CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Resources Recommended for the Careof Pediatric Patients in HospitalsKimberly D. Ernst, MD, MSMI, FAAP, COMMITTEE ON HOSPITAL CARE

abstractIt is crucial that all children are provided with high-quality and safe healthcare. Pediatric inpatient needs are unique in regard to policies, equipment,facilities, and personnel. The intent of this clinical report is to providerecommendations for the resources necessary to provide high-quality andsafe pediatric inpatient medical care.

In 2016, there were 5.5 million hospitalizations of children 17 years andyounger, with a mean length of stay of 4.0 days.1 The primary indicationfor inpatient pediatric hospitalizations is respiratory illness, includingpneumonia, acute bronchiolitis, and asthma.2 Other common reasons forpediatric hospital admissions include appendicitis, seizures, infections,and dehydration.2 Although many of these patients can be appropriatelycared for in community settings, there must be a balance between familyconvenience, safe health care, and resource use. It is widely accepted thata minimum case volume is necessary to maintain competence and isassociated with better outcomes; therefore, health care administrators andprofessionals need to evaluate their ability to care for the unique needs ofthe pediatric population and determine if they have the diagnostic andtreatment capabilities, as well as the equipment and staffing, to providehigh-quality and safe health care for these patients. Hospitals need tocarefully evaluate their resources and may decide to be proactive instabilizing and then transferring pediatric patients to facilities with higherpediatric inpatient volumes and more resources.

The intent of this clinical report is to provide recommendations for theresources (policies, equipment, facilities, and personnel) necessary toprovide high-quality and safe pediatric inpatient medical care. Although allhospitals are obligated to provide emergency stabilization for children ofall ages, including newly born infants,3 this document’s intent is specific toinpatient care after hospital admission, especially those hospitals withlower pediatric volumes that may need additional guidance. For pediatricemergency care, the American Academy of Pediatrics (AAP) providesdetailed information in “Joint Policy Statement--Guidelines for Care ofChildren in the Emergency Department,”4 and newborn care guidelinescan be found in Guidelines for Perinatal Care.5 For pediatric intensive care,

Section of Neonatal-Perinatal Medicine, Department of Pediatrics,College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma

Dr Ernst was responsible for the literature review, writing the firstdraft, and revising the final draft with the input of all reviewers andapproved the final manuscript as submitted.

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2020-0204

Address correspondence to Kimberly D. Ernst, MD, MSMI, FAAP. E-mail:kimberly-ernst@ouhsc.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The author has indicated she has no financialrelationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The author has indicated she hasno potential conflicts of interest to disclose.

To cite: Ernst KD, AAP COMMITTEE ON HOSPITAL CARE.Resources Recommended for the Care of PediatricPatients in Hospitals. Pediatrics. 2020;145(4):e20200204

PEDIATRICS Volume 145, number 4, April 2020:e20200204 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 29, 2020www.aappublications.org/newsDownloaded from

the AAP and Society of Critical CareMedicine provide resources in“Criteria for Critical Care Infants andChildren: PICU Admission,Discharge, and Triage PracticeStatement and Levels of CareGuidance.”6

POLICIES, PROCEDURES, ANDPROTOCOLS

The care of the pediatric inpatientpopulation is sufficiently differentfrom that of the adult inpatientpopulation, and these differencesneed to be taken into account whencaring for this vulnerablepopulation. Hospitals shouldelectively admit only patients forwhom they have appropriateresources, such as physical space,size-appropriate equipment, andqualified staff necessary for theunique needs of pediatric patients.In cases in which these resources arenot available, policies to assisthealth care professionals withdetermining appropriate triage,consultation, and referral decisionsare necessary. Hospitals that providepediatric inpatient or outpatientservices need both a plan in place(whether internally or throughtransport agreements) andresources available to provideurgent and emergent transfer toa facility with a higher level of careto best meet a patient’s needs. Thesepolicies should address compliancewith the Emergency MedicalTreatment and Labor Actrequirements.3 A board-certifiedgeneral pediatrician or pediatricmedical subspecialist is stronglyrecommended to providea leadership role to ensure allhospital policies, procedures, andprotocols sufficiently address carefor pediatric patients of all ages. Ifa pediatrician is not available, thena physician board certified in familyor emergency medicine with currentpediatric expertise could fulfill thatrole. Ideally, this physician wouldalso be active in the evaluation of

hospital-wide pediatric care andquality improvement efforts.

Regionalization and InterfacilityTransfer

Hospitals and/or physiciansproviding care for children need well-established networks for timelyconsultation by subspecialists withpediatric expertise and, whennecessary, for transfer of a patient toa facility that offers more advancedlevels of care. Guidance forregionalization of care, the care ofpediatric trauma patients, the care ofpediatric critical care patients, andpatient transfer has been publishedby the AAP, the American College ofSurgeons, the Society of Critical CareMedicine, and the Emergency MedicalServices for Children (EMSC)program.6–10 Formal writteninterfacility transfer agreementsshould be in place for consultationand transport of a pediatric patient toa facility with a higher level of care.10

These include access to air andground transportation systems thatare responsive and appropriatelyequipped and staffed on the basis ofmedical illness severity to care forchildren of all ages.11 It is importantfor these referral relationships to bedeveloped proactively and forprotocols to be standardized tofacilitate safe and efficient transports.

Regular multidisciplinary review ofchildren transferred out of the facilityas well as cases of deterioration canbe conducted to reevaluate thehospital’s admission, discharge, andtransfer criteria. Ideally, this reviewwould occur in collaboration with theregional referral facility. Such reviewmay reveal minor modifications inequipment or training that wouldallow the facility to safely care for thehigher-acuity patients it haspreviously transferred out, oralternatively, it may identify high-riskdiagnoses that warrant immediatetransfer on presentation. The goal isto ensure that all children in thefacility receive the optimal care most

appropriate for their medical andpsychosocial needs.

Telehealth care may provideadditional opportunities forcollaboration between hospitals. Inaddition to direct patient interactionswith pediatric medical subspecialists,tertiary centers may have outreachprograms that can provide ongoingeducational support for thosepracticing in the community.12,13 Oneexample of this model is ProjectECHO (Extension for CommunityHealthcare Outcomes),a telementoring program designedto leverage widely availablevideoconferencing technology, clinicalmanagement tools, and case-basedlearning to increase workforcecapacity by improving quality,reducing variety, and standardizingbest practices withina multidisciplinary, team-basedapproach.14 Establishing formalizedrelationships in advance can benefitboth the referring hospital and thereceiving tertiary care center bycreating joint quality improvementteams to optimize patient care.Comprehensive informationregarding the use of telehealthcare can be found in “AmericanTelemedicine Association OperatingProcedures for PediatricTelehealth.”15

Patient Safety

The provision of care for hospitalizedchildren should reflect an awarenessof the unique patient safety concernsin the pediatric population:

� patient identification strategiesthat meet Joint Commissionstandards16;

� the child’s current weight inkilograms documented atadmission and at regular intervals;

� a full set of vital signs documentedin the medical record witha process for reporting abnormalage-specific vital sign values to thechild’s medical provider;

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 29, 2020www.aappublications.org/newsDownloaded from

� all medication doses prescribedand dispensed by using weight-based dosing in kilograms withchecks to ensure doses do notexceed the expected maximumdosages17;

� precalculated medication dosagesbased on the child’s weight inkilograms for common emergencymedications18;

� radiation safety procedures forimaging by using as low asreasonably achievable ionizingand shielding techniques19; and

� a rapid response team with atleast 1 person having expertise inpediatric airway management aswell as pediatric-specific criterialeading to activation of the team.20

The security of pediatric patientsshould be addressed withinindividual facilities. The JointCommission standards require thatthe facility identifies and implementssecurity procedures to addresshandling an infant or childabduction.21 For younger children,the use of security bracelets orumbilical cord tags provide one layerof security, and locked units mayprovide security for older children.A risk assessment should bemultidisciplinary, with each staffmember providing input in his or herarea of expertise to address actualand potential risks.21 Not all pediatricpatients will have family supervision,and the facility will be responsible forensuring that children andadolescents do not leave the facilityunattended or with a noncustodialparent or guardian. The physicallayout, the number and arrangementof exits, the vulnerability of thepatient population, intended level ofguardian and/or visitor access, andcommunity risk need to be addressed.Abduction and missing patientexercises are effective means tovalidate pediatric securityeffectiveness.21 Facilities will need toaddress whole-hospital securitymeasures to provide safety to

patients, families, and staff in cases ofactive-shooter or other violentscenarios.21

Policies, procedures, and protocolsshould also be developed andimplemented for all-hazards disasterpreparedness.4,22 Because of thecomplexities and need for advanceplanning, disaster preparedness ismentioned in this report to remind allfacilities to address the issue. Hospitaldisaster plans are unique to eachfacility and community depending onthe patient populations served as wellas local, state, and regional resourcesand partners. The AAP has publishedadditional information in “Ensuringthe Health of Children in Disasters,”22

and links to additional resources canbe found on the AAP DisasterPreparedness Advisory Council andEMSC Web sites.23,24 The EMSCprogram has prepared a checklist toassist facilities in incorporatingpediatric preparedness into existingdisaster policies.25 Information forspecial populations, such as infants inthe NICU and children with specialhealth care needs, can be found inseparate resources.26,27

Family-Centered Care

Facilities striving to provide patient-and family-centered care will includeactive family involvement indecision-making, medication safetyprocesses, patient and familyeducation, and dischargeinstruction.28 It is important toaddress situations such as familieswith limited English proficiency and/or low general literacy, especiallywith regard to informed consent andfamily involvement and education.29

Tailoring discussions with familiesby using the principles of healthliteracy universal precautions iscritical for good communication.30

Religious and cultural considerationsmay require adjustments to thechild’s care plan. Hospital policiesallowing at least 1 caregiver toremain with the child at all timesshould be standard practice,

especially with younger children.Ethical and legal guidelines for thecare of adolescents need to beconsidered with regard to privacyand medical decision-making. Notonly does consent need to beaddressed but also assent on thebasis of the child’s age anddevelopmental understanding.29,31

Policies should be developed thatspecify where children will be placedin the hospital once admitted. Singlerooms provide better isolation for thecommon infectious diseases for whichchildren are hospitalized and shouldalso provide a space for caregivers tosleep and monitor care. If singlerooms are not available, guidelinesfor appropriate age and sex cohortingshould be established, taking intoaccount adults who may beaccompanying minors. Invitingfamilies in the community toparticipate in policy making or designof a facility remodel can be a valuableresource for hospital leadership.

As the number of children withchronic illnesses increases, hospitalsmay care for more pediatric patientswith life-limiting illnesses, even if onlyin an emergency situation. Processesshould be in place for dealing with “donot resuscitate” or “allow naturaldeath” orders with the understandingthat individual situations requireflexibility depending on the family andchild’s needs. The assessment andmanagement of pain may bechallenging because of thedevelopmental and individualdifferences in experiencing andexpressing pain. Several tools exist toprovide improved pain controlassessment and management.32 TheAAP statement “Patient- and Family-Centered Care and the Pediatrician’sRole” can also act as a resource forfacilities as they design their policiesand processes.28

Policies regarding personnel andtraining will be addressed later in thisreport under Personnel and Training.

PEDIATRICS Volume 145, number 4, April 2020 3 by guest on June 29, 2020www.aappublications.org/newsDownloaded from

EQUIPMENT

Emergency Resuscitation Equipment

Essential equipment for care of thepediatric patient in hospitals includesresuscitation equipment for patientswhose status has deteriorated sinceadmission. All hospitals should beprepared for the emergency occurringin a pediatric patient, whether theyroutinely admit pediatric patients ornot. A child who requires transfer toa facility with a higher level ofpediatric care should be stabilizedwhile transport is being arranged.The AAP policy statement “JointPolicy Statement--Guidelines for Careof Children in the EmergencyDepartment” provides specificinformation for these situations.33

Separate pediatric emergencyresuscitation carts are preferablylocated in or near areas such as theemergency department, pediatricinpatient unit, labor and deliveryarea, imaging area, and operatingroom. Supplies recommended forthese carts include the following:

� inventory checklist;

� standardized code sheets with themedication dosages and Joulesprecalculated on the basis ofweight in kilograms;

� pediatric backboard;

� personal protective equipment(gloves, gowns, masks);

� sharps container;

� cardiorespiratory and pulseoximetry monitors withappropriate alarm limits forpediatric patients;

� automated external defibrillatorscapable of treating pediatricpatients with cardiac defibrillatorpaddles sized for infants andchildren;

� airway management equipmentthat fits children of all sizes(newborn to adolescents):

○ oxygen tanks;

○ pediatric oxygen masks;

○ bag-valve masks andmanometers;

○ suctioning equipment;

○ laryngoscope blades;

○ oropharyngeal andnasoharyngeal airways;

○ endotracheal tubes (laryngealmasks are beneficial for healthcare professionals who rarelyhave the opportunity to intubateor rarely intubate children);

○ feeding tubes to provide gastricdecompression duringventilation; and

○ chest tubes and large needles toevacuate pneumothoraces;

� vascular access devices andsupplies:

○ skin preparation supplies andbandages;

○ small needle sizes, includingbutterfly needles;

○ various sizes of syringes;

○ umbilical line kits; and

○ intraosseous needles and drill;

� pediatric emergency medications,including fluids appropriate forpediatric patients (10% dextrosevials, 5% dextrose, and normalsaline [NS] bags); and

� chemical mattress pads to providewarmth for infants.

Maintaining a code sheet with themedication dosages and Joulesprecalculated on the basis of thechild’s actual weight in kilograms isdesirable in the patient’s room (and,ideally, kept at all times with thepatient during transport betweendepartments or facilities). Anextensive checklist of more specificsupply items can be found in theresources and toolkit section on theEMSC Web site.18

Routine Hospital Equipment

Essential equipment is necessary toprovide for the most commondiagnoses seen in hospitals such asrespiratory illness, appendicitis, seizuredisorders, infections, and dehydration.

This equipment should account for thewide differences observed in thepediatric population ranging fromnewborn infants to adolescents. Thefollowing list supplements standardadult equipment:

� infant, standing, and bed scales tomeasure patients in kilograms;

� appropriately sized respiratoryequipment such as oxygen masks,nasal cannulas, bag-valve masks,artificial airways, and suctioningsupplies;

� supplemental oxygen deliverysystems, including low-flowmeters;

� oximeter monitoring supplies thatfit infants and small children;

� nebulizers and metered-doseinhalers with masks and spacers;

� “smart” infusion pumps designedfor pediatric use with preciseadministration of low infusionrates with built-in libraries of thestandard pediatric concentrationsof medications;

� heel warmers to improveperipheral blood flow for samplingin infants;

� topical anesthetics for blood andspinal fluid sampling34;

� pediatric lumbar puncture trays;

� sterile urine collection supplies inpediatric sizes;

� mercury-free thermometers withmeasurements in Celsius;

� pediatric-sized blood pressure cuffs;

� common pediatric fluids such as10% dextrose vials, NS bags, 5%dextrose with 1/2 normal saline(D5-1/2NS), and 5% dextrosewith normal saline (D5 NS);

� orogastric and nasogastric feedingtubes in sizes to fit children fromnewborn infants to adolescents;

� common infant formula types andbottles with nipples;

� pacifiers to provide newborn painanalgesia or soothing for neonatalabstinence;

4 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 29, 2020www.aappublications.org/newsDownloaded from

� dedicated enteral pumps (theseprovide safety because theyprevent inadvertentadministration of enteral productsvia the intravenous route);

� electric breast pumps for mothersof young infants, including labelsfor storage and accessible storagefacilities;

� incubators and/or warmers forinfants and cribs with sleepingsurfaces meeting safe-sleepguidelines35;

� Various sizes of diapers;

� age-appropriate restraint devices,including soft wrist and legrestraints and arm and/or wristimmobilizers, to help preservelife-saving equipment such asendotracheal tubes, feeding tubes,and intravenous lines; and

� wheelchairs, crutches, slings, andsplints in pediatric sizes.

Electronic Clinical InformationSystems

Electronic clinical informationsystems play an important role inensuring the safety and quality ofpediatric care. A comprehensive AAPresource “Pediatric Aspects ofInpatient Health InformationTechnology Systems” providesguidance for facilities inunderstanding the unique aspects ofsafety, care, and documentation needswith regard to pediatric patients.36

Although no dedicated pediatricinpatient clinical information systemexists, some unique pediatric needsfrom this resource are highlightedbelow:

� anthropometric measurements(weight, length, headcircumference) in metric unitswith automatic plotting onappropriate growth charts basedon sex and age;

� storage of age-specific data, suchas Apgar scores, pediatric painscales, neonatal abstinence scores,pediatric mortality predictionscores, and ages in hours or days;

� ability to designate anindeterminate gender;

� configuration of access toadolescent patient data based onlegal status and stateconfidentiality laws37;

� ability to maintain continuity ofaccess to health care informationin cases in which children aremobile between various legal orphysical custodians, for example,the foster care system;

� linking between infant andmaternal medical charts andunlinking in cases of custodial lossor adoption;

� management of immunizationdata, including the ability to shareadministration data with themedical home and immunizationregistries;

� management of age-specific datafor handoff reports including thetransmission of the report to themedical home38,39;

� ability to manage newbornscreening and hearing screeningdata;

� availability of age-appropriatenormal values for laboratory testresults;

� ability to documentdevelopmental milestones;

� automated nutritionalcalculations;

� ability to manage the storage,tracking, and administration ofhuman milk;

� electronic ordering of medicationsand infusions with weight-basedcalculations and alerts specific tothe pediatric population;

� ability to preadmit patients likelyto be admitted (preterm infantgoing to the NICU) so medicationsare readily available;

� medication dosing and druginteractions relative to pediatricpatients;

� barcode scanning capabilities formedications, blood, and human

milk as an additional layer ofsecurity for error prevention40;

� discharge outpatient prescriptionprescribing with weight-baseddosing, including total metric dose,as well as milliliters for liquidmedications, name of medication,and reason for use; and

� ability to provide family educationin their native language formedical issues as well asmedications.

FACILITIES

Patient Care Area Facilities

The Joint Commission provides theComprehensive Accreditation Manualfor Hospitals that addresses thestandards of hospital facilities toprovide safe, quality health care.41

These standards generally addressthe physical space and the featuresthat protect patients, visitors, andstaff. Caring for children requiresadditional considerations:

� single- or double-occupancyrooms that comply with guidelinesfor prevention of hospital-acquired infections (groupingpediatric rooms allows forefficient use of resources);

� pediatric beds allowing for bedrails to be raised;

� rooms with enough space toaccommodate caregivers who staywith their children, includinga sleeping space for at least 1caregiver;

� adjustable privacy screens thatallow convenient observation andsupervision of patients;

� space to accommodate anaccompanying adult in elevatorsand procedural rooms;

� a negative-pressure room forchildren admitted with suspectedinfectious illness that require thattype of isolation;

� age-appropriate furniture,including cribs equipped withoverhead safety devices and beds

PEDIATRICS Volume 145, number 4, April 2020 5 by guest on June 29, 2020www.aappublications.org/newsDownloaded from

having covered mechanical orelectrical controls;

� high chairs for infant and toddlermealtimes;

� bookshelves or other large orbulky furniture anchored to thewall and that meet ConsumerProduct Safety Commissionstandards with a process in placeto monitor for product recalls42;

� specific safety products, such aselectrical outlet covers, windowlocks, cabinet door safety latches,padding for sharp corners andedges, and toilet latches, forspaces in children’s areas;

� cordless window coverings;

� cordless phones;

� magnet-free status communicationboards;

� trash cans and sharps containersout of reach of toddlers and smallchildren;

� alcohol-containing hand sanitizerdispensers not accessible to smallchildren;

� age-appropriate spaces wherechildren can feel safe from painfulor scary medical procedures43;

� a separate treatment room forprocedures43;

� entertainment consoles,computers, as well as educationaland other age-appropriateactivities help to keep childrendistracted; all toys, equipment,and play surfaces should beregularly cleaned with appropriategermicidal solutions;

� an indoor and/or secure outdoorplayground area with equipmentthat has accommodations forthose with impaired mobility;

� Internet access, with appropriatesafeguards, available to allpatients and families forentertainment, work, andeducation;

� facilities for families to safely storefood and human milk and forpersonal hygiene (laundry,

showers, etc) while they arestaying with their children in thefacility; and

� affordable or free parking forfamilies with hospitalized childrento encourage family involvement.

Although interior design and decor isbeyond the scope of this document,additional information about child-friendly, developmentallyappropriate environments may beobtained from the Institute forPatient- and Family-Centered CareWeb site.44

Therapeutic and Diagnostic Facilities

The following therapeutic anddiagnostic facilities are necessary, and24-hour availability is stronglyrecommended:

� routine radiographic imaging,using techniques to reduceradiation exposure in children,19

with a radiologist skilled inpediatric assessment availableeither on-site or by teleradiologyfor interpreting images;

� clinical laboratory with servicesappropriate for infant andpediatric needs, includinghematologic profiles, bloodchemistries (including serumbilirubin levels), blood gasstudies, microbiology studies,common locally used antibioticlevels, and standard urinestudies:

○ equipment to process allcommonly ordered tests, such ascomplete blood cell counts andblood chemistry levels, by usingsamples of less than 1 mL(“micro” samples);

○ serum drug concentrations foraminoglycoside antibiotics, forexample, known to causeototoxicity and nephrotoxicity,with results available in a timelymanner; send-out testing maynot allow appropriateadjustments in dosing; and

○ standard laboratory regulationsrequire appropriate criticalreference values based onpatient age45;

� pharmacy services to provide age-and size-appropriate drugadministration and dosing thatincludes both a weight-based doseand a final calculated amount46:

○ commonly used oralsuspensions, including oralsucrose solutions to use foranalgesia with painfulprocedures in young infants,quickly available34;

○ supplies and expertise to safelycreate pediatric liquidformulations at nationallyaccepted standardconcentrations14;

○ orally administered liquidmedications dispensed withmetric dosing (milligrams,micrograms) on the label insmall-volume milliliter-baseddosing devices, such assyringes47;

○ doses of medications calculatedby using computer programs orcalculations based onappropriate neonatal orpediatric pharmacokineticmodels; and

○ medications for pediatricsstored in a separate locationfrom adult formulations bothwithin and outside of thepharmacy; and

� nutritional services to providechild-friendly meals:

○ common infant and toddlerformulas, pediatric nutritionalsupplements, and rehydrationformulas stocked in pediatricareas and readily retrieved forthose in the emergencydepartment or other areaswhere children are treated;

○ in cases in which the hospitalcafeteria does not remain open24 hours, prepackaged mealsand patient nutritional supplies

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 29, 2020www.aappublications.org/newsDownloaded from

stocked in the pediatric areasbefore the cafeteria closes forthe night;

○ nutritious meals and drinkingwater readily available forbreastfeeding mothers; and

○ donor human milk, which isbecoming more widely availableand is a consideration forhospitals treating infants whomay benefit from this resource.

PERSONNEL AND TRAINING

Because respiratory illnesses are themost common pediatric diagnosesrequiring inpatient admission, theneed for health care facilities to haveready access to personnel skilled inairway management as well asspecialized equipment in sizesappropriate for children fromnewborn infants to adolescents isimperative. Respiratory therapistswith pediatric expertise are especiallyimportant for providing safe pediatriccare because pediatric patients tendto experience respiratory arrestrather than the cardiac arrest seen inadults. Health care professionals withexpertise in pediatric life supporttechniques should know the locationof carts and equipment forcardiopulmonary resuscitation. Mockcodes conducted on a regular basiswith debriefings either by pediatric-trained internal staff or by usingpersonnel from tertiary centers arestrongly recommended. It is helpful ifthe multidisciplinary medical teamtrains together during life supportcourses so that the team functionsoptimally in times of emergency. Thistraining complements, but does notreplace, real-life experience in caringfor hospitalized children. Educationsessions, clinical trainingopportunities, and mock codes shouldbe documented for review by hospitalquality assurance committees andThe Joint Commission.

Physicians and other health careprofessionals responsible for the careof inpatient pediatric patients should

be licensed and have training in thecare of hospitalized children eitherthrough a formal training programand/or through supervisedexperience consistent with theindividual facility’s bylaws forcredentialing. Health careprofessionals need to maintainprofessional expertise throughcontinuing education as well asmaintenance of active life supportcredentials, including neonatal andpediatric advanced life support orequivalent training.48 Those who arein charge of a pediatric patient’s caremay be either on-site or on-call,depending on the severity of a child’sillness, and policies may address anacceptable response time for on-callprofessionals. Children who requireintermediate- or higher-level careneed a high-level health careprofessional who is in-house andreadily available to respond to thepatient immediately should thechild’s condition deteriorate.49 TheAAP and Society of Critical CareMedicine publication “Criteria forCritical Care Infants and Children:PICU Admission, Discharge, andTriage Practice Statement and Levelsof Care Guidance” helps identifyresource needs in those settings.6

Facilities must have policies in placeso that the responsible health careprofessional is known to all personnelcaring for the child, whether it be theprimary physician, on-call physician,or an in-house emergencydepartment physician with abilitiesto care for pediatric patients.Procedures should be in place so thatboth families and the medical teamare able to easily identify this person.

Because a child’s age, as well ascognitive level, influences his or herability to cooperate, sedation inchildren is often administered torelieve pain and anxiety as well as toprovide immobility to allow the safecompletion of a procedure. Healthcare professionals should have an in-depth knowledge of the agents theyintend to use and their potential

complications. It is important to beable to recognize the various levels ofsedation in addition to possessing theskills and age- and size-appropriateequipment necessary to provideappropriate monitoring as well ascardiopulmonary support if needed.50

Because normal vital sign valuesdiffer in younger age groups,instruction on the use ofcardiorespiratory monitors and theiralarms is necessary for all staff.Competencies and case volumes inpediatric sedation should bereviewed annually.50 Childrenyounger than 1 year are at a fourfoldhigher risk of anesthesia-relatedcardiac arrest than those between 1and 18 years of age.51 For this reason,for children younger than 2 years orolder children with complex medicaldiseases, it is preferred that board-certified pediatric surgeons andanesthesiologists supervise allelective surgical procedures.51 TheAAP statement “Critical Elementsfor the Pediatric PerioperativeAnesthesia Environment” has detailedinformation.50

Pediatric nursing experience andtraining is crucial in determininga facility’s ability to provide high-quality and safe pediatric medicalcare. Because nurses spend moreface-to-face time with the patientthan any other member of the healthcare team, it is important that theyare able to identify signs ofdecompensation and are able tointervene in an emergency. Theyshould understand that normallaboratory values may differ inpediatric patients. Nurses mustunderstand the behavioral differencesthat occur in children to modify theircare on the basis of the child’sunderstanding of the situation (eg,the use of age-appropriate pediatricpain scales)34 or developmentaldifferences in their ability to respondto a neurologic examination.Adolescents require a fine balancebetween guidance and autonomy, andpediatric nurses need skill in

PEDIATRICS Volume 145, number 4, April 2020 7 by guest on June 29, 2020www.aappublications.org/newsDownloaded from

recognizing signs of abuse or self-harm. In cases in which nurses haverelatively low skill in obtainingintravenous access, it is preferablethat the most experienced staffmember attempt to obtain access todecrease the child’s emotional andphysical trauma. Although havinga pediatric nursing educator is ideal,facilities lacking a pediatric educatorshould ensure they dedicate timeto pediatric competencies. It isimportant for hospitals to anticipatepediatric personnel shortages ortimes of higher pediatric census bycrosstraining nonpediatric staff, whoshould only be used after successfullydemonstrating the essential duties ofnurses caring for pediatric inpatients.If skilled pediatric staff are notavailable, consideration should begiven to transfer of children toa facility that can meet the patients’needs. Baseline and annualevaluations that include age-specificand psychosocial competencies aswell as the performance of essentialpediatric skills should be verified byqualified personnel.

Similar to medical and nursing staff,pharmacists caring for pediatricpatients need experience and specifictraining in their roles. Pediatricpatients are at higher risk formedication error and may experiencea more serious consequence should anerror occur.17 It is helpful forpharmacists with pediatric experienceto participate in prospective orderreview, safety and technologycommittees, protocol development,staff education, quality improvement,and other high-impact patient careduties.52 Pharmacy technicians whoprepare pediatric medications,including parenteral solutions, need tomaintain documented pediatricpharmacy competencies. Not allfacilities will have a pediatricpharmacist on staff, and a liaisonpediatric pharmacist from a children’shospital may be a beneficial resourceto assist in minimizing the possibilityof adverse consequences.

It is highly recommended that thefollowing health care professionals beavailable on a routine basis to provideservices to the inpatient pediatricpatients: radiology technologists,nutritionists, lactation specialists,rehabilitation therapists, child lifespecialists, mental health specialists,social workers, and medicalinterpreters. Professionals providingthese services should have adequatetraining and continuing education inthe pediatric applications of theirrespective fields. Baseline andperiodic competency evaluationsshould include competencies specificto the pediatric populations cared forin the individual facility. In manyfacilities, nurses often fill the roleof providing lactation support tomother-infant dyads with commonlactation issues. Staff who are askedto fill the gaps when other personnelare not available routinely should beprovided continuing educationopportunities to ensure competencein the roles they are performing. It isnot acceptable to use family membersas interpreters of health careinformation, and hospital staff shouldpractice health literacy universalprecautions. Only 12% of US adultsare fluent in the language of healthcare, and the ability to absorb anduse health information can becompromised by stress.30 The Agencyfor Healthcare Research and Quality’sAHRQ Health Literacy UniversalPrecautions Toolkit, Second Edition,can help facilities increase patientand family understanding of healthinformation and enhance support forpeople of all health literacy levels.30

Foreign and sign language assistancemay be provided by a telephone ortelehealth interpretive service, andeducational materials may betranslated by an off-site service if aninterpreter is not available in-house.When it is not feasible to employ full-time personnel or crosstrain staffbecause of financial or staffing issues,facilities should maintain appropriateconsultative relationships with

tertiary hospital staff members. Thesepoints of contact may provide regulareducational sessions, consultationsfor specific patients, and assistancewith policy development.8,9

SPECIAL CONSIDERATIONS

Although all health care professionalswho provide care to pediatricpatients should be familiar with theunique and changing physical andpsychosocial needs of children andthe core concepts of patient- andfamily-centered care, havinga child life specialist on staff isrecommended.28 If it is not feasibleto maintain a dedicated child lifespecialist, facilities should consultone at a tertiary center to assist withongoing education of the localhospital staff in the provision ofpsychosocial care and family- andchild-friendly services.43 Theassessment of pain can be difficult innonverbal children, and health careprofessionals need training in how touse age-appropriate pediatric painscales appropriately. Staff may alsoneed training on how to supportchildren with intellectual disabilitiesor autism spectrum disorder, forexample, who present with a medicalillness needing treatment. Training inthe physical as well as the emotionalcomponents of end-of-life situationsand palliative care may be helpful forstaff because many find it difficult todeal with a child’s impending oractual death.

Hospitalized children, especiallythose with hospital stays anticipatedto last more than a week, needa designated hospital liaison (nurse,social worker, discharge planner, childlife specialist) to partner with thechild’s school to ensure thehospitalization does not causeinterruption in the child’s educationendeavors. In some cases, havingaccess to videoconferencing or onlineattendance at a child’s school cankeep the child from getting behind inhis or her studies.

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 29, 2020www.aappublications.org/newsDownloaded from

Children may be seen in theemergency department for medicaldisorders that can either present as orcoexist with psychiatric or behavioraldisorders needing appropriate triage.It is important to be sensitive to theneeds of adolescent patients by askingnonprejudiced questions in privateabout sexual partners and substanceuse. Although toxic ingestions intoddlers may be accidental, those inadolescents may be a sign of suicidalintentions.53 Sixteen percent ofadolescents have seriouslyconsidered, and 8% have attempted,suicide in the past year.54 Certainethnic groups, those with a family orpersonal history of suicide attemptsor behavioral disorders, and thosewho identify as a sexual minority areat higher risk.55 Personnel should beable to recognize these issues and befamiliar with the hospital’s mentalhealth resources and policies forappropriate triage.

Health care professionals responsiblefor the care of children should betrained in the recognition and initialmanagement of child abuse,maltreatment, and neglect whetherphysical, sexual, emotional, or medical.They should be aware of the types ofinjuries that can occur at various agesand which ones are unlikely to haveoccurred in the manner in which theyare described by the child oraccompanying adult.56,57 Children whohave experienced physical or sexualabuse, children who have experiencedviolence in the home, or children whoare diagnosed with a psychologicaldisorder should have timelyintervention with a child maltreatmentteam and/or mental health specialist.There should be policies in place toensure proper reporting of allegationsto authorities for further investigationas well as appropriate transfer toa facility with mental health serviceswith expertise in pediatric care if notavailable locally. Guidance in the areaof child maltreatment can be found onthe AAP Council on Child Abuse andNeglect Web site.58

CONCLUSIONS

Inpatient facilities caring for theunique pediatric population shouldbe well resourced to provide high-quality and safe health care byproviding the appropriate policies,equipment, facilities, and personnelas outlined in this clinical report.

LEAD AUTHOR

Kimberly D. Ernst, MD, MSMI, FAAP

COMMITTEE ON HOSPITAL CARE, 2018–2019

Daniel A. Rauch, MD, FAAP, ChairpersonKimberly D. Ernst, MD, MSMI, FAAPVanessa Lynn Hill, MD, FAAPMelissa Marie Mauro-Small, MD, FAAPBenson S. Hsu, MD, MBA, FAAPVinh Thuy Lam, MD, FAAPCharles David Vinocur, MD, FAAPJennifer Ann Jewell, MD, FAAP, FormerChairperson

LIAISONS

Karen Castleberry – Family LiaisonKristin Hittle Gigli, PhD, RN, CPNP-AC,CCRN – National Association of PediatricNurse PractitionersNancy Hanson – Children’s HospitalAssociationMichael S. Leonard, MD, MS, FAAP –Representative to The Joint CommissionBarbara Romito, MA, CCLS – Association ofChild Life Professionals

STAFF

S. Niccole Alexander, MPP

ABBREVIATIONS

AAP: American Academy ofPediatrics

EMSC: Emergency MedicalServices for Children

NS: normal saline

REFERENCES

1. Freeman WJ, Weiss AJ, Heslin KC.Overview of U.S. Hospital Stays in 2016:Variation by Geographic Region.Statistical Brief #246. Rockville, MD:Agency for Healthcare Research andQuality; 2018. Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/

sb246-Geographic-Variation-Hospital-Stays.pdf. Accessed March 30, 2019

2. Witt WP, Weiss AJ, Elixhauser A.Overview of Hospital Stays for Childrenin the United States, 2012. StatisticalBrief #187. Rockville, MD: Agency forHealthcare Research and Quality; 2014.Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.pdf. AccessedMarch 30, 2019

3. Centers for Medicare and MedicaidServices. Emergency Medical Treatmentand Labor Act (EMTALA). 2012. Availableat: www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/.Accessed March 30, 2019

4. American Academy of Pediatrics,Committee on Pediatric EmergencyMedicine; American College ofEmergency Physicians, PediatricCommittee; Emergency NursesAssociation, Pediatric Committee. Jointpolicy statement–Guidelines for care ofchildren in the emergency department.Pediatrics. 2009;124(4):1233–1243.Reaffirmed February 2016

5. American Academy of Pediatrics,Committee on Fetus and Newborn;American College of Obstetricians andGynecologists, Committee on ObstetricPractice. Guidelines for Perinatal Care.In: Riley LE, Stark AR, eds. 7th ed. ElkGrove Village, IL: American Academy ofPediatrics and Washington, DC:American College of Obstetricians andGynecologists; 2012

6. Frankel LR, Hsu BS, Yeh TS, et al; VotingPanel. Criteria for critical care infantsand children: PICU admission,discharge, and triage practicestatement and levels of care guidance.Pediatr Crit Care Med. 2019;20(9):847–887

7. American Academy of Pediatrics,Section on Transport Medicine.Guidelines for Air and GroundTransport of Neonatal and PediatricPatients. In: Insoft RM, ed. 4th ed. ElkGrove Village, IL: American Academy ofPediatrics; 2016

8. American College of Surgeons,Committee on Trauma. Resources forOptimal Care of the Injured Patient. 6thed. Chicago, IL: American College ofSurgeons; 2014

PEDIATRICS Volume 145, number 4, April 2020 9 by guest on June 29, 2020www.aappublications.org/newsDownloaded from

9. Committee on Pediatric EmergencyMedicine, Council on Injury; Violence,and Poison Prevention, Section onCritical Care, Section on Orthopaedics,Section on Surgery, Section onTransport Medicine, Pediatric TraumaSociety, and Society of Trauma NursesPediatric Committee. Management ofpediatric trauma. Pediatrics. 2016;138(2):e20161569

10. Emergency Nurses AssociationPediatric Committee; Society of TraumaNurses Pediatric Special Interest Group.Inter Facility Transfer Tool Kit for thePediatric Patient. Houston, TX:Emergency Medical Services forChildren Innovation and ImprovementCenter; 2017. Available at: https://emscimprovement.center/resources/toolboxes/interfacility-transfer-toolbox/.Accessed March 30, 2019

11. American Academy of Pediatrics;American College of EmergencyPhysicians; American College ofSurgeons Committee on Trauma;Emergency Medical Services forChildren; Emergency NursesAssociation; National Association ofEMS Physicians; National Association ofState EMS Officials. Equipment forground ambulances. Pediatrics. 2014;134(3). Available at: www.pediatrics.org/cgi/content/full/134/3/e919

12. Marcin JP, Rimsza ME, Moskowitz WB;Committee on Pediatric Workforce. Theuse of telemedicine to address accessand physician workforce shortages.Pediatrics. 2015;136(1):202–209

13. Burke BL Jr., Hall RW; Section onTelehealth Care. Telemedicine: pediatricapplications. Pediatrics. 2015;136(1):e293–e308

14. American Academy of Pediatrics. AAPECHO. Available at: www.aap.org/en-us/professional-resources/practice-transformation/echo/Pages/default.aspx. Accessed March 30, 2019

15. McSwain SD, Bernard J, Burke BL Jr.,et al; American TelemedicineAssociation. American TelemedicineAssociation operating procedures forpediatric telehealth. Telemed J E Health.2017;23(9):699–706

16. The Joint Commission. National PatientSafety Goals. Oakbrook Terrace, IL: TheJoint Commission; 2015. Available at:www.jointcommission.org/assets/1/6/

2015_NPSG_HAP.pdf. Accessed March30, 2019

17. Levine SR, Cohen MR, Blanchard NR,et al. Guidelines for preventing medicalerrors in pediatrics. J PediatrPharmacol Ther. 2001;6:426–442

18. Emergency Medical Services forChildren, Innovation and ImprovementCenter. Pediatric Disaster PreparednessToolkit. 2009. Available at: https://emscimprovement.center/resources/publications/checklist-essential-for-every-hospitals-disaster-preparedness-policies/. Accessed March 30, 2019

19. Image Gently. Interventional Radiology -Step Lightly Resources. Available at:https://www.imagegently.org/Procedures/Interventional-Radiology/Image-Safely-Resources. AccessedMarch 30, 2019

20. Institute for Healthcare Improvement.Rapid response teams. Available at:www.ihi.org/Topics/RapidResponseTeams/Pages/default.aspx. Accessed March 30, 2019

21. US Department of Health and HumanServices, Office of the AssistantSecretary for Preparedness andResponse. Incorporating Active ShooterIncident Planning Into Health CareFacility Emergency Operations Plans.Washington, DC: US Department ofHealth and Human Services; 2014

22. Disaster Preparedness AdvisoryCouncil; Committee on PediatricEmergency Medicine. Ensuring thehealth of children in disasters.Pediatrics. 2015;136(5). Available at:www.pediatrics.org/cgi/content/full/136/5/e1407

23. American Academy of Pediatrics,Disaster Preparedness AdvisoryCouncil. Children and disasters:disaster preparedness to meetchildren’s needs. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/default.aspx.Accessed March 30, 2019

24. Emergency Medical Services forChildren Innovation and ImprovementCenter. Education & resources. Availableat: https://emscimprovement.center/resources/. Accessed March 30, 2019

25. American Academy of Pediatrics;American College of Emergency

Physicians; Emergency NursesAssociation. Checklist of EssentialPediatric Domains and Considerationsfor Every Hospital’s DisasterPreparedness Policies. Houston, TX:Emergency Medical Services forChildren Innovation and ImprovementCenter; 2014. Available at: https://emscimprovement.center/documents/144/Checklist_HospitalDisasterPrepared2125.pdf. Accessed March 30, 2019

26. Barfield WD, Krug SE; Committee onFetus and Newborn; DisasterPreparedness Advisory Council. Disasterpreparedness in neonatal intensive careunits. Pediatrics. 2017;139(5):e20170507

27. American Academy of Pediatrics;Committee on Pediatric EmergencyMedicine and Council on ClinicalInformation Technology; AmericanCollege of Emergency Physicians;Pediatric Emergency MedicineCommittee. Policystatement–emergency informationforms and emergency preparednessfor children with special health careneeds. Pediatrics. 2010;125(4):829–837.Reaffirmed October 2014

28. Committee on Hospital Care andInstitute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician’srole. Pediatrics. 2012;129(2):394–404

29. Committee on Pediatric EmergencyMedicine; Committee on Bioethics.Consent for emergency medicalservices for children and adolescents.Pediatrics. 2011;128(2):427–433.Reaffirmed September 2015

30. Agency for Healthcare Research andQuality. AHRQ Health Literacy UniversalPrecautions Toolkit. Rockville, MD:Agency for Healthcare Research andQuality; 2018. Available at: www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed March 30, 2019

31. Committee on Bioethics. Informedconsent in decision-making in pediatricpractice. Pediatrics. 2016;138(2):e20161484

32. American Academy of Pediatrics;American College of EmergencyPhysicians; Emergency NursesAssociation. Pediatric Pain ManagementToolkit. Houston, TX: Emergency MedicalServices for Children Innovation andImprovement Center; 2017. Available at:

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 29, 2020www.aappublications.org/newsDownloaded from

https://emscimprovement.center/resources/toolboxes/pediatric-pain-management-toolbox/. Accessed March30, 2019

33. Fleisher GR, Ludwig S. Textbook ofPediatric Emergency Medicine. 6th ed.Philadelphia, PA: Lippincott Williams &Wilkins; 2010

34. Committee on Fetus and Newborn;Section on Anesthesiology and PainMedicine. Prevention and management ofprocedural pain in the neonate: anupdate. Pediatrics. 2016;137(2):e20154271

35. Task Force on Sudden Infant DeathSyndrome. SIDS and other sleep-relatedinfant deaths: updated 2016recommendations for a safe infantsleeping environment. Pediatrics. 2016;138(5):e20162938

36. Lehmann CU; Council on ClinicalInformation Technology. Pediatricaspects of inpatient health informationtechnology systems. Pediatrics. 2015;135(3). Available at: www.pediatrics.org/cgi/content/full/135/3/e756

37. Committee on Adolescence. Achievingquality health services for adolescents.Pediatrics. 2016;138(2):e20161347

38. Jewell JA; Committee on Hospital Care.Standardization of inpatient handoffcommunication. Pediatrics. 2016;138(5):e2016281

39. Kuo DZ, Houtrow AJ; Council on Childrenwith Disabilities. Recognition andmanagement of medical complexity.Pediatrics. 2016;138(6):e20163021

40. Bates DW, Cohen M, Leape LL, OverhageJM, Shabot MM, Sheridan T. Reducingthe frequency of errors in medicineusing information technology. J Am MedInform Assoc. 2001;8(4):299–308

41. The Joint Commission. ComprehensiveAccreditation Manual for Hospitals.Oakbrook Terrace, IL: The JointCommission; 2016

42. US Consumer Product SafetyCommission. Regulations, laws &standards. Available at: www.cpsc.gov/Regulations-Laws–Standards. AccessedMarch 30, 2019

43. Committee on Hospital Care and ChildLife Council. Child life services.Pediatrics. 2014;133(5). Available at:

www.pediatrics.org/cgi/content/full/133/5/e1471

44. Institute for Patient- and Family-Centered Care. Resources. Available at:http://ipfcc.org/resources/index.html.Accessed March 30, 2019

45. Clinical and Laboratory StandardsInstitute. Defining, Establishing, andVerifying Reference Intervals in theClinical Laboratory; Approved Guideline[CLSI Document EP28-A3c]. 3rd ed.Wayne, PA: Clinical and LaboratoryStandards Institute; 2008

46. American Society of Health-SystemPharmacists. ASHP compounded oralliquid version 1.01: finalized list July2017. 2017. Available at: www.ashp.org/-/media/assets/pharmacy-practice/s4s/docs/s4s-ashp-oral-compound-liquids.ashx?la=en&hash=4C2E4F370B665C028981B61F6210335AD5D0D1D6. Accessed March 30,2019

47. Committee on Drugs. Metric units andthe preferred dosing of orallyadministered liquid medications.Pediatrics. 2015;135(4):784–787

48. Lye PS; American Academy ofPediatrics. Committee on Hospital Careand Section on Hospital Medicine. Clinicalreport–physicians’ roles in coordinatingcare of hospitalized children. Pediatrics.2010;126(4):829–832

49. Jaimovich DG; American Academy ofPediatrics Committee on Hospital Careand Section on Critical Care. Admissionand discharge guidelines for thepediatric patient requiringintermediate care. Pediatrics. 2004;113(5):1430–1433. Reaffirmed May 2017

50. Polaner DM, Houck CS; Section onAnesthesiology and Pain Medicine;American Academy of Pediatrics.Critical elements for the pediatricperioperative anesthesia environment.Pediatrics. 2015;136(6):1200–1205

51. Society for Pediatric Anesthesia. Societyfor Pediatric Anesthesia PolicyStatement on Provision of PediatricAnesthesia Care. Richmond, VA: Societyfor Pediatric Anesthesia; 2017. Availableat: www.pedsanesthesia.org/about/provision-of-pediatric-anesthesia-care/.Accessed March 30, 2019

52. Boucher EA, Burke MM, Johnson PN,Klein KC, Miller JL; Advocacy Committeefor the Pediatric Pharmacy AdvocacyGroup. Minimum requirements for corecompetency in pediatric pharmacypractice. J Pediatr Pharmacol Ther.2015;20(6):481–484

53. Chun TH, Mace SE, Katz ER; AmericanAcademy of Pediatrics; Committee onPediatric Emergency Medicine;American College of EmergencyPhysicians; Pediatric EmergencyMedicine Committee. Evaluation andmanagement of children and adolescentswith acute mental health or behavioralproblems. Part I: common clinicalchallenges of patients with mental healthand/or behavioral emergencies.Pediatrics. 2016;138(3):e20161570

54. Shain B; Committee on Adolescence.Suicide and suicide attempts inadolescents. Pediatrics. 2016;138(1):e20161420

55. Eaton DK, Kann L, Kinchen S, et al;Centers for Disease Control andPrevention (CDC). Youth Risk BehaviorSurveillance - United States, 2011.MMWR Surveill Summ. 2012;61(4):1–162

56. Flaherty EG, Perez-Rossello JM, LevineMA, Hennrikus WL; American Academyof Pediatrics Committee on Child Abuseand Neglect; Section on Radiology,American Academy of Pediatrics;Section on Endocrinology, AmericanAcademy of Pediatrics; Section onOrthopaedics, American Academy ofPediatrics; Society for Pediatric Radiology.Evaluating children with fractures forchild physical abuse. Pediatrics. 2014;133(2). Available at: www.pediatrics.org/cgi/content/full/133/2/e477

57. Christian CW; Committee on Child Abuseand Neglect, American Academy ofPediatrics. The evaluation of suspectedchild physical abuse. Pediatrics. 2015;135(5). Available at: www.pediatrics.org/cgi/content/full/135/5/e1337

58. Flaherty EG, Stirling J; AmericanAcademy of Pediatrics, Committee onChild Abuse and Neglect. Thepediatrician’s role in childmaltreatment prevention. Pediatrics.2010;126(4):833–841. Reaffirmed May2014

PEDIATRICS Volume 145, number 4, April 2020 11 by guest on June 29, 2020www.aappublications.org/newsDownloaded from

originally published online March 23, 2020; Pediatrics Kimberly D. Ernst and COMMITTEE ON HOSPITAL CARE

Resources Recommended for the Care of Pediatric Patients in Hospitals

ServicesUpdated Information &

020-0204http://pediatrics.aappublications.org/content/early/2020/03/19/peds.2including high resolution figures, can be found at:

References

020-0204#BIBLhttp://pediatrics.aappublications.org/content/early/2020/03/19/peds.2This article cites 26 articles, 19 of which you can access for free at:

Subspecialty Collections

bhttp://www.aappublications.org/cgi/collection/hospital_medicine_suHospital Medicinel_carehttp://www.aappublications.org/cgi/collection/committee_on_hospitaCommittee on Hospital Carehttp://www.aappublications.org/cgi/collection/current_policyCurrent Policyfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on June 29, 2020www.aappublications.org/newsDownloaded from

originally published online March 23, 2020; Pediatrics Kimberly D. Ernst and COMMITTEE ON HOSPITAL CARE

Resources Recommended for the Care of Pediatric Patients in Hospitals

http://pediatrics.aappublications.org/content/early/2020/03/19/peds.2020-0204located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on June 29, 2020www.aappublications.org/newsDownloaded from