Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Discharging a child from the emergency department can be a complex process and having a standardized discharge process can prevent harm to the child. A sentinel event at Boston’s Children Hospital in Massachusetts prompted a team at the hospital to create a quality improvement program with the goal eliminating serious preventable adverse events linked to discharge by February 2019. At the virtual 2021 Pediatric Academic Societies meeting, Niloufar Paydar-Darian, MD, attending physician at Boston Children’s Hospital, presented the results of the program.

The improvement program occurred at Boston Children’s Hospital, a 400-bed academic children’s hospital that has approximately 60,000 emergency department visits every year, which results in 80% of emergency department patients being discharged. The team used data from the data warehouse, safety event reporting system, and Press Ganey patient survey results. The program had 4 key drivers:

Ensure that parents felt equipped to provide care for the child at home

Promote communication between care team members

Completely reconcile all components or testing and treatment

Foster awareness of the value of high-quality discharge to the outpatient setting

To help parents be prepared to care for their child, the program created a “5 things to know before you go” handout that had 5 questions that parents should have the answer to: (1) what is the diagnosis; (2) what medications or treatments does the child need; (3) who should the child receive follow-up care from and when should this occur; (4) what reasons may require the child return to the emergency department; and (5) does the parent have any other questions. For fostering awareness, the program emailed out data and success stories from the program twice during the program as well as an initial marketing push.

To assist with care team communication, the program created a discharge checklist that was nicknamed ‘the golden ticket’ and has 3 sections: a doctor to-do list, a nurse to-do list, and a huddle meeting between doctor and nurse. The doctor to-do list includes writing any prescriptions, reviewing the discharge plan with the patient and the family, and printing discharge instructions. The nurse to-do includes removing medical equipment, asking if the patient or family has any questions, and reviewing medication administration. During the huddle, both should check for outstanding orders and vital signs within an hour of discharge and ensure that the patient name matches all instructions and prescriptions.

Over the course of the program, the discharge checklist was completed roughly 87% of the time, with initiation of the marketing and data sharing leading to spikes in completion. Before the program, the vital signs were assessed within 60 minutes of discharge 61% of the time. After the initiative, they were assessed 83% of the time. Although there was no change in how parents perceived discharge information as well as length of stay or 72 hour return visits to the emergency department, there have been no serious preventable safety events since April 2018.

1. Paydar-Darian N. Improving discharge safety in a pediatric emergency department. Pediatric Academic Societies Meeting 2021; May 4, 2021; virtual. Accessed May 4, 2021.

Articles

At the virtual 2021 Pediatric Academic Societies meeting, Niloufar Paydar-Darian, MD, attending physician at Boston Children’s Hospital, presented the results of a quality improvement program with the aim of eliminating serious preventable adverse events linked to discharge.

Improve discharge safety with a checklist

Adolescent pregnancy often leads to poorer outcomes for both the mother and child, in part due to the disruption in the mother’s education, which may lead to a lifetime of decreased earning ability. With infant outcomes, teenaged pregnancies are associated with increased risk of infant mortality, preterm birth, and low birthweight. Fortunately, the number has drastically decreased from its height decades ago. Catherine G. Coughlin, MD, a resident at Boston Children’s Hospital in Massachusetts, presented the results of a study that she along with a team of researchers had performed on the role of a teenaged mother’s attainment on infant outcomes at the virtual 2021 Pediatric Academic Societies meeting.

The team did a retrospective, cross-sectional analysis of live birth and infant deaths of teenagers aged 14 to 19 years and compared them to a cohort of women aged 20 to 24 years. They used data from the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research database. Age-appropriate education was defined as higher than 8th grade for girls aged 15 to 18 years and higher than 9th to 12 grade or a high school graduate for women aged 19 to 24 years. The examined outcomes were infant mortality rate in infants delivered at more than 37 weeks and death within the year after birth; an extremely preterm birth that occurs at less than 28 weeks’ gestation; and low birth weight in full-term infants.

In the cohort of 1,976,334 births, 11.1% of the mothers were adolescents. Two-thirds of the mothers were using public health insurance. Thirty percent were Hispanic and 43.3% were non-Hispanic White. Many of the mothers had at least 9th to 12 grade or high school graduate educational attainment. Some of the key findings that the team found was that non-Hispanic teenaged mothers had overall worse infant outcomes in extremely preterm birth, low birth weight in full term infants, and infant mortality rates. They also found worse outcomes in infant mortality and low birth weight in adolescent mothers who did not have age-appropriate educational attainment. No link was found between extremely preterm birth and age-appropriate educational attainment.

The team noted that social policies that target adolescent mothers’ education could lead to better outcomes in their infants. Those policies would also positively affect the mothers’ financial prospects.

1. Coughlin C. Infant outcomes among teenage mothers: racial inequities and the role of educational attainment. Pediatric Academic Societies Meeting 2021; May 4, 2021; virtual. Accessed May 4, 2021.

Pregnancy in adolescence can lead to poorer outcomes in both mother and child. An investigation presented at the virtual 2021 Pediatric Academic Societies meeting looks at how educational attainment could impact the outcomes.

Examining factors in teen pregnancies that lead to poorer infant outcomes

Dr Farber is a pediatrician in Woodbridge, Virginia.

The ethics of the clinical application of predictive testing for infants at high risk for autism spectrum disorder (ASD) are still unclear, according to a recent report. Given that a predictive test for ASD does not allow for immediate treatment, the benefits of testing are questionable.

However, an immediate benefit may be relief from parental anxiety caused by uncertainty or, when results are positive, targeted access to intervention, such as frequent monitoring for emerging ASD symptoms and enrollment in individualized behavioral intervention as soon as development begins to diverge from the norm. On the negative side, behavioral intervention could pose logistical or financial burdens on families. In addition, societal harm could result from introducing children who had received a predictive ASD diagnosis into an already highly stressed service system. The authors also noted that the relative weight of the benefits and harms of ASD prediction vary with the different perspectives and priorities of parents, clinicians, investigators, and neurodiversity advocates. What is clear, however, is that efforts to develop and evaluate predictive testing for infants at high risk for ASD are ethically warranted.

For those who believe that ethical early diagnosis issues apply only to conditions such as Huntington disease, or that early intervention is a no-brainer, this article is food for thought. Because in most instances a prediagnosis of autism will be far from certain, I will still stick with careful monitoring and referral once delays are noted.

1. Wolff J, Piven J. Predicting autism in infancy. 

Journal of the American Academy of Child & Adolescent Psychiatry

. November 5, 2020. Epub ahead of print. doi:10.1016/j.jaac.2020.07.910

Is there value in predictive testing for autism spectrum disorder (ASD)? A study examines the ethics.

Predictive testing for ASD: Should it be done and for whom?

Both pediatricians and parents can breathe a sigh of relief: The US Food & Drug Administration (FDA) is about to authorize use of the Pfizer-BioNTech COVID-19 vaccine for adolescents aged 12 to 15 over the next several days, according to federal officials.

The news means not only that millions more Americans can get vaccinated, but the goal of reaching herd immunity can be attained even more quickly. It also means that children in this age group would be able to be fully immunized for the 2021 summer as well as for the beginning of the school year 2021-2022.


The US Food & Drug Administration is about to authorize use of the Pfizer-BioNTech COVID-19 vaccine for children aged 12 to 15 years old.

The FDA plans to authorize Pfizer-BioNTech vaccine for children aged 12 to 15 years

Julia Reading, medical student at the David Geffen School of Medicine at UCLA in Los Angeles, California started her session at the 2021 Pediatric Academic Societies virtual meeting with a definition of ACEs. She noted they were stressful and often traumatic experiences that included abuse, neglect, and house challenges, are associated with poor health outcomes

 and that despite what this could mean in terms of public health implications, screening is still not a widely adopted practice for these experiences. 

For this study, individual phone interviews were conducted, questions adapted from previous surveys and barriers, and structure was adapted from prior semi-structured interviews on social risk.

 Process flow diagrams were made for each physician's ACEs screening workflow and overall groupings according to guidelines from the Institute for Healthcare Improvement.

The aims of the study were to describe common ACEs screening workflow processes; provide examples of clinical ACEs screening workflows; and look at key informant interview study design.

The common workflow elements consisted of patient check in; question delivery (either verbally or via questionnaire by a patient portal or clinical staff at visits); and questions answered. Results included screenings based on predetermined protocolized criteria (ie, score and/or presence of symptoms) as well as primary provider intervention on an ad hoc basis, based on individual factors. The study noted substantial variations in these screening workflows, with protocolization hinging on factors that included availability of administration; beliefs about patient risk; availability of support staff; and intervention resource accessibility. 

It was also noted that almost all participants conducted a screening at preventive care visits, with more than a third adding a screening if relevant symptoms were reported (using either the Adverse Childhood Experiences Questionnaire (ACE-Q) or the Pediatric Adverse Childhood Experiences abnd Related Life-Events Screener (PEARLS).

The study concluded that ACEs screening workflow variations is largely a result of differences in intervention thresholds as well as access to intervention resources. It also noted that successful screenings can be accomplished regardless of the degree of workflow protocolization; and workflows should be tailored to the needs and limitations of an individual practice.

References
1. Bethel CD, Solloway MR, Guinosso S, et al. Prioritizing possibilities for child and family health: an agenda to address adverse childhood experiences and foster the social anbd emotional roots of wellbeing in pediatrics. 

 2017;17(7s):S36-S50. doi:10.1016/j.acap.2017.06.002
2. Bodendorfer V, Koball AM, Rasmussen C, et al. Implementation of the adverse childhood experiences conversation in primary care. 

 2020;37(3):355-359. doi:10.1093/fampra/cmz065
3. Hamity C, Jackson A, Peralta L, Bellows J. Perceptions and experience of patients, staff, and clinicians with social needs assessment. 

 2018;22:18-105. doi:10.7812/tpp/18-105.
4. Institute for Healthcare Improvement. Accessed May 3, 2021. http://www.ihi.org/resources/Pages/Tools/Flowchart.aspx

Adverse childhood experiences (ACEs) are associated with poor health outcomes over the course of a life, but there is still little information on clinical workflows to guide these implementation practices. At the virtual 2021 virtual Pediatric Academic Societies meeting, Julia I. Reading discussed models and variations in ACE screening workflows.

A study of pediatrician's adverse childhood experiences screening workflows

A trip to the grocery store will clearly illustrate the increasing number of processed foods available with new types of cookies, crackers, and other snacks seeming to pop up every week. These foods are specifically engineered to be as tempting as possible, but consuming a lot of them has been linked to adverse physical outcomes in children. A 

Journal of the Academy of Nutrition and Dietetics

 looked at children’s school lunches and snacks to see how much of it is processed as well as whether an intervention could reduce the amount of processed foods a child takes to school.1

The investigators looked at children in 3rd and 4th grade in public elementary schools in Massachusetts. The Great Taste Less Waste program is a 22-lesson classroom curriculum that also includes homework activities, school-wide announcements, food demonstrations, and a poster contest for the children. For parents, the program includes a monthly parent newsletter as well as a food shopping and packing guide. Photos of food were used to estimate the calorie content of the foods children brought to school. The food was also assigned to a processing level: less processed or unprocessed, moderately processed, or highly processed.

A majority of the food that children brought to school was considered highly processed and accounted for 70% of the food energy. Snack foods and desserts provided the greatest percentage of total energy in the highly processed category at both baseline and follow-up (72% and 69%, respectively). When compared to food meant for lunchtime such as sandwiches, items that were brought in for snacks were more highly processed. The intervention appeared to have no significant differences between consumption before the intervention and after it with the percentage of energy that was from processed foods in adjusted models (β: −1.1, standard error: 2.2, 

Investigators concluded that processed food was very prevalent in food brought to school, particularly with snack food choices; this continued even after an intervention. They urged further research into identifying strategies that can improve the healthfulness quality of foods brought for lunch and snack. Until those strategies are determined, clinicians can discuss good nutrition habits at well-child visits and why processed foods should not be a common part of a child’s diet.

Blondin S, AlSukait R, Bleiweiss-Sande R, Economos C, Tanskey L, Goldberg J. Processed and packed: how refined are the foods that children bring to school for snack and lunch?. 

. 2021;121(5):883-894. doi:10.1016/j.jand.2020.07.017

Processed foods have continued to be a big part of the everyday diet, even with research showing how unhealthy they are. A study examines how much processed food ends up in a child’s lunch and school snacks.

How processed are children's lunches?

Food allergies can develop in individuals at any age, although many develop during childhood. Milk, eggs, peanut, tree nuts, fish, shellfish, soy, and wheat make up approximately 90% of food allergies in the United States. The National Institute of Allergy and Infectious Diseases (NIAID) defines food allergy “as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food.”

 Approximately 8% of children and adolescents in the United States have food allergies, and the incidence continues to grow.

 Between 1997 and 2007, food allergies increased by 18% in individuals 18 years or younger,

 and in 2006, 88% of schools had at least 1 student with a food allergy.

When assessing patients for food allergies, the pediatrician should remember that patients reporting a food allergy are far more common than challenge-confirmed food allergy, that food allergies are more common in children and those with atopic diseases, and that a small number of foods account for the great majority of food allergies.

Patients are frequently referred to pediatric allergists due to concern that a food might have caused a particular set of symptoms. Common complaints include rash, rhinitis, itchy mouth, loose stools, and/or abdominal pain. It is important to realize that imunoglobulin E (IgE)-mediated food allergy will almost always elicit a response within 2 hours after food ingestion and is reproducible when that type of food is consumed again. For instance, if a rash develops when a patient drinks milk, then a thorough dietary history should include what other types of dairy the patient consumes. If the patient is eating cheese, yogurt, or ice cream without symptoms, then milk allergy can be eliminated from the differential diagnoses.

Another situation is confusion around lactose intolerance and milk allergy. If a patient can tolerate lactose-free cow milk, they are not allergic because the milk protein is still present. A reaction consisting of hives, swelling, vomiting, severe abdominal pain, coughing, wheezing, and other IgE-mediated symptoms is concerning for true food allergy. It is important that patients with a history of a reaction concerning for food allergy see an allergist promptly, especially when milk or egg is presumed to be the culprit. These patients often can tolerate extensively baked products that have milk or egg as ingredients, so a thorough review with an allergist can determine if and when the patients can tolerate these products.

Patients also are commonly referred for consultation following food exposure with complaints of rhinitis. There are no published studies of food allergy presenting with rhinitis symptoms alone. There is no evidence of IgE-mediated food-induced rhinitis symptoms without anaphylaxis with whole-body symptoms (ie, hives, difficulty breathing, or diarrhea); therefore, there is no indication to test for food allergens in patients presenting with rhinitis symptoms.5 Furthermore, there is no reason to eliminate a food a child has been eating and tolerating regardless of specific IgE level or skin prick test results.

Serum IgE levels for an indiscriminate panel of foods should never be drawn when evaluating food allergy. A thorough history that includes foods ingested, timing of symptom onset in relation to the food, symptoms, symptom duration, and subsequent exposure to the food should be obtained. If the patient has been able to tolerate a normal amount of the food following the reaction, food allergy can be eliminated. The misinterpretation of IgE levels often leads to the inappropriate avoidance of a food, which may lead to the development of true IgE-mediated food allergy. Although food-specific IgE levels and skin prick testing can be useful, it is important to recognize that the gold standard for determining if a patient has a true food allergy is ingestion of the food. If it is tolerated without reaction, there is no food allergy and any positive testing results are false positives.

Social media has had positive and negative aspects in the realm of food allergy. Social media allows patients and families to connect with one another to share their experiences, swap recipes geared toward those with food allergies, and find support. However, it also allows for open discussion of food allergy and food sensitivity in which information presented might not be evidenced based or accurate. Advertising for IgG (not IgE) testing has led to inappropriate food allergy testing and unnecessary food avoidance. IgG is a marker of exposure, and one would not be surprised to find that foods that are routinely consumed have detectable IgG values. An elevated IgG value has no role in diagnosing food allergy. IgE or skin prick testing is used to bolster the evidence that there was a particular food responsible for the symptoms that are compatible with allergy; it cannot be used by itself to make the diagnosis of a food allergy. The overuse of serum IgG testing for dietary guidance can lead to unnecessary avoidance of foods, which may lead to nutritional deficient dietary practices, a big concern in a growing child.

Perhaps the newest breakthrough in the area of food allergy over the past year has been the US Food and Drug Administration approval of Palforzia, an oral immunotherapy product aimed at reducing the severity of reactions to peanut exposure among individuals with a peanut allergy. Although there are allergists across the United States who offer oral immunotherapy for various foods, these are typically not covered by insurance and cost can be a barrier. Whereas Palforzia is not a cure for peanut allergy and does not allow an individual to eat peanut ad lib, it is another option for managing food allergies. With the advancements over the past few years in food allergy, such as recommendations about early peanut introduction in infants at higher risk of developing peanut allergy, patients should be evaluated by an allergist who keeps abreast of the latest developments in the field.

1. Boyce J, Assa’ad A, Burks AW, et al; NIAID-Sponsored Expert Panel. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. 

 2010;126(suppl 6):S1-S58. doi:10.1016/j.jaci.2010.10.007

2. Branum AM, Lukacs S. Food allergy among U.S. children: trends in prevalence and hospitalizations. 

3. O’Toole TP, Anderson S, Miller C, Guthrie J. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006

. 2007;77(8):500-521. doi:10.1111/j.1746-1561.2007.00232.x

4. Stapel SO, Asero R, Ballmer-Weber BK, et al. Testing for IgG4 against foods in not recommended as a diagnostic tool: EAACI Task Force Report. 

 2008;63(7):793-796. doi:10.1111/j.1398-9995.2008.01705.x


With the incidence of food allergies continuing to go, understanding the diagnostic process and available treatment is important.

The Dx and Rx of food allergies

Last week the International Society for Vaccines hosted it’s fifth COVID-19 vaccine update in its Virtual Congress. The latest update looked at vaccines being produced in China by 3 companies: CanSino Biological, Sinopharm CNBG, and Sinovac Biotech, Co., Ltd.

The CanSino vaccine is a recombinant adenovirus 5 vector based COVID-19 vaccine. The data was in participants aged 18 years and older and 28 days after the vaccination was received. Efficacy was 65.28 for symptomatic cases and 90.07 for severe cases. Adverse reactions seen include lethargy, fever, headache, nausea, diarrhea, vomiting, myalgia, pain, swelling, and redness. The average duration of the reaction 2 days, except for fever, which was 1 day. No serious adverse events were found. No statistically difference in the incidence of medically attended adverse event was seen between the vaccine and placebo groups. The vaccine appears to be quite effective against variants, although more research needs to be done with the South African variant. The company is currently running a trial in children and adolescents.

The Sinopharm CNBG is an inactivated vaccine. The active component is inactivated severe acute respiratory syndrome coronavirus 2 virus and the adjuvant used is aluminum hydroxide. Its dose is 6.5U/dose and it comes packaged in a prefilled syringe that should be stored at 2 to 8 degrees Celsius with an efficacy of around 72 in adults aged 18 and older. The majority of adverse events were grade 1 and the placebo group had higher incidence of grade 1 adverse events. Some adverse events were erythema, pain, and swelling at the injection site; fever; and fatigue. Pain at the injection site was the most common event after dose 1. Serum samples indicate that the vaccine has good cross-neutralization abilities for fighting variants. A trial has been completed in children aged 3 to 17 years and will start the approval process soon.

The Sinovac Biotech, Co., Ltd. vaccine called CoronaVac is also an inactivated COVID-19 vaccine. Its research and development started in early 2020 and Phase III trials started in Brazil on July 21, 2020. Other countries for the Phase III trial included Turkey, Indonesia, and Chile. Participant were either general population, medical staff, or a mix of both. The efficacy of the vaccine was found to be 50.65% in Brazil, 83.5% in Turkey, and 65.3% in Indonesia. Efficacy for hospitalized cases was 100%. The most common adverse events were pain at injection site, headache, fatigue, and myalgia. The vaccine has been approved for emergency use by 40 authorities and 180 million doses have been given globally. Vaccine trials for CoronaVac will be starting soon in children.

1. International Society for Vaccines. 5th COVID-19 Vaccine Update; April 27, 2021; virtual. Accessed May 4, 2021.

The International Society for Vaccines (ISV) presented its fifth update on COVID-19 vaccines around the world. This update focused on vaccines produced in China.

ISV COVID-19 vaccine update highlights Chinese vaccines

The Pediatric Pharmacy Association (PPA) is the leading pharmacy association dedicated to pediatric pharmacy practice. Due to the COVID-19 pandemic, its annual conference was held virtually. Below is a brief synopsis of some of the pertinent presentations.

The KIDs list: Key potentially inappropriate drugs in pediatrics


The KIDs List (key potentially inappropriate drugs in pediatrics) was published in 2020 by a panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association to raise awareness of medications and excipients that should be used cautiously, monitored, or avoided altogether in specific pediatric age groups. Primary, secondary, and tertiary literature; US Food & Drug Administratin (FDA) Pediatric Safety Communications; electronic drug reference database; and product information was evaluated and rated using predefined criteria. This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients.

Dr Seerat Kapoor, PharmD and her colleagues Dr Kelly Bobo, PharmD; Dr William Mabry, PharmD; and Dr Dhyana Naik, PharmD from Le Bonheur Children's Hospital in Memphis, Tennessee, were awarded the PPA Best Practice Award for their work on Integration of the KIDs List with Formulary Management and Clinical Decision Support in a Freestanding Children’s Hospital. The purpose of their project was to review existing alerts for congruency with the recommendations in the KIDs list and identify changes that needed to occur to maximize patient safety. Using the Plan, Do, Study, Act process, the team evaluated current practices and then worked with their institution's medication committees to make inventory modifications, modify dose ranges, and develop pharmacy and provider alerts within their electronic medical record system. Ultimately, 23 interventions were made to reduce potential for patient harm.

Vaccine recommendations and updates for 2021


Vaccine recommendations are reviewed by the Advisory Committee on Immunization Practices (ACIP) annually; however, in 2020, ACIP met 14 times due to the continuous changes with the COVID-19 pandemic. This year, Dr Lea Eiland, PharmD, from the Harrison School of Pharmacy at Auburn University in Meridian, Mississippi, presented the changes most likely to affect providers and pharmacists caring for pediatric patients.

HPV vaccine updates
This year, special comments were added to state that if the human papillomavirus (HPV) series is interrupted, the series does not need to be restarted.

Flu vaccine updates
The live attenuated influenza vaccine (LAIV) abbreviation was changed to LAIV4.
Special situations were also updated to include guidance for administering the flu vaccine in patients with egg allergy who have symptoms other than hives and information on severe allergic reactions.

Hepatitis B vaccine updates
Clarification was provided on when to administer the Hepatitis B vaccine in infants < 2kg. Instructions now state to give 1 dose of the Hepatitis B vaccine at chronical age of 1 month or upon hospital discharge (whichever is earlier and even if < 2kg).

In addition to these updates, Dr Eiland discussed vaccines on the horizon, including the PCV-15, PCV-20, and the much anticipated pediatric data on administration of the COVID-19 vaccine in children as young as 6 months of age that are expected to be reviewed and disseminated in Fall 2021.

To combat the impact of moving many ambulatory care services to telehealth in 2020 for social distancing, the Public Readiness and Emergency Preparedness Act (Prep Act) has also been amended to allow more individuals to be vaccinated by pharmacists. As of September 2020, pharmacists and pharmacy interns (depending on state law) can administer FDA-approved vaccines to children aged 3 years and older per ACIP recommendations, with some states allowing vaccine administration by pharmacists to patients as young as 6 months.

Shortening duration of therapy for pediatric infections


Antimicrobials are the most common class of medications prescribed to pediatric patients. A common question prescribers face is how long to treat various infections. Antimicrobial stewardship efforts within pediatrics often focus on appropriate short courses of antibiotic therapy which are crucial to reducing antimicrobial overuse in these patients. Current literature has evaluated short-course antibiotics for the treatment of many pediatric infections, including community acquired pneumonia (CAP), urinary tract infections (UTI), skin and soft tissue infections (SSTI), ventilator-associated tracheitis (VAT), and uncomplicated bacteremia. In their presentation, Drs. Aimee Dassner, PharmD, at Children's National Hospital in Washington, DC; and Karisma Patel, PharmD, Children's Medical Center, Dallas, Texas, reviewed the many benefits of shortening antimicrobial courses and while providing an overview of the recent literature examining antimicrobial duration in common pediatric infections.

Compared to recently published literature, most of the current Infectious Diseases Society of America (IDSA) and American Academy of Pediatrics (AAP) guidelines for common pediatric infections recommend longer durations. For example, recent literature suggests clinicians may successfully treat CAP with 5 days of antibiotic therapy and complicated UTIs with 7 days of therapy as compared to guideline recommendations of 10 and 14 days, respectively. For VAT, prolonged courses have not been shown to reduce development of hospital-acquired pneumonia/ventilator-associated pneumonia (HAP/VAP), and thus, prescribers are encouraged to use shorter durations in these patients. When evaluating patients with uncomplicated bacteremia, the consensus is shorter durations will mitigate the need for central lines which introduce another risk of infection. An exception to this is with skin and soft tissue infections (SSTI), where antibiotic durations tend to exceed that of what guidelines recommend.

Don’t take the risk, learn about MIS-C: Pharmacologic treatment strategies for MIS-C


The COVID-19 pandemic has been a constant factor in the healthcare setting and the world over. Thanks to global collaborations, evidence has been shared and disseminated, though there are frequent updates and changes as more data are collected and reported. Dr Sarah Parsons, PharmD, Children's Hospital of The King's Daughters, Norfolk, Virginia; Dr Van Tran, Pharmacy Manager, CVS Health, Pikesville, Maryland; Kelli Crowley, PharmD, University of Pittsburgh School of Pharmacy, Pennsylvania; and Dr Alexandra Kibler, PharmD, UPMC Children's Hospital of Pittsburgh, Pennsylvania, provided a comprehensive review of the coronavirus diagnosis, pathways, and pharmacologic management of this viral disease. Identified mainstays of therapy include dexamethasone and remdesivir. An interesting fact with remdesivir is the powder is supposed to be utilized (versus the solution) in patients weighing less than 40kg due to the amount of sulfobutylether-β cyclodextrin (SBECD) in the solution. This compound can accumulate in patients with impaired renal function of < 50 mL/min, which can cause liver necrosis and obstruct renal tubules. Regrettably, the level and quality of evidence to support these treatments, as well as other therapies such as tocilizumab are weak and limited, and many other medications are not recommended due to a lack of perceived benefit.

Multi-Inflammatory Syndrome in Children (MIS-C) has been reported since April of 2020 with 99% of cases testing positive for the COVID-19 virus and is often diagnosed between 1 and 6 weeks post-acute COVID-19 infection. More than 3100 cases have been tracked by the CDC, with 63% of MIS-C diagnosed patients described as Black or Hispanic race, and ages ranging from infants through adults (median age: 9 years). Treatment options that have reasonable evidential support include immune globulin (up to 2g/kg), low-dose (1-2mg/kg/day) and high-dose (30mg/kg/day) methylprednisolone, with consideration given to high-dose anakinra (

 4mg/kg/day) for high-dose steroid-refractive MIS-C. Low-dose aspirin is also indicated in these patients for cardiac considerations, while enoxaparin or heparin should be administered in patients who meet specific requirements.

Caring for the chronically critically ill child: A new conundrum


Dr Katie Hughes, PharmD in Mount Juliet, Tennessee; and Dr Pete Johnson, University of Oklahoma Health Sciences Center College of Pharmacy, Oklahoma City, closed out the meeting with some key insight into this challenging patient dynamic. Chronic critical illness in pediatrics lends itself to unique and often complex situations where competing interests frequently occur. A prime example of this is incorporating preventative medicine while managing a myriad of multifaceted medical and pharmacologic interventions. One commonly forgotten area of care is addressing vaccinations in these children as they are likely to have fallen behind on their vaccine schedule. Fortunately, the ACIP has a catch-up schedule for patients with evidence-based accelerated timelines for multiple vaccines, including the common ones administered in the first year of life as well as live vaccines. It’s important to remember that some medical interventions require a particular period of time to elapse before vaccinating in order to achieve optimal antibody development. Corticosteroids administered at prednisone-equivalent doses of ≥2mg/kg or ≥20mg/day, IVIG administration, and blood transfusions require adjustments to vaccination schedules as they can all decrease the immunologic response and result in reduced coverage of preventable diseases.

A second key point involved the management of iatrogenic withdrawal symptoms (IWS). It’s likely that chronic critically ill patients will receive extensive pain and sedation medications over the course of their stay. Once they are stable enough to reduce and eventually stop these agents, the optimal method for weaning and discontinuation remains elusive. Many factors, including duration of therapy, cumulative doses, use of neuromuscular blockade, and younger age, need to be considered when developing tapering plans. Appropriately identifying withdrawal in infants and younger patients can be difficult to separate from what would be normal functions, such as irritability or short gut syndrome and diarrhea. Regardless, standardized protocols are recommended to both reduce exposure to and time on these therapies.

A look at the highlights from the 30th annual Pediatric Pharmacy Association meeting.

Highlights from the 30th Pediatric Pharmacy Association Meeting

A quality improvement initiative of 2 interventions showed that documenting the use of sleep hygiene for sleep disturbances in children with neurodevelopmental disorders (NDD) improves adherence to evidence-based sleep hygiene strategies. Parents were given a screening questionnaire related to the child’s sleep and embedding prompts in the electronic medical record (EMR) to guide assessment.

In the first intervention, 144 parents completed the BEARS sleep screening tool (bedtime issues, excessive daytime sleepiness, night awakenings, regularity and durations of sleep, and snoring), which was adapted for this population to help identify patients with sleep disturbance. Sleep hygiene was considered documented if the provider used the term or documented behaviors or environmental conditions pertaining to sleep. In the second intervention, 2 evidence-based SmartPhrases were embedded within the EMR system. The first SmartPhrase was used during history collection in response to positive answers on the BEARS screening tool and contained evidence-based prompts to guide the assessment. The second intervention inserted individualized, evidence-based strategies for sleep hygiene into the patient instruction section of the discharge summary.

Investigators compared EMR data after implementation of the practice change with the same data obtained before implementation 13 weeks earlier. In the 6 months before implementation, 44 patients had received diagnoses of sleep disturbance, insomnia, or behavioral insomnia in the EMR. Sleep hygiene was documented in 27% of the identified charts. After the interventions, the number increased, with 53 patients’ having received 1 of the 3 diagnoses. Sleep hygiene documentation in the EMR of identified patients nearly doubled. The postimplementation query also found a 55% increase in documentation of sleep hygiene when melatonin was initiated. Of those patients prescribed melatonin for the first time, 100% had documentation for sleep hygiene.

As much as I appreciate melatonin, which has been a boon for many parents of children with NDD, we should not necessarily jump to it as the first approach. This study is a reminder to look at traditional sleep hygiene techniques (eg, bedtime routine with a wind-down, turning off electronic devices) before advising medication.

1. Hosley S, Fortney C, Harrison T, Steward D. Documentation of sleep hygiene with melatonin use in management of sleep disturbance in children with neurodevelopmental disorders: a quality improvement project. 

. February 3, 2021. Epub ahead of print. doi:10.1016/j.pedhc.2020.11.011

A study examines the efficacy of using documentation to improve sleep treatment.