In 2024, we witnessed changes both within the U.S. and abroad, ranging from vaccine hesitancy, uncertainty about the future of governmental health organizations, rapidly advancing medical technology, and marginalized patient populations becoming even more vulnerable.
While the hospital is the primary practice site for pediatric hospitalists, we see the impact of these changes every day in our patients. Within our role as healthcare practitioners, we seek to provide reassurance and empathy to our patients and their families during some of their most vulnerable moments.
For the 2024 update, we highlight the amazing work of healthcare practitioners and researchers aiming to provide the best care for our pediatric patients. These topics range from management of bronchiolitis to addressing racial disparities in healthcare to methods of incorporating new technology within our daily practice.
In this article, we identify the top 10 most impactful articles for pediatric hospital medicine in 2025, as presented at the Pediatric Update at SHM Converge 2025 in Las Vegas. Four publications are highlighted here, along with a summary of the remaining top 10 publications.
1. High-flow nasal cannula therapy for infants with bronchiolitis
Armarego M, et al. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev. 2024;3(3):CD009609. doi:10.1002/14651858.CD009609.pub3
Background: Bronchiolitis is the most common cause of hospitalization in infants under 12 months of age, resulting in an annual estimated cost of $1.73 billion.1 Bronchiolitis typically affects infants younger than 24 months of age, and the mainstay of treatment is supportive, with supplemental oxygen, fluid resuscitation, and respiratory support. Heated, humidified, high-flow nasal cannula (HFNC) therapy is a commonly used form of respiratory support in acute bronchiolitis. A number of theories exist for why HFNC may provide benefits, such as reduction of damage to upper airway mucosa and washing out of nasopharyngeal deadspace.2,3 This Cochrane review assessed the effects of HFNC compared to conventional respiratory support for the treatment of bronchiolitis in infants less than 24 months of age.
Findings: This systematic review included a total of 16 randomized control trials and quasi-randomized control trials that included infants less than 24 months of age, comparing HFNC to either standard oxygen delivery (low flow) or continuous positive airway pressure (CPAP). Infants with significant cardiorespiratory disorders were excluded from this review. Primary outcomes were length of hospital stay and adverse events, with multiple secondary outcomes, most notably the need for treatment escalation. For length of hospital stay, the review showed a mean difference in length of hospital stay for patients on HFNC to be 0.65 days shorter compared to standard oxygen therapy (95% confidence interval [CI], -1.23 to -0.06). For adverse events, the risk ratio (RR) was 1.20 (95% CI, 0.38 to 3.74), suggesting no difference in adverse events between HFNC and low flow. For the need for treatment escalation, the RR was 0.55 (95% CI, 0.39 to 0.79), indicating HFNC reduces the need for treatment escalation by 0.55 times. The review comparing HFNC to CPAP was limited in the total number of studies, with mixed results, precluding making recommendations to support one respiratory support modality over the other.
Practice implications: HFNC appears to reduce the length of hospital stay and decrease the need for treatment escalation. Evidence remains uncertain in terms of the superiority of HFNC compared to CPAP. This updated systematic review assessing the efficacy of HFNC in the treatment of bronchiolitis was much needed, given the significant increase in available studies (increased from one study to 16 studies). HFNC does appear to be safe when compared to low-flow oxygen therapy. While there was a high degree of heterogeneity in the available studies, this review demonstrates that infants under 24 months of age hospitalized with bronchiolitis who were treated with HFNC had a modest reduction in length of hospital stay.
2. Nirsevimab and hospitalization for RSV bronchiolitis
Assad Z, et al. Nirsevimab and hospitalization for RSV bronchiolitis. N Engl J Med. 2024;391(2):144-154. doi:10.1056/NEJMoa2314885.
Background: Respiratory syncytial virus (RSV) is the leading cause of bronchiolitis and is responsible for 33.1 million cases in children less than five years of age.4 Almost 10% of cases result in hospitalizations, and it causes 100,000 deaths worldwide annually.5 Previously, palivizumab was the only approved agent for RSV prophylaxis, and its use was restricted to high-risk infants. Nirsevimab has emerged as an alternative monoclonal antibody, and initial studies have demonstrated it to be effective at reducing the risk of RSV in late preterm and term infants.6
Findings: This prospective, multicenter, matched case-control study of children less than 12 months of age was conducted in metropolitan France between October and December 2023 at six tertiary hospitals. There were 642 case patients who met the criteria of being hospitalized with polymerase chain reaction (PCR)-confirmed RSV. Matching of 321 control patients was performed by identifying patients visiting a participating pediatric emergency department. The median age was similar for case (3.2 months) and control (3.4 months) patients. The study showed that 8.7% of case patients had previously received a nirsevimab injection compared to 28.1% of control patients, indicating an 83% estimated adjusted effectiveness of nirsevimab treatment against bronchiolitis hospitalization. In addition, nirsevimab was 69.6% effective against RSV leading to PICU admission and 67.2% effective against RSV bronchiolitis leading to ventilatory support.
Practice implications: This study shows that nirsevimab is effective at preventing RSV bronchiolitis leading to hospitalization among children less than 12 months of age. Further studies are needed to determine the long-term effectiveness of nirsevimab.
3. Ultrasound-assisted lumbar punctures in children: An updated systematic review with meta-analysis
Ćwiek A, Kołodziej M. Ultrasound-assisted lumbar punctures in children: an updated systematic review with meta-analysis. Hosp Pediatr. 2024;14(3):209-215. doi:10.1542/hpeds.2023-007480.
Background: Lumbar punctures (LPs) are a routine diagnostic procedure performed by pediatric hospitalists for diagnosing a variety of life-threatening conditions. A traumatic LP and an unsuccessful LP are known risks that can result in a variety of complications or changes in the care plan. Point-of-care ultrasound (POCUS) has been shown in adults to be a safe and cost-effective bedside tool to improve LP success rates and decrease rates of traumatic LPs.7 This study differed from prior systematic reviews by not using the red blood cell (RBC) count as part of the definition of a successful first attempt LP. With improved diagnostic technology, such as PCR-based diagnostic testing, and literature supporting the safe use of blood-contaminated cerebrospinal fluid (CSF) samples for a CSF culture, this study focused on successful first-attempt LP regardless of RBC count.8
Findings: This study aimed to examine the efficacy of POCUS-assisted LPs in pediatric patient populations. This was a systematic review and meta-analysis that identified seven studies involving pediatric patients who underwent POCUS-assisted LPs between 2014 and 2021. For the first-attempt LP success rate, the calculated risk difference was 13.0% (95% CI, 3% to 23%) that favored the POCUS-assisted group. For the rate of traumatic LPs, the calculated risk difference was -12% (95% CI, -22% to -0.3%) that favored the POCUS-assisted group. For the LP failure rate, the calculated risk difference was -7% (95% CI, 17.0% to -0.3%), again favoring the POCUS-assisted group. The mean time difference was -1.11 minutes (95% CI, -288 to 0.66), showing that the time to complete the procedure was similar in length.
Practice implications: POCUS increased the success rate of first-attempt LP (regardless of CSF RBC count) while reducing the failure rate and rate of traumatic LPs. POCUS does not add significant time to the procedural time. Overall, POCUS is accessible, easy to learn, and safe for patients. If available, POCUS should be routinely used before every pediatric LP.
4. Discharge time of day and 30-day hospital reutilization at an academic children’s hospital
Lee J, et al. Discharge time of day and 30-day hospital reutilization at an academic children’s hospital. Hosp Pediatr. 2024;14(4):242-250. doi:10.1542/hpeds.2023-007529.
Background: Discharge from a pediatric hospital is a multistep process involving multiple members of the healthcare team and is an important component of the overall hospitalization. Suboptimal discharges can result in preventable readmissions, while delayed discharges can lead to an increased risk of healthcare-associated infections.9-10The timing of optimal discharge from the hospital has not been well studied in pediatric patients, with a previous study focusing only on pediatric surgical patients.11 This study aimed to determine the discharge time of day associated with the lowest hospital reutilization (emergency department visits and hospital readmission) over 30 days.
Findings: This single-center, retrospective, cohort study evaluated children less than 18 years old discharged from a children’s hospital from July 2016 to December 2019. The discharge time was defined as the time the patient left the unit and was divided into morning (8:00 a.m. to 12:59 p.m.), afternoon (1:00 p.m. to 5:59 p.m.), and evening (6:00 p.m. to 10:59 p.m.). The unadjusted 30-day hospital reutilization rates based on time of day were: morning 14.1%, afternoon 18.2%, and evening 19.3%. This indicated a higher unadjusted 30-day hospital reutilization rate for evening discharges compared to morning discharges (P <0.001). Patients discharged in the evening were older and more likely to have one or more complex chronic conditions.
Practice implications: This study suggests that evening discharges are associated with higher rates of 30-day hospital reutilization compared to morning discharges.
Remaining Top 10 Articles
Jone PN, et al. Update on diagnosis and management of Kawasaki disease: a scientific statement from the American Heart Association. Circulation. 2024;150(23):e481-e500. doi:10.1161/CIR.0000000000001295.
The American Heart Association guideline update on Kawasaki Disease provides a comprehensive updated resource for the care of pediatric patients with Kawasaki Disease. Two highlights from this guideline update are, first, criteria for high-risk patients that would be considered for intensification of primary therapy, and second, that select high-risk patients may be eligible for dual antiplatelet therapy or even triple therapy with the consideration of direct oral anticoagulants.
Brewster RCL, et al. Performance of ChatGPT and Google Translate for pediatric discharge instruction translation. Pediatrics. 2024;154(1):e2023065573. doi:10.1542/peds.2023-065573
Given the vulnerability that exists with care of patients who speak languages other than English, this study investigated the use of large language models (LLMs), specifically Google Translate and ChatGPT, compared to professional translation in Spanish, Brazilian Portuguese, and Haitian Creole. The study demonstrated that LLMs were comparable to professional translation for Spanish and Portuguese but had a much higher risk for clinically significant errors with translations for Haitian Creole.
Smith LB, et al. Black-white disparities in asthma hospitalizations and ED visits among Medicaid-enrolled children. Hosp Pediatr. 2024;14(6):490-498. doi:10.1542/hpeds.2023-007477
This study highlights the racial disparities that exist in Medicaid-enrolled Black children with pre-existing asthma compared to white children. Black children were two times more likely to have asthma-related emergency department visits and hospitalizations compared to white children. Even with access to health insurance, healthcare-related racial disparities still exist in pediatric asthma care, calling for continued advocacy to address other sources of inequity.
Parikh K, et al. Disparities in racial, ethnic, and payer groups for pediatric safety events in U.S. hospitals. Pediatrics. 2024;153(3):e2023063714. doi:10.1542/peds.2023-063714
Preventable harm events in the hospital are known to affect the most socially disadvantaged groups of children. This study sought to determine if disparities in patient safety events in hospitalized pediatric patients persisted between race and ethnic groups, as well as insurance status. Hospitals receiving higher safety grades demonstrated persistent disparities between racial and ethnic groups, with non-Hispanic Black and Hispanic children being most affected, even when limiting the analysis to private pay patients.
Wolf RM, et al. Disparities in pharmacologic restraint for children hospitalized in mental health crisis. Pediatrics. 2024;153(1):e2023061353. doi:10.1542/peds.2023-061353
Due to limited resources, many pediatric patients with primary mental health conditions are admitted to a non-psychiatric acute care hospital while awaiting transfer to an inpatient psychiatric hospital. This study demonstrated that Black youth were more likely to receive pharmacological restraint than other racial and ethnic groups when admitted with primary mental health diagnoses.
McCulloh RJ, et al. A national quality improvement collaborative to improve antibiotic use in pediatric infections. Pediatrics. 2024;153(5):e2023062246. doi:10.1542/peds.2023-062246
This quality improvement initiative sought to increase the proportion of children evaluated in the emergency department or admitted to the hospital who received appropriate antibiotics for common pediatric infections. The initiative focused on improving empirical, definitive selection and duration of antibiotics for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections.
Dr. Burroughs-Ray
Dr. Symons
Dr. Burroughs-Ray is a combined internal medicine-pediatrics academic hospitalist, associate professor, and associate program director of the internal medicine-pediatrics residency program at the University of Tennessee Health Science Center, a pediatric hospitalist at Le Bonheur Children’s Hospital, and a hospitalist at Regional One Health, all in Memphis, Tenn. Dr. Symons is a second-year pediatric hospital medicine fellow at the University of Nebraska Medical Center and Children’s Nebraska in Omaha, Neb., where he will be staying on as faculty as an internal medicine-pediatrics hospitalist in July 2025.
References
- Ralston SL, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742.
- Dysart K, et al. Research in high flow therapy: mechanisms of action. Respir Med. 2009;103(10):1400-1405. doi:10.1016/j.rmed.2009.04.007.
- Manley BJ and Owen LS. High-flow nasal cannula: Mechanisms, evidence and recommendations. Semin Fetal Neonatal Med. 2016;21(3):139-145. doi:10.1016/j.siny.2016.01.002
- Dalziel SR, et al. Bronchiolitis. Lancet. 2022;400(10349):392-406. doi:10.1016/S0140-6736(22)01016-9
- Shi T, et al. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study. Lancet. 2017;390(10098):946-958. doi:10.1016/S0140-6736(17)30938-8
- Hammitt LL, et al. Nirsevimab for prevention of RSV in healthy late-preterm and term infants. N Engl J Med. 2022;386(9):837-846. doi:10.1056/NEJMoa2110275
- Pingree EW, et al. The effect of traumatic lumbar puncture on hospitalization rate for febrile infants 28 to 60 days of age. Acad Emerg Med. 2015;22(2):240-243. doi:10.1111/acem.12582
- Shu L, et al. Efficacy of ultrasound guidance for lumbar punctures: a systematic review and meta-analysis of randomised controlled trials. Postgrad Med J. 2021;97(1143):40-47. doi:10.1136/postgradmedj-2020-138238
- Toomey SL, et al. Potentially preventable 30-day hospital readmissions at a children’s hospital. Pediatrics. 2016;138(2):e20154182. doi:10.1542/peds.2015-4182
- Rosman M, et al. Prolonged patients’ in-hospital waiting period after discharge eligibility is associated with increased risk of infection, morbidity and mortality: a retrospective cohort analysis. BMC Health Serv Res. 2015;15:246. doi:10.1186/s12913-015-0929-6
- Richards MK, et al. Factors associated with 30-day unplanned pediatric surgical readmission. Am J Surg. 2016;212(3):426-432. doi:10.1016/j.amjsurg.2015.12.012