Pediatrics Commons^™

Drug Metabolizing Enzymes And Transporters May Help Determine Effective Budesonide Dosing In Eoe, Laurie Mccann, Lisa Harvey, Norah Almahbub, Wendy Y. Wang, Erin C. Boone, Janelle R. Noel-Macdonnell, Rachel Chevalier

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Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder diagnosed in children with painful or difficult swallowing, vomiting, or poor weight gain.  Current treatment models adopt a trial-and-error approach in regard EoE treatment, including restrictive elimination diets, proton pump inhibitors, and topical budesonide. This approach can delay effective treatment which increases risk of disease progression and increases medical costs to families for frequent clinic visits and endoscopy.   Objectives/Goal: The objective of this study is to determine the CYP3A5 genotype and expression of patients with eosinophilic esophagitis to discover which patients will respond to standard dosing of topical budesonide treatment (1, …

Concern For Authenticity In Rational And Relational Autonomy, Joshua J. Daniel, Abram Brummett, Mark C. Navin, Jason A. Wasserman

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The four principles of bioethics described by Beauchamp and Childress are beneficence, nonmaleficence, justice, and autonomy. Two definitions of autonomy are very commonly used: rational autonomy, which refers to a patient making decisions based on their own beliefs and customs, and relational autonomy, which refers to shared decision making with the input of a patient’s close trusted individuals. Beauchamp and Childress described autonomous actions as those with intention, understanding, and lack of controlling factors. A fourth component that is sometimes included is authenticity, or making decisions true to one’s self. The primary goal of this study is to determine whether …

The Meaning Of Pediatric Assent: A Critical Scoping Review, Natalie Liogas, Amelia Najor, Jason Wasserman, Stephanie Swanberg, Abram Brummett, Naomi Levanthal

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The moral obligation to include children and adolescents in medical decisions has been long recognized. Soliciting pediatric assent is a component essential to this effort. Despite the AAP characterization of assent (AAP 1995; AAP 2016), there appears to be a lack of consensus regarding the operational and conceptual meanings of pediatric assent. This this critical scoping review provides an analysis of the varied meanings of pediatric assent in the clinical context.

Pediatric Assent In Clinical Practice: A Critical Scoping Review On The Ethical Justifications For Assent, Amelia Najor, Natalie Liogas, Jason Wasserman, Stephanie Swanberg, Abram Brummett, Naomi Laventhal, Mark C. Navin

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Pediatric assent is an important ethical construct, yet there is little agreement on what precisely it means, including the ethical justifications for assent. The term is used to indicate everything from acquiescence to an analogue of informed consent itself. The primary goal of this study is to assess the range of ways that pediatric assent is specified in the clinical ethics literature, as well as what different conceptions intimate about its moral value. This systematic review will summarize the normative claims about pediatric assent in recent literature. Analysis will map divergent constructs and various moral and ethical justifications for pediatric …

Who’S My Child’S Main Doctor?​ Caregiver Perceptions Of Teaching Teams, Jonathan Ermer, Shelby Chesbro, Jessica Boerner, Jacqueline M. Walker, Joy L. Solano

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Background: At academic medical centers, children are cared for by large medical teams consisting of multi-level learners including medical students, interns, senior residents and fellows on patient-and family-centered rounds (PFCR). The size and structure of these teaching teams can make it difficult for patients and families to know who is caring for them and establish a trusting relationship. Also, research has shown when residents are perceived as a “team leader,” they learn more. Previous literature in adults has shown that patients often perceive the intern as their “main doctor,” but this has not been studied in pediatrics. Objective: We sought …

Clinical Course Of A Patient With Agammaglobulinemia Caused By Slc39a7 Defect, Thao Le, Emily Farrow, Alvin Singh, Isabelle Thiffault, Nikita Raje

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Case Report: A 10-year-old unimmunized boy initially presented to the hospital at 18-months of age with pneumonia and failure to thrive. He had multiple infections including Escherichia coli urosepsis, viral croup, chronic otitis media with bilateral ruptured tympanic membranes, and bacterial pneumonia. On physical examination, he was ill appearing and had diffuse crackles. His laboratory work-up showed leukocytosis, normocytic anemia, undetectable immunoglobulin (Ig) G, A, and E, low IgM (28 mg/dL), absent B cell with normal T cell (7800 mm3) and NK cell (527 mm3) counts, and low zinc level (63 mcg/dL). Genetic testing was negative for Bruton tyrosine kinase …

Bone Marrow Transplant For Macrophage Activation Syndrome In Systemic Juvenile Idiopathic Arthritis​, Shailly Gaur, Michael J. Holland, J Allyson Hays, Ibrahim A. Ahmed

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7yo w/ systemic juvenile idiopathic arthritis who developed macrophage activation syndrome and interstitial lung disease non-responsive to steroids, immunosuppression, and directed biologics with significant adverse reactions who required chemotherapy and eventual bone marrow transplant leading to complete resolution of symptoms.

Lessons From A Community Health Elective In Rural Guatemala On Cultural Humility, Roxana Guggenmous

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No abstract provided.

My Global Health Experience - Eldoret, Kenya, Megan Carroll

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Describes her experience in Eldoret as a 4th year medical student.

Practicing Pediatrics In Lake Atitlan, Guatemala, Chandra Swanson

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Describes her experience working in Lake Atitlan, Guatemala.

Phlebotomy-Free Days In Common Conditions Among Hospitalized Children And The Association With Clinical Outcomes, Megan Collins, M Hall, Ss Shah, Mj Molloy, Pl Aronson, Jm Cotter, Mj Steiner, Mj Tchou, Jr Stephens, Jessica L. Markham

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Background: Phlebotomy is an invasive procedure associated with pain and iatrogenic anemia. Minimizing phlebotomy for hospitalized children could improve their experience and avoid unnecessary tests. Objective: To describe: 1) the prevalence of phlebotomy-free days among children hospitalized with common conditions and 2) the association of phlebotomy-free days with clinical outcomes. Design/Methods: We performed a multicenter, cross-sectional study of children hospitalized 1/1/2018 to 12/31/2019 with an All Patient Refined Diagnosis Related Group (APR-DRG) for common infections across 38 hospitals in the Pediatric Health Information System (PHIS) database. We excluded patients with length of stay (LOS) < 2 days, medical complexity, interhospital transfers, and those receiving intensive care. We defined phlebotomy-free days (PFDs) as hospital days with no laboratory blood testing and measured the proportion of PFDs per hospital day (PFD ratio) for each condition and hospital. Hospitals were grouped into low, moderate and high average PFD ratios. Adjusted outcomes were compared across groups and included LOS, costs, and all-cause 14- and 30-day readmission rates. Results: We identified 126,135 patient encounters (Table 1). Bronchiolitis (N=31,302), non-bacterial gastroenteritis (N=20,430), and pneumonia (N=16,031) accounted for the greatest number of hospital days. Bronchiolitis (0.78) and pneumonia (0.54) had the highest overall PFD ratios, while bone and joint infections (0.28) and non-bacterial gastroenteritis (0.30) had the lowest overall PFD ratios. There was wide variation across hospitals and conditions in PFD ratios (Figure 1). We identified 8 hospitals with low, 21 with moderate, and 9 with high PFD ratios (Figure 1 and Table 1). There were statistically significant but small differences in the distributions of age, payer, and H-RISK among patients in the low, moderate, and high PFD hospital groups (Table 1). There were no differences in adjusted outcomes across low, moderate, and high PFD hospital groups (Table 2). Conclusion(s): Among children hospitalized with common infectious conditions, there was variation across conditions and hospitals in the proportion of PFDs per hospital day. Hospitals with low, moderate and high ratios of PFDs had no differences in outcomes. Our data suggest at least some laboratory overuse and opportunities to improve the experience and care of children hospitalized with infections.

Sepsis-Induced Acute Lung Injury And The Development Of Bronchopulmonary Dysplasia In Premature Infants, Jacob S. Ward, Hung-Wen Yeh, Megan Tucker, Venkatesh Sampath

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Background: Bronchopulmonary dysplasia (BPD) is a significant cause of morbidity and mortality in premature infants with several known risk factors. Recent literature described the harmful effect of inflammation on the developing lung. Recently, we showed that late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) causes acute lung injury (ALI) in preterm infants as measured by increases in pulmonary severity scores (PSS). The aim of this study was to investigate the association between LOS-induced ALI and BPD outcomes. We hypothesized that LOS would increase the likelihood of developing BPD, and the associated LOS-induced ALI will add to the ability to predict development …

Innovative Management Of Posterior Upper Thigh Pain In Two Adolescent Athletes, Thomas Munro, Brian Harvey

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Case history: Two 16-year-old males with posterior upper leg pain. Athlete A reports he had been exploding up to dunk a basketball when he felt a pop with immediate pain in his posterior LLE. He was treated conservatively with activity modification and PT resulting in improvement of symptoms and return to full activity. He returned 15-months after the initial injury due to recurrence of pain. Athlete B stated he had tweaked his hamstring multiple times over the summer and had been working with a physical therapist for rehabilitation. He had attempted full rest for a couple weeks with graded return …

A Metabolic, Mechanical, Multi-Organ Masterpiece: Dural Device Support Bridge To En-Bloc Heart-Liver Transplantation In Propionic Acidemia, Rebecca Juhl, Brian Birnbaum, Aliessa P. Barnes, William Gibson, Bhargava Mullapudi, Beth Lang, Megan Faseler, Daniel E. Heble, Victoria Urban, Ryan T. Fischer, Jennifer L. Gannon, David Sutcliffe

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Introduction: Propionic Acidemia (PA) is a disorder related to abnormal protein and lipid metabolism resulting in progressive neurological injury and dilated cardiomyopathy (DCM). Interventions for PA and secondary disease manifestations can require multi-organ transplantation. Herein we report the case of a child with PA and end-stage DCM requiring left ventricular assist device (LVAD) support with eventual heart-liver transplant. Case Report: A 17 year old male diagnosed in childhood with PA developed chronically progressive DCM culminating in end stage heart failure with acute decompensations. In a recurrent admission, he progressed to require dual inotropic support and systemic anticoagulation for new LV …

Insidious Ankle Swelling, Catharine Kral, Brian Harvey

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10-year-old female presented to clinic for left heel pain and swelling. She participates in dance for an estimated 8-9 hours a week. Symptoms started four weeks prior to presentation. She does not remember any inciting event, fall, trauma, or other mechanism of injury prior to onset. She says the pain is localized to the lateral aspect of her calcaneus and extending up to her Achilles. She has never seen any bruising, erythema, or skin changes overlaying the swollen region. Family reports she intermittently has a limp. It is most tender to touch or when she bumps her foot on something. …

If We Know Better, Why Don’T We Do Better? A Qi Project Aimed At Addressing Pain Related To Vaccinations, Haley J. Killian, Amanda D. Deacy, Elizabeth Edmundson, Lucy Raab, Jennifer Verrill Schurman

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Introduction: Evidenced-based tools have long existed to combat pain and anxiety associated with needle sticks, yet the gap between knowledge and uptake persists. Prior to COVID-19, our institution initiated a quality improvement (QI) program to improve comfort measure (CM) uptake, beginning with specific clinical areas with intent to scale up over time. When the COVID-19 vaccine was approved, mass vaccination clinics provided an opportunity to rapidly improve CM uptake across the institution. Methods: Mass vaccination clinics were staffed by nurses from across the hospital. Clinics occurred in 3 waves, based on federal approval for age groups (1: 12y+, 2: 5-11y, …

Objective And Self-Report Outcomes Of Intensive Interdisciplinary Pain Treatment For Youth With Chronic Pain With And Without Functional Neurological Disorder, Kelsey Zaugg, Dustin Wallace, Kayla Friesen, Cara M. Hoffart

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Introduction: Intensive interdisciplinary pain treatment (IIPT) is effective for youth with chronic pain (CP). Many from this population also experience functional neurological disorder (FND). Treatment outcomes for patients with CP and FND during and after IIPT have not been thoroughly examined, and studies utilizing objective physical and occupational therapy measures are particularly lacking. Methods: 301 adolescents (M age=15.34 years, 84.4% girls, CP only: 187, CP and FND: 114) participated in individualized physical, occupational, psychological, and other therapies. Self-report (COPM, functioning) and objective (BOT-2, 6-minute-walk) measures were administered pre-IIPT, post-IIPT, 6-months-post, and one-year-post. Results: Overall, there were strong and statistically significant …

A Case Of Hexasomy 15q Due To A Tricentric Supernumerary Chromosome 15, Emily Farrow, Laura A. Cross, Bonnie Sullivan, Keely M. Fitzgerald, Joseph Alaimo, Elena Repnikova, John Herriges, Lei Zhang

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Background: A 7-month-old male with a history of developmental delay, plagiocephaly, hypotonia, chronic cough/congestion was admitted for abnormal movements. Prolonged EEG revealed focal epilepsy and epileptic spasms. Genetic testing revealed a complex structurally rearranged chromosome 15 which contains two inverted duplicated chromosome 15s joined together at one end, resulting in partial hexasomy for 15q. Case presentation: The proband was born to a G2P2 33-year-old mother following an uncomplicated pregnancy at 40 weeks 2 days gestation. At birth he was 6lbs 8oz, 20in long, and APGARs were 3/5/9 at 1/5/10 minutes. At delivery he was limp, pale and had poor tone …

Psychosocial Needs Of Pediatric Patients With Cancer Predisposition Syndromes: Standardized Screening Needed, Meredith Ehrhardt, Mirae Fornander, Rachel Moore

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Introduction Cancer predisposition syndromes (CPS; e.g., Li-Fraumeni syndrome, Von Hippel-Lindau syndrome) require routine, standardized medical monitoring with accompanying unique, complex psychosocial needs (e.g., family medical needs). Despite limited research within pediatric populations, emerging literature has begun to support the benefit of routine psychosocial screening in this population. Very few pediatric CPS clinics with dedicated psychosocial care (i.e., psychology) exist in the U.S. and there is currently no standard of care for psychosocial support of CPS patients. This study aims to better understand the psychosocial needs of pediatric CPS patients and support the need for a standardized psychosocial screening protocol among …

Prevalence Of Iron Deficiency In Patients With Inherited Bleeding Disorders, Thomas Cochran, Brian Lee, Shannon Carpenter

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Background: Synthesis of hemoglobin is one of several important roles iron plays in the human body. Approximately 50% of all anemia cases may be caused by iron deficiency which is frequently caused by chronic blood loss. Patients with bleeding disorders have greater propensity for blood loss and therefore may have a higher prevalence of iron deficiency when compared to the general population. However, few studies have assessed the prevalence of iron deficiency in children with inherited bleeding disorders. Objectives: This study aims to identify the prevalence of iron deficiency in children with an inherited bleeding disorder. Methods: A retrospective analysis …

Late Onset Paradoxical Effect Of Zolpidem After Anoxic Brain Injury: A Pediatric Case Report, Amanda Lindenberg, Sathya Vadivelu

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Case Diagnosis Acquired brain injury (ABI) is a common cause of disability. It is defined as an insult to the brain that subsequently results in impairments of communication, cognition, sensorimotor function and behavior. Anoxic brain injuries can be particularly disabling. A common cause of a anoxic injury in children is cardiopulmonary arrest. The revised coma recovery scale (CRS-R) is a standardized assessment for level of arousal after brain injury. Case Description A 16 year old healthy boy was admitted after an unwitnessed pulseless cardiopulmonary arrest requiring 3 defibrillations and 2mg of epinephrine. His cardiac and genetic workup was negative. His …

Successful Va Ecmo For A Pre-B Cell Acute Lymphoblastic Leukemia Patient With Necrotizing Faciitis From Clostridium Septicum, Johanna I. Orrick, Brittany Rouchou, Cara Holton, Jenna Miller

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REPORT: It can be challenging to calculate the risks versus benefits of a potential Extracorporeal Membrane Oxygenation (ECMO) pediatric candidate. A patient with an oncologic comorbidity and an increased potential of needing near-future surgical interventions carries higher ECMO risks. We report a successful VA ECMO run of a newly diagnosed acute lymphoblastic leukemia (ALL) adolescent with Clostridium septicum necrotizing fasciitis. A previously healthy 16-year-old male was diagnosed with pre-B cell ALL after having an ileocolic intussusception and a Clostridium septicum blood infection. He underwent successful surgical intussusception reduction, started induction chemotherapy, and completed a ten-day course of antibiotics. On hospital …

Experiences Of Racism Among Black And African Children With Asthma, Esosa Adah, Rayanna Tucker, Bridgette Jones

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Rationale: The relationship between adverse childhood experiences, toxic stress and asthma risk has been previously described in the literature among adult and pediatric populations. Studies have identified experiences of racism as a chronic stressor associated with asthma morbidity however, most studies have focused primarily on adults or parental perspectives. We initiated a pilot study to characterize described experiences of racism among Black/African American children with persistent asthma and describe some of our initial results. Methods: Children were asked to complete the “Perceptions of Racism in Children and Youth,” a validated questionnaire, measuring perceptions of racism and discrimination. Responses were analyzed …

San Pedro Hospital - San Pedro La Laguna, Guatemala, Jennifer Paumen

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Primary objective: to learn about the healthcare system of Guatemala including the challenges and strengths.

Philippines Global Health, Thomas Rieth, Kourtney Bettinger, Ryan Northup

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Provides reflections on resident's experience working with cardiologists and neonatologists in Manila.

Eosinophilic Myocarditis Secondary To Hypereosinophilic Syndrome Vs. Eosinophilic Granulomatosis With Polyangiitis: A Diagnostic Dilemma, Nathan Lavoy, Brian Birnbaum, Julia G. Harris, Aarti Pandya, Allison Taber

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Introduction: Hypereosinophilic syndrome (HES) is a rare but detrimental diagnosis in the pediatric population. Cardiac involvement within HES can present as a diagnosis of Eosinophilic Myocarditis which can progress to irreversible damage and potentially death. This case report discusses a 16-year-old male treated for HES, although HES can have overlap with Eosinophilic Granulomatosis with Polyangiitis (EGPA) and requires a multi-disciplinary approach to patient management. Case Description: The patient was a 16-year-old male, with a history of asthma, presenting with acute onset of chest pain. He was found to have peripheral eosinophilia with an absolute eosinophil count of 11.71. He had …

Improving Fluid Management Of Extreme Premature Infants By Providing A Restrictive Fluid Management Algorithm In The Icn, Jacob S. Ward, Dena Hubbard, Nicholas Clark

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Intro: Excessive fluid intake in extremely premature infants during the first week of life is known to increase risk of adverse events such as necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and overall mortality. There also is some correlation with the need for mechanical ventilation and development bronchopulmonary dysplasia (BPD). While fluid restriction is recommended to decrease the likelihood of adverse outcomes, at our institution we found there was a wide variability in and lack of evidence-based standards on fluid management in this vulnerable population. We aimed to improve the fluid management of the extremely premature infants by standardizing a …

Cardiac Biomarkers In Differentiating Kawasaki Disease And Multisystem Inflammatory Syndrome In Children Associated With Covid-19, Mollie Walton, Geetha Raghuveer, K Kamakoti, N Dahdah, L Garrido, S Tierney, T Harris, M Khoury, M Hicar, E Braunlin, D Thacker, M Khare, F Dallaire, R Lowndes, I Glassmeyer, J Ballweg, G Goldenberg, S Merves, C Manlhiot, P Farid, Bw Mccrindle

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Introduction – Kawasaki disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 show considerable clinical overlap making differentiation challenging, particularly in the absence of evidence of evidence of prior COVID-19. Hypothesis – Cardiac biomarkers can differentiate KD from MIS-C. Methods – The International KD Registry enrolled n=2903 contemporaneous KD, MIS-C and acute COVID-19 pediatric patients from 42 sites in 8 countries from January 2020 through July 2022. The study population was confined to 1489 MIS-C patients meeting CDC criteria with confirmed evidence of prior COVID-19 infection and 387 KD patients meeting AHA guideline criteria with confirmed evidence …

Mobile Health Software Platform Implementation To Improve Pediatric Remote Patient Monitoring Outcomes, Lori A. Erickson, Amy Ricketts, Jenny Marshall, Krista Nelson, Peter Churchill, Dawn Wolff, Robert W. Steele

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Background: Children’s High Acuity Monitoring Program (CHAMP®) is a software platform for pediatric remote patient monitoring. It is used with a proactive, personalized, pediatric care model providing a link for communication with a specialized healthcare team to patients and families in their homes. Successful implementation since 2014 includes: adoption at 12 pediatric hospitals and over 870 infants with a survival of 96.5% (down from 20% in 2012). This work led our team to engage leadership to discuss a remote patient monitoring department with new monitoring devices and expanded access to pediatric conditions.

Methods: Strategic Planning and Innovation facilitated navigation of …

Inverted Appendix Presenting As Abdominal Pain And Lower Gastrointestinal Bleeding, Moises Alatorre-Jimenez, Thomas M. Attard

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Background: Cecal polyps are challenging insofar as the region represents the highest risk of bleeding and perforation during polypectomy . In addition, polypoid lesions in the cecum may represent a morphologically abnormal ileocecal valve or an inverted appendix. Inadvertent polypectomy in those scenarios would lead to serious sequelae including perforation. Case report: Our patient is a 6-year-old male with a background history of prematurity, lactose intolerance, chronic esophagitis, gastritis, constipation, and painless rectal bleeding. He presented with a acute onset diffuse, severe abdominal pain associated with diarrhea that evolved to include hematochezia. At the time of presentation, he required aggressive …