of Adverse Events.

Steven M Green, Mark G Roback.

   STUDY OBJECTIVE: We sought to compile the reported frequencies of adverse events from studies including ≥250 subjects of pediatric emergency department (ED) ketamine sedation by the intravenous route and determine their variances and pooled estimates. We then inventoried the described predictor variables and estimated their clinical importance.
METHODS: Systematic review of studies including ≥250 subjects of children receiving intravenous ketamine in the ED for pediatric procedural sedation published after a 2009 systematic review.
RESULTS: We identified 20 qualifying studies totaling 67,871 children. There were no reported patient deaths or permanent adverse outcomes/neurologic deficits. The pooled frequency estimate of other sentinel outcomes (ie, tracheal intubation, neuromuscular blockade, chest compressions, aspiration, vasoactive drugs) was 0.0087% (95% confidence interval 0.003% to 0.020%), or 1 per 11,558 sedation encounters. Serious adverse events (defined as sentinel above plus positive pressure ventilation, oral airway, bolus intravenous fluids, sedation insufficient, escalation of care or hospitalization) were noted in 0.34%, with 3 identified predictors: age ≥10 years, upper respiratory infection, and coadministered opioids. Their magnitude of effect was modest; however, we estimate 1 additional serious adverse event for every 103, 110, and 156 ketamine sedations, respectively. Nonpredictors were American Society of Anesthesiologists physical status and coadministered benzodiazepines.
CONCLUSION: In this large systematic review, we found that sentinel adverse events were extremely rare, strongly supporting the safety of ED ketamine for procedural sedation of children. The clinical predictor variables studied showed modest or no association with serious adverse events.

Keywords:  Adverse events; Dissociative sedation; Ketamine; Procedural sedation

DOI:  https://doi.org/10.1016/j.annemergmed.2026.03.030
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e842

A Quality Improvement Project to Increase Nurse-initiated Care from Triage and Improve Timeliness to Care in the Pediatric Emergency Department.

Nichole McCollum, Sarah Isbey, Lauren Waterhouse, Kelly Williams, Sandra P Spencer, Tanika Jones, Anthony Thomas, Lindsay Stein, Kathleen Brown, Jaclyn Kline.

Introduction: Initiating care during emergency department (ED) triage is an effective way to decrease time to treatment. Triage nurse-initiated standing orders (SOs) are safe, evidence-based, and allow care to begin for patients before provider evaluation. We describe a multidisciplinary approach to increase the use of SOs across 2 pediatric EDs.
Methods: Interventions for this quality improvement initiative were driven by frontline staff input and included education, fostering competition among nurses, individual feedback, and editing of SOs. The primary outcome measure was the use of SO per patient encounter, monitored using a U-chart. The secondary outcome measures were time to dexamethasone in patients with asthma and provider time to disposition for discharged patients with gastroenteritis or streptococcal pharyngitis, monitored by X-bar and S-charts. The process measure was the percentage of orders placed outside of SOs, monitored by a P-chart. The balancing measure was the length of stay for patients with gastroenteritis and streptococcal pharyngitis.
Results: The rate of SOs improved from 165 to 234 per 1,500 patient encounters at the main campus and from 53 to 82 per 500 patient encounters at the satellite campus, each resulting in statistical process control chart centerline shifts. There was an improvement in the process measure at both pediatric EDs.
Conclusions: SO use increased across the 2 campuses. SO use is associated with shorter length of stay, decreased time to medication, and decreased provider time to disposition for 3 specific patient populations. SOs improve throughput and can be used in the care of pediatric patients.

DOI: https://doi.org/10.1097/pq9.0000000000000842
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e847

Improving Documentation of Language Interpreter Use to Increase Compliance, Quality, and Safety.

Cara E Texler, Emily Sentman, Charles Hardy, Lydia Michael, Shravani Vundavalli, Maria Moauro, Anup D Patel.

Introduction: The standard of care for language interpretation in healthcare encounters is well established and supported by civil rights law and hospital policy. However, the use of language interpreters for healthcare communication is inconsistent for families who use languages other than English. To promote interpreter use and improve compliance, a quality improvement team implemented a project to enhance documentation of interpreter use in clinical notes.
Methods: The team developed a rule-based electronic health record tool to prompt documentation of interpreter use for the right patient at the right time. The team piloted and revised the tool in a primary care setting, and then implemented and disseminated it in a more complex inpatient pediatric hospital setting. The team measured compliance with documentation in hospital pediatric history and physical and discharge summary notes using statistical process control p-charts. Balancing measures included the authors' time spent documenting interpreter use and perceived difficulty in documenting in the clinical notes.
Results: On the hospital pediatrics service, the rate of compliant documentation in history and physical notes increased from 15% to 74% and was sustained for 14 months. Compliant documentation for discharge summary notes increased from 11% to 93% and sustained for 14 months.
Conclusions: Electronic health record tools designed to document interpreter use can effectively prompt and monitor compliance through integrated and rule-based systems. Thus, they are essential for comprehensive quality improvement initiatives that encourage clinicians to use language interpreters and optimize communication, quality, and safety for children and families who use languages other than English.

DOI: https://doi.org/10.1097/pq9.0000000000000847
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e855

Improving Influenza Vaccination in the Pediatric Emergency Department.

Courtney E Nelson, Shannon Baumer-Mouradian, Snezana Nena Osorio, Jack Stevens, Jonathan M Miller.

Introduction: The American Academy of Pediatrics recommends annual influenza vaccination for patients aged 6 months or older. In 2019, our local pediatric emergency department (ED) vaccination rate was below the national average. We aimed to increase influenza vaccination screening from 53% to 95% and vaccine administration from 48% to 58% by March 2023.
Methods: We included patients older than 6 months of age who were discharged from the ED, excluding those resuscitated or transferred from outside hospitals. Interventions included triage screening questions and electronic health record alerts to prompt vaccination. The baseline period was February-April 2020, with interventions during the next 3 influenza seasons, and a poststudy period from September 2023 to March 2024. Measures included vaccine administration (outcome), screening rate (process), provider discontinuation, family refusal, and discharge time (balancing). Data were analyzed using Shewhart charts (P and P').
Results: We achieved nearly universal screening for vaccine eligibility (98%) and administered the vaccine to 70% of eligible patients during season 1 of implementation. Thereafter, the influenza screening rate dropped to 85% and 86% (seasons 2 and 3, respectively) and 79% (poststudy). Likewise, influenza immunization rates decreased below baseline in season 2 (37%) and remained low at 40% (season 3) and 50% (poststudy). There was no difference in parental refusal of the vaccine at the time of discharge; however, there was an increase in provider discontinuation from 1 consecutive season to the next.
Conclusions: An ED-based influenza vaccine delivery model can be successful when the triage process includes screening, a consistent group of ED-based staff orders the vaccine, and there is effective use of the electronic health record.

DOI: https://doi.org/10.1097/pq9.0000000000000855
Pediatrics. 2026 May 14. pii: e2025073802. [Epub ahead of print]

Beyond Medicare ACOs: Pediatric Alternative Payment Models and Financial Risk-Sharing.

Eli Sprecher, James M Perrin.

Pediatric clinicians are increasingly asked to participate in alternative payment models (APMs) that hold clinicians financially accountable for population-level spending. Drawing heavily on evidence from Medicare, policymakers promote accountable care organizations and other risk-sharing arrangements as pathways to lower costs and higher quality. Yet the pediatric context differs in fundamental ways that limit the direct applicability of adult models. Child health care has fewer short-term opportunities for cost savings, and small numbers of children with medical complexity drive much spending, with substantial year-to-year volatility in spending. Coverage churn across Medicaid, Children's Health Insurance Program, and commercial plans, and the relative lack of pediatric-specific data, infrastructure, and capital further complicate efforts to manage the total cost of care. In this special article, we summarize the evidence base for APMs; highlight how selection, benchmarking, and coding practices can overstate apparent savings in adult programs; and explain why these dynamics may not translate to pediatrics. We then outline key design features needed for pediatric-appropriate APMs, including multi-year pediatric baselines, exclusion of birth hospital and neonatal intensive care unit costs, robust stop-loss and reinsurance protections, pediatric-validated clinical and social risk adjustment, attribution methods that reflect medical home, and quality "gates" focused on actionable, child-relevant measures. We conclude that pediatric clinicians should approach downside risk arrangements cautiously and only under conditions that align financial accountability with clinical influence and available infrastructure. Poorly designed pediatric APMs risk destabilizing already fragile pediatric systems and access to them, whereas carefully tailored models could enable innovation in prevention-oriented, team-based child health care.

DOI: https://doi.org/10.1542/peds.2025-073802
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e857

A Multidisciplinary Quality Improvement Initiative to Improve Hospital Throughput in a Pediatric Tertiary Care Center.

Satvika Mikkilineni, Rebecca Cantu, David M Spiro, Shelly Keller, Justin Criddle, Ryan Kwong, Sara C Sanders.

Introduction: Overcrowding in the emergency department (ED) can lead to patient delays, increased medical errors, and increased left without being seen (LWBS) rates. Identifying systemic factors that hinder patient throughput can be beneficial to optimizing patient flow and thereby reducing LWBS rates. This quality improvement project aimed to improve hospital throughput in our pediatric tertiary care center through a multidisciplinary systemic approach.
Methods: This study included patients admitted from the ED to an inpatient medical-surgical unit on the pediatric hospital medicine service. This project was a multidisciplinary effort with participation from the ED, hospital medicine, operations center, hospital administration, and nursing, who met biweekly to review data, assess the impact of changes, and discuss new interventions. The project's key drivers were the duration of the admission process, a shared mental model of admission and discharge processes, and inpatient efficiency. The team conducted a total of 10 interventions during the study period.
Results: The percentage of patients admitted within 90 minutes increased from the baseline of 18% to 42% by the end of the study period. The escalation of care and LWBS rates decreased by the end of the study.
Conclusions: A multidisciplinary approach to hospital throughput, incorporating initiatives from the ED and inpatient units for admission and discharge processes, along with the support from ancillary services, can significantly enhance patient flow throughout the hospital system.

DOI: https://doi.org/10.1097/pq9.0000000000000857
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e865

Increasing Recommended Care for Immigrant Children in an Ambulatory Care Network.

Zachary S Berlant, Mariellen M Lane, Laura E Robbins-Milne, Rajasekhar Ramakrishnan, Ashley B Stephens, Morgan A Finkel.

Introduction: The American Academy of Pediatrics has established recommendations to ensure that the unique needs of immigrant children are addressed in pediatric primary care. A needs assessment of a single institution's pediatric ambulatory network revealed that the majority of recommendations were not provided.
Methods: A 1-year quality improvement (QI) project starting in October 2021 used electronic health record aids, education, and provider input to increase the rate of providing recommended care for migrant children 18 years of age or younger in a general pediatrics ambulatory network. The primary outcome was whether providers delivered the majority of the 5 universally recommended aspects of care established by the American Academy of Pediatrics for migrant children. The secondary outcomes included each of the 5 recommended care elements evaluated individually. The process measure was the use of electronic health record aids. Rates of provider compliance with providing a majority of recommended care were tracked with a statistical process control chart and compared with those of 20 months prior.
Results: Monthly compliance rates increased from a baseline mean of 24.4% to 56.1%. Following the first QI intervention, a run of 11 consecutive points above the centerline met the statistical process control rules for special cause variation.
Conclusions: Using QI methodology, rates of delivering recommended care for all migrant children exceeded the goal and more than doubled from baseline. The shift initiated at the start of the QI project, and the maximal rate of care provision peaked at the end of the QI period.

DOI: https://doi.org/10.1097/pq9.0000000000000865
Emerg Radiol. 2026 May 12.

Imaging appropriateness in pediatric emergency department using the American College of Radiology criteria: an observational study.

Michele Carella, Marcello Benevento, Davide Ferorelli, Giandomenico Stellacci, Antonello Sacco, Alessandro Dell'Erba, Biagio Solarino.

   BACKGROUND: Even though children are typically more susceptible to radiation-induced illnesses than adults, pediatric radiology is an essential part of contemporary practice. Consequently, one of the most important performance metrics for patient safety is the appropriateness of radiologic procedures. The appropriateness criteria of the American College of Radiology (ACR) are evidence-based guidelines designed to assist referring physicians and other healthcare providers in decision-making regarding diagnostic imaging.
METHODS: Using ACR criteria as a reference, this study attempts to assess the suitability of radiologic procedures sought by pediatric emergency physicians. Furthermore, the investigation ought to pinpoint and emphasize possible causes of improper requests. A trainee operator consecutively collected 462 requests for radio diagnostic imaging for neurological diseases of the emergency department of an Italian pediatric hospital and used the pediatric panel of ACR criteria to rate the appropriateness of each request.
RESULTS: Due to the absence of crucial clinical information, 24.7% of the requests were not complete. Of the complete requests, only 16.1% were classified as "usually appropriate", 29.9% as "may be appropriate", and 54.0% as "usually not appropriate". CT requests were commonly inappropriate (55.7%, p < 0.01).
CONCLUSION: Overuse of CT scans can result in costly procedures and unwarranted radiation exposure. In pediatric practice, communication between radiologists and emergency physicians should encourage the use of evidence-based decision-making.

Keywords:  Diagnostic appropriateness; Pediatrics; Radiology

DOI:  https://doi.org/10.1007/s10140-026-02452-8
Acad Pediatr. 2026 May 08. pii: S1876-2859(26)00117-8. [Epub ahead of print] 103335

Rising Use of Observation Status for Pediatric Populations in Six States, 2012-2019.

Yao Tian, Michelle L Macy, Jason M Hockenberry, Ronald T Ackermann, Amber K Sabbatini, Kristin Kan, Lynn Huang, Jane L Holl, Mehul V Raval.

   OBJECTIVE(S): Despite a wide adoption of observation status policy for Medicare beneficiaries with diverse conditions across U.S., little is known about population-level changes in observation status use for children. This study aimed to examine statewide trends in observation status use for pediatric population.
METHODS: This repeated cross-sectional analysis used statewide hospital discharge data from six states from 2012 through 2019 to characterize inpatient and observation stays for patients <18 years old with conditions that may require short-term hospital stay (i.e., <3 days). The population-level use of observation status was measured by observation stay rate, defined as the number of observation stays per 100,000 children per year for each state. Population-level changes were examined using linear regressions with generalized estimating equations to account for within-state clustering. Subgroup analyses were conducted by patient demographics, neighborhood socioeconomic characteristics, diagnosis groups, chronic condition status, and length of stay.
RESULTS: Among 808,181 hospital stays, 299,483 (37.1%) were observation stays. From 2012 through 2019, observation stay rates increased in all six states, with an average annual growth of 17.8 (95% Confidence Interval (CI): 10.4-25.3) per 100,000 children. Observation stay rates significantly increased for children who were <6 years old, non-White, and publicly insured. Red blood cell disorders had the fast-growing use of observation status, with a percentage increase of 25.7% (95%CI: 18.6%-33.3%).
CONCLUSION: Although descriptive, we found substantial yet differential increases in observation-status use among children, especially for younger, non-White, publicly insured children and for conditions previously cared under an inpatient designation, using multi-state population-level data.

Keywords:  Observation status; Pediatric population

DOI:  https://doi.org/10.1016/j.acap.2026.103335
Health Aff Sch. 2026 May;4(5): qxag084

Patient and staff safety implications of emergency department boarding: a systematic review.

Marisa K Dowling, Steve Farmer, Surbhi Dixit, Nicholas Taylor, Lynn Chollet-Hinton, Alice Tang, Ericka Powell, Sean S Michael.

   Introduction: Emergency departments (EDs) are a vital part of the US healthcare system, yet they are increasingly overwhelmed by the practice of boarding, which involves holding admitted patients in the ED after the decision for hospital admission has been made. Despite extensive evidence, the issue has only worsened. Evidence-based policymaking requires analysis of contemporary studies differentiating boarding from broader crowding consequences.
Methods: Leveraging US-based literature from 2014 to 2024, this review synthesizes the health and safety effects of boarding on patients and staff. Twenty-one studies were included: 17 on patient outcomes and 4 on staff impacts.
Results: Prolonged boarding times were associated with severe consequences, including worsened mortality, morbidity, length of stay, medication errors, and treatment delays. High-risk populations (eg, pediatric, psychiatric, and older) suffered greater harm. For clinical staff, boarding added workload, hindered resident education, and worsened burnout.
Conclusion: This review extends previous studies' findings and supports the proposition that boarding (distinguished from crowding more generally) is not only an operational inconvenience but also a systemic safety hazard with implications for healthcare and policy leaders as they prioritize strategies to improve patient safety. The largest opportunity for further research is in rigorous, prospective, multi-center studies with standardized definitions and outcome measures.

Keywords:  access block; admit holding; boarding; capacity; crowding; emergency department; emergency room; overcrowding; patient flow; patient safety; staff safety

DOI:  https://doi.org/10.1093/haschl/qxag084
Sage Open Pediatr. 2026 Jan-Dec;13:13 30502225261445743

Artificial Intelligence-Driven Triage in Pediatric Emergency Departments: Accuracy, Bias, and Impact on Clinical Outcomes: A Narrative Review.

Eslam Abady, Mandy Elewa, Habiba Abdelhameed Elrefaey, Kevin Thomas Mathew, Panos Tamvakologos, Kayleigh Kuhn, Mohammed Alsabri.

  AI-driven triage presents a transformative opportunity to address persistent challenges in pediatric emergency care, from overcrowding and waiting times to human error and outcome disparities. This narrative review demonstrates that AI systems can achieve high accuracy in predicting critical outcomes, with pooled AUROCs of 0.87 for hospital admission, 0.93 for ICU admission, and 0.93 for mortality, significantly outperforming traditional triage scales, while observational studies report associations with improved efficiency, reduced triage errors, and enhanced resource allocation. However, publication bias favoring positive results affects the available evidence, and studies reporting no benefit or performance degradation exist. The promise of AI is tempered by significant challenges: performance varies across pediatric subgroups, the risks of perpetuating and amplifying bias remain inadequately addressed, and workflow integration and medico-legal liability require careful navigation. AI augments clinical judgment, guided by robust governance frameworks, fairness auditing, and human oversight for more equitable emergency care.

Keywords:  artificial intelligence; bias; clinical decision support; health equity; implementation science; machine learning; narrative review; natural language processing; pediatric emergency medicine; triage

DOI:  https://doi.org/10.1177/30502225261445743
Digit Health. 2026 Jan-Dec;12:12 20552076261431431

Extracting structured clinical data from pediatric emergency records using LLMs: A multimodel retrospective study of children with medical complexity.

Gloria Brigiari, Marco Franzoi, Chiara La Piana, Franco Quarantiello, Anna Zanin, Franca Benini, Dario Gregori.

   Importance: Emergency departments (EDs) face significant documentation burdens due to reliance on unstructured clinical narratives, hindering efficiency, particularly in pediatric care. Large language models (LLMs) offer a potential solution by automating data extraction to improve clinical workflows.
Objective: To determine whether an LLM can accurately and efficiently extract structured clinical data from free-text pediatric ED records in a non-English setting.
Design: Diagnostic accuracy study using retrospective data from 2007 to 2023. Manual clinician classification served as the gold standard to assess model performance.
Setting: Single-center study conducted at the pediatric ED of Padova University Hospital, a tertiary care referral center in Italy.
Participants: A convenience sample of 697 anonymized ED records from children with complex medical conditions.
Exposure: Automated data extraction using OpenAI's GPT-5.2 model via structured prompts processed in Python. All texts were in Italian and translated to English in the workflow.
Main Outcomes and Measures: Primary outcomes included accuracy, AUC, sensitivity, and specificity of the LLM in extracting triage color codes, ED outcomes, reasons for ED visit, and performed procedures. Efficiency gains were also measured by comparing manual and automated extraction times.
Results: Among 697 records analyzed, the primary model (GPT-5.2) achieved high accuracy in classifying triage color (0.99) and ED outcome (0.984). Accuracy for laboratory tests was 0.96, oxygen therapy 0.95, and nasogastric tube placement 0.987. Results were consistent across all seven models (mean Fleiss' kappa = 0.922). Processing time was reduced from ∼5 min to 6 s per record, with a total cost of € 23.42.
Conclusions: In this study of pediatric ED encounters in a non-English setting, LLMs reliably extracted structured clinical data and substantially reduced documentation processing time. These findings supported their potential to streamline workflows, particularly in resource-constrained environments. Further research was warranted to improve classification of complex or ambiguous information.

Keywords:  Large language models; artificial intelligence; clinical documentation; emergency department; natural language processing; pediatric care

DOI:  https://doi.org/10.1177/20552076261431431
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e863

Evidence-based Evaluation to Promote High-value Care in Pediatric Critical Care: It Is Time to Fully Adopt.

Maya Dewan, Rajit K Basu, Erin Bennett, Lily B Glater-Welt, Mark Hall, Benson S Hsu, Lia Lowrie, Venessa Lynn Pinto, Alexandre T Rotta, Edward Seferian, Linda Siegel, Heather A Wolfe, Vijay Srinivasan.

Introduction: Evidence-based recommendations for high-value care in pediatric critical care are needed. We sought to develop recommendations to identify unnecessary interventions, enhance outcomes, and promote efficient, patient-centered practices.
Methods: Using a modified Delphi process, a multi-institutional panel of pediatric intensivists from a national pediatric critical care quality improvement group identified 30 potential topics and selected 20 high- and medium-priority topics for further evaluation, and narrowed them to 10 by consensus voting. A structured scoping review of literature published between 2014 and 2023 identified 10 practices, which were critically assessed using the PICOST framework. The panel selected 5 priority recommendations based on evidence strength, feasibility, and potential impact.
Results: The panel developed 5 evidence-based recommendations: (1) prioritize early and progressive mobilization in the pediatric intensive care unit, (2) avoid reflexive culture testing in febrile children without clinical signs of infection, (3) conduct daily tracheal extubation readiness assessments to prevent unnecessary delays, (4) limit red blood cell transfusions in stable, nonbleeding patients with hemoglobin greater than 7 g/dL, and (5) initiate enteral nutrition within 48 hours when clinically safe and feasible. Each recommendation is grounded in current best evidence and aims to minimize harm while optimizing resource use and outcomes.
Conclusions: Incorporating high-value care principles into pediatric critical care holds promise for reducing unwarranted variation, minimizing harm, and improving the efficiency and effectiveness of care. Future efforts should focus on implementation strategies, practice integration, and ongoing evaluation to sustain improvements and close the gap between evidence and adoption.

DOI: https://doi.org/10.1097/pq9.0000000000000863
Pediatr Blood Cancer. 2026 May 14. e70410

Timeliness and Adherence to Opioid Administration Guidelines for Acute Sickle Cell Pain in Pediatric Patients: A Comparison of Pediatric and Adult Emergency Departments.

Ibrahim Gwarzo, Harish Chandra Dega, David C Brousseau.

  We leveraged the Epic Cosmos database to compare the timeliness of opioid administration for children with sickle cell disease pain in pediatric and adult emergency departments (EDs). Our analysis of 44,415 ED visits from 2019 to 2025 demonstrated that median times to the first and second opioid doses were substantially shorter in pediatric EDs (44 and 38 min, respectively) compared with adult EDs (76 and 78 min, respectively). Adherence to national guidelines recommending pain treatment within one hour of arrival was higher in pediatric EDs (64.9%) compared with adult EDs (37.3%). These results underscore significant disparities in care.

Keywords:  emergency department; guideline adherence; opioids; pain; pediatrics; sickle cell disease; timeliness

DOI:  https://doi.org/10.1002/1545-5017.70410
Pediatr Qual Saf. 2025 Nov-Dec;10(6):10(6): e849

Using a Quality Improvement Initiative to Decrease Oxygen Toxicity among Mechanically Ventilated Children.

Salim Aljabari, Ethan Gillett, Zach Settle, Esma Birisci, Abdallah Dalabih.

Introduction: Excessive oxygen supplementation in critically ill children can lead to hyperoxia, resulting in systemic toxicity and worse outcomes. Despite evidence linking hyperoxia to adverse outcomes, the overuse of oxygen therapy remains a widespread practice. This quality improvement initiative aimed to reduce hyperoxia exposure among mechanically ventilated children in the pediatric intensive care unit at Arkansas Children's Hospital, aligning with the Second Pediatric Acute Lung Injury Consensus Conference guidelines.
Methods: A multidisciplinary team implemented interventions in 2 Plan-Do-Study-Act cycles. The first cycle focused on staff education and standardizing oxygen saturation (SpO2) goals (90%-97%) in electronic health records. The second cycle introduced a best practice advisory to alert bedside staff when SpO2 exceeded 97% with the fraction of inspired oxygen (FiO2) greater than 0.21, prompting FiO2 weaning. Hyperoxia was defined as SpO2 98%-100% with FiO2 greater than 0.21. We collected hourly SpO2-FiO2 data pairs from mechanically ventilated patients and calculated hyperoxia rates monthly.
Results: Baseline data (January 2021 through June 2022) showed an average hyperoxia rate of 54.8%. Following the first Plan-Do-Study-Act cycle, the rate decreased to 41.0%, and after best practice advisory implementation, it further dropped to 28%, sustaining this reduction for more than 12 months. Mortality and mechanical ventilation duration did not change significantly (11.7%-9.4%, P = 0.12; and 8.16-4.8 d, P = 0.11, respectively).
Conclusions: Using quality improvement methodology and electronic health record-based clinical decision support tools, we successfully reduced hyperoxia rates among mechanically ventilated children in the pediatric intensive care unit. This initiative highlights the importance of standardized oxygen management and real-time staff reminders in improving care practices.

DOI: https://doi.org/10.1097/pq9.0000000000000849
Pediatrics. 2026 May 11. pii: e2025073479. [Epub ahead of print]

Sociodemographic Variability in Pediatric Emergency Decisions by AI.

Mahmud Omar, Reem Agbareia, Razi Abu Salah, Nicola Luigi Bragazzi, Donald U Apakama, Benjamin S Glicksberg, Bruce D Gelb, Emma Holmes, Girish N Nadkarni, Eyal Klang.

BACKGROUND AND OBJECTIVES: Large language models (LLMs) have the potential to support clinical decision-making in pediatric settings. However, whether they exhibit sociodemographic differences in clinical recommendations for similar clinical presentations is unknown.
METHODS: We analyzed sociodemographic variations in pediatric emergency recommendations from an ensemble of 10 LLMs, evaluating 500 validated standardized cases and 500 real clinical scenarios, totaling more than 3.7 million model outputs.
RESULTS: Significant deviations emerged, particularly for cases labeled with socioeconomic adversity, such as unstable housing or low family income. Although increased vigilance toward certain risk factors might be clinically reasonable, the magnitude and consistency of model recommendations were notably high compared with the physician-derived ground truth, especially for low-income and immigrant groups. Intersectionality involving Black race consistently intensified these differences. For example, cases labeled Black unhoused received substantially higher recommendations for urgent interventions (+10.5 percentage points [pp]; adjusted P < .001), additional investigations (+14.1 pp; adjusted P < .001), and suspicion of maltreatment (+26.6 pp; adjusted P < .001), even without clinical justification, compared with white or high-income cases. The LLMs also demonstrated clinical sensitivity to caregiver demographics, as expected. However, caregiver factors were associated with different recommendation patterns to a slightly lesser degree yet still showed significant variations and similar trends as child factors.
CONCLUSION: This suggests the models demonstrate differential sensitivity to sociodemographic factors that warrants further investigation to distinguish appropriate clinical sensitivity from potential bias. We suggest caution when interpreting LLM recommendations that incorporate sociodemographic identifiers, especially when based on limited early clinical information. Integrating explicit guideline-based safeguards and developing smaller, context-specific models may reduce these biases, ensuring safe and clinically appropriate pediatric care.

DOI: https://doi.org/10.1542/peds.2025-073479
J Trauma Acute Care Surg. 2026 May 15.

Trends in length-of-stay per total body surface area burn in pediatric patients: A report from the pediatric injury and quality improvement collaborative.

Columbus, Ohio

   BACKGROUND: Previous studies have shown that a length of stay (LOS) of one day per percent total body surface area (TBSA) burn is expected in children with burn injuries, with variability by mechanism. Recent practice has shifted towards earlier discharge and outpatient management. We predicted that an updated multi-institutional analysis of LOS/TBSA burn would demonstrate a downward trend.
METHODS: A retrospective study from five pediatric burn centers conducted between March 2022 and February 2025 of burn patient demographics and clinical course metrics. LOS/TBSA burn ratios were calculated and compared across multiple variables using χ2 and Kruskal-Wallis tests. p <0.05 was considered statistically significant.
RESULTS: Among 1,543 unique patients, 57.4% were male and the median age was 2.52 years [interquartile range (IQR), 1.32-7.1]. Burn etiology was most commonly scald burn (55.3%), as well as flame/fire-related burns (10.7%), and other mechanisms (34.0%). Most burns were small, with 56.0% of patients presenting with TBSA burn <5% and 27.4% of patients with TBSA burn 5% to 10%. Inhalation injury was rare (2.7%). Median LOS/TBSA for all burn patients was 0.6 days (IQR, 0.33-1.2). Patients with accidental injuries had significantly shorter median LOS/TBSA than those with nonaccidental injuries [0.61 d (IQR, 0.33-1.14) vs. 1.31 d (IQR, 0.50-2.31); p<0.001]. Median LOS/TBSA also varied significantly by mechanism of burn injury [cald 0.48 d (IQR, 0.29-0.88) vs. fire-related 0.90 d (IQR, 0.50-1.60) vs. other 1.00 d (IQR, 0.50-2.00); p<0.001].
CONCLUSIONS: Data from this multi-institutional cohort of pediatric burn patients reports updated burn injury demographics and establishes that the median LOS/TBSA burn is less than the previously established one-day/TBSA burn. Focus on earlier discharge and frequent outpatient visits likely decreased median LOS/TBSA. Factors such as nonaccidental etiology and fire-related burn led to higher predicted LOS/TBSA, and these families should be counseled accordingly. Total burn care delivered, rather than inpatient census, should be used to set standards for pediatric burn centers. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
LEVEL OF EVIDENCE: Level II.

Keywords:  Pediatric surgery; burn length of stay; burn surgery

DOI:  https://doi.org/10.1097/TA.0000000000005043
Turk J Emerg Med. 2026 Apr-Jun;26(2):26(2): 87-93

Pediatric blast injuries: Distinguishing features and unique challenges.

Charlie Joe Layoun, Eveline Hitti, Rachelle El Helou.

  Blast injuries are a major cause of morbidity and mortality in modern conflicts and terrorist incidents, placing children in particular danger in both combat and civilian settings. Pediatric blast trauma differs notably from adult presentations due to unique anatomical, physiological, and developmental factors. This review highlights the etiology, demographic distribution, and injury patterns in pediatric blast victims, emphasizing distinctions from adults and the implications for clinical management. Children are frequently injured in terrorism-related explosions, explosive remnants of war, and accidental incidents such as fireworks, with a consistent male predominance. Head injuries are more common and severe in children, reflecting larger head-to-body ratios, thinner skulls, and a lack of protective equipment. Ocular trauma, tympanic membrane rupture, and primary blast lung injury occur at higher rates than in adults. Abdominal trauma, though less frequent, contributes disproportionately to mortality due to thinner abdominal walls and larger solid organs. Extremity injuries are the most common overall, particularly upper limb amputations from unexploded ordnance and lower limb amputations from landmines. Burn and inhalation injuries, although less prevalent, are associated with markedly higher mortality in children compared to adults. Management poses unique challenges: pediatric airway anatomy predisposes to obstruction; permissive hypotension strategies used in adults are inappropriate; and surgical needs, including laparotomy and orthopedic interventions, are more frequent. Beyond the physical trauma, psychosocial consequences are profound and require early, age-appropriate support. Pediatric blast injuries, therefore, demand customized guidelines that address their distinctive injury patterns and management requirements, highlighting the need for pediatric-specific protocols in emergency medicine.

Keywords:  Blast injury; emergency management; pediatric trauma

DOI:  https://doi.org/10.4103/tjem.tjem_381_25
Front Med (Lausanne). 2026 ;13 1740700

Dexmedetomidine for acute respiratory conditions requiring non-invasive respiratory support in pediatric and adult patients: systematic review and meta-analysis of the literature.

Luisa Zupin, Lotte Wijers, Ludovica Barbi, Giorgio Cozzi, Francesca Foglia, Lorenzo Alvio De Luca, Filippo Pigani, Alessandro Amaddeo.

   Background: Dexmedetomidine is increasingly used as an anxiolytic and sedative in pediatric patients with acute respiratory distress for managing anxiety and agitation. However, its effectiveness and safety in the pediatric population remain unclear, and clinical practice is often guided by evidence derived from adults.
Aim: A systematic review was conducted to examine the evidence on the use of dexmedetomidine in patients undergoing non-invasive respiratory support (NRS) for acute respiratory conditions in both pediatric and adult individuals.
Methods: A comprehensive literature search was conducted on PubMed, Web of Science and Embase up to September 2025, evaluating dexmedetomidine in patients requiring NRS. The risk of bias was assessed using JBI's critical appraisal tools, and available comparative studies randomized controlled studies (RCT) were analyzed in a meta-analysis. Certainty was graded according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology.
Results: Ten studies evaluating dexmedetomidine in pediatric NRS were identified. While most studies suggested that dexmedetomidine may improve tolerance to NRS and reduce agitation, the pediatric evidence base consists mainly of observational studies without randomized trials, preventing a quantitative synthesis. Consequently, any direct comparisons with adult results cannot be directly extrapolated and should be considered strictly exploratory. Twenty-four studies (9 RCTs) were conducted in adult patients. The evidence from adult studies was more robust, showing that dexmedetomidine has the potential to reduce agitation, aid NRS acceptance, and decrease the need for intubation, as well as the incidence of delirium.
Conclusion: Current evidence supporting the use of dexmedetomidine in pediatric patients undergoing NRS is promising but remains insufficient. Findings from adult populations suggest that dexmedetomidine can effectively reduce agitation and may facilitate NRS acceptance in various conditions requiring respiratory support. However, future robust randomized controlled trials in pediatric patients are needed to determine efficacy, optimal dosing and safety in children with acute respiratory distress. These data will enable the development of age-specific guidelines and recommendations, ensuring a safer and more effective use.

Keywords:  acute respiratory distress; dexmedetomidine; non-invasive respiratory support; sedation; systematic review

DOI:  https://doi.org/10.3389/fmed.2026.1740700
MDM Policy Pract. 2026 Jan-Jun;11(1):11(1): 23814683261438831

Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study.

Courtney W Mangus, Sarah J Parker, Brian J Zikmund-Fisher, Anupam Kharbanda, Melissa Brooks, Helene M Epstein, Timothy C Guetterman, Emma Griffin, Aparna Joshi, Bryan Judge, Heather Orman-Lubell, Milisa Manojlovich, Brigid Rice, Gul R Sachwani-Daswani, Suz Schrandt, Karen Elizabeth Speck, Prashant Mahajan, Elizabeth M Schoenfeld.

  Background. Pediatric abdominal pain accounts for more than 1 million emergency department (ED) visits annually, and appendicitis is the most common surgical emergency. Guidelines recommend ultrasound as the initial imaging study for diagnosing pediatric appendicitis. However, because of the variability in both the availability and interpretation of pediatric ultrasounds in general EDs, clinicians may potentially overuse computed tomography (CT). Shared decision making (SDM) and clinical decision support (CDS) tools may help avoid unnecessary CTs; however, it is not clear to what extent such tools are used. Our objective was to describe the current diagnostic approaches and challenges faced by physicians in general EDs when assessing potential pediatric appendicitis. Understanding the nuances specific to this context may help inform the creation of more universally applicable diagnostic guidelines and CDS tools. Methods. We conducted semi-structured interviews with physicians practicing in general EDs to assess the current approaches and challenges in diagnosing pediatric appendicitis. We sought input on the use of existing CDS tools such as the pediatric appendicitis risk calculator (pARC) and the role of SDM. We analyzed interview transcripts using a thematic approach. Results. We conducted 15 interviews and identified 5 themes: 1) the limited availability of ultrasound often precludes routine use, 2) physicians tend to rely on gestalt over CDS tools, 3) guidelines regarding the transfer of patients to pediatric centers are needed, 4) the pARC could be improved with the integration of general ED-specific recommendations, and 5) physicians described using SDM frequently, but conceptualization and execution varied. Conclusion. Physicians in general EDs identified challenges in the current approaches to diagnosing pediatric appendicitis. A diagnostic pathway that incorporates validated CDS and general ED-specific recommendations could optimize the process, enhance SDM, and potentially reduce unnecessary CTs.
Highlights: Diagnosing pediatric appendicitis is challenging, especially in general EDs where pediatric resources are often limited.Physicians in general EDs reported that current imaging techniques and clinical decision support tools often fail to meet the needs of their setting.Physicians often rely on their own experience and often incorporate family preferences (via shared decision making) into their diagnostic planning.Physicians in general EDs reported that better guidelines and community-specific diagnostic algorithms and clinical decision support tools would improve patient care.

Keywords:  appendicitis; emergency medicine; shared decision making

DOI:  https://doi.org/10.1177/23814683261438831
JAMA Health Forum. 2026 May 01. 7(5): e261199

Mapping Meaningful Populations of Children With Special Health Care Needs.

Amanda K Gatewood, Makenzie Morgen, Jens Eickhoff, Jeffrey P Brosco, Amy J Houtrow, Paul J Chung, Reem M Ghandour, Shirley Payne, Ryan J Coller.

Importance: The heterogeneous population of children and youth with special health care needs (SHCN) has suboptimal health indicators. Subpopulations may have distinct health needs and indicators.
Objective: To identify distinct subpopulations of children and youth with SHCN and examine associations with policy-relevant health indicators.
Design, Setting, and Participants: Using pooled data from the nationally representative National Survey of Children's Health, latent class analysis identified subpopulations of children and youth with SHCN aged 0 to 17 years from 2019 to 2021. Weighted multivariable logistic regressions examined associations between class membership and 7 health indicators, adjusting for demographic and household characteristics. Data were analyzed from September 2023 to February 2026.
Exposure: Fourteen indicators reflecting health-related needs, functional limitations, and health care use were selected from the national survey by dual review.
Main Outcomes and Measures: Health indicators representing the 10 domains for a healthy life conceptual framework were selected by dual review. Seven indicators rated by a national expert panel as potentially modifiable and high impact were included.
Results: The National Survey of Children's Health had a sample size of 29 433 in 2019, 42 777 in 2020, and 50 892 in 2021. The estimated male population of children and youth with SHCN was 56% (n = 10 106 838), and the estimated female population was 44% (n = 7 920 925). A total of 19% (n = 3 332 877) were aged 0 to 5 years, 36% (n = 6 476 250) were aged 6 to 11 years, and 46% (n = 8 218 637) were aged 12 to 17 years. Among a weighted population of 18 027 763 children and youth with SHCN, 4 distinct classes were observed: low intensity (67%; n = 12 083 605), developmental and behavioral impacts (14%; n = 2 542 398), dynamic (13%; n = 2 349 486), and complex (6%; n = 1 053 274). Classes differed significantly in demographic characteristics and health indicator associations. The low-intensity class exhibited few health-related needs, little functional limitation, and minimal health care use. The developmental and behavioral impacts class exhibited predominantly functional limitations, while the dynamic class exhibited primarily health care use. The complex class exhibited substantial health-related needs, functional limitations, and health care use. Compared with the low-intensity class, the other classes had significantly lower odds of experiencing positive health indicators (household always able to provide basics: adjusted odds ratio [aOR], 1.51; 95% CI, 1.32-1.70; family demonstrates resilience: aOR, 1.31; 95% CI, 1.15-1.49; child received care when needed: aOR, 3.02; 95% CI, 2.44-3.74; child had adequate and continuous insurance: aOR, 1.94; 95% CI, 1.72-2.18; insurance covers mental and behavior health: aOR, 2.47; 95% CI, 2.19-2.77; no difficulty accessing specialists: aOR, 2.24; 95% CI, 1.87-2.70; no difficulties finding mental health treatment: aOR, 1.93; 95% CI, 1.62-2.30).
Conclusions and Relevance: This study identified 4 distinct subpopulations of children and youth with SHCN. The unique sociodemographic and health indicator associations for latent classes suggest that policies and programs may require tailoring to maximize efficiency and effectiveness across this otherwise diverse and heterogeneous pediatric population.

DOI: https://doi.org/10.1001/jamahealthforum.2026.1199
Acad Pediatr. 2026 May 07. pii: S1876-2859(26)00116-6. [Epub ahead of print] 103334

Disparities in health insurance and healthcare access for immigrant children with special healthcare needs.

Katherine E Douglas, Michael C Monuteaux, Katherine R Peeler, Ananya Tadikonda, Catherine G Coughlin, Julie M Linton, Lois K Lee.

   OBJECTIVE: Our objective was to examine healthcare access disparities for children and youth with special healthcare needs (CYSHCN), comparing immigrant and US-born CYSHCN.
METHODS: This was a cross-sectional, retrospective study of 2016-2022 National Survey of Children's Health data including CYSHCN. The primary exposure was child nativity. Primary outcomes were adequate health insurance, usual place for primary care, usual place for sick care, foregone medical care, and difficulty with referrals. We calculated descriptive frequencies and performed univariate analyses with the chi square statistic. We then estimated multivariable logistic regression models evaluating each of the five outcomes, adjusting for individual and state-level characteristics.
RESULTS: From 2016-2022, 62,391 US-born children and 1,733 immigrant children were identified as CYSHCN [population estimates: US-born 13,518,819 (19.5%), immigrant 462,757 (14.9%)]. Immigrant compared to US-born CYSHCN had higher rates of inadequate insurance, not having a usual place of primary care, and not having a usual place for sick care (p<0.001). In multivariable models, immigrant CYSHCN had lower odds of uninterrupted health insurance (aOR 0.57, 95%CI 0.37, 0.87), usual place for primary care (aOR 0.59, 95%CI 0.37, 0.92), and usual place for sick care (aOR 0.67, 95%CI 0.50, 0.89) compared to US-born CYSHCN. There were no statistically significant differences for foregone medical care or difficulty with referrals.
CONCLUSIONS: Immigrant compared to US-born CYSHCN in our study had worse access to health insurance, primary care, and sick care. Given the significant healthcare needs of CYSHCN, these health disparities must be addressed to improve their health outcomes.

Keywords:  children with special healthcare needs; disparities; immigrant health

DOI:  https://doi.org/10.1016/j.acap.2026.103334
J Am Acad Orthop Surg. 2026 May 14.

Trends of E-Scooter-Related Pediatric Orthopaedic Injuries: 20 Years of Nationally Representative Data.

Sarah Lu, Christopher J Williams, Isabella G Marsh, Patrick P Nian, Samuel A Beber, Shane Ross, Stephanie Logterman, Jessica H Heyer.

INTRODUCTION: The rise in popularity of battery-powered 2-wheeled electric scooters (e-scooters) has fostered safety concerns, particularly because of a lack of universally recommended safety precautions. Orthopaedic injuries are common in the pediatric population, yet little is known about the trends of e-scooter-related orthopaedic injuries in this population. The aim of this study was to investigate the national trends in orthopaedic injuries among children operating e-scooters over a twenty-year period.
METHODS: The National Electronic Surveillance System, a publicly available database of 102 emergency departments, was retrospectively queried for patients aged 0 to 21 years with an orthopaedic injury related to e-scooter usage between 2005 and 2024. Each case was assigned a sampling weight to produce nationally representative estimates. Linear regressions were used to calculate trends.
RESULTS: An estimated 55,653 pediatric orthopaedic injuries were reported during the study period. The weighted estimates of orthopaedic injuries related to e-scooter use had an upward trend from 2005 to 2024, with notable peaks in 2020 and 2024, which were paralleled by annual incident rates. The estimated average annual incidence rate was 204 injuries per 100,000 children per year. Most (65%) of the injuries occurred in male individuals. Children (aged 0-13) accounted for 63% of injuries, and adolescents (aged 14-21) accounted for 37% of injuries. Fractures were the most common injury (71.7%), followed by strain or sprain (25.2%). Most commonly injured anatomical areas were in the upper extremities, particularly the wrist (21.5%), forearm (15.6%), and shoulder (8.4%). Most (90.2%) of the injuries were treated and discharged on the same day.
CONCLUSION: Pediatric orthopaedic-related e-scooter injuries have increased over the past 20 years, with injuries occurring more commonly in male individuals and children sustaining mostly fractures and upper body injuries. As new technologies facilitating high-speed travel emerge, orthopaedic surgeons should be cognizant of the injuries associated with the new products.

DOI: https://doi.org/10.5435/JAAOS-D-25-01580
JAMA Surg. 2026 May 13.

Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial.

Mehul V Raval, Yao Tian, Willemijn Schäfer, Salva N Balbale, Mallory N Perez, Martha-Conley E Ingram, Alison Lehane, Charesa J Smith, Gwyneth A Sullivan, Audra J Reiter, Andrew Hu, Johanna M Borst, Sarah C Blake, Sharron Close, Teaniese L Davis, Bonnie S Essner, Kurt F Heiss, Lynn W Huang, Erin Wymore, Deysi Paniagua-Perez, Kirsty M Engelhardt, Peter M Graffy, Julie K Johnson, Craig W Lillehei, Brian W Gray, Seth D Goldstein, Scott S Short, Samir R Pandya, Janice A Taylor, Christopher Gayer, Adam B Goldin, Matthew M Boelig, Kristy L Rialon, Tim Jancelewicz, Aaron M Lipskar, Mubeen Jafri, Elisabeth T Tracy, Matthew T Harting, Jason P Sulkowski, P Benson Ham, Kaveh Vali, Robert A Cina, David T Schindel, Saleem Islam, Erin A Teeple, Sohail R Shah, Ankush Gosain, David H Rothstein, Megan A Brockel, Jillian Chown, Jane L Holl.

Importance: Despite evidence that enhanced recovery protocols (ERPs) improve outcomes in adults undergoing surgery, adoption for pediatric populations has lagged.
Objective: To assess the implementation and clinical effectiveness of a consensus-based ERP for pediatric patients undergoing elective gastrointestinal (GI) surgery.
Design, Setting, and Participants: A prospective type 2 hybrid implementation-effectiveness, stepped-wedge, cluster-randomized by entry date into implementation phase, trial of pediatrics patients, 10 to 18 years of age, undergoing elective GI surgery at 18 US sites from September 2019 to June 2024.
Interventions: Sites were randomized into 3 groups, each spending at least 9 months in a control phase, with usual care, followed by an implementation phase at 6-month intervals that included a 21-element ERP supported by a structured Implementation Toolkit, based on 5 Active Implementation Frameworks (5AIFs), and a sustainment phase (12-24 months). Implementation was facilitated by a 1-year, group-based Learning Collaborative curriculum, a repository of tools, ERP adherence feedback, and implementation report cards.
Main Outcomes and Measures: Site-level scores were created based on 5AIFs domains. ERP adherence was assessed by ERP elements delivered at patient and site level. The primary effectiveness outcome, postoperative length of stay (LOS), and secondary effectiveness outcomes (including opioid use, time to regular diet, complications, readmission, and patient-reported health-related quality of life [HRQOL]) were evaluated across study phases (baseline, implementation, and sustainability). Correlations between site-level implementation scores and fidelity were estimated.
Results: Of the 597 enrolled pediatric patients (median [IQR] age, 15 [13-17] years; 274 [45.9%] female; 323 [54.1%] male), 433 (72.5%) had inflammatory bowel disease. No significant differences were found by study phase in LOS or secondary outcomes, except shorter time to regular diet and decreased opioid use during hospitalization. Patients who received at least 13 ERP elements had shorter median LOS (-1.14 days [95% CI -2.01 to -0.27]) and fewer complications (adjusted odds ratio, 0.48 [95% CI, 0.28-0.82]). Patient-level adherence increased by study phase (number of ERPs: 11 [10-13], 14 [12-15], and 14 [13-15], [P < .001]). ERP integration into order sets and site culture were moderately correlated with fidelity.
Conclusions and Relevance: This stepped-wedge cluster-randomized trial found that despite multifaceted implementation strategies, a pediatric GI surgery ERP did not significantly reduce LOS. However, when accounting for implementation fidelity at the patient level, it resulted in significantly lower LOS and complications.
Trial Registration: ClinicalTrials.gov Identifier: NCT04060303.

DOI: https://doi.org/10.1001/jamasurg.2026.1382
Perspect Clin Res. 2026 Apr-Jun;17(2):17(2): 65-70

Clinical research in pediatric population: Scientific and ethical aspects.

Arun Bhatt.

  Children are a unique population with important differences in physical, physiological, and emotional differences from adults. Hence, research outcomes of studies conducted in adults cannot be extrapolated to pediatric population. However, there is scarcity of data on the safety and efficacy of new interventions in children, due to concerns about risks of research in children. It is vital to conduct scientifically robust and ethically sound observational noninterventional studies and interventional therapy clinical trials in children to provide supporting evidence for medical practices in the pediatric population, to advance understanding of diseases, and to provide quality health care. This is a brief review of scientific and ethical considerations in planning and conduct of clinical research in children.

Keywords:  Clinical research; ethics; new interventions; pediatric; risks

DOI:  https://doi.org/10.4103/picr.picr_144_25
Pediatr Infect Dis J. 2026 May 12.

Describing the Utility of Fungal Blood Cultures in Patients Hospitalized at a Large Pediatric Academic Center.

Lorenzo Chiusaroli, Mickael Boustany, Jean K Millimono, Jesse Blumenstock, Craig L K Boge, Morgan A Zalot, Brian T Fisher.

   BACKGROUND: Routine blood cultures (BCs) are frequently obtained in hospitalized children with suspected infection. Although bacterial pathogens are the primary concern, fungal infections remain a consideration in high-risk populations, prompting clinicians to order fungal blood cultures (FBCs) in addition to routine BCs. However, given the prolonged incubation time and labor-intensive nature of FBCs, their incremental diagnostic value beyond routine BCs is uncertain.
METHODS: We performed a retrospective, single-center study of hospitalized children aged 0-18 years at the Children's Hospital of Philadelphia between October 2015 and December 2022. Electronic health record data were used to identify all FBCs and associated BCs obtained during hospitalizations lasting ≥24 hours. Demographic and clinical characteristics, including admitting service, neutropenia status and presence of a central venous catheter, were collected. Culture results were grouped into diagnostic episodes by hospitalization. FBC results were compared with BCs obtained within 5 days to assess diagnostic yield and clinical utility, defined as identification of a unique organism leading to a change in clinical management.
RESULTS: A total of 540 FBCs were ordered for 244 patients across 159,563 inpatient admissions, representing 296 diagnostic episodes. Patients were predominantly male, non-Hispanic, and White, with 28.7% younger than 1 year. Most diagnostic episodes occurred in oncology, hematology, transplant, critical care or surgical settings; 25.3% involved patients with central venous catheters and 17.2% with neutropenia. Fifty-four FBCs were positive, corresponding to 22 diagnostic episodes (7.4%). Most positive cultures grew fungal pathogens, commonly Candida parapsilosis , Trichosporon asahii and Candida albicans . Only 1 FBC identified an organism not detected on routine BCs, and this finding did not alter the management.
CONCLUSIONS: Over 7 years, FBCs provided no additional clinically actionable information beyond routine BCs. These findings support diagnostic stewardship efforts to limit routine FBC use and clarify scenarios in which they may be beneficial.

Keywords:  children; fungal blood culture; hospitalized; invasive fungal infection; pediatric

DOI:  https://doi.org/10.1097/INF.0000000000005282
Kans J Med. 2026 Mar-Apr;19(Suppl 1):19(Suppl 1): 17

Pediatric Residents' Intubation Competency Through Simulation-Based Training: A Quality Improvement Initiative.

Roy Ghanem, Lukas Hall, Harsh Nathani, Sara Powell, Anton Rogachov, Robert Steele, Michael Nelson, Jacob Hunter, William Krogman, Christopher Plymire.

Introduction: Intubation is a critical skill in pediatric emergency medicine, yet many residents report limited procedural exposure. Simulation-based training provides a safe and structured environment to address this gap. Authors of this ongoing quality improvement (QI) initiative aimed to enhance pediatric residents' intubation skills through simulation-based assessment in partnership with the Department of Anesthesiology.
Methods: A total of 24 residents participated (Pediatrics = 17; Med-Peds = 5). Stage 1 of the QI initiative consisted of a didactic seminar led by anesthesiology residents, followed by a skills workshop with four stations: bag-mask ventilation (BMV), oropharyngeal/nasopharyngeal airway placement, laryngeal mask airway insertion, and endotracheal intubation. Outcomes included pre- and post-intervention multiple-choice examinations (MCQs), self-reported confidence surveys, and objective skills assessments evaluated by anesthesiology faculty. Primary outcomes were changes in knowledge, confidence, and intubation competency scores.
Results: Mean pre-MCQ scores were 11.75 (±3.2) out of 20, increasing to 16.4 (±2.8) post-intervention (p < 0.001). Skills assessment identified lower performance in LEMON assessment, head positioning, and BMV technique. Self-reported confidence in airway management increased from 3.6 (±2.1) to 7.2 (±1.5) (p < 0.001). Confidence in BMV improved from 5.7 (±2.3) to 8.5 (±1.7) (p < 0.01), and confidence in intubation increased from 3.5 (±1.9) to 7.0 (±1.4) (p < 0.001).
Conclusions: Stage 1 of this QI initiative improved both knowledge and self-reported confidence in pediatric airway management among residents. These findings suggest that simulation-based training may enhance short-term competency in pediatric intubation skills. Long-term skill retention will be evaluated in Stage 2 using a delayed post-intervention MCQ following a high-fidelity simulation session.

DOI: https://doi.org/10.17161/kjm.vol19.25386
Front Pain Res (Lausanne). 2026 ;7 1826942

Interventions to reduce pharmacologic opioid exposure in neonatal opioid withdrawal syndrome: a systematic review and meta-analysis of randomized studies.

Muhammad Ahmad, Ayoola Awosika, Chinenye Iguh, Wagma Khan, Neha Choudhary, Marya Aisha, Fatima Shaukat, Soura Rajeshwara, Maheen Zahid, Muneeba Shaukat.

   Background: Neonatal opioid withdrawal syndrome (NOWS) is increasingly prevalent and is frequently managed with pharmacologic opioid therapy, raising concerns regarding early-life opioid exposure and prolonged hospitalization. Interventions aimed at reducing pharmacologic exposure while maintaining safety have emerged, most notably care-model-based approaches. This study aims to systematically review the evidence evaluating interventions designed to reduce pharmacologic opioid exposure in neonates with NOWS compared with standard care.
Methods: A systematic review was conducted in accordance with PRISMA guidelines. PubMed/MEDLINE, Cochrane CENTRAL, and Google Scholar were searched from inception through the final search date. Randomized controlled trials, comparative observational studies, and quality-improvement studies evaluating exposure-reduction strategies were included. Interventions of interest primarily comprised care-model approaches such as Eat-Sleep-Console (ESC). Outcomes included duration of opioid therapy, cumulative opioid exposure, length of hospital stay, and safety outcomes. Due to substantial heterogeneity across studies, findings were synthesized narratively.
Results: Six studies met inclusion criteria, comprising three randomized studies and three observational or quality-improvement studies. Meta-analysis of randomized evidence showed ESC-based care significantly reduced hospital stay length (MD -6.50 days; 95% CI -9.63 to -3.36; p < 0.0001; I2 = 0%) and decreased opioid therapy duration (MD -3.06 days; 95% CI -3.74 to -2.38; p < 0.00001; I2 = 36%) compared to standard care. A subgroup analysis showed lower cumulative opioid exposure (MD -4.1 MME/kg; p = 0.001). Observational and quality-improvement studies consistently reported substantial reductions in opioid exposure and hospitalization following ESC implementation. Across all included studies reporting safety outcomes, no increase in adverse events or hospital readmissions was observed.
Conclusions: Care-model interventions emphasizing functional assessment and nonpharmacologic support-particularly the ESC approach-are associated with reduced pharmacologic opioid exposure and shorter hospitalization for infants with NOWS without compromising short-term safety. These findings support evolving guideline recommendations favoring exposure-reduction strategies in NOWS management.

Keywords:  eat–sleep–console therapy; neonatal abstinence syndrome; neonatal opioid withdrawal syndrome; pediatric pain; pharmacologic opioid exposure

DOI:  https://doi.org/10.3389/fpain.2026.1826942
Adv Nutr. 2026 May 13. pii: S2161-8313(26)00072-4. [Epub ahead of print] 100658

PEDIATRIC HEALTH AT THE CROSSROADS OF CLIMATE CHANGE, FOOD INSECURITY, AND MALNUTRITION.

Tindara Scirocco, Daniela Martini, Carlo Agostoni, Mario Raviglione, Stefano Bocchi, Cristiana Berti.

  Climate change poses a major global threat to the health of current and future generations, disproportionately affecting pediatric populations. Investigating the links between climate change and pediatric diseases is crucial to inform research and prevention strategies aimed at breaking the transgenerational cycle of social inequalities. This narrative review explores the complex interactions between early-life exposures to climate change, food insecurity, and malnutrition, and their impact on infectious and non-communicable diseases (NCDs) in pediatric populations. Data reveal a concerning global scenario: half of the world's children live in areas highly vulnerable to climate change; malaria, enteric, and lower respiratory-tract infections account for approximately 60% of the global communicable disease burden and related-deaths in children and adolescents; over 2.1 billion people under-20 suffer from NCDs; almost 865 million children under-15 experience moderate to severe food insecurity; and millions of children under-5 face stunting (150.2), wasting (42.8), or obesity (35.5). The greatest burdens fall on low- and middle-income countries and the most disadvantaged households. Although the causal pathways and mechanisms linking climate change to health outcomes have not been fully elucidated, epidemiological evidence shows that exposure from conception through adolescence increases risks of acute and chronic diseases, potentially altering lifelong health trajectories. This is plausibly driven by climate-induced disruptions in eco-agrofood systems, which compromise nutrition security and worsen malnutrition. Food systems are both vulnerable to and significant contributor to climate change, and poor dietary patterns further amplify disease burdens. Addressing these intertwined challenges requires a holistic approach promoting healthy, sustainable, and equitable diets from infancy through adolescence, and employing an integrated "glocal" strategy taking into account both global and local contexts. Cross-sector collaboration and targeted pediatric research are paramount to enhance understanding of causal pathways and develop effective interventions to safeguard child health and well-being within a planetary health framework. Statement of Significance This review critically examines how early life exposure to climate-related disruptions in eco-agrofood systems exacerbates the pediatric disease burdens. It also provides actionable insights to help guide research, policy, and actions tackling these interrelated challenges, focusing on the connection between climate change and the food environments, from a "glocal" perspective, ultimately protecting child health.

Keywords:  agroecology; breastfeeding; climate change; eco-agrofood system; food and nutrition insecurity; infectious diseases; malnutrition; non-communicable-diseases; pediatric populations; sustainable healthy diet

DOI:  https://doi.org/10.1016/j.advnut.2026.100658
JAMA. 2026 May 13.

A Pediatric Perspective on the 2025-2030 Dietary Guidelines.

Mary T Story, Anisha I Patel, Megan Elsener Lott, Marlene B Schwartz.

DOI: https://doi.org/10.1001/jama.2026.6696