Hospital-Based Playrooms, Classrooms, and Pet Therapy

A unique feature of most pediatric healthcare facilities is that they provide opportunities for both inpatients and outpatients to participate in play with developmentally appropriate toys during their medical care. Reasons for play in hospitalized pediatric patients may include providing mechanisms to educate children about their particular medical conditions, providing stress reduction during frightening procedures, assisting in the development of coping strategies, and attempting to maintain a sense of normalcy during long hospitalizations. Although toys and playroom environments provide a vital psychosocial and quality-of-life function, however, they are also known to contribute to the transmission of infectious agents. This chapter provides guidance on minimizing transmission of pathogens in hospital-based playrooms and classrooms: pathogens that are commonly found in pediatric healthcare facilities. This chapter also discusses the transmission challenges with pet therapy programs for children, and suggests approaches for safe implementation of these programs. Sample policies are included.

Clostridioides difficile and Norovirus

Clostridioides difficile and norovirus are common causes of healthcare-associated gastroenteritis and both organisms cause outbreaks in pediatric healthcare settings. The spores are resistant to routine environmental cleaning with detergents and can survive in the environment for months. C. difficile can easily be transmitted on the hands of healthcare workers, either from direct patient care activities or through contact with a contaminated environment. Norovirus is highly contagious, with an estimated infectious dose as low as 18 viral particles. Transmission occurs either person-to-person or through ingestion of contaminated food and water. This chapter outlines strategies to prevent transmission of healthcare-associated C. difficile and norovirus infections. It includes recommendations for surveillance, isolation, hand hygiene, environmental cleaning and removal of isolation precautions. Diagnostic methods are reviewed, highlighting the challenge of distinguishing between colonization and clinically significant C. difficile infection in young children.

Device-Associated Infections in the Neonatal Intensive Care Unit (NICU)

Infants, especially preterm, in neonatal intensive care units (NICU) are especially susceptible to healthcare-associated infections (HAI), given their immature immune system, the acuity of care that they need, and the frequency of invasive procedures performed. Moreover, HAIs have major impacts on premature infant outcomes. HAIs in the NICU have been associated with a twofold increase in the risk of death. This chapter reviews several strategies to prevent healthcare-associated infections, including central line–associated bloodstream infection, ventilator-associated pneumonia, and catheter-associated urinary tract infection, in the neonatal intensive care unit setting. The importance of the neonatal microbiome in the prevention of infections is emphasized.

Device-Associated Infections (Outside of the Neonatal Intensive Care Unit)

Device-associated infections cause substantial morbidity in children. These healthcare-associated infections (HAI) can increase length of stay and healthcare costs. The strategies used to prevent device-associated infections in children can vary, depending on many patient-specific factors, including the child’s age and physical location when receiving inpatient pediatric care. In addition, infection prevention strategies in children are not always the same as adult prevention strategies. This chapter reviews practical, evidence-based strategies to prevent pediatric ventilator-associated events (VAE), central line–associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI). The recommendations focus on patients outside the neonatal intensive care unit (NICU) setting.

Antimicrobial Stewardship in Pediatrics

The rapid emergence of multidrug-resistant bacteria has become a global public health crisis. As antibiotics are the only class of medications where use in one patient can compromise their efficacy in another patient, stewardship is critical to preserve this shared resource. The Centers for Disease Control and Prevention (CDC) have focused on improving antimicrobial use for many years. One effective strategy used to decrease the emergence of multi‐drug-resistant organisms (MDROs) is the antimicrobial stewardship program (ASP): a coordinated healthcare program that seeks to provide optimal antimicrobial treatment to patients to reduce the emergence of MDROs, improve patient outcomes, and decrease cost. This chapter reviews the importance of an antimicrobial stewardship program, reviews core elements of a pediatric hospital ASP, and provides guidance on tracking and reporting antimicrobial prescribing in pediatric healthcare facilities.

Pertussis and Influenza Cocooning Immunization Strategies

This chapter discusses the adult immunization strategy called “cocooning” to protect young infants from vaccine-preventable disease. Cocooning focuses on immunizing all close contacts of infants and high-risk children, thereby decreasing their exposure to these infectious diseases. The cocooning strategy is frequently recommended as a strategy to prevent transmission of influenza and pertussis. Cocooning may include the vaccination not only of mothers but also of fathers, grandparents, siblings, extended family members, daycare providers, healthcare workers, and other caregivers in contact with the infant. This chapter provides suggestions for implementing an adult immunization program in both ambulatory and inpatient pediatric settings.

Management of Hospital Visitors

Policies and practices regarding management of visitors vary by hospital system. Current guidance from the Society for Healthcare Epidemiology (SHEA) suggests that practices should be based on (a) the pathogen suspected or confirmed, (b) the underlying medical condition of the patient and the visitor, and (c) the endemicity of that pathogen in the hospital and surrounding community—distinguishing between outbreak and non-outbreak settings. Pediatric infection prevention strategies should strive to balance family centered care with policies that minimize the risk of acquiring or transmitting pathogens. This chapter provides guidance on managing hospital visitors when a child’s infection requires isolation precautions. Age-based visitor restriction policies are reviewed. This chapter also includes discussion about high-consequence pathogens such as Ebola virus.

Breast Milk Handling and Misadministration

Human milk is the preferred nutritional source for all newborns, including ill infants and premature neonates. The ability of a mother to provide milk for her infant may be hindered by maternal illness or poor milk production, and may be influenced by cultural expectations and personal preferences. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life. Infectious risks to the newborn from a single feeding of the wrong mother’s breast milk are not generally measurable; however, studies of viruses and bacteria potentially transmissible in human milk can be used to inform a rational approach when misadministration occurs. In healthcare settings, administration of breast milk to the incorrect infant is generally treated like a blood and body fluid exposures. This chapter reviews the pathogens that can be transmitted via breast milk and suggests approaches to prevent administration of expressed breast milk to the wrong infant. This chapter also provides guidance on managing a breast milk misadministration incident (disclosure; post-exposure testing of source and recipient).

Surgical Site Infections

Surgical site infections (SSIs) not only increase morbidity and healthcare costs, they also impose emotional and physical burdens on patients and families. The SSI risk for patients undergoing a surgical procedure is specific to the type of surgery, degree of contamination of the operative field, and underlying patient risk factors (both modifiable and non-modifiable. This chapter reviews strategies to prevent surgical site infections in pediatric patients following general surgery, spine surgery for scoliosis, neurosurgical ventricular shunts, and cardiovascular surgery. Best practices and bundles used in leading pediatric healthcare facilities are described, including recommendations for perioperative antibiotic prophylaxis.

Pediatric Long-Term Care, Behavioral Health, Residential Facilities, and Similar Settings

There are unique infection prevention issues associated with pediatric long-term care facilities, behavioral health units, rehabilitation hospitals, and other residential facilities. All of these facilities provide care to children with complex, chronic medical conditions. These children are at increased risk for healthcare-associated infection due to factors such as age-related vulnerability to infections, especially respiratory viral infections; chronic exposure to indwelling medical devices such as tracheostomies, gastrostomy tubes, and central venous catheters; and frequent close contact with other children and healthcare providers during therapeutic and social activities. This chapter provides infection prevention and control guidance in special healthcare settings outside of acute care, including pediatric long-term care, behavioral health, and residential facilities. The adaptation of strategies such as transmission-based precautions while maintaining a homelike environment is described. Recommendations for infection surveillance in these setting are provided, along with algorithms for managing respiratory and gastrointestinal illness.