About

Christopher P. Bonafide, MD, MSCE, is an Associate Professor of Pediatrics (General Pediatrics) at the Children's Hospital of Philadelphia. His clinical role includes serving as an Attending Physician in the Division of General Pediatrics. His research expertise centers on implementation science within the pediatric hospital setting, with specific interests in deimplementing overused and ineffective practices. His focus areas include bronchiolitis and other lung diseases in children, patient safety, clinical communication, human factors engineering, physiologic monitoring systems, and alarm and alert fatigue. Bonafide is also involved in clinical informatics and pediatric hospital medicine. He holds a BA in Psychology from Colby College, an MD from Pennsylvania State University College of Medicine, and an MSCE in Clinical Epidemiology from the University of Pennsylvania. His research aims to improve pediatric hospital care through the development and implementation of evidence-based practices, with a particular emphasis on safety, communication, and health systems engineering. Bonafide is actively engaged in various roles at the Children's Hospital of Philadelphia and the University of Pennsylvania, including co-directing pediatric hospital epidemiology and outcomes research training programs and serving as research director of the hospital medicine section.

Research topics

• Intensive care medicine
• Anesthesia
• Emergency medicine
• Internal medicine
• Pediatrics
• Medicine

Selected publications

• DAGs: Directed Acyclic Graphs for Drawing Assumptions and Guiding Causal Inference

  Hospital Pediatrics · 2026-05-08

  articleSenior author

  In pediatric hospital medicine, we often rely on observational data to conduct hospital-based research studies. Observational studies may establish a correlation between an exposure and outcome, but for this correlation to be considered causation, researchers must incorporate causal inference methods to control for confounding and reduce study bias. This methodology article reviews the concept of a directed acyclic graph (DAG), which is a causal inference tool that visually depicts the assumed relationships among study variables to guide study design and analytic plans. First, we outline the introductory steps to guide researchers toward building a basic DAG for their research question. Next, we explore the different types of study variables, including mediators, effect modifiers, confounders, and colliders, and clarify the causal assumptions linking them to the exposure and outcome. Finally, we share recommendations for how investigators can incorporate findings from their DAG into their study design and analysis plan. Although DAGs are only as strong as their creator's understanding of the system of interest and its underlying context, we hope to equip readers with the tools necessary to build powerful DAGs that communicate their study assumptions and guide causal inference in research.

  PublisherDOI

• Disparities in Family-Centered Rounds Participation by Caregiver’s Preferred Language

  Hospital Pediatrics · 2025-12-02

  articleOpen access

  OBJECTIVE: Data exploring family-centered rounds (FCR) participation for caregivers who prefer a language other than English (LOE) are limited. We sought to characterize baseline rates of LOE-preferring caregiver FCR participation and reasons for not participating as part of the current-state analysis for a QI initiative. METHODS: From July 1, 2023, to April 19, 2024, rounding data were recorded, including caregiver presence at bedside and caregiver participation in rounds, for patients admitted to general pediatrics resident teams at a free-standing children's hospital. For LOE-preferring caregivers, we documented reasons for not joining rounds. We used logistic regression to compare FCR participation rates by preferred language and team; we used statistical process control P-charts to visualize participation over time. RESULTS: Data were recorded for 7586 rounding encounters. This included 6781 encounters with English-preferring caregivers and 805 encounters with LOE-preferring caregivers, representing 231 patients with LOE-preferring caregivers. LOE-preferring (70.3%, n = 566) and English-preferring (69.7%, n = 4725) caregivers were present at bedside with equal frequency. Of caregivers present at bedside, LOE-preferring caregivers participated in 55.6% (n = 315) of rounding encounters compared with 88.1% (n = 4165) for English-preferring caregivers (P < .001). The most-common reason that LOE-preferring caregivers did not participate in FCR was not being invited to join (82%, n = 251). LOE-preferring caregiver participation varied over time (27%-81%), by care team (39%-91%), and by individual LOE (27%-83%). CONCLUSIONS: LOE-preferring caregivers participated in FCR less often than English-preferring caregivers despite similar bedside presence, largely because they were not invited to join. Identifying opportunities to improve LOE-preferring caregiver participation in FCR is essential to ensure the provision of equitable care.

  PublisherOA PDFDOI

• Flu in Flux: The Evolving Controversy Over Oseltamivir for Children Who Are Hospitalized

  Hospital Pediatrics · 2025-10-23

  articleOpen accessSenior author

  The 2024 to 2025 influenza season marked the worst in 15 years, with at least 216 influenza-associated pediatric deaths.1 This severity was undoubtedly multifactorial. Although vaccine efficacy was similar to prior seasons, lower vaccination rates in pediatrics (less than 50%) likely played a notable role.2Given worsening public trust in vaccines, cancellation of the advisory meeting to select target influenza strains for vaccine development, and federal orders to halt the vaccine’s publicity campaign,3 pediatric hospitalists may face an even worse influenza season. If we cannot reliably prevent severe influenza cases, understanding the evidence behind available therapeutics becomes paramount. The American Academy of Pediatrics, Infectious Diseases Society of America, and Centers for Disease Control and Prevention strongly recommend every child hospitalized with influenza (regardless of risk, severity, or symptom duration) receive oseltamivir (a neuraminidase inhibitor) or another antiviral.4–6However, there is controversy among pediatric hospitalists regarding the use of oseltamivir in this setting. A recent survey of pediatric providers demonstrated wide variability in treatment preferences for children hospitalized with influenza, likely because of concerns surrounding the evidence of antiviral use in this population, particularly those presenting late into illness, and potential adverse effects.7This skepticism is not unfounded. For years, scholars raised concerns that recommendations favoring oseltamivir were unduly influenced by unpublished pharmaceutical data.8 Attempting to overcome publication bias, Jefferson et al obtained pharmaceutical clinical study reports to conduct a Cochrane systematic review.9 This 2014 review found oseltamivir was associated with shorter symptom duration for healthy children and increased vomiting but no association with symptom relief for children with asthma, pediatric hospitalizations, or complications including pneumonia, acute otitis media, and sinusitis. Additionally, despite case reports linking oseltamivir use to neuropsychiatric events like delirium or suicide attempts, the review found no association (but was underpowered for this outcome). However, a 2020 population-based study found no increased risk of neuropsychiatric events in children prescribed oseltamivir.10Since 2014, subsequent meta-analyses of predominantly adult populations have shown mixed benefits of oseltamivir use. The only pediatric-specific meta-analysis among these showed that healthy children who received oseltamivir in the outpatient setting within the first 48 hours of symptom onset (“early treatment”) had shorter illness courses and decreased risk of acute otitis media.11 Notably, most of these reviews were underpowered to investigate influenza-related complications, and none explored the effects of oseltamivir on children who are hospitalized.Unfortunately, there are no high-quality prospective studies in the pediatric inpatient setting. Therefore, to interpret the effectiveness of oseltamivir in this population, we are left to extrapolate from (1) trial data in outpatient children, (2) trial and observational data in adults who are hospitalized, and (3) observational data in children who are hospitalized.Outpatient pediatric trial data has shown children with mild to moderate disease benefit from early treatment. It may be reasonable to assume children who are hospitalized with moderate to severe disease would similarly benefit. However, the outpatient data have not shown benefits for children treated later in illness. Importantly, no studies have adequately explored adverse effects in children who are hospitalized, in which the 1.7-fold increased risk of vomiting from oseltamivir may have important implications, as dehydration is an important indication for continued hospitalization among children with viral illnesses.9 Newer antivirals, like baloxavir, may offer milder adverse effects but also lack prospective data in the inpatient pediatric setting.12Some trials and observational studies in adults who are hospitalized have shown benefits of early oseltamivir treatment, and some studies showed mortality benefits with treatment initiation as late as 5 days into illness.6 These latter studies likely provided some basis for the recommendation to treat all children who are hospitalized regardless of symptom duration. However, the US Food and Drug Administration’s position is that children “should be given medicines that have been appropriately evaluated for their use in those populations.” They state that extrapolation of adult data to pediatrics when disease course and response to treatment are presumed similar “may be possible.”13 We advise skepticism with direct extrapolation and suggest that the children we serve in the hospital, with unique susceptibilities to respiratory disease and adverse gastrointestinal effects, deserve pediatric-specific evidence.Finally, observational studies in children who are hospitalized are limited. Three studies using the Pediatric Health Information System (PHIS) administrative database reported associations between early oseltamivir treatment in children who are hospitalized and decreased length of stay (LOS).14–16 However, a subsequent study exploring the accuracy of influenza diagnoses and oseltamivir use in the “unexposed” cohort of the PHIS studies found 63% of patients were misclassified because they did not truly have influenza or were labeled unexposed despite receiving oseltamivir prior to hospitalization. As these misclassified patients had longer LOS, including them in the PHIS studies could have inappropriately skewed findings away from the null.17Other observational pediatric studies using different data sources with laboratory-confirmed influenza have demonstrated benefits of oseltamivir for certain high-risk populations. Louie et al used medical record data of critically ill children to show a mortality benefit of antiviral treatment, particularly with early treatment.18 Meanwhile, Campbell et al used data from the Influenza Hospitalization Surveillance Network to evaluate children with underlying medical conditions and critically ill children and found an association with decreased LOS only for those with early treatment.19 Taking the findings from all these studies together, the benefits of oseltamivir likely outweigh the risks for critically ill children, those with severe comorbidities, and those presenting within 48 hours of illness.Most children hospitalized with influenza are not critically ill, lack severe comorbidities, and present after 48 hours of illness.20 We need to shrink the knowledge gap around the benefits of antivirals for stable, children who are hospitalized presenting later in their illness course and the impact that gastrointestinal effects may have on populations particularly at risk for dehydration, including neonates and children with medical complexity. Ideally this would come from prospective, randomized, placebo-controlled, and comparative effectiveness trials of oseltamivir and baloxavir in children hospitalized for influenza.Such trials should capture family-centered outcomes including time to symptom resolution (with strict criteria for symptom onset/resolution), time to return to school/daycare/work, household transmission, and incidence of adverse effects. These trials would also ideally be powered to capture common influenza-related complications. Lastly, they should include operational outcomes such as LOS, hydration requirements, duration of respiratory support, escalation to intensive care, and revisit/readmission rates.In our opinion, prescribing oseltamivir for all children hospitalized with influenza, regardless of symptom duration, is not sufficiently supported by high-quality evidence, and professional societies should reconsider this recommendation. Although it remains unanimously recommended in national guidelines, a perceived lack of equipoise could make it challenging to compel funders to support a traditional patient-randomized efficacy trial. Alternative designs to obtain more definitive inpatient data could be a pragmatic cluster-randomized trial with a waiver of consent, instrumental variable analysis based on hospital-level oseltamivir utilization, or a hybrid effectiveness implementation approach, combining the evaluation of comparative clinical effectiveness while preparing for the implementation of best practices that derive from the results, whether supporting or refuting the use of antivirals. These approaches could allow us to reevaluate oseltamivir’s effectiveness for children hospitalized with influenza, compare outcomes and adverse effects of baloxavir with the current standard of care, and identify strategies to improve uptake of guidelines across clinical sites.Further, future research could also explore which pediatric patients are at highest risk for poor outcomes and who would most benefit from home testing for early detection and antiviral prophylaxis.Meanwhile, winter is coming. So, what are we, as pediatric hospitalists, to do? As rigorous clinical trials take time to design, fund, and conduct, we do not anticipate having clear answers for children who are hospitalized before influenza season.Presently, the most honest thing we can offer families is transparency for shared decision-making. In our practice, we share with all families that (1) oseltamivir is safe and recommended by national guidelines; (2) some research suggests it could shorten time with symptoms and lower the risk of associated ear infections; (3) there has been mixed evidence on how much it helps, particularly if your child has been sick for more than 2 days; and (4) there is an increased risk of vomiting.More critically, we must advocate for vaccination. This includes recommending influenza vaccination for all children aged 6 months and older at every clinical encounter, including in the hospital. In these conversations, we should emphasize the value of vaccination in preventing severe disease rather than infection itself. As the virus mutates rapidly with no guarantee of an ideal match for circulating strains, providing false reassurance that vaccination prevents all infections may worsen medical mistrust. Instead, reinforcing that vaccination prevents severe illness may be more compelling. Finally, we should call for the influenza campaign’s publicity strategies to be reinstated. If not, health systems should launch more comprehensive outreach to promote vaccine uptake in our communities.At the end of the day, we face many unknowns. We likely have another severe influenza season ahead of us, and it remains unclear whether we can rely on antivirals like oseltamivir to help all children who are hospitalized. Nevertheless, what remains certain is the importance of vaccination to prevent and mitigate severe influenza and fostering more prospective nonindustry-sponsored clinical antiviral trials to guide our treatment plans for all influenza seasons to come.We thank Dr Alan Schroeder for critically reviewing this manuscript prior to submission.

  PublisherOA PDFDOI

• Clinician Communication and Patient Safety in Pediatrics: A Practical Application of Human-Centered Design for Problem Identification and Analysis

  Journal of Patient Safety · 2025-09-23 · 2 citations

  articleOpen access

  BACKGROUND: We established a Patient Safety Learning Lab (AHRQ R18HS029473) to examine the sociotechnical system that drives interprofessional communication in pediatric inpatient settings in the context of evolving communication technologies, and to co-create and evaluate solutions with clinician end users. Here, we describe the use of human-centered design and system engineering processes for the Problem Analysis phase of this project. METHODS: We applied the "Empathize" and "Define" steps of the design thinking process to our Problem Analysis. The goal of the Empathize step is to generate a comprehensive understanding of a problem(s) as experienced by the end user. We conducted interviews and observations with interprofessional clinicians from pediatric inpatient units in a single children's hospital. We used other operational and clinical data to triangulate findings (clinician secure messaging metadata, survey data, and policies/procedures). In the "Define" step, we iteratively developed user-centered problem statements. RESULTS: Data synthesized for the problem analysis included: interviews with 28 clinicians, 32 hours of unit observations; metadata for 433,432 secure messages; 155 free-text clinician survey responses; and 40 communication-related policies/procedures. The Problem Analysis revealed communication challenges in the following domains for clinicians providing frontline care (i.e., bedside nurses, residents, frontline fellows): (1) efficiently locating and contacting other members of the care team; (2) communicating urgency level of information; and (3) managing high volume of minimally informative messages. CONCLUSIONS: Practical application of human-centered design and systems thinking contributed to a more holistic understanding of communication challenges, and their patient safety implications, from the perspective of multiple end-user groups.

  PublisherDOI

• Acceptance and implementation of evidence-based practices in delivery room resuscitation: A qualitative study

  SSM - Qualitative Research in Health · 2025-04-04

  articleOpen access

  Variation persists in the implementation of evidence-based practices (EBPs) for delivery room resuscitation associated with high-quality care. To date, research has often studied leaders and rarely focused on the perspectives of delivery room resuscitation team members. We investigated team member perspectives on facilitators and barriers to accepting and implementing EBPs in delivery room resuscitation. This is a qualitative analysis of responses to open-ended questions in a twice-administered survey of delivery room resuscitation team members from a 16-hospital network. We conducted a two-phase content analysis, I) inductive conventional content analysis and II) deductive directed content analysis, to map response themes onto the three elements of the Promoting Action on Research Implementation in Health Services (PARIHS) framework – evidence, facilitation, and context. There were 569 responses from 322 individuals representing all delivery room resuscitation team member roles. We identified five main themes that influence acceptance and implementation of EBPs: evidence, education, process characteristics, leadership, and change mindset. These themes aligned with the PARIHS framework elements of Evidence, Facilitation (occurring through education and process characteristics), and Context (determined by leadership and change mindset). We identified 12 sub-themes; 9 applied to both acceptance and implementation of EBPs, 1 applied only to acceptance of EBPs, and 2 applied only to implementation of EBPs. While many facilitators and barriers are consistent for both acceptance and implementation, some differ. To optimize EBPs in delivery room resuscitation, organizations may benefit from tailoring interventions to incorporate facilitators and address barriers that influence EBP acceptance and/or implementation. • The Promoting Action on Research Implementation in Health Services framework applies to delivery room resuscitation teams. • Evidence, education, process characteristics, leadership, and change mindset affect practice acceptance & implementation. • Sub-themes reveal specific barriers and facilitators to acceptance and/or implementation of evidence-based practice. • Findings suggest tailored approaches to improve acceptance and/or implementation of evidence-based delivery room care.

  PublisherDOI

• Caregiver experiences with deimplementation of continuous pulse oximetry monitoring for children hospitalized with bronchiolitis: A qualitative study

  Journal of Hospital Medicine · 2025-07-03

  articleOpen access

  BACKGROUND: Continuous pulse oximetry monitoring in stable children with bronchiolitis not requiring supplemental oxygen has been identified as a low-value practice. However, little is known about how parents and other caregivers experience efforts to deimplement this practice. OBJECTIVES: This study investigated caregivers' experiences during their child's recent hospitalization for bronchiolitis on units involved in a deimplementation trial. METHODS: We conducted semi-structured qualitative interviews with 15 caregivers of children hospitalized with bronchiolitis at 11 hospitals participating in deimplementation strategies to reduce unnecessary continuous pulse oximetry monitoring as part of the Eliminating Monitoring Overuse (EMO) trial. Interviews were recorded, transcribed, and coded using an integrative analytic approach. RESULTS: Caregivers were a mean (SD) 31.1 (5.7) years old, predominantly female (93.3%), white (73.3%), and Non-Hispanic (86.7%). Previous hospitalization experiences and prior knowledge and training influenced caregiver perceptions of the value of monitoring. Participants did not discuss noticing changes in monitoring practices in interviews. CONCLUSIONS: Findings suggest that tailored education about monitoring may lessen caregiver concerns.

  PublisherOA PDFDOI

• Low‐value care and variation in practice in the care of children hospitalized with bronchiolitis in Canada (CareBEST): Protocol for a multi‐center prospective cohort study

  Journal of Hospital Medicine · 2025-11-10

  articleOpen access

  INTRODUCTION: Low-value care refers to health services for which the potential harms or costs outweigh the benefits of use. Bronchiolitis is the most common and among the most costly causes of pediatric hospitalizations. Evidence consistently shows that many common tests and treatments used to manage bronchiolitis do not improve outcomes. Further, differential use of low-value care between patients may perpetuate care inequities. In Canada, rates of low-value care use in children hospitalized with bronchiolitis, and differences in care across hospitals, clinicians, and patient subgroups, remain poorly characterized. OBJECTIVE: To understand practice patterns for six low-value health services in the care of children aged 1-12 months hospitalized for bronchiolitis: respiratory virus testing; chest X-rays; continuous pulse oximetry; short-acting beta-agonists; systemic corticosteroids; and antibiotics. METHODS: We are conducting a multi-center prospective cohort study of children admitted with bronchiolitis in 15 Canadian hospitals. We will use chart reviews to compare low-value care use between hospitals and clinicians, and caregiver surveys to compare between sociodemographic groups. Questionnaires will also collect caregiver perspectives on their child's bronchiolitis care, including role in medical decision-making and understanding of treatment decisions. DISCUSSION: Our study will provide critical information on the usage and variation in delivery of low-value care for bronchiolitis in Canada, elucidating potential care inequities. Findings will inform the development of interventions to address such inequities, and improve opportunity costs for health systems. Enrollment began in October 2024 and is projected to be completed in May 2026, with analyses and reporting shortly following.

  PublisherOA PDFDOI

• The Appropriate Use of High-Flow Nasal Cannula in Bronchiolitis: A Delphi Approach

  Hospital Pediatrics · 2025-12-08 · 1 citations

  articleOpen access

  OBJECTIVES: There is considerable practice variation nationally for using high-flow nasal cannula (HFNC) to treat hospitalized children with bronchiolitis, despite an abundance of literature supporting specific practices. We developed recommendations for using HFNC based on available evidence and expert opinion. METHODS: Following the Research and Development (RAND)/University of California, Los Angeles Appropriateness Method, we conducted an exhaustive literature search for studies regarding the use of HFNC in bronchiolitis and drafted proposed use recommendations based on these findings. We convened an expert panel composed of nominees from national professional organizations with a range of professions (nursing, respiratory therapy, medicine) and clinical expertise (intensive care, emergency medicine, hospital-based care). Panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting. RESULTS: The 15-member panel evaluated 60 recommendations for the initiation, reassessment, escalation, and de-escalation of HFNC in bronchiolitis. The panel reached agreement on the appropriateness of HFNC for 52 of 60 recommendations and on necessity for 46 of 52. The panel agreed with practices that may curtail HFNC use, including initiating HFNC only for refractory hypoxemia or impending respiratory failure, initiating HFNC at flow rates of 1.5 to 2 L/kg/min, and discontinuing HFNC once a patient is stable on fraction of inspired oxygen of 0.21 for 1-4 hours. CONCLUSIONS: A national expert panel agreed on the appropriateness and necessity of parameters for HFNC use in bronchiolitis. These recommendations allow for standardization of practice that may optimize outcomes and curb indiscriminate use of this respiratory support modality.

  PublisherOA PDFDOI

• From rare procedure to institutional capability: a proposal to embed systematic training and adoption of emergency front of neck access

  British Journal of Anaesthesia · 2025-10-08 · 2 citations

  reviewOpen access
  PublisherOA PDFDOI

• Protocol for a multisite, observational clinical study of the association between skin colour and pulse oximeter accuracy in children undergoing cardiac catheterisation (PACH study)

  BMJ Open · 2025-04-01 · 1 citations

  articleOpen access

  Introduction Prospective, real-world clinical studies of the association between skin color and pulse oximeter (SpO2) accuracy in children are needed to address the limitations of previous research. Such studies are essential for generating evidence for clinicians, regulators and industry. This is the protocol for a multisite study funded by the National Heart, Lung, and Blood Institute (R01HL171313; 1 January 2024–31 December 2028). Methods and analysis In this pragmatic, observational study conducted in three large paediatric cardiac catheterisation centres in the USA, children undergoing cardiac catheterisation with directly measured arterial oxygen saturation will be prospectively enrolled. The outcome variable (SpO 2 bias) is the difference between contemporaneous paired measurements of pulse oximetry (SpO 2 ) and the standard reference comparator, arterial blood sample oxygen saturation (SaO 2 ), obtained during the catheterisation procedure. The independent variable is an objective measure of skin colour obtained via spectrophotometry. Our primary analysis is a multivariable regression model testing the relationship between skin colour and SpO 2 bias, after adjusting for covariates. We will also conduct a moderator analysis to identify factors that may affect the magnitude of the association. The target sample size is 584 participants. Ethics and dissemination This study was approved by the University of Pennsylvania Institutional Review Board (#854895) under expedited review. Study risks are minimal. Parental permission, and child assent when applicable, are obtained prior to enrolment. In accordance with the NIH Public Access Policy, publications associated with the study will be made publicly available through PubMed Central. The analytic dataset will be contributed to a repository for future use. In collaboration with a children’s hospital-based research family advisory council, interpretation and dissemination of the results for lay, clinical and scientific audiences will be considered. Trial registration number Although not a clinical trial, this observational study is registered on ClinicalTrials.gov (identifier: NCT06529575 ) for public awareness.

  PublisherDOI

Recent grants

• Eliminating Monitor Overuse (EMO) Hybrid Effectiveness-Deimplementation Trial

  NIH · $5.3M · 2021–2026

• Pediatric Hospital Epidemiology and Outcomes Research Training Program

  NIH · $5.5M · 2010–2026

• Impacts of False Alarms in Critically Ill Patients with Heart and Lung Failure

  NIH · $866k · 2014–2020

• Preparing for a hybrid trial of pulse oximetry de-implementation in stable infants with bronchiolitis

  NIH · $1.2M · 2018–2021

• Pediatric patient safety learning laboratory to re-engineer continuous physiologic monitoring systems

  NIH · $2.4M · 2018–2023

Frequent coauthors

• Christopher P. Landrigan

  Harvard University

  77 shared

• Patrick Brady

  University of Cincinnati Medical Center

  66 shared

• Halley Ruppel

  University of Pennsylvania

  50 shared

• Irit R. Rasooly

  Children's Hospital of Philadelphia

  48 shared

• Vinay Nadkarni

  Children's Hospital of Philadelphia

  46 shared

• Ron Keren

  Children's Hospital of Philadelphia

  44 shared

• Naveen Muthu

  Emory University

  42 shared

• Amanda C. Schondelmeyer

  University of Cincinnati

  42 shared