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Top Pediatric Hospital Medicine Articles in Pediatrics

April 19, 2023

Commentary From the AAP Section on Hospital Medicine

The Section on Hospital Medicine (SOHM) was founded in 1999 with the mission to optimize the delivery of equitable health care to children in inpatient settings by advocating and innovating to promote an inclusive and sustainable professional environment for clinicians who care for hospitalized children. The section believes that nurturing the careers of inpatient clinicians is essential to creating a high-quality, equitable, collaborative, and effective system of care for children who require hospitalization. Currently, SOHM has 2,788 members, and the SOHM active listserv has 4,300 subscribers, including members and nonmembers.

SOHM leadership commissioned Dr. Ken Roberts to respond to the invitation to compile and submit a list of the top articles published in Pediatrics since 1948 related to pediatric hospital medicine. Dr. Roberts created an ad hoc committee and invited select members of SOHM with demonstrated knowledge of the literature to nominate articles. He also opened the process to the listserv, which garnered additional suggestions. The ad hoc committee voted on the preliminary list to select the final articles for the commentary. Dr. Alan Schroeder and Dr. John Stephens joined Dr. Roberts to write the short commentaries that highlight the impact of each article.

Top Pediatric Hospital Medicine Articles in Pediatrics

Kenneth Roberts, MD1 on behalf of the Section on Hospital Medicine

Affiliation: 1Department of Pediatrics, University of North Carolina School of Medicine

Highlighted Articles From Pediatrics

First Quarter Century (1948 to 1973)


Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823-832

Prior to this article, physicians calculated a child’s maintenance fluid volumes in proportion to body mass. This methodology conflicted with the observation that the maintenance fluid requirement was more accurately proportioned to daily caloric expenditure, a reflection of metabolic rate, that declines from infancy to adulthood (as the gradual decreases in normal heart and respiratory rates with increasing age substantiate). Holliday and Segar speculated that the need to use a table to calculate daily caloric expenditure and convert to a daily water requirement was a key obstacle to the process of determining maintenance fluid needs based on metabolism. Accordingly, they innovated to create 3 weight groupings, each of which had a different per kg daily fluid requirement due to the declines in basal metabolic rate with age. The calculation of a child’s daily maintenance fluid volume was 100 mL/kg/d for children 1-10 kg; 1000 mL plus 50 mL/kg/d for each kg above 10 kg for children 11-20 kg; and 1500 mL plus 20 mL/kg/d for each kg above 20 kg for children over 20 kg. This article not only taught pediatricians about how changes in basal metabolism affect maintenance fluid requirements, but also explained how the daily fluid requirement could be considered to be the net of insensible water loss and renal water loss minus the water of oxidation. This simplified approach to calculating daily water requirement has served as a standard of care for maintenance fluid therapy for 61 years. The AAP Clinical Practice Guideline “Maintenance Intravenous Fluids in Children” altered the recommended composition of the fluid, but notably the recommendations for daily maintenance fluid volume were not changed from the 1957 guidance by Holliday and Segar 61 years before.


Wright FH, Beem MO. Diagnosis and treatment: Management and treatment: Management of acute viral bronchiolitis in infancy. Pediatrics. 1965;35(2):334-337

Bronchiolitis is the quintessential “bread and butter” condition in pediatric hospital medicine. Clinicians continue to employ many pharmacologic interventions, but most have limited or no efficacy as determined by randomized clinical trials. This tension between the futility of our interventions and the desire to “want to do something” was captured back in 1965 by Wright and Beem, who cautioned readers “the principle of primum non nocere should temper frustrated anxiety to do something—anything—to relieve severe dyspnea.” Their article foreshadowed the philosophy of the 2015 AAP Clinical Practice Guideline published 50 years later (see below).

Second Quarter Century (1973-1998)


Kawasaki T, Kosaki F, Okawa S, Shigematsu I, Yanagawa H. A new infantile acute febrile mucocutaneous lymph node syndrome (MLNS) prevailing in Japan. Pediatrics. 1974;54(3):271-276

In 1967, Kawasaki proposed in a Japanese journal a new syndrome that now bears his name, but it was not until 1974 that a lead article in Pediatrics presented his observations to an English-speaking audience. Despite the passage of nearly 50 years, we have yet to discover the cause of this disease or to develop a gold standard diagnostic test. Hence, the “cardinal features” described by Kawasaki remain the basis of diagnosis. The article might have been overlooked by many readers as yet another exotic syndrome from a country far away, had it not been for a companion editorial that raised the alert: “Mucocutaneous Lymph Node Syndrome (MLNS): A Disease Widespread in Japan Which Demands Our Attention” and the article that followed the report, which identified a dramatic consequence of the syndrome: “Myocardial Infarction Due to Coronary Thromboarteritis, Following Acute Febrile Mucocutaneous Lymph Node Syndrome (MLNS) in an Infant.”


AAP Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89(6):1120–1126

The success of the “Back to Sleep” campaign in reducing an important cause of infant mortality is clear 30 years after this publication. This publication was highly relevant to pediatric hospital medicine because of its impact on inpatient and nursery procedures and staff. The new recommendation to promote the supine, rather than the prone, sleep position required staff to relearn what they likely had done with their own children and to educate parents and families about the importance of adopting the new and safer “back to sleep” recommendations. Although supine positioning is now accepted, hospital staff and providers initially struggled with this novel recommendation 30 years ago.

Third Quarter Century (1998-Present)


Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. 1999;104(1):79–86

Prolonged administration of intravenous (IV) antimicrobials well beyond clinical recovery is a practice that has characterized the treatment of many bacterial infections in children. However, 2 landmark Pediatrics studies have compelled re-evaluation of this practice. A 1999 randomized trial by Hoberman et al demonstrated similar outcomes in infants with urinary tract infection who received 14 days of oral cefixime compared to 3 days of IV cefotaxime + 11 days of oral cefixime. This trial was followed a decade later by a similar study of IV duration of antimicrobial treatment for osteomyelitis (Zaoutis et al, see below). The duration of IV antimicrobial courses has since shortened substantially for these 2 infections. More importantly, these investigations have pushed the broader question of when, if ever, the benefits of continued IV antimicrobials for a child who has recovered from any bacterial infection outweigh the considerable risks and costs.


Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009;123(2):636-642

This study followed the authors’ demonstration of the harm associated with the provision of prolonged IV antimicrobials using central catheters (Pediatrics. 2006;117(4):1210-1215). Children across 29 children’s hospitals transitioned early to oral antimicrobials had similar outcomes to those who received prolonged IV antimicrobials. This article is an excellent example of “Safely Doing Less” as proposed by Schroeder, Harris, and Newman in Pediatrics 2 years later.


Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502

Heeding the principle of primum non nocere espoused by Wright and Beem in 1965 (see above), the 2015 AAP bronchiolitis clinical practice guideline recommended that most medications and diagnostic tests had little to no utility. Most notably, the guidelines specifically recommended against treatment with bronchodilators (which in previous guidelines had been recommended as something “to consider”) and against the use of continuous pulse oximetry, which has been associated with overdiagnosis of hypoxemia in bronchiolitis. These new recommendations have been associated with meaningful reductions in unnecessary bronchiolitis care.

Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6):e20163360

Neonatal abstinence syndrome emerged in the early 2000s as an increasingly common diagnosis in pediatric hospital medicine due to the national opioid epidemic. The article by Grossman et al resulted in a marked transformation in care. The method of care described, now commonly called “eat, sleep, console,” resulted in dramatic reductions in the number of infants treated with opioids (from 98% to 14%) and the mean length of stay (from 22 days to 6 days) at a single center. These findings have since been replicated at other centers and have been widely implemented, resulting in a profound change in the care of a vulnerable population.

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