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OBJECTIVE: To summarize the principles and application of phototherapy consistent with the current 2022 American Academy of Pediatrics "Clinical Practice Guideline Revision for the Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation." METHODS: Relevant literature was reviewed regarding phototherapy devices in the United States, specifically those that incorporate blue to blue-green light-emitting diode, fluorescent, halogen, or fiberoptic light sources, and their currently marketed indications. RESULTS: The efficacy of phototherapy devices varies widely because of nonstandardized use of light sources and configurations and irradiance meters. In summary, the most effective and safest devices have the following characteristics: (1) incorporation of narrow band blue-to-green light-emitting diode lamps (~460-490 nm wavelength range; 478 nm optimal) that would best overlap the bilirubin absorption spectrum; (2) emission of irradiance of at least 30 µW/cm²/nm (in term infants); and (3) illumination of the exposed maximal body surface area of an infant (35% to 80%). Furthermore, accurate irradiance measurements should be performed using the appropriate irradiance meter calibrated for the wavelength range delivered by the phototherapy device. CONCLUSIONS: With proper administration of effective phototherapy to an infant without concurrent hemolysis, total serum or plasma bilirubin concentrations will decrease within the first 4 to 6 hours of initiation safely and effectively. [ABSTRACT FROM AUTHOR]

In all 50 states, the District of Columbia, and the Commonwealth of Puerto Rico, pediatricians, dental professionals, and other physicians are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this clinical report is to review the oral aspects of abuse and dental neglect in children and the role of pediatricians, dental professionals, and other physicians in evaluating such conditions. This clinical report addresses recommendations on the evaluation of bite marks, as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Some physicians may have received less education pertaining to oral health, dental injury, and oral disease. These physicians may not detect the mouth and gum findings possibly related to abuse or neglect as readily as abuse injuries involving other areas of the body. Therefore, pediatricians, dental professionals, and other physicians are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children. [ABSTRACT FROM AUTHOR]

OBJECTIVES: (1) Assess whether health-related social needs (HRSN)/caregiver mental health concerns (CMHC) disclosure rates differ when screening questions are administered on paper versus electronic tablet. (2) Evaluate whether changes in need identification alters referral rates to social work and our medical-legal partnership (MLP). METHODS: We conducted a retrospective review of HRSN/CMHC screening in publicly insured patients 0-18 years presenting for well-child visits in three primary care practices. Our primary outcome was HRSN/CMHC disclosure rate, comparing the proportion of positive HRSN/ CMHC screens during the 11 months before and after screening modality change. Generalized estimating equations and interrupted time series (ITS) were used to assess changes over time. Mediation analyses assessed the indirect effect of HRSN/CMHC disclosure during the electronic screening period on changes in referrals to social work/MLP. RESULTS: A total of 16,151 patients had paper-based HRSN/CMHC screens; 13,019 patients had electronic screens. Overall, 11% of paper-based screens identified ≥1 need, compared to 26% of electronic screens (p<0.001). All three practices saw an increase in disclosure rate after transition from paper to electronic screening (odds ratio [OR] range 1.54 to 4.24). Using ITS, two of three practices had significantly increased odds of need disclosure with electronic screens compared to paper (OR 3.0, 95% confidence interval [CI] 2.5, 3.6; and OR 1.7, 95%CI 1.2, 2.4). Increased HRSN/CMHC disclosure rates from transitioning to electronic screening mediated increased referrals to social work/MLP. CONCLUSIONS: Electronic screening was associated with an increased HRSN/CMHC disclosure rate compared to paper, which led to increased referrals to social work/MLP. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The purpose of this study was to develop, pilot, and evaluate a culturally grounded, family-based program to prevent adverse childhood experiences (ACEs) among low-income and Indigenous children aged 10 to 14. The Tiwahe Wicagwicayapi program (TWP) is a 7-session program that teaches skills to prevent ACEs and is rooted in Lakota culture, language, and history. METHODS: A total of 124 families (124 caregivers [96% Indigenous; 90% reported yearly income <$40 000] with 194 children aged 10 to 14 [93% Indigenous]) were randomly assigned to treatment (N = 66 families and 173 individuals) or waitlist (N = 58 families and 145 individuals) control groups. Caregivers and children completed a baseline, immediate posttest, and 6-month follow-up survey. RESULTS: Treatment effects were detected, indicating, compared with control participants, reductions in the incidence of child ACEs (incidence rate ratio [IRR] = 0.64), bullying victimization (odds ratio = 0.53), depression (d = -0.20), and externalizing behaviors (d = -0.23) and increased parent-child communication (g = 0.27) and child help-seeking behaviors (d = 0.28). For caregivers, the effects indicated that the program prevented intimate partner violence victimization (IRR = 0.36) and perpetration (IRR = 0.45), harsh parenting (g = -0.35), and depression (d = -0.24) and increased emotion regulation (d = 0.37), social support (d = 0.33), and cultural connection (d = 0.34). CONCLUSIONS: The TWP holds great promise in preventing ACEs among low-income, Indigenous children, showing potential promise for widespread public health impact. Future rigorous research on the TWP is warranted. [ABSTRACT FROM AUTHOR]

BACKGROUND: Neonatal hypothermia is a common and preventable cause of neonatal morbidity and mortality. Although hypothermia prevention has been extensively studied in infants <32 weeks' gestation, the authors of few studies have targeted moderate- and late-preterm infants (MLPIs) in the delivery room. METHODS: This quality improvement initiative was conducted from June 2019 to June 2023 at the Massachusetts General Hospital NICU and Labor and Delivery Unit. All inborn MLPIs 32 1 0/7 to 36 1 6/7 weeks' gestation admitted to the NICU were included. We expanded thermoregulatory measures typically used in protocols for infants <32 weeks' gestation, including increasing delivery room ambient temperature to 74° F and thermal mattress use. The primary outcome was hypothermia (<36.5°C) after NICU admission. The balancing measure was hyperthermia (≥38 °C). RESULTS: During the study period, there were 566 inborn MLPIs with a mean gestational age of 34 1 3/7 weeks and a mean birth weight of 2269 g. Special cause variation in neonatal hypothermia incidence was observed with a decrease from a mean baseline of 27% to 7.8% postintervention. Special cause variation was observed in hyperthermia incidence, with an increase from 1.4% to 6.2% postintervention largely initially associated with noncompliance with the protocol for thermal mattress removal. CONCLUSIONS: The expansion of several thermoregulation techniques commonly used in infants <32 weeks' gestation, particularly thermal mattress use, was associated with a decreased incidence of NICU admission hypothermia in MLPIs, with an increase in mild hyperthermia predominantly associated with concomitant polyethylene wrap use. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Failed extubations are associated with pulmonary morbidity in hospitalized premature newborns. The objective of this study was to use quality improvement methodology to reduce failed extubations through practice standardization and integrating a real-time extubation success calculator into the electronic medical record (EMR). METHODS: A specific, measurable, achievable, relevant, and time-bound aim was developed to reduce failed extubations (defined as reintubation <5 days from primary extubation) by 50% among infants <32 weeks' gestational age (GA) or <1500 g birth weight by December 31, 2022. Plan-do-study-act cycles were developed to standardize postextubation respiratory support and integrate the EMR-based calculator. Outcome measures included extubation failure rates. Balancing measures included days on mechanical ventilation and number of patients intubated <3 days. Process measures were followed for guideline compliance. Statistical process control charts were used to track time-ordered data and detect special cause variation. RESULTS: We observed a reduction in failed extubations from 10.3% to 2.3%, with special cause variation noted after both plan-do-study-act cycle #1 and #2. Special cause variation was detected in both GA subgroups: <28 weeks' GA (22.0%-8.6%) and ≥28 weeks' GA (4.6%-0.3%). Additionally, the average number of infants intubated <3 days increased (60.2%-73.6%), whereas average ventilator days decreased (10.8-7.0). Finally, the time from infants' extubation score reaching threshold (≥60%) to extubation decreased (14.1-6.4 days) after launching the EMR-integrated calculator. CONCLUSIONS: Practice standardization and implementation of an EMR-based real-time clinical decision support tool improved extubation success, promoted earlier extubation, and reduced ventilator days in premature newborns. [ABSTRACT FROM AUTHOR]

CONTEXT: Meningitis is associated with high mortality risk in young infants, yet the optimal treatment regimen is unclear. OBJECTIVES: To systematically evaluate the efficacy of antibiotic regimens to treat meningitis in young infants aged 0 to 59 days on critical clinical outcomes. DATA SOURCES: MEDLINE, Embase, CINAHL, WHO Global Index Medicus, and Cochrane Central Registry of Trials. STUDY SELECTION: We included randomized controlled trials (RCTs) of young infants with meningitis (population) comparing the efficacy of antibiotic regimens (interventions) with alternate regimens (control) on clinical outcomes. DATA EXTRACTION: We extracted data on study characteristics and assessed risk of bias in duplicate. Grading of Recommendations Assessment, Development, and Evaluation was used to assess certainty of evidence. RESULTS: Of 1088 studies screened, only 2 RCTs were identified. They included 168 infants from 5 countries and were conducted between 1976 and 2015. Neither study compared current World Health Organization--recommended regimens. One multisite trial from 4 countries compared intrathecal gentamicin plus systemic ampicillin/gentamicin to systemic ampicillin/ gentamicin and found no difference in mortality (relative risk, 0.88; 95% confidence interval, 0.41--1.53; 1 trial, n 5 98, very low certainty of evidence) or adverse events (no events in either trial arm). Another trial in India compared a 10-day versus 14-day course of antibiotics and found no difference in mortality (relative risk, 0.88; 95% confidence interval, 0.41--1.53; 1 trial, n 5 98, very low certainty of evidence) or other outcomes. CONCLUSIONS: Trial data on the efficacy of antibiotic regimens in young infant meningitis are scarce. Rigorous RCTs are needed to inform recommendations for optimal antibiotic regimens for meningitis treatment in this vulnerable population, particularly within the context of changing epidemiology and increasing antimicrobial resistance. [ABSTRACT FROM AUTHOR]

CONTEXT: Pneumonia is a leading cause of death in young infants. OBJECTIVES: To evaluate the efficacy of different antibiotic regimens to treat young infant pneumonia on critical clinical outcomes. DATA SOURCES: MEDLINE, Embase, CINAHL, World Health Organization (WHO) Global Index Medicus, Cochrane Central Registry of Trials. STUDY SELECTION: We included randomized controlled trials of young infants aged 0 to 59 days with pneumonia (population) comparing the efficacy of antibiotic regimens (intervention) with alternate regimens or management (control) on clinical outcomes. DATA EXTRACTION: We extracted data and assessed risk of bias in duplicate. We used Grading of Recommendations, Assessment, Development, and Evaluation to assess certainty of evidence. LIMITATIONS: Trials were heterogeneous, which precluded data pooling. RESULTS: Of 2601 publications screened, 10 randomized controlled trials were included. Seven trials were hospital-based ( 5 869) and 3 were nonhospital-based ( 5 4329). No hospital-based trials evaluated WHO-recommended first-choice regimens. One trial found the WHO-recommended second-choice antibiotic, cefotaxime, to have similar rates of treatment success as non-WHO- recommended regimens of either amoxicillin--clavulanate (RR 0.99, 95% confidence interval 0.82--1.10) or amoxicillin--clavulanate/cefotaxime (RR 1.02, 95% confidence interval 0.86--1.12). Among 3 nonhospital-based trials comparing oral amoxicillin to alternate regimens to treat isolated tachypnea among infants aged 7--59 days, there were no differences in treatment failure between amoxicillin and alternate regimens. Certainty of evidence was low or very low for all primary outcomes. CONCLUSIONS: We found limited evidence to support the superiority of any single antibiotic regimen over alternate regimens to treat young infant pneumonia. [ABSTRACT FROM AUTHOR]

CONTEXT: Sepsis is a leading cause of young infant mortality. OBJECTIVE: To evaluate the efficacy of different antibiotic regimens to treat young infant sepsis or possible serious bacterial infection (PSBI) on clinical outcomes. DATA SOURCES: MEDLINE, Embase, CINAHL, World Health Organization Global Index Medicus, Cochrane Central Registry of Trials. STUDY SELECTION: We included randomized controlled trials (RCTs) of young infants 0 to 59 days with sepsis or PBSI (population) comparing the efficacy of antibiotic regimens (intervention) with alternate regimens or management (control) on clinical outcomes. DATA EXTRACTION: We extracted data and assessed risk of bias in duplicate. We performed random- effects meta-analysis, and used Grading of Recommendations, Assessment, Development, and Evaluation to assess certainty of evidence. RESULTS: Of 2390 publications, we included 41 RCTs (n 5 18 054). Thirty-five trials were hospital-based and 6 were nonhospital-based. Meta-analysis of 4 trials demonstrated similar rates of treatment success with intramuscular/intravenous third generation cephalosporins versus intramuscular/intravenous penicillin or ampicillin 1 gentamicin (RR 1.03, 95% CI 0.93--1.13]; n 5 1083; moderate certainty of evidence). Meta-analysis of 3 trials demonstrated similar rates of treatment failure with oral amoxicillin 1 intramuscular gentamicin versus intramuscular penicillin 1 gentamicin for nonhospital treatment of clinical severe illness (RR 0.86, 95% CI 0.72--1.02]; n 5 5054; low certainty of evidence). Other studies were heterogeneous. LIMITATIONS: RCTs evaluated heterogeneous regimens, limiting our ability to pool data. CONCLUSIONS: We found limited evidence to support any single antibiotic regimen as superior to alternate regimens to treat young infant sepsis or PSBI. [ABSTRACT FROM AUTHOR]

A 13-day-old, late preterm male, born appropriate for gestational age, presented to the pediatric clinic for his routine 2-week well visit with less than 1-day history of decreased oral intake and lethargy. During the baby's well exam, he acutely decompensated and required resuscitation and transfer to the emergency department, where he was intubated for frequent apneic events. He was admitted to the NICU for management and further workup. Physical examination and initial laboratory tests were unremarkable. An EEG demonstrated electrographic and clinical seizures. His initial MRI was unremarkable, and infection studies revealed the diagnosis. We review the patient's initial presentation, evaluation, hospital course, and the long-term implications of his diagnosis. [ABSTRACT FROM AUTHOR]

CONTEXT: Accurate identification of possible sepsis in young infants is needed to effectively manage and reduce sepsis-related morbidity and mortality. OBJECTIVE: Synthesize evidence on the diagnostic accuracy of clinical sign algorithms to identify young infants (aged 0--59 days) with suspected sepsis. DATA SOURCES: MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials. STUDY SELECTION: Studies reporting diagnostic accuracy measures of algorithms including infant clinical signs to identify young infants with suspected sepsis. DATA EXTRACTION: We used Cochrane methods for study screening, data extraction, risk of bias assessment, and determining certainty of evidence using Grading of Recommendations Assessment Development and Evaluation. RESULTS: We included 19 studies (12 Integrated Management of Childhood Illness [IMCI] and 7 non-IMCI studies). The current World Health Organization (WHO) 7-sign IMCI algorithm had a sensitivity of 79% (95% CI 77%--82%) and specificity of 77% (95% CI 76%--78%) for identifying sick infants aged 0--59 days requiring hospitalization/antibiotics (1 study, N 5 8889). Any IMCI algorithm had a pooled sensitivity of 84% (95% CI 75%--90%) and specificity of 80% (95% CI 64%--90%) for identifying suspected sepsis (11 studies, N 5 15523). When restricting the reference standard to laboratory-supported sepsis, any IMCI algorithm had a pooled sensitivity of 86% (95% CI 82%--90%) and lower specificity of 61% (95% CI 49%--72%) (6 studies, N 5 14278). LIMITATIONS: Heterogeneity of algorithms and reference standards limited the evidence. CONCLUSIONS: IMCI algorithms had acceptable sensitivity for identifying young infants with suspected sepsis. Specificity was lower using a reference standard of laboratory-supported sepsis diagnosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: To inform World Health Organization guidelines for the management of serious bacterial infection (SBI) (suspected or confirmed sepsis, pneumonia, or meningitis) in infants aged 0-59 days. OBJECTIVE: To conduct an "overview of systematic reviews" to: (1) understand which systematic reviews have examined diagnosis and management of SBI in infants aged 0-59 days in the last 5 years; and (2) assess if the reviews examined PICOs (population, intervention, comparator, outcomes) and regimens currently being recommended in low and middle income countries (LMICs) by the World Health Organization. DATA SOURCES: MEDLINE; Embase; Cochrane Library; Epistemonikos; PROSPERO. Study selection: Systematic reviews of randomized controlled trials or observational studies of infants aged 0-59 days examining diagnostic accuracy and antibiotic regimens for SBI from January 1, 2018 to November 3, 2023. DATA EXTRACTION: Dual independent extraction of study characteristics, PICOs, and methodological quality. RESULTS: Nine systematic reviews met our criteria. Two reviews examined diagnostic accuracy for sepsis, and no reviews examined pneumonia or meningitis. Five reviews examined antibiotic effectiveness (sepsis [n = 4]; pneumonia [n = 1]), and no reviews examined meningitis. One review examined antibiotic duration for sepsis and one for meningitis, and no reviews for pneumonia. Only 4 of the 9 systematic reviews met criteria for high-quality. LIMITATIONS: Our review was limited to the last 5 years to inform current guideline updates. CONCLUSIONS: Few studies have examined antibiotic regimens currently being used in LMICs and quality is of concern in many studies. More high-quality data are needed to inform management of SBI in newborns, especially in LMICs. [ABSTRACT FROM AUTHOR]

The article discusses evidence for global management of serious bacterial infections (SBIs) in young infants. Topics include the risk faced by survivors of SBIs, proposed case definitions and clinical algorithms for SBI by organizations like World Health Organization, (WHO) and UNICEF, and concern on antimicrobial resistance to common bacterial pathogens in young infants.

OBJECTIVES: Consciousness assessment is an important component in the prehospital care of ill or injured children. Both the Glasgow Coma Scale (GCS) and the Alert, Verbal, Pain, Unresponsive (AVPU) scale are used for this purpose. We sought to identify cut points for the GCS to correspond to the AVPU scale for pediatric emergency medical services (EMS) encounters. METHODS: We conducted a retrospective cross-sectional analysis using the 2019-2022 National EMS Information System data set, including children (<18 years) with a GCS and AVPU score. We evaluated several approaches to develop cut points for the GCS within the AVPU scale and reported measures of performance. RESULTS: Of 6 186 663 pediatric encounters, 4 311 598 with both GCS and AVPU documentation were included (median age was 10 years [interquartile range 3-15]; 50.9% boys). Lower AVPU scores correlated with life-sustaining procedures, including those for airway management, seizure, and cardiac arrest. Optimal GCS cut points obtained via a grid-based search were 14 to 15 for alert, 11 to 13 for verbal, 7 to 10 for pain, and 3 to 6 for unresponsive. Overall accuracy was 0.95, with kappa of 0.61. Intraclass F1 statistics were lower for verbal (0.37) and pain (0.50) categories compared with alert (0.98) and unresponsive (0.78). CONCLUSIONS: We developed a cross-walking between the AVPU and GCS scales. Overall performance was high, though performance within the verbal and pain categories was lower. These findings can be useful to enhance clinician handovers and to aid in the development of EMS-based prediction models. [ABSTRACT FROM AUTHOR]

CONTEXT: There is an increasing population of childhood cancer survivors (CCS) at risk for treatment-related toxicities, including skeletal morbidities. Bone mineral density (BMD) is a proxy for bone health and reductions are associated with osteoporosis and fractures. OBJECTIVE: To investigate bone health in CCS by conducting a systematic review and meta-analysis of BMD after completed treatments. DATA SOURCES: We searched Medline, Embase, Cochrane, and Web of Science in May 2019 and updated in May 2023. STUDY SELECTION: Studies reporting BMD Z-scores measured with dual-energy x-ray absorptiometry in CCS after treatment completion. DATA EXTRACTION: We performed a pooled analysis of studies reporting BMD Z-scores and thereafter we analyzed studies comparing BMD in survivors and healthy controls. All analyses were performed based on the site of BMD measurement. RESULTS: Of 4243 studies, 84 were included (N = 8106). The mean time off-treatment across the studies ranged from 2 months to 24 years. The overall pooled mean Z-score was -0.57 (95% confidence interval [CI] -0.59 to -0.55) in the whole-body, -0.84 (95% CI -0.86 to -0.83) in the lumbar spine, -0.79 (95% CI -0.81 to -0.77) in the femoral neck and -0.14 (95% CI -0.18 to -0.11) in the total hip. When comparing survivors with controls, BMD was significantly lower in survivors at all sites. LIMITATIONS: English publications, study-level meta-analysis. CONCLUSIONS: We showed a significant reduction of BMD Z-scores in CCS. Given the increased fracture risk already within -1 SD, these results emphasize the need for BMD surveillance and secondary prevention in CCS. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Geographic accessibility predicts pediatric preventive care utilization, including vaccine uptake. However, spatial inequities in the pediatric coronavirus disease 2019 (COVID-19) vaccination rollout remain underexplored. We assessed the spatial accessibility of vaccination sites and analyzed predictors of vaccine uptake. METHODS: In this cross-sectional study of pediatric COVID-19 vaccinations fromthe US Vaccine Tracking Systemas of July 29, 2022,we described spatial accessibility by geocoding vaccination sites,measuring travel times fromeach Census tract population center to the nearest site, and weighting tracts by their population demographics to obtain nationally representative estimates.We used quasi-Poisson regressions to calculate incidence rate ratios, comparing vaccine uptake between counties with highest and lowest quartile Social Vulnerability Index scores: socioeconomic status (SES), household composition and disability (HCD),minority status and language (MSL), and housing type and transportation. RESULTS: We analyzed 15 233 956 doses administered across 27 526 sites. Rural, uninsured, white, and Native American populations experienced longer travel times to the nearest site than urban, insured, Hispanic, Black, and Asian American populations. Overall Social Vulnerability Index, SES, and HCD were associated with decreased vaccine uptake among children aged 6 months to 4 years (overall: incidence rate ratio 0.70 [95% confidence interval 0.60-0.81]; SES: 0.66 [0.58-0.75]; HCD: 0.38 [0.33-0.44]) and 5 years to 11 years (overall: 0.85 [0.77-0.95]; SES: 0.71 [0.65-0.78]; HCD: 0.67 [0.61-0.74]), whereas social vulnerability byMSLwas associatedwith increased uptake (6 months-4 years: 5.16 [3.59-7.42]; 5 years-11 years: 1.73 [1.44-2.08]). CONCLUSIONS: Pediatric COVID-19 vaccine uptake and accessibility differed by race, rurality, and social vulnerability. National supply data, spatial accessibility measurement, and place-based vulnerability indices can be applied throughout public health resource allocation, surveillance, and research. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends screening during the first 3 years of life for developmental risk/delay, maternal depression, and social determinants of health (SDOH) using standardized tools. Adoption of these guidelines has been gradual, and barriers to screening are as varied as pediatric practices are themselves. METHODS: We analyzed 2019 American Academy of Pediatrics Periodic Survey data. The survey included pediatricians' screening practices for developmental delay, maternal depression, and SDOH, and barriers to screening. We used Cochran's Q and McNemar's tests to compare barriers across topics, and χ² tests and multivariable logistic regression to examine the relationship between barriers and screening practices. RESULTS: The survey response ratewas 46.9% (n = 688). Most pediatricians reported screening/surveilling for developmental delay (98.1%), maternal depression (83.2%), and SDOH (76.7%), but fewer used standardized instruments to do so (59.0%, 44.9%, 12.6%, respectively). Those not screening/only surveilling for maternal depression were more likely to report that screening is not an appropriate role for the pediatrician and difficulty prioritizing time. For SDOH, those not screening/only surveilling were more likely to report instruments not available in the electronic health record, lack of knowledge regarding referral options, and lack of treatment options for positive screens. CONCLUSIONS: Rates of standardized screening, and barriers pediatricians encounter, have important implications for improving quality of early childhood preventive care. Opportunities include expanding the primary care team and integrating screening tools into the electronic health record. Programs to support social needs and maternal mental health could be strengthened to ensure robust referral options are available. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Conversations about dignity are fundamental to person-centered care in pediatrics, yet practical language strategies to promote and support dignity remain understudied. To address this gap, we aimed to identify and characterize language used by pediatric oncologists to recognize and affirm dignity across advancing illness. METHODS: In this longitudinal prospective study, we audio-recorded serial disease reevaluation encounters between pediatric oncologists, children with cancer, and families across 24 months or until the child's death. Using a hybrid deductive--inductive qualitative approach, we defined dignity language a priori on the basis of existing descriptions of dignity in the literature and then conducted a content analysis to refine the definition specific to pediatric cancer care before coding serial medical encounters. Thematic frequencies were reported by using descriptive statistics. RESULTS: A total of 91 discussions at timepoints of disease progression were audio-recorded for 36 patients and their families. No dignity language was identified in nearly half (45%) of "bad news" encounters, and the time spent by the oncologist engaging in dignity language represented a minority (<7%) of overall recorded dialogue. Within coded dialogue, we characterized 3 key themes upholding dignity language (empowerment, autonomy, respect). CONCLUSIONS: Opportunities exist to improve dignity communication in childhood cancer, and the authors propose a conceptual model ("Lend an EAR") to guide dignity-based communication in pediatric cancer. Future research should emphasize patient and parent perspectives on language to support dignity for children with advanced cancer, with stakeholder-driven refinement of the Lend an EAR model before integration and testing in communication skills training programs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Autism spectrum disorder (ASD) is estimated to be ???10 times higher in children with versus without an autistic sibling in population-based studies. Prospective studies of infant siblings have revealed even higher familial recurrence rates. In the current prospective longitudinal study, we provide updated estimates of familial ASD recurrence using a multinational database of infants with older autistic siblings. METHODS: Data were collated across 18 sites of the Baby Siblings Research Consortium, an international network studying the earliest manifestations of ASD. A total of 1605 infants with an older autistic sibling were followed from early in life to 3 years, when they were classified as ASD or non-ASD. Hierarchical generalized linear modeling, with site as a random effect, was used to examine predictors of recurrence in families and calculate likelihood ratios. RESULTS: A total of 20.2% of siblings developed ASD, which is not significantly higher than the previously reported rate of 18.7%. Male infant sex and >1 older affected sibling were significant predictors of familial recurrence. Proband sex also influenced recurrence rates, with siblings of female probands significantly more likely to develop ASD than siblings of male probands. Race and maternal education were also associated with recurrence in families. CONCLUSIONS: The familial recurrence rate of ASD, as measured in infant sibling studies, has not changed appreciably since previous estimates were made in 2011. Younger siblings of autistic children, particularly those who are male, have an affected female sibling, multiple affected siblings, or are impacted by social inequities, should be closely monitored and promptly referred for diagnostic evaluation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Vitamin B12 deficiency (VitB12D) might cause neuro-developmental impairment in the first year of life. Newborn screening (NBS) for VitB12D was shown to be technically feasible and early treated infants developed favorably. This study aims to evaluate the impact of NBS in prevention of symptomatic infantile VitB12D. METHODS: In a nationwide surveillance study in cooperation with the German Pediatric Surveillance Unit, incident cases with VitB12D (<12 months of age) were prospectively collected from 2021 to 2022. RESULTS: In total, 61 cases of VitB12D reported to German Pediatric Surveillance Unit were analyzed, either identified by NBS (N = 31) or diagnosed after the onset of suggestive symptoms (non-NBS; N = 30). Ninety percent of the infants identified by NBS were still asymptomatic, whereas the non-NBS cohort presented at median 4 month of age with muscular hypotonia (68%), anemia (58%), developmental delay (44%), microcephalia (30%), and seizures (12%). Noteworthy, symptomatically diagnosed VitB12D in the first year of life was reported 4 times more frequently in infants who did not receive NBS for neonatal VitB12D (14 in 584 800) compared with those screened for VitB12D as newborns (4 in 688 200; Fisher's Exact Test, odds ratio 4.12 [95% confidence interval: 1.29-17.18], P = .008). The estimated overall cumulative incidence was 1:9600 newborns per year for neonatal VitB12D and 1:17 500 for symptomatic infantile VitB12D. CONCLUSIONS: NBS for neonatal VitB12D may lead to a fourfold risk reduction of developing symptomatic VitB12D in the first year of life compared with infants without NBS. [ABSTRACT FROM AUTHOR]

Protoporphyria is a subtype of porphyria characterized primarily by painful phototoxic skin reactions after light exposure at specific wavelengths. Historically, phototherapy is not contraindicated in patients with protoporphyria since there have not been any reports of phototoxic reactions. However, patients with protoporphyria are advised to avoid direct sunlight. In this case report, we describe a neonate not known to have X-linked protoporphyria who received phototherapy for 1 to 2 hours. Within hours after initiation of phototherapy, this neonate developed a life-threatening reaction consisting of rash over the distribution of phototherapy, acute liver failure with coagulopathy, diffuse hypotonia with diaphragmatic failure, and subsequent acute respiratory failure that required mechanical ventilation. As in this case, patients with protoporphyria-related acute liver failure can have signs and symptoms similar to that of an acute hepatic porphyria attack. Neither neonatal reactions to phototherapy nor liver failure temporally associated with phototherapy have been reported in patients with X-linked protoporphyria. Early recognition of this entity is crucial in light of potential life-threatening complications. Therefore, providers must react quickly when neonates have abnormal reactions to phototherapy and consider protoporphyria in the differential diagnosis. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study described disease characteristics and long-term outcomes in patients diagnosed with very early onset inflammatory bowel disease (VEOIBD) (diagnosed before 6 years of age) and infantile-IBD (before 2 years). METHODS: Cases from 21 centers worldwide diagnosed with VEOIBD (2008-2018), with minimum 2 years of follow-up, were retrospectively reviewed. RESULTS: The cohort included 243 patients (52% males, median follow-up of 5.8 [range 2-18] years, including 69 [28%]) with infantile-IBD. IBD subtypes included Crohn's disease (CD), ulcerative colitis (UC), or IBD-unclassified (IBDU) in 30%, 59%, and 11%, respectively. Among patients with CD, 94% had colonic involvement, and among patients with UC/IBDU, 75% had pancolitis. Patients with infantile-IBD presented with higher rates of IBDU, lower hemoglobin and albumin levels, and higher C-reactive protein, and had lower response rates to first-induction therapy and corticosteroids therapy (P < .05 for all). Colectomy and diversion surgeries were performed in 11% and 4%, respectively, with no significant differences between age groups. Corticosteroid-free remission rates were 74% and 78% after 3 and 5 years, respectively, and 86% at end of follow-up. Genetic testing was performed in 96 (40%) patients. Among tested population, 15 (16%) were identified with monogenic disease. This group demonstrated lower response rates to induction therapies, higher rates of surgical intervention, and higher rates of major infections (P < .05 for all). CONCLUSIONS: Patients with VEOIBD, including infantile-IBD, exhibit low rate of complications and surgical interventions at the long term. Patients with monogenic IBD are at risk for more severe disease course. [ABSTRACT FROM AUTHOR]

Sensorineural hearing loss is a well-known complication of Streptococcus pneumoniae meningitis. Given the propensity for fibrosis and ossification of the cochlea in bacterial meningitis, implantation must be performed in a timely fashion because a delayed attempt at implantation can frustrate obtaining an optimal technical result or lead to an inability to implant. Obtaining optimal audiometric outcomes is reliant on early hearing screening in patients with streptococcal meningitis. In the absence of standardized protocols, audiometric testing is often overlooked or delayed in the workup and management of meningitis. Our institution implemented a meningitis protocol with a particular focus on timing of audiometric testing in patients with meningitis. We present a patient diagnosed with streptococcal meningitis in the first week of life. Early hearing screening allowed the diagnosis of profound unilateral sensorineural hearing loss and subsequent cochlear implantation at 10 weeks of age, the youngest described in the medical literature. Despite early implantation, there was cochlear fibrosis at the time of implantation. Fortunately, the majority of electrodes were implanted to achieve a serviceable hearing outcome. Serial magnetic resonance imaging scans were obtained because of her contralateral ventriculoperitoneal shunt that allowed unique visualization of the progression of cochlear fibrosis over time. This case demonstrates the importance of including audiometric testing in a standardized meningitis protocol to diagnose hearing loss in a timely and accurate way and to achieve optimal long-term hearing outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Maple syrup urine disease (MSUD), a life-threatening metabolic disorder, is included in newborn screening (NBS) programs worldwide. The study aims to evaluate the impact of NBS on the long-term outcome of MSUD patients. METHODS: We performed a prospective, national, multicenter, observational study. RESULTS: In the studied NBS cohort (N = 33; 22 classic MSUD [cMSUD], 11 variant MSUD [vMSUD]; median age at last visit 10.4 years), 32 (97%) patients survived, 58% of them had normal cognitive functions (median IQ 87). Initial peak leucine increased linearly with age in cMSUD (median: 1712 mmol/L), but not in vMSUD. Global IQ correlated inversely with the initial peak leucine concentration (P = .04; β = -0.0081) and the frequency of decompensations (P = .02; β = -9.133). A cluster analysis identified 2 subgroups differing in their long-term metabolic control (median leucine concentration: 162 vs 278 mmol/L; P < .001). In cMSUD, lower leucine concentrations were associated with a higher IQ (95.5 vs 80; P = .008). Liver transplantation (median age 5.8 years) was not associated with better cognitive outcome. NBS is highly sensitive for cMSUD, but vMSUD might be missed (N = 2 missed by NBS). CONCLUSIONS: NBS and the early start of treatment improve survival and long-term outcome in individuals with cMSUD. Disease severity is an important modifier of outcome; however, the time to NBS report and the quality of long-term metabolic control had an independent impact on cognitive outcome, highlighting the importance of an early diagnosis and the quality of treatment. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Quality improvement may reduce the incidence and severity of intraventricular hemorrhage in preterm infants. We evaluated quality improvement interventions (QIIs) that sought to prevent or reduce the severity of intraventricular hemorrhage. METHODS: PubMed, CINAHL, Embase, and citations of selected articles were searched. QIIs that had reducing incidence or severity of intraventricular hemorrhage in preterm infants as the primary outcome. Paired reviewers independently extracted data from selected studies. RESULTS: Eighteen quality improvement interventions involving 5906 infants were included. Clinical interventions in antenatal care, the delivery room, and the NICU were used in the QIIs. Four of 10 QIIs reporting data on intraventricular hemorrhage (IVH) and 9 of 14 QIIs reporting data on severe IVH saw improvements. The median Quality Improvement Minimum Quality Criteria Set score was 11 of 16. Clinical intervention heterogeneity and incomplete information on quality improvement methods challenged the identification of the main reason for the observed changes. Publication bias may result in the inclusion of more favorable findings. CONCLUSIONS: QIIs demonstrated reductions in the incidence and severity of intraventricular hemorrhage in preterm infants in some but not all settings. Which specific interventions and quality improvement methods were responsible for those reductions and why they were successful in some settings but not others are not clear. This systematic review can assist teams in identifying potentially better practices for reducing IVH, but improvements in reporting and assessing QIIs are needed if systematic reviews are to realize their potential for guiding evidence-based practice. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Packed red blood cell transfusions (pRBCT) in pre-term infants have been associated with significant morbidity. Although infants <26 weeks' gestational age typically require several pRBCT, preterm infants born between 26 and 34 weeks' gestational age may also require pRBCT during their hospitalization that are potentially preventable. We aimed to reduce pRBCT in this population by 20%. METHODS: This quality improvement project was conducted in the Duke University Hospital NICU between July 2018 and February 2023. Interventions included the implementation of evidence-based transfusion thresholds, supporting bone marrow erythropoiesis, and reducing laboratory specimen volumes by increasing capillary test panels. The rates per 1000 patient days for pRBCT (outcome measure), number of new patients initiated on erythropoietin (process measure), number of basic metabolic panels (process measure), and total capillary panels (process measure) were monitored during the project period. Statistical process control charts were used to observe trends over time. RESULTS: Among infants born between 260/7 and 346/7 weeks' gestational age, the rate of pRBCT decreased from an average of 23.8 to 12.7 transfusions per 1000 patient days, which is a 46.6% decrease. Increases in the use of erythropoietin and capillary panels were observed, along with a decrease in the use of basic metabolic panels. There was no change in mortality or the rate of necrotizing enterocolitis. Improvement was sustained for 24 months after implementation. CONCLUSIONS: pRBCT can be decreased in preterm infants born between 26 and 34 completed weeks' gestation through a combination of strategies utilizing quality improvement methodology. [ABSTRACT FROM AUTHOR]

BACKGROUND: The coronavirus disease 2019 pandemic disrupted respiratory syncytial virus (RSV) seasonality resulting in early, atypical RSV seasons in 2021 and 2022, with an intense 2022 peak overwhelming many pediatric healthcare facilities. METHODS: We conducted prospective surveillance for acute respiratory illness during 2016-2022 at 7 pediatric hospitals.We interviewed parents, reviewed medical records, and tested respiratory specimens for RSV and other respiratory viruses.We estimated annual RSV-associated hospitalization rates in children aged <5 years and compared hospitalization rates and characteristics of RSV-positive hospitalized children over 4 prepandemic seasons (2016-2020) to those hospitalized in 2021 or 2022. RESULTS: There was no difference in median age or age distribution between prepandemic and 2021 seasons. Median age of children hospitalized with RSV was higher in 2022 (9.6 months vs 6.0 months, P < .001). RSV-associated hospitalization rates were higher in 2021 and 2022 than the prepandemic average across age groups. Comparing 2021 to 2022, RSV-associated hospitalization rates were similar among children <2 years of age; however, children aged 24 to 59 months had significantly higher rates of RSV-associated hospitalization in 2022 (rate ratio 1.68 [95% confidence interval 1.37-2.00]). More RSV-positive hospitalized children received supplemental oxygen and there were more respiratory virus codetections in 2022 than in prepandemic seasons (P < .001 and P 5 .003, respectively), but there was no difference in the proportion hypoxemic, mechanically ventilated, or admitted to intensive care. CONCLUSIONS: The atypical 2021 and 2022 RSV seasons resulted in higher hospitalization rates with similar disease severity to prepandemic seasons. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing. METHODS: We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years. RESULTS: Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%). CONCLUSIONS: Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the management and outcomes of afebrile infants who received a pediatric dermatology consultation for pustules and/or vesicles. METHODS: Medical records were reviewed for all infants 60 days of age or younger who received a pediatric dermatology consult across 6 academic institutions between September 1, 2013 and August 31, 2019 to identify those infants with pustules and/or vesicles. RESULTS: Of the 879 consults, 183 afebrile infants presented with pustules and/or vesicles. No cerebrospinal fluid cultures or blood cultures were positive for bacteria. No concordant positive urine cultures were identified in infants with cutaneous infection. Nine infants were diagnosed with herpes simplex virus (HSV). Five preterm infants were diagnosed with angioinvasive fungal infections. CONCLUSIONS: No serious bacterial infections attributable to a skin source were identified, yet 53% of these infants received parenteral antibiotics. HSV was diagnosed in 7% of this cohort, 77.8% (7/9) of whom were term infants and 22.2% (2 of 9) of whom were preterm. Angioinvasive fungal infection was diagnosed in 3%, all of whom (100%, 5 of 5) were extremely preterm at <28 weeks gestational age. These findings suggest that in full-term afebrile infants #60 days, the likelihood of a life-threatening etiology of isolated pustules or vesicles is low once HSV infection is excluded. In preterm infants with pustules and/or vesicles, a high index of suspicion must be maintained, and broad infectious evaluation is recommended. HSV testing is recommended for all infants with vesicles, grouped pustules and/or punched-out erosions. [ABSTRACT FROM AUTHOR]

The article discusses research which determined differences in clinical outcomes, hospital costs and related hospital readmissions among children with acute hematogenous osteomyelitis on the basis of timing of surgical procedures. The study identified interventional radiology and bedside aspiration procedures. It evaluated outcomes across patient groups by age, race, ethnicity, payer status, admission season, critical illness and emergency department visit without admission.

OBJECTIVES: Urinary tract infections (UTIs) are common, but overdiagnosed, in children with spina bifida. We sought to evaluate the diagnostic test characteristics of urinalysis (UA) findings for symptomatic UTI in children with spina bifida. METHODS: Retrospective cross-sectional study using data from 2 centers from January 1, 2016, to December 31, 2021. Children with myelomeningocele aged <19 years who had paired UA (and microscopy, when available) and urine culture were included. The primary outcome was symptomatic UTI. We used generalized estimating equations to control for multiple encounters per child and calculated area under the receiver operating characteristics curve, sensitivity, and specificity for positive nitrites, pyuria ($10 white blood cells/high-powered field), and leukocyte esterase (more than trace) for a symptomatic UTI. RESULTS: We included 974 encounters from 319 unique children, of which 120 (12.3%) met our criteria for UTI. Pyuria had the highest sensitivity while nitrites were the most specific. Comparatively, nitrites were the least sensitive and pyuria was the least specific. When the cohort was limited to children with symptoms of a UTI, pyuria remained the most sensitive parameter, whereas nitrites remained the least sensitive. Nitrites continued to be the most specific, whereas pyuria was the least specific. Among all encounters, the overall area under the receiver operating characteristics curve for all components of the UA was lower in children who use clean intermittent catheterizations compared with all others. CONCLUSIONS: Individual UA findings have moderate sensitivity (leukocyte esterase or pyuria) or specificity (nitrites) but overall poor diagnostic accuracy for symptomatic UTIs in children with spina bifida. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVE: There is a paucity of pooled synthesized data on the epidemiology of neonatal acute kidney injury (AKI). Our objective with this study is to systematically assess the worldwide incidence of AKI in neonates. METHODS: We searched 3 electronic databases (Embase, PubMed, Web of Sciences) from January 2004 to December 2022 without language restrictions. We included cohort and cross-sectional studies that reported the incidence of AKI or associated mortality in neonates. Eligible studies had at least 10 participants and used standard criteria (Acute Kidney Injury Network/Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease (pRIFLE)/ Kidney Disease Improving Global Outcomes) to define AKI. Two authors independently retrieved data on demographic characteristics, clinical setting, and outcomes (incidence and AKI-associated mortality) using a semi-structured proforma and assessed the risk of bias. We used a random-effects metaanalysis to calculate pooled estimates with 95% confidence intervals. RESULTS: We included 201 studies (98 228 participants) from 45 countries. The incidence of any stage AKI was 30% (95% confidence interval 28-32), and that of severe AKI was 15% (14-16). Overall, AKI-associated mortality was 30% (27-33). The odds of mortality were higher (odds ratio 3.4; 2.9-4.0) in neonates with AKI compared with those without AKI. We found that perinatal asphyxia, sepsis, patent ductus arteriosus, necrotizing enterocolitis, and nephrotoxic medications were significant risk factors for AKI. Significant heterogeneity in the pooled estimates was a limitation of this study. CONCLUSIONS: AKI was observed in one-third of the neonates and was associated with increased risk of mortality. The incidence of AKI was almost similar in neonates with perinatal asphyxia and sepsis, but mortality was higher in the former group. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Children perinatally exposed to hepatitis C virus (HCV) should be screened for infection, yet testing rates are low. Clinical perinatal HCV testing recommendations vary and may contribute to poor completion. This study examines pediatric care factors associated with perinatal HCV testing completion. METHODS: A cohort of people living with HCV in Philadelphia, Pennsylvania, who delivered a live birth in 2016 to 2020 and their children were followed by the Philadelphia Department of Public Health. The association of completion of HCV screening with pregnant/postpartum person demographics, pediatric care factors, and testing policy were retrospectively explored. χ² and multivariable logistic regressions were used. RESULTS: HCV-positive pregnant people gave birth to 457 children of whom 307 (67.2%) were tested for HCV according to recommendations and 79 (17.2%) were inadequately tested. Children were more likely to be tested if born to a pregnant person with HIV coinfection (P = .007), if they were always on schedule for vaccinations (P < .001), and if they attended the 18-month well visit (P < .001). Completion rates varied significantly by pediatrician's testing policy: 90.9% tested if the policy was for 2 months, 79.6% if 2 to 12 months, 61.9% if 12 months, and 58.5% if 18 months of age (P < .001). CONCLUSIONS: Timing of perinatal HCV testing policies was significantly associated with testing completion rates. Testing at 2 months was associated with far better HCV testing completion than other strategies, regardless of birthing person and pediatrician factors. These findings suggest routine HCV testing of children perinatally exposed to HCV is best achieved in the first year of life. [ABSTRACT FROM AUTHOR]

A 4-month-old full-term female presented with growth faltering associated with progressive feeding difficulty, rash, abdominal distension, and developmental delays. She was found to have disconjugate gaze, abnormal visual tracking, mixed tone, bruising, and splenomegaly on examination. Initial workup was notable for thrombocytopenia and positive cytomegalovirus (CMV) immunoglobulin G and immunoglobulin M antibodies. She initially presented to the infectious diseases CMV clinic, where she was noted to have severe malnutrition, prompting referral to the emergency department for hospital admission to optimize nutrition with nasogastric tube feeding and facilitate additional evaluation. An active CMV infection with viruria and viremia was confirmed, but elements of her presentation and workup including brain magnetic resonance imaging were not consistent with isolated CMV infection. To avoid premature diagnostic closure, a multidisciplinary workup was initiated and ultimately established her diagnosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patient portals provide parents access to their child's health information and direct communication with providers. Our study aimed to improve portal activation rates of newborns during nursery hospitalization to >70% over 6 months. Secondarily, we describe the facilitators and barriers to portal use. METHODS: The study design used a mixed-methodology framework of quality improvement (QI) and cross-sectional analyses. The Model for Improvement guided QI efforts. The primary outcome was the proportion of portals activated for newborns during nursery hospitalization. Interventions included portal activation algorithm, staff huddles, and documentation templates. Telephone interviews were conducted with a randomized sample of mothers of infants who activated the portal. These mothers were divided into portal "users" and "nonusers." We examined sociodemographic variables and health care utilization outcomes in the 2 groups. RESULTS: Portal activation increased from 12.9% to 85.4% after interventions. Among 482 mothers with active portals, 127 (26.3%) were interviewed. Of those, 70% (89 of 127) reported using the portal, and 85.4% (76 of 89) found it useful. Reasons for accessing the portal included checking appointments and reviewing test results. Lack of knowledge of portal functionality was the main barrier to portal use (42.1%). Portal users were less likely to have a no-show to primary care appointments compared with nonusers (44.9% versus 78.9%, P < .001). CONCLUSIONS: Portal activation rates increased after QI interventions in the nursery. Most parents accessed the portal and found it useful. Portals can improve health care delivery and patient engagement in the newborn period. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Sleep promotion is not specifically recommended as a target for hypertension management. We examined associations of sleep duration and timing with blood pressure parameters in patients referred to pediatric nephrology clinic for elevated blood pressure evaluation. METHODS: This is a retrospective study of initial ambulatory blood pressure monitoring data and self-report sleep data collected from patients referred to nephrology clinic for the evaluation of elevated blood pressure. Linear and logistic regression modeling determined associations between sleep exposures (duration and timing) and continuous and dichotomous blood pressure outcomes, respectively, adjusted for age, sex, body mass index, and weekday versus weekend status. RESULTS: The study sample included 539 patients with mean age 14.6 years and 56% meeting hypertension criteria. Sleep duration averaged 9.1 hours per night. Average timing of sleep onset and offset were 11:06 PM and 8:18 AM, respectively. Longer sleep duration was associated with better daytime blood pressure parameters (eg, every extra hour of sleep duration was associated with a reduced odds of wake hypertension [odds ratio, 0.88; 95% CI, 0.79-0.99]). Later sleep onset was associated with worse daytime blood pressure parameters (eg, each additional hour of later sleep onset was associated with higher wake systolic blood pressure index [mean wake blood pressure/95th percentile]) (β = 0.07; 95% CI, 0.02-0.13). Associations were consistent across sex, age, body mass index, and weekday status. CONCLUSIONS: Longer sleep duration and earlier sleep onset were associated with lower blood pressure. This suggests that sleep optimization may be an important target for intervention in hypertension management. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: The messenger RNA (mRNA)-based coronavirus disease 2019 vaccines approved for use in children <5 years of age have different antigen doses and administration schedules that could affect vaccine immunogenicity and effectiveness. We sought to compare the strength and breadth of serum binding and neutralizing antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) elicited by monovalent mRNA-based coronavirus disease 2019 vaccines in young children. METHODS: We conducted a prospective cohort study of children 6 months to 4 years of age who completed primary series vaccination with monovalent mRNA-1273 or BNT162b2 vaccines. Serum was collected 1 month after primary vaccine series completion for the measurement of SARS-CoV-2-specific humoral immune responses, including antibody binding responses to Spike proteins from an ancestral strain (D614G) and major variants of SARS-CoV-2 and antibody neutralizing activity against D614G and Omicron subvariants (BA.1, BA.4/5). RESULTS: Of 75 participants, 40 (53%) received mRNA-1273 and 35 (47%) received BNT162b2. Children receiving either primary vaccine series developed robust and broad SARS-CoV-2-specific binding and neutralizing antibodies, including to Omicron subvariants. Children with a previous history of SARS-CoV-2 infection developed significantly higher antibody binding responses and neutralization titers to Omicron subvariants, which is consistent with the occurrence of identified infections during the circulation of Omicron subvariants in the region. CONCLUSIONS: Monovalent mRNA-1273 and BNT162b2 elicited similar antibody responses 1 month after vaccination in young children. In addition, previous infection significantly enhanced the strength of antibody responses to Omicron subvariants. The authors of future studies should evaluate incorporation of these vaccines into the standard childhood immunization schedule. [ABSTRACT FROM AUTHOR]

The article discusses research which examined the prevalence of invasive bacterial infection (IBI) in febrile young infants in an urban tertiary pediatric emergency department to clarify the role of viral testing when procalcitonin is not available. Data shows the demographic characteristics of infants and prevalence of IBI and viral status among febrile infants classified as high or low risk for IBI based on C-reactive protein, absolute neutrophil count and maximum temperature measurements.

OBJECTIVE: In conjunction with widening legalization, there has been a rapid rise in unintentional cannabis ingestions in young children. We sought to determine if the legal status of recreational cannabis was associated with resource use in young children with cannabis poisoning. METHODS: This retrospective cross-sectional study of the Pediatric Health Information System included emergency department encounters between January 2016 and April 2023 for children <6 years of age with a diagnosis indicating cannabis ingestion. The primary exposure was recreational cannabis legalization status in the state in which the encounter occurred.We used logistic regression models to determine the association of recreational cannabis legality with resource utilization outcomes, adjusting for demographic covariates. RESULTS: We included 3649 children from 47 hospitals; 29% of encounters occurred in places in which recreational cannabis was legal. Compared with environments in which recreational cannabis was illegal, cannabis-legal locations had lower uses of advanced neuroimaging (24% vs 35%; adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI]: 0.55-0.77), lumbar puncture (1.6% vs 3.8%; aOR, 0.42; 95% CI: 0.24-0.70), ICU admission (7.9% vs 11%; aOR, 0.71; 95% CI: 0.54-0.93), and mechanical ventilation (0.8% vs 2.9%; aOR, 0.30; 95% CI: 0.14-0.58). Urine testing was more common in places in which recreational cannabis was legal (71% vs 58%; aOR, 1.87; 95% CI: 1.59-2.20). CONCLUSIONS: State-level legalization of recreational cannabis was associated with a significant decrease in the utilization of advanced medical resources in cases of cannabis intoxication in children. These findings suggest the need for a focus on policies and procedures to minimize invasive testing in cases of cannabis intoxication in children. [ABSTRACT FROM AUTHOR]

Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children. METHODS: Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old. RESULTS: We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%). CONCLUSIONS: The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Repurposed medications for acute coronavirus disease 2019 (COVID-19) continued to be prescribed after results from rigorous studies and national guidelines discouraged use. We aimed to describe prescribing rates of nonrecommended medications for acute COVID-19 in children, associations with demographic factors, and provider type and specialty. METHODS: In this retrospective cohort of children <18 years in a large United States all-payer claims database, we identified prescriptions within 2 weeks of an acute COVID-19 diagnosis.We calculated prescription rate, performed multivariable logistic regression to identify risk factors, and described prescriber type and specialty during nonrecommended periods defined by national guidelines. RESULTS: We identified 3082626 COVID-19 diagnoses in 2 949 118 children between March 7, 2020 and December 31, 2022. Hydroxychloroquine (HCQ) and ivermectin were prescribed in 0.03% and 0.14% of COVID-19 cases, respectively, during nonrecommended periods (after September 12, 2020 for HCQ and February 5, 2021 for ivermectin) with considerable variation by state. Prescription rates were 4 times the national average in Arkansas (HCQ) and Oklahoma (ivermectin). Older age, nonpublic insurance, and emergency department or urgent care visit were associated with increased risk of either prescription. Additionally, residence in nonurban and low-income areas was associated with ivermectin prescription. General practitioners had the highest rates of prescribing. CONCLUSIONS: Although nonrecommended medication prescription rates were low, the overall COVID-19 burden translated into high numbers of ineffective and potentially harmful prescriptions. Understanding overuse patterns can help mitigate downstream consequences of misinformation. Reaching providers and parents with clear evidence-based recommendations is crucial to children's health. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Human metapneumovirus (hMPV) and parainfluenza virus type 3 (PIV3) are common respiratory illnesses in children. The safety and immunogenicity of an investigational mRNA-based vaccine, mRNA-1653, encoding membrane-anchored fusion proteins of hMPV and PIV3, was evaluated in hMPV/PIV3-seropositive children. METHODS: In this phase 1b randomized, observer-blind, placebo-controlled, dose-ranging study, hMPV/PIV3-seropositive children were enrolled sequentially into 2 dose levels of mRNA-1653 administered 2 months apart; children aged 12 to 36 months were randomized (1:1) to receive 10-mg of mRNA-1653 or placebo and children aged 12 to 59 months were randomized (3:1) to receive 30-mg of mRNA-1653 or placebo. RESULTS: Overall, 27 participants aged 18 to 55 months were randomized; 15 participants received 10-µg of mRNA-1653 (n = 8) or placebo (n = 7), whereas 12 participants received 30-µg of mRNA-1653 (n = 9) or placebo (n = 3). mRNA-1653 was well-tolerated at both dose levels. The only reported solicited local adverse reaction was tenderness at injection site; solicited systemic adverse reactions included grade 1 or 2 chills, irritability, loss of appetite, and sleepiness. A single 10-µg or 30-µg mRNA-1653 injection increased hMPV and PIV3 neutralizing antibody titers (geometric mean fold-rise ratio over baseline: hMPV-A = 2.9-6.1; MPV-B = 6.2-13.2; PIV3 = 2.8-3.0) and preF and postF binding antibody concentrations (geometric mean fold-rise ratio: hMPV preF 5 5.3-6.1; postF = 4.6-6.5 and PIV3 preF = 13.9-14.2; postF = 11.0-12.1); second injection did not further increase antibody levels in these seropositive children. Binding antibody responses were generally preF biased. CONCLUSIONS: mRNA-1653 was well-tolerated and boosted hMPV and PIV3 antibody levels in seropositive children aged 12 to 59 months, supporting the continued development of mRNA- 1653 or its components for the prevention of hMPV and PIV3. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the association between congenital cytomegalovirus (cCMV) and autism spectrum disorder (ASD) administrative diagnoses in US children. METHODS: Cohort study using 2014 to 2020 Medicaid claims data.We used diagnosis codes to identify cCMV (exposure), ASD (outcome), and covariates among children enrolled from birth through ≥4 to <7 years. Covariates include central nervous system (CNS) anomaly or injury diagnosis codes, including brain anomaly, microcephaly within 45 days of birth, cerebral palsy, epilepsy, or chorioretinitis. We used Cox proportional hazards regression models to estimate hazard ratios and 95% confidence intervals, overall and stratified by sex, birth weight and gestational age outcome (low birth weight or preterm birth), and presence of CNS anomaly or injury. RESULTS: Among 2 989 659 children, we identified 1044 (3.5 per 10 000) children with cCMV and 74 872 (25.0 per 1000) children with ASD. Of those with cCMV, 49% also had CNS anomaly or injury diagnosis codes. Children with cCMV were more likely to have ASD diagnoses (hazard ratio: 2.5; 95% confidence interval: 2.0-3.2, adjusting for birth year, sex, and region). This association differed by sex and absence of CNS anomaly or injury but not birth outcome. CONCLUSIONS: Children with (versus without) cCMV diagnoses in Medicaid claims data, most of whom likely had symptomatic cCMV, were more likely to have ASD diagnoses. Future research investigating ASD risk among cohorts identified through universal cCMV screening may help elucidate these observed associations. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Safe drinking water and closed sanitation are fundamental to health and are assumed in the United States, however, gaps remain, disproportionately affecting marginalized communities. We sought to describe household sanitation access for children in rural Alabama and local health provider knowledge of sanitation related health concerns. METHODS: Data were collected from self-administered surveys obtained from children enrolled in a larger cross-sectional study to determine soil transmitted helminthiasis prevalence in Alabama, from a survey of health providers from local federally qualified health centers and from a baseline knowledge check of Alabama health providers enrolled in an online sanitation health course. RESULTS: Surveys completed on 771 children (approximately 10% of county pediatric population) revealed less than half lived in homes connected to centralized sewers; 12% reported "straight-pipes," a method of discharging untreated sewage to the ground outside the home, and 8% reported sewage contamination of their home property in the past year. Additionally, 15% of respondents were likely to use well water. The local health providers surveyed did not include routine screening for water and sanitation failures or associated infections. Regional healthcare providers have limited knowledge of soil transmitted helminthiasis. CONCLUSIONS: A significant number of children from rural counties of Alabama with high rates of poverty reside in homes with water and sanitation challenges that predominantly affect African American families. This is an under-recognized health risk by local health providers, and its contribution to well-documented health disparities in this region is poorly understood. [ABSTRACT FROM AUTHOR]

BACKGROUND: Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. METHODS: We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. RESULTS: Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%.We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. CONCLUSIONS: We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement. [ABSTRACT FROM AUTHOR]

BACKGROUND: The role of maternal vitamin D supplementation in the prevention of infantile rickets is unknown, particularly in low- and middle-income countries without routine infant vitamin D supplementation. Through secondary analysis of a randomized, placebo-controlled trial in Bangladesh, we examined the dose-ranging effects of maternal vitamin D supplementation on the risk of biochemical rickets at 6 to 12 months of age. METHODS: Pregnant women (n = 1300) were randomized into 5 groups: placebo, or vitamin D 4200 IU/week, 16 800 IU/week, or 28 000 IU/week from second trimester to delivery and placebo until 6 months postpartum; or 28 000 IU/week prenatally and until 6 months postpartum. Infants underwent biochemical rickets screening from 6 to 12 months of age (n = 790). Relative risks (RR) and 95% confidence intervals (95% CI) of biochemical rickets were estimated for each group versus placebo. RESULTS: Overall, 39/790 (4.9%) infants had biochemical rickets. Prevalence was highest in the placebo group (7.8%), and the risk was significantly lower among infants whose mothers received combined prenatal and postpartum vitamin D at 28 000 IU/week (1.3%; RR, 0.16; 95% CI, 0.03-0.72). Risks among infants whose mothers received only prenatal supplementation (4200 IU, 16 800 IU, 28 000 IU weekly) were not significantly different from placebo: 3.8% (RR, 0.48; 95% CI, 0.19-1.22), 5.8% (RR, 0.74; 95% CI, 0.33-1.69), and 5.7% (RR, 0.73; 95% CI, 0.32-1.65), respectively. CONCLUSIONS: Maternal vitamin D supplementation (28 000 IU/week) during the third trimester of pregnancy until 6 months postpartum reduced the risk of infantile biochemical rickets. Further research is needed to define optimal postpartum supplementation dosing during lactation. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Polycystic Ovary Syndrome (PCOS) is common among females, with significantmetabolic and reproductive comorbidities.We describe PCOS development in a pediatric population. METHODS: We assessed cardiometabolic biomarkers and adiposity at the midchildhood (mean 7.9 y), early teen (mean 13.1 y), and midteen (mean 17.8 y) visits among 417 females in the prospective Project Viva cohort. We defined PCOS via self-reported diagnosis or ovulatory dysfunction with hyperandrogenism in midlate adolescence. We used multivariable logistic regression to assess associations of metabolic and adiposity markers at each visit with PCOS. RESULTS: Adolescents with PCOS (n = 56, 13%) versus without had higher mean (SD) BMI z-score and truncal fat mass at the midchildhood (0.66 [0.99] vs 0.30 [1.04]; 3.5 kg [2.6] vs 2.7 [1.5]), early teen (0.88 [1.01] vs 0.25 [1.08]; 9.4 kg [6.7] vs 6.1 [3.4]), and midteen (0.78 [1.03] vs 0.33 [0.97]; 11.6 kg [7.2] vs 9.1 [4.9]) visits as well as lower adiponectin to leptin ratio at the early (0.65 [0.69] vs 1.04 [0.97]) and midteen (0.33 [0.26] vs 0.75 [1.21]) visits. In models adjusted for maternal PCOS, education and child race and ethnicity (social factors), we found higher odds of PCOS per 1-SD increase in truncal fat at midchildhood (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.03-1.95) and early teen visits (OR 1.61; 95% CI 1.14-2.28) and lower odds per 1-SD increase in adiponectin/leptin ratio at the midteen visit (OR 0.14; 95% CI 0.03-0.58). CONCLUSIONS: Childhood excess adiposity and adipose tissue dysfunction may be a first signs of later PCOS risk. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Respiratory viral infections increase risk of asthma in infants and children. Infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus can cause severe lung inflammation and prolonged respiratory symptoms. We sought to determine whether SARS-CoV-2 infection modified pediatric incident asthma risk. METHODS: This retrospective cohort study examined children ages 1 to 16 within the Children's Hospital of Philadelphia Care Network who received polymerase chain reaction (PCR) testing for SARS-CoV-2 between March 1, 2020 and February 28, 2021. Multivariable Cox regression models assessed the hazard ratio of new asthma diagnosis between SARS-CoV-2 PCR positive and SARS-CoV-2 PCR negative groups within an 18-month observation window. Models were adjusted for demographic characteristics, socioeconomic variables, and atopic comorbidities. RESULTS: There were 27 423 subjects included in the study. In adjusted analyses, SARS-CoV-2 PCR positivity had no significant effect on the hazard of new asthma diagnosis (hazard ratio [HR]: 0.96; P = .79). Black race (HR: 1.49; P = .004), food allergies (HR: 1.26; P = .025), and allergic rhinitis (HR: 2.30; P < .001) significantly increased the hazard of new asthma diagnosis. Preterm birth (HR: 1.48; P = .005) and BMI (HR: 1.13; P < .001) significantly increased the hazard of new asthma diagnosis for children <5 years old. CONCLUSIONS: SARS-CoV-2 PCR positivity was not associated with new asthma diagnosis in children within the observation period, although known risk factors for pediatric asthma were confirmed. This study informs the prognosis and care of children with a history of SARS-CoV-2 infection. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To analyze the performance of commonly used blood tests in febrile infants ≤90 days of age to identify patients at low risk for invasive bacterial infection (bacterial pathogen in blood or cerebrospinal fluid) by duration of fever. METHODS: We conducted a secondary analysis of a prospective single-center registry that includes all consecutive infants #90 days of age with fever without a source evaluated at 1 pediatric emergency department between 2008 and 2021. We defined 3 groups based on caregiver-reported hours of fever (<2, 2-12, and ≥12) and analyzed the performance of the biomarkers and Pediatric Emergency Care Applied Research Network, American Academy of Pediatrics, and Step-by-Step clinical decision rules. RESULTS: We included 2411 infants; 76 (3.0%) were diagnosed with an invasive bacterial infection. The median duration of fever was 4 (interquartile range, 2-12) hours, with 633 (26.3%) patients with fever of <2 hours. The area under the curve was significantly lower in patients with <2 hours for absolute neutrophil count (0.562 vs 0.609 and 0.728) and C-reactive protein (0.568 vs 0.760 and 0.812), but not for procalcitonin (0.749 vs 0.780 and 0.773). Among well-appearing infants older than 21 days and negative urine dipstick with <2 hours of fever, procalcitonin ≥0.14 ng/mL showed a better sensitivity (100% with specificity 53.8%) than that of the combination of biomarkers of Step-by-Step (50.0% and 82.2%), and of the American Academy of Pediatrics and Pediatric Emergency Care Applied Research Network rules (83.3% and 58.3%), respectively. CONCLUSIONS: The performance of blood biomarkers, except for procalcitonin, in febrile young infants is lower in fever of very short duration, decreasing the accuracy of the clinical decision rules. [ABSTRACT FROM AUTHOR]