OBJECTIVES:

To assess hospital-level variation in laboratory testing and intravenous fluid (IVF) use and examine the association between these interventions and hospitalization outcomes among infants admitted with neonatal hyperbilirubinemia.

METHODS:

We performed a retrospective multicenter study of infants aged 2 to 7 days hospitalized with a primary diagnosis of hyperbilirubinemia from December 1, 2016, to June 30, 2018, using the Pediatric Health Information System. Hospital-level variation in laboratory and IVF use was evaluated after adjusting for clinical and demographic factors and associated with hospital-level outcomes by using Pearson correlation.

RESULTS:

We identified 4396 infants hospitalized with hyperbilirubinemia. In addition to bilirubin level, the most frequently ordered laboratories were direct antiglobulin testing (45.7%), reticulocyte count (39.7%), complete blood cell counts (43.7%), ABO blood type (33.4%), and electrolyte panels (12.9%). IVFs were given to 26.3% of children. Extensive variation in laboratory testing and IVF administration was observed across hospitals (all P < .001). Increased use of laboratory testing but not IVFs was associated with a longer length of stay (P = .007 and .162, respectively). Neither supplementary laboratory use nor IVF use was associated with either readmissions or emergency department revisits.

CONCLUSIONS:

Substantial variation exists among hospitals in the management of infants with hyperbilirubinemia. With our results, we suggest that additional testing outside of bilirubin measurement may unnecessarily increase resource use for infants hospitalized with hyperbilirubinemia.

Hyperbilirubinemia represents 1 of the most prevalent diagnoses for hospitalized newborns,1  with admissions typically reserved for infants at a high risk for development of acute bilirubin encephalopathy and subsequent kernicterus. Although the overall incidence for kernicterus is low, it is a highly preventable neurotoxic brain injury that results in lifelong neurologic compromise. To prevent kernicterus, ∼35 000 infants per year are hospitalized after their birth hospitalization for treatment of hyperbilirubinemia. These hospitalizations account for an estimated $361 million in charges per annum.2 

Because of the high prevalence of hyperbilirubinemia and largely preventable complication of kernicterus, the American Academy of Pediatrics (AAP) created guidelines for the management of neonatal hyperbilirubinemia. These guidelines, which were last updated in 2004, are focused on reducing the complications as well as unnecessary treatments and costs.3  Although recommendations regarding the utility of diagnostic laboratory testing or intravenous fluid (IVF) use among infants admitted for hyperbilirubinemia are addressed in these guidelines, they are based on low-quality evidence, and the extent to which these guidelines are followed is unclear.3 

The absence of high-quality data within evidence-based guidelines can create a climate for significant variation in clinical care.46  Previous studies have revealed that among certain disease processes (eg, pneumonia, bronchiolitis, and orbital cellulitis) high variation in resource use is associated with increased hospital length of stay (LOS) and hospital costs, without significant benefit in clinical outcomes.79  However, the impact of variability in diagnostic laboratory testing and IVF use on outcomes for infants hospitalized with hyperbilirubinemia is unknown.

Knowledge of variation and outcomes may help to inform an evidence-based approach to medical decision-making for neonates with hyperbilirubinemia and high-value approach to care. Therefore, we sought to (1) describe variation in laboratory testing and IVF use among infants admitted with hyperbilirubinemia and (2) examine the association of laboratory testing and IVF use with LOS, 3-day emergency department (ED) revisits, and 3-day readmissions. We hypothesized that there would be significant hospital-level variation in both laboratory testing and IVF use and that laboratory testing and IVF use would be associated with prolonged hospital LOS.

We conducted a retrospective multicenter cohort study using the Pediatric Health Information System (PHIS) database. The PHIS database includes deidentified daily billing and administrative data from 49 freestanding pediatric hospitals affiliated with the Children’s Hospital Association (Lenexa, KS). Data are deidentified at the time of entry into the database and are subjected to rigorous quality checks before inclusion. Patients can be tracked across encounters by using a consistently encrypted medical record number. This study was deemed nonhuman subjects research by the institutional review board at our institution.

We included infants aged 2-to-7 days with an observation or inpatient hospitalization to a PHIS-reporting hospital and primary diagnosis of hyperbilirubinemia between December 1, 2016, and June 30, 2018. The following International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes were used to identify infants with hyperbilirubinemia: Rh isoimmunization of newborn (P55.0); ABO isoimmunization of newborn (P55.1); other hemolytic disease of newborn (P55.8); hemolytic disease of newborn, unspecified (P55.9); neonatal jaundice due to other specified excessive hemolysis (P58.8); neonatal jaundice from other specified causes (P59.8); neonatal jaundice from breast milk inhibitor (P59.3); neonatal jaundice, unspecified (P59.9); and disorder of bilirubin metabolism, unspecified (E80.7). In general, we excluded infants that are not included in the AAP guidelines for hyperbilirubinemia management or who are at risk for complicated clinical courses that may warrant testing or treatment not related to hyperbilirubinemia. We excluded all infants with a hospital LOS >48 hours because the vast majority of hospitalizations are <30 hours and infants with a substantially longer LOS likely represent outliers with complicated or unique clinical courses. Additionally, we excluded infants with a gestational age <37 weeks, a birth weight <2500 g, direct admission to an ICU, a discharge diagnosis corresponding to fever and/or temperature instability, shock, sepsis and/or bacteremia, a urinary tract infection and a history of surgical procedure, major congenital anomaly, or complex chronic condition.10  Birth hospitalizations and infants <2 days of age were excluded because we wished to study infants admitted specifically for management of hyperbilirubinemia. Nonstandard discharges (such as those infants transferred to other facilities) and infants transferred into PHIS participating sites from an outside facility were excluded because of risk of incomplete data. We also excluded infants admitted to hospitals with a mean annual volume of <10 admissions for hyperbilirubinemia (Fig 1) because of risk of bias from small sample sizes.

FIGURE 1

Consort diagram. CCC, complex chronic condition; prin dx, principle diagnosis; UTI, urinary tract infection.

FIGURE 1

Consort diagram. CCC, complex chronic condition; prin dx, principle diagnosis; UTI, urinary tract infection.

Close modal

We used billing codes to identify laboratory testing and receipt of IVF within the first 2 days of hospitalization. We defined supplementary laboratories as tests drawn in addition to bilirubin levels, including a complete blood cell (CBC) count (with or without differential), peripheral smear, electrolyte panel, reticulocyte count, ABO blood type, type and screen, glucose-6-phosphate dehydrogenase activity, urinalysis, and direct antiglobulin testing (DAT). We examined hospital-level rates of use for IVFs and the top 5 most frequently obtained supplementary laboratories.

We included hospital LOS in hours, all-cause 3-day ED revisit and 3-day hospital readmission rates, transfer to ICU level of care, incidence of blood transfusion, diagnosis of hearing loss, and diagnosis of kernicterus as clinical outcomes. We chose to examine returns within 3 days given the acute nature of hyperbilirubinemia and risk of progression to bilirubin encephalopathy if treatment is not initiated in a timely manner. We did not specifically examine the rate of exchange transfusion in our population because billing data specific to exchange transfusion are not well detailed in the PHIS database. The incidence of blood transfusion was used as a surrogate marker for receipt of exchange transfusion. We assessed incidence of hearing loss to evaluate sequelae of extreme hyperbilirubinemia that does not progress to kernicterus.

The following patient-level characteristics were identified: age in days, sex, race and/or ethnicity, primary payer type, presence of a hemolytic disease process, and illness severity. Infants were identified as having a hemolytic disease process if they had an ICD-10-CM diagnosis code corresponding to any of the following: Rh isoimmunization of newborn, ABO isoimmunization of newborn, other hemolytic disease of newborn, or hemolytic disease of newborn not otherwise specified, neonatal jaundice due to other specified excessive hemolysis. Illness severity was measured by using the hospitalization resource intensity scores for kids algorithm.11 

We summarized continuous variables using medians and interquartile ranges (IQRs) and categorical variables by frequencies and percentages. We used generalized linear mixed effects models to calculate risk-adjusted hospital-level laboratory testing and IVF rates after adjusting for sex, race and/or ethnicity, payer, illness severity, and hemolytic disease. To assess hospital-level variation in risk-adjusted laboratory testing and IVF use, we used a covariance test to assess the significance of the hospital random effect. We then determined each hospital’s diagnostic laboratory testing performance on the basis of their risk-adjusted laboratory use score. To determine laboratory use scores, we first ranked hospital-level laboratory and fluid use into quintiles on the basis of ordering frequency. Each laboratory and fluid quintile were then assigned a use score from 0 to 4, with a score of 0 corresponding to least frequently ordered laboratories or fluids and score of 4 corresponding to most frequently ordered laboratories or fluids. Total hospital laboratory use scores were obtained by summing the individual laboratory scores for each hospital. For each hospital, we summed the 5 individual laboratory quintiles to create a total laboratory use score. This score could range from 0 (lowest quintile on all tests) to 20 (highest quintile on all tests). We correlated both the risk-adjusted total laboratory use score and risk-adjusted IVF rate with clinical outcomes by using Pearson correlation coefficient. All statistical analyses were performed by using SAS version 9.4 (SAS Institute, Inc, Cary, NC), and P values <.05 were considered statistically significant.

We identified 4396 children hospitalized with hyperbilirubinemia from 36 PHIS-reporting children’s hospitals during the study period (Fig 1). Patient- and hospital-level characteristics as well as unadjusted patient outcomes are portrayed in Table 1. The median age of infants was 4 days (IQR 3–5), and 57% were male. One-half of infants (50.2%) had private insurance, and 40% were non-Hispanic white race and ethnicity. Approximately 8% of infants had a diagnosis code corresponding to a hemolytic disease process. Overall, the median LOS was 25 hours (IQR 20–41), the 3-day ED revisit rate was 1.9%, and the 3-day hospital readmission rate was 1.4%. Among infants with a 3-day ED revisit or readmission, 77% and 74% had a primary diagnosis corresponding to hyperbilirubinemia at these repeat encounters, respectively. Among the cohort, 3 infants were transferred to an ICU, and 6 infants received red blood cell transfusions. No infants had a diagnosis of hearing loss nor a diagnosis of kernicterus.

TABLE 1

Demographic and Clinical Characteristics of the Cohort

Characteristicsn (%) or median (IQR)
Discharges, N 4396 
Age, d, median (IQR) 4 (3–5) 
Age, d, n (%)  
 2 190 (4.3) 
 3 1180 (26.8) 
 4 1305 (29.7) 
 5 918 (20.9) 
 6 531 (12.1) 
 7 272 (6.2) 
Sex, n (%)  
 Male 2505 (57) 
 Female 1890 (43) 
Race and/or ethnicity, n (%)  
 Non-Hispanic white 1753 (39.9) 
 Non-Hispanic Black 389 (8.8) 
 Hispanic 1243 (28.3) 
 Asian 539 (12.3) 
 Other 472 (10.7) 
Hospital region, n (%)  
 Midwest 1173 (26.7) 
 Northeast 294 (6.7) 
 South 1201 (27.3) 
 West 1728 (39.3) 
Payer, n (%)  
 Government 1971 (44.8) 
 Private 2219 (50.5) 
 Other 206 (4.7) 
Hemolytic disease, n (%)  
 No 4050 (92.1) 
 Yes 346 (7.9) 
Characteristicsn (%) or median (IQR)
Discharges, N 4396 
Age, d, median (IQR) 4 (3–5) 
Age, d, n (%)  
 2 190 (4.3) 
 3 1180 (26.8) 
 4 1305 (29.7) 
 5 918 (20.9) 
 6 531 (12.1) 
 7 272 (6.2) 
Sex, n (%)  
 Male 2505 (57) 
 Female 1890 (43) 
Race and/or ethnicity, n (%)  
 Non-Hispanic white 1753 (39.9) 
 Non-Hispanic Black 389 (8.8) 
 Hispanic 1243 (28.3) 
 Asian 539 (12.3) 
 Other 472 (10.7) 
Hospital region, n (%)  
 Midwest 1173 (26.7) 
 Northeast 294 (6.7) 
 South 1201 (27.3) 
 West 1728 (39.3) 
Payer, n (%)  
 Government 1971 (44.8) 
 Private 2219 (50.5) 
 Other 206 (4.7) 
Hemolytic disease, n (%)  
 No 4050 (92.1) 
 Yes 346 (7.9) 

After adjusting for patient- and hospital-level characteristics, the 5 most commonly used supplementary laboratory studies among hospitalized neonates with hyperbilirubinemia were DAT (45.7%), CBC count (43.7%), reticulocyte count (39.7%), ABO blood typing (33.4%), and electrolyte panel (12.9%). IVFs were used in 26.3% of infants. Figure 2 reveals the distribution of laboratory use and fluid use across hospitals. We found significant variation in unadjusted rates of both laboratory testing and IVF use (Fig 2). DAT and ABO blood typing were the 2 most highly variable laboratories, with IQRs between 25.2% and 59.0% and 19.5% and 46.9%, respectively. Both laboratory tests had rates of use that ranged between 0% and 96.2%. Reticulocyte count testing was the test performed with the least variation with regards to IQR but still had a wide range of obtainment, from 7.9% to 91%.

FIGURE 2

Unadjusted variation in laboratory and IVF use across the hospital.

FIGURE 2

Unadjusted variation in laboratory and IVF use across the hospital.

Close modal

We assigned hospitals quintile scores on the basis of risk-adjusted use of an individual laboratory test or IVF. Figure 3 reveals differences in the risk-adjusted use score quintile for each specific laboratory test and IVF. Hospitals are ordered from top to bottom according to the highest to lowest total risk-adjusted use score. Although no hospital performed at the lowest or highest quintile across each outcome, in general, hospitals tended to follow similar patterns of laboratory use and IVF use.

FIGURE 3

Heat map of interhospital variation in laboratory and fluid use.

FIGURE 3

Heat map of interhospital variation in laboratory and fluid use.

Close modal

After adjusting for important demographic and clinical factors, we found higher hospital-level total laboratory use scores were associated with a longer hospital LOS (P = .007). There were no associations with laboratory use and either readmission rates or ED revisits. Higher hospital-level rates of IVF were not associated with LOS and had no significant associations with risk of either an ED revisit or readmission for any condition (Supplemental Fig 4).

In this multicenter retrospective cohort analysis of infants hospitalized with a primary diagnosis of hyperbilirubinemia, we illustrate considerable hospital-level variation in the inpatient management of hyperbilirubinemia. We observed that increases in laboratory use, but not IVF use, were associated with a longer LOS. Neither laboratory nor IVF use were associated with an ED revisit or hospital readmission rates. Although finding variation in the management of a common illness is not surprising, demonstrating the etiology and clinical impact of variation is 1 of the first steps toward improving diagnostic stewardship and practice standardization for infants hospitalized with hyperbilirubinemia.

Our observations of substantial hospital-level variation in laboratory testing may be a consequence of limited evidence regarding the role of laboratory evaluation in the management of patients with hyperbilirubinemia. In the latest guideline from the AAP, it is recommended that infants receiving phototherapy undergo evaluation with DAT, ABO blood typing, and CBC count with peripheral smear. These recommendations, however, are based on the lowest quality of evidence, consisting of expert opinion, case reports, and clinical reasoning.3  Wide hospital-level variation in obtainment of these laboratories as well as the common obtainment of nonrecommended laboratories, such as electrolyte testing, draws into question the effectiveness of these guidelines. Given the lack of strong evidence-based recommendations for laboratory testing among infants admitted with hyperbilirubinemia, local expert opinions may drive differing hospital cultures of laboratory use. Additionally, a lack of integration of health-system technology likely contributes to our observations (eg, lack of availability of birth records and laboratory data on admission). Because insufficient investigation of the underlying etiology can contribute to extreme hyperbilirubinemia, in future evaluations, researchers should seek to define which infants may be safely managed with limited supplementary laboratories and evaluate the utility of novel diagnostic tests, such as genetic sequencing, in the management of these infants.1214 

A lack of clear evidence regarding the utility of supplemental fluids may contribute to variation in IVF use. Although the AAP states the use of routine IVFs among infants who appear well hydrated is unnecessary, in the most recent policy statement, the AAP avoids making a firm recommendation for or against routine IVF use.2  Although several studies have revealed that IVF supplementation in term neonates decreases the duration of phototherapy and rate of exchange transfusion,15,16  others have found no differences in bilirubin levels, the duration of phototherapy, or the rate of exchange transfusion.17,18  In a 2017 Cochrane review of IVF use among otherwise healthy infants receiving phototherapy, the authors describe that IVF may reduce the bilirubin level at certain time points but the use of IVF was not associated with a reduction in rates of bilirubin encephalopathy. In addition, no associations between IVF use and duration of phototherapy or exchange transfusion could be determined.19  Consequently, differences in interpretation of available evidence by clinicians and differences in provider experiences and biases may drive variation in IVF use among hospitals and highlight the need to identify which infants would benefit most from supplemental fluid administration.

Laboratory use is associated with longer LOS for other pediatric conditions.35,20  Consistent with these previous reports and as we hypothesized, admission for hyperbilirubinemia to hospitals with higher testing use scores was associated with longer LOS. IVF use was not associated with LOS, and neither laboratory nor fluid use was associated with rates of readmission or revisit. Although IVF use is theorized to potentially decrease the duration of phototherapy, and thus one might argue decrease LOS, in recent research in other pediatric conditions, researchers describe IVF use to be independently associated with prolonged LOS.21  In our cohort of term, otherwise well infants, the harms and risk of routine IVF use (pain associated with procedure, IV infiltrates, and potential electrolyte derangements) may outweigh any benefits.

Our study has several limitations. First, because, in this study, we relied on ICD-10-CM and billing codes, differences in hospital coding practices may influence our results. We attempted to mitigate differences in coding and billing practices by excluding hospitals with known poor data quality and infants seen at hospitals with a mean of <10 cases per year. Second, although we controlled for illness severity as a measure of hospital resource use (hospitalization resource intensity scores for kids algorithm), using a billing database such as PHIS limits our ability to control for severity of illness. Some patient-level characteristics not attainable within the PHIS database may influence clinical decision-making, including knowledge of breastfeeding history, a family history of hemolytic processes, and physical examination findings. By looking at hospital-level variation in testing, however, we hoped to decrease the influence of these more granular clinical characteristics; however, we acknowledge some associations between laboratory and/or fluid use and clinical outcomes may be confounded by illness severity. Finally, we were unable to account for any laboratory testing performed before hospitalization that might influence in-hospital testing.

High degrees of variability exist between children’s hospitals in the use of laboratory testing and IVFs among infants hospitalized with hyperbilirubinemia. Greater laboratory testing use was correlated with longer LOS without reductions in subsequent ED revisits or hospital readmissions. Fluid use was associated with neither LOS nor return visits. Further study into sources of practice variation is needed to inform standardization efforts.

Dr DePorre conceptualized and designed the study, drafted the initial manuscript, interpreted the data, and reviewed and revised the manuscript; Dr Hall conceptualized and designed the study, conducted the statistical analyses, supervised data interpretation, and reviewed and revised the manuscript; Drs Puls, Daly, Gay, and Bettenhausen assisted with study design and initial manuscript writing and critically reviewed the manuscript for important intellectual content; Dr Markham supervised the conceptualization and design of the study, interpreted the data, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

1
Keren
R
,
Luan
X
,
Localio
R
, et al
;
Pediatric Research in Inpatient Settings (PRIS) Network
.
Prioritization of comparative effectiveness research topics in hospital pediatrics
.
Arch Pediatr Adolesc Med
.
2012
;
166
(
12
):
1155
1164
2
Agency for Healthcare Research and Quality
.
HCUPnet: Healthcare Cost and Utilization Project. Available at: https://hcupnet.ahrq.gov/. Accessed April 15, 2019
3
American Academy of Pediatrics Subcommitee of Hyperbilirubinemia
.
Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation
. [
published correction appears in Pediatrics. 2004;114(4):1138
].
Pediatrics
.
2004
;
114
(
1
):
297
316
4
Aronson
PL
,
Thurm
C
,
Alpern
ER
, et al
;
Febrile Young Infant Research Collaborative
.
Variation in care of the febrile young infant <90 days in US pediatric emergency departments
. [
published correction appears in Pediatrics. 2015;135(4):775
].
Pediatrics
.
2014
;
134
(
4
):
667
677
5
Landrigan
CP
,
Conway
PH
,
Stucky
ER
,
Chiang
VW
,
Ottolini
MC
.
Variation in pediatric hospitalists' use of proven and unproven therapies: a study from the Pediatric Research in Inpatient Settings (PRIS) Network
.
J Hosp Med
.
2008
;
3
(
4
):
292
298
6
In
H
,
Neville
BA
,
Lipsitz
SR
,
Corso
KA
,
Weeks
JC
,
Greenberg
CC
.
The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence
.
Ann Surg
.
2012
;
255
(
5
):
890
895
7
Florin
TA
,
French
B
,
Zorc
JJ
,
Alpern
ER
,
Shah
SS
.
Variation in emergency department diagnostic testing and disposition outcomes in pneumonia
.
Pediatrics
.
2013
;
132
(
2
):
237
244
8
Florin
TA
,
Byczkowski
T
,
Ruddy
RM
,
Zorc
JJ
,
Test
M
,
Shah
SS
.
Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines
.
J Pediatr
.
2014
;
165
(
4
):
786.e1
792.e1
9
Markham
JL
,
Hall
M
,
Bettenhausen
JL
,
Myers
AL
,
Puls
HT
,
McCulloh
RJ
.
Variation in care and clinical outcomes in children hospitalized with orbital cellulitis
.
Hosp Pediatr
.
2018
;
8
(
1
):
28
35
10
Feudtner
C
,
Feinstein
JA
,
Zhong
W
,
Hall
M
,
Dai
D
.
Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation
.
BMC Pediatr
.
2014
;
14
:
199
11
Richardson
T
,
Rodean
J
,
Harris
M
,
Berry
J
,
Gay
JC
,
Hall
M
.
Development of hospitalization resource intensity scores for kids (H-RISK) and comparison across pediatric populations
.
J Hosp Med
.
2018
;
13
(
9
):
602
608
12
Christensen
RD
,
Yaish
HM
.
Hemolytic disorders causing severe neonatal hyperbilirubinemia
.
Clin Perinatol
.
2015
;
42
(
3
):
515
527
13
Alkén
J
,
Håkansson
S
,
Ekéus
C
,
Gustafson
P
,
Norman
M
.
Rates of extreme neonatal hyperbilirubinemia and kernicterus in children and adherence to national guidelines for screening, diagnosis, and treatment in Sweden
.
JAMA Netw Open
.
2019
;
2
(
3
):
e190858
14
Sgro
M
,
Campbell
D
,
Shah
V
.
Incidence and causes of severe neonatal hyperbilirubinemia in Canada
.
CMAJ
.
2006
;
175
(
6
):
587
590
15
Mehta
S
,
Kumar
P
,
Narang
A
.
A randomized controlled trial of fluid supplementation in term neonates with severe hyperbilirubinemia
.
J Pediatr
.
2005
;
147
(
6
):
781
785
16
Saeidi
R
,
Heydarian
F
,
Fakehi
V
.
Role of intravenous extra fluid therapy in icteric neonates receiving phototherapy
.
Saudi Med J
.
2009
;
30
(
9
):
1176
1179
17
Iranpour
R
,
Nohekhan
R
,
Haghshenas
I
.
Effect of intravenous fluid supplementation on serum bilirubin level in jaundiced healthy neonates during conventional phototherapy
.
J Res Med Sci
.
2004
;
4
:
186
190
18
Boo
N-Y
,
Lee
H-T
.
Randomized controlled trial of oral versus intravenous fluid supplementation on serum bilirubin level during phototherapy of term infants with severe hyperbilirubinaemia
. [
published correction appears in J Paediatr Child Health. 2002;38(6):625
].
J Paediatr Child Health
.
2002
;
38
(
2
):
151
155
19
Lai
NM
,
Ahmad Kamar
A
,
Choo
YM
,
Kong
JY
,
Ngim
CF
.
Fluid supplementation for neonatal unconjugated hyperbilirubinaemia
.
Cochrane Database Syst Rev
.
2017
;
8
(
8
):
CD011891
20
Tieder
JS
,
McLeod
L
,
Keren
R
, et al
;
Pediatric Research in Inpatient Settings Network
.
Variation in resource use and readmission for diabetic ketoacidosis in children’s hospitals
.
Pediatrics
.
2013
;
132
(
2
):
229
236
21
Pinto
JM
,
Petrova
A
.
Detection of acute gastroenteritis etiology in hospitalized young children: associated factors and outcomes
.
Hosp Pediatr
.
2017
;
7
(
9
):
536
541

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data