In Reply: Factors Predicting Readmission to the Emergency Department After a Diagnosis of Acute Respiratory Infection: A Two-year Experience at a Pediatric Tertiary Care Hospital in Italy

To the Editors: We read with great interest the article by Cappelli et al.,1 “Factors predicting readmission to the emergency department after a diagnosis of acute respiratory infection.” This timely study highlights an important clinical problem, as pediatric acute respiratory infections acute respiratory infections (ARI)s contribute substantially to healthcare utilization, with unplanned emergency readmission serving as a critical quality indicator. While the study provides valuable insights, we wish to address several methodological and interpretive concerns that may limit its generalizability and applicability. First, the study’s retrospective single-centered design restricts external validity. Conducted exclusively in a tertiary care pediatric hospital in Italy; the findings may not be representative of broader healthcare contexts. Furthermore, reliance on hospital information system excludes important nonclinical determinants, such as socioeconomic status, parental education, access to primary care, all of which are established predictors of pediatric emergency department utilization.2 Without accounting for these social determinants, the model risks underestimating key drivers of readmission. Second, the authors defined the outcomes as all-cause readmission within 7 days. While this broader window captures delayed complications, it complicates comparison with previous studies that typically use 48–72 hours for illness-related revisit.3 Additionally, some readmissions may have been unrelated to the index ARI, introducing heterogeneity in the analysis. A sensitive analysis restricted to respiratory-related returns might have provided greater clinical clarity. Third, while the multivariable regression identified significant predicators such younger age, acute bronchiolitis, triage code and antibiotics prescription, the interpretability of these associations requires caution. Many predicators are nonmodifiable (eg, age and disease severity), limiting their utility for prevention interventions. Moreover, the strong association between systemic antibiotic prescription and readmission (odds ratio: 4.86) is likely confounded by illness severity, yet this nuance was not fully addressed in the discussion. Finally, although the author advocates for targeted interventions and predictive modeling, actionable strategies were not clearly outlined. Integrating advanced analysis that combine clinical, sociodemographic and behavioral data may improve risk stratification and guide follow-up planning, but such approaches warrant prospective validation. In conclusion, Cappelli et al.1 advance our understanding of pediatric ARI readmission, yet future studies should incorporate social determinants, restrict outcomes to illness-related returns, and evaluate interventions that address modifiable risk factors. Broader, multicenter, prospective research will be essential to strengthen the evidence base and translate predictive findings into practice. ACKNOWLEDGMENTS The author expresses his thankfulness to Dr. Salman Zahir for their guidance and encouragement in writing of this manuscript.