OBJECTIVE: To evaluate neonatal risk factors and the predictive value of prior assessments for language development at age 3 in toddlers born before 32 weeks of gestation. STUDY DESIGN: Data were acquired retrospectively...OBJECTIVE: To evaluate neonatal risk factors and the predictive value of prior assessments for language development at age 3 in toddlers born before 32 weeks of gestation. STUDY DESIGN: Data were acquired retrospectively from infants' hospitalizations (level 3 perinatal center, Medical University of Vienna) and annual assessments (Bayley Scales of Infant and Toddler Development). We included children born in 2012-2020 at < 32 weeks of gestation, with annual follow-ups, at least one German-speaking parent, and unimpaired hearing. Predictors of 3-year language development were analyzed using Gradient Boost Decision Trees and interpreted through SHapely Additive exPlanations (SHAP) values. RESULTS: The cohort comprised 476 children (202 [42.4%] females; mean [standard deviation] gestational age, 27.4 [2.0] weeks). Risk factors were multilingualism (mean|SHAP| = 3.93, P ≤ .001), lower maternal education (mean|SHAP| = 2.51, P ≤ .001), reduced birth weight (mean|SHAP| = 1.92, P = .003), shorter gestational age (mean|SHAP| = 1.64, P = .009), grade of intraventricular hemorrhage in the left hemisphere (mean|SHAP| = 1.07, P = .005), severe intraventricular hemorrhage (mean|SHAP| = 0.80, P = .011, surgical necrotizing enterocolitis (mean|SHAP| = 0.80, P = .018), and surgical retinopathy of prematurity (mean|SHAP| = 0.59, P = .045). CONCLUSIONS: The identification of SHAP values allowed us to evaluate the additive effect of neonatal and sociodemographic risk factors predicting language impairments in this cohort of children born preterm. Replication in other cohorts will be important, but SHAP-based analyses may be useful for tailored monitoring and implementation of early language support.
Selesner L, Hedges M, Pung R
… +13 more, Vaughn C, Burns A, Aloia M, Henson J, Tobias J, Olyaei A, Nizich S, Swift K, Veshagh A, Andres SF, Fialkowski E, Jordan BK, Scottoline B
OBJECTIVES: To evaluate the incidence of necrotizing enterocolitis before probiotic introduction, during probiotic administration, and after its cessation following the 2023 US Food and Drug Administration advisory disco...OBJECTIVES: To evaluate the incidence of necrotizing enterocolitis before probiotic introduction, during probiotic administration, and after its cessation following the 2023 US Food and Drug Administration advisory discouraging probiotic use in preterm infants. STUDY DESIGN: Retrospective non-concurrent cohort study of very low birthweight (VLBW) infants (birthweight <1500 g), admitted to a level IV neonatal intensive care unit (NICU) from 2014 through 2024. Infants were grouped into three epochs based on Bifidobacterium longum ssp. infantis (B. infantis) EVC001 use: pre-EVC001 (no probiotic), EVC001 (routine use), and post-EVC001 (post-discontinuation). The primary outcome was NEC incidence. Secondary outcomes included NEC-associated mortality, all-cause mortality, NEC severity and NEC incidence among extremely low birthweight (ELBW; <1000 g) infants. Multivariable log-binomial and ordinal logistic regression models were used. RESULTS: Among 733 VLBW infants, NEC incidence was 12% pre-EVC001, 2.6% EVC001, and 16% post-EVC001 (P < .001). NEC risk was higher both pre-EVC001 (adjusted relative risk [aRR] 4.4, 95% confidence interval [CI] 2.2-9.0) and post-EVC001 (aRR 4.5, 95% CI 2.0-9.9; both P < .001) compared to during EVC001 administration. ELBW infants showed similar trends. EVC001 use was associated with reduced odds of severe NEC compared to epochs without EVC001 use (VLBW odds ratio 5.3, 95% CI 2.5-11.0; ELBW odds ratio 5.0, 95% CI 2.2-11.7; both P < .001). NEC-related mortality was lowest during EVC001exposed infants (0.9%) compared to unexposed (2.8, P = .05). CONCLUSIONS: NEC rates were higher before, lower during and rose after discontinuation of EVC001 in this single center retrospective study. There is a need for multicenter trials evaluating B. infantis for NEC prevention.
Rivkin MJ, Linds A, Slim M
… +13 more, Surmava AM, Beslow LA, Dowling MM, Mackay M, Kirton A, Jordan LC, Fox CK, Felling R, Dlamini N, Bernard T, Amlie-Lefond C, deVeber G, International Pediatric Stroke Study Group
OBJECTIVE: To determine if children enrolled in the International Pediatric Stroke Study (IPSS) database (4294 patients enrolled, 2003-2014, neonates through 18 years of age) demonstrate demographic, clinical, radiograph...OBJECTIVE: To determine if children enrolled in the International Pediatric Stroke Study (IPSS) database (4294 patients enrolled, 2003-2014, neonates through 18 years of age) demonstrate demographic, clinical, radiographic, and therapeutic characteristics that relate to age and development at the time of stroke. STUDY DESIGN: Participants with arterial ischemic stroke or cerebral sinus venous thrombosis were enrolled using standardized consent and case report forms. Data were entered on-site and electronically transferred to a central data storage site in Toronto, Canada. Children were stratified into 4 age groups for analysis of developmental features: neonates (0-28 days of age); infants (29 days to <2 years of age); young children (2 years to <10 years old), and adolescents (≥10 years to <18 years old). Continuous and categorical variables were examined using appropriate statistical techniques in SAS (SAS Institute, Inc). RESULTS: Three thousand eight-hundred nine children were analyzed: 1112 (29.2%) neonates, 728 (19.1%) infants, 1088 (28.6%) young children, and 881 (23.1%) adolescents. Arterial ischemic stroke alone occurred in 3201 (916 neonates; 2285 older children) and cerebral sinovenous thrombosis alone occurred in 608 (196 neonates; 412 older children). Age group specific clinical and neuroimaging features that segregate by ischemic stroke type were identified and are reported. CONCLUSIONS: The IPSS database comprises a very large, structured pediatric stroke database used by investigators to advance the understanding and treatment of pediatric stroke. Developmentally based analyses of IPSS data reveal features of childhood stroke that segregate by ischemic stroke type and age at stroke occurrence. These features should aid in understanding age-related pathophysiology and in clinical stroke recognition.
OBJECTIVE: To explore potential associations between neighborhood-level factors and early organ dysfunction in children who are critically ill. STUDY DESIGN: This retrospective, ecological cohort study assessed the assoc...OBJECTIVE: To explore potential associations between neighborhood-level factors and early organ dysfunction in children who are critically ill. STUDY DESIGN: This retrospective, ecological cohort study assessed the association between neighborhood factors and early organ dysfunction in 8289 encounters for children who were critically ill from January 2013 to December 2019 at a quaternary pediatric hospital in an urban setting. The exposures were neighborhood factors, which were measured using 3 composite indices: Child Opportunity Index (COI), Social Vulnerability Index (SVI), and Neighborhood Disorder Index (NDI). Peak Pediatric Logistic Organ Dysfunction [PELOD]-2 scores in the first 72 hours measured early organ dysfunction as the primary outcome. An adjusted Poisson regression with robust modeling was used to measure the association. RESULTS: Most encounters were for patients from very low opportunity (28%), very high vulnerability (29%), and very high physical disorder neighborhoods (27%). Median peak PELOD-2 score was 3 (interquartile range 2-5). No association was identified for COI or NDI with peak PELOD-2 scores; however, there was an association between a very high SVI and greater peak PELOD-2 scores (P = .004). CONCLUSIONS: No association was found among COI or NDI with worse early organ dysfunction. Very high SVI was associated with worse early organ dysfunction. Further studies should assess whether specific aspects of neighborhoods drive critical illness in organ-specific diseases.
de Baat T, van de Loo M, Aarnoudse-Moens CSH
… +19 more, Halbmeijer NM, Onland W, van Kaam AH, Koopman C, Swarte RMC, Mulder-de Tollenaer SM, van Stuijvenberg M, Tan RNGB, de Kort E, Bruneel E, Cools F, Steiner K, Debeer A, Van Mechelen K, Blom H, Maréchal Y, Plaskie K, Leemhuis AG, SToP-BPD Trial Collaborators
OBJECTIVE: To examine neurodevelopmental outcomes at 5.5 years of corrected age in children included in the Systemic hydrocortisone (HC) To Prevent Bronchopulmonary Dysplasia in preterm infants (SToP-BPD) study, and to i...OBJECTIVE: To examine neurodevelopmental outcomes at 5.5 years of corrected age in children included in the Systemic hydrocortisone (HC) To Prevent Bronchopulmonary Dysplasia in preterm infants (SToP-BPD) study, and to investigate the neurodevelopmental outcomes and mortality with HC treatment started between 7 and 14 days after birth compared with placebo in infants born preterm who required mechanical ventilation. STUDY DESIGN: Data at 5.5 years of corrected age on cognitive, motor and neurosensory functioning, behavior, schooling, and general health outcomes were derived from regular follow-up visits. The primary outcome was death or moderate-severe neurodevelopmental impairment (NDI, complete case analysis), with NDI defined as a disability in at least 1 of the domains of cognition, motor development, vision, or hearing. Other outcomes included neurologic and behavioral assessments as well as parent reports of service use and school function. RESULTS: NDI was assessed in 213 of the 277 (77%) surviving children. Children attending follow-up were more likely to have highly educated or nonsmoking parents and had better neurodevelopmental outcomes at 2 years of corrected age than nonattending children. Baseline characteristics of assessed children were comparable between treatment arms. No significant difference was found on the primary outcome (OR 0.75; 95% CI 0.49-1.14; P = .18). All developmental outcomes were comparable between the HC and placebo group. CONCLUSIONS: Treatment with HC started between 7 and 14 days after birth in infants born preterm at risk of BPD did not affect death or moderate-severe NDI nor any of the separate developmental outcome measures at 5.5 years of corrected age. TRIAL REGISTRATION: 2010-023777-19; https://www.clinicaltrialsregister.eu.
OBJECTIVE: To investigate the physical and mental health of a national cohort of Swedish adults born with extremely low birth weight (ELBW, ≤1000 g) and its impact on self-reported health-related quality of life (HRQoL)....OBJECTIVE: To investigate the physical and mental health of a national cohort of Swedish adults born with extremely low birth weight (ELBW, ≤1000 g) and its impact on self-reported health-related quality of life (HRQoL). STUDY DESIGN: This prospective, follow-up study was conducted on a Swedish national cohort of individuals born between 1990 and 1992 with a birth weight of ≤1000 g (n = 201), along with a matched control group (n = 327) born appropriate for gestational age at term. All participants were between 26 and 29 years old at the time of the study. Data were collected through web-based questionnaires assessing physical and mental health, including the 36-item Short Form Health Survey version 2 to evaluate HRQoL. In addition, registered diagnoses were obtained from the Swedish National Board of Health and Welfare. Multivariable linear regressions were performed to investigate factors associated with HRQoL. RESULTS: Compared with the control group, adult individuals born ELBW had a significantly higher prevalence of physical morbidities. In terms of mental health, developmental and psychiatric conditions were also more prevalent, with the exception of mood disorders. However, there were no significant differences in self-reported HRQoL between ELBW and the control group. CONCLUSIONS: Despite a higher prevalence of impairments, ELBW individuals may not perceive themselves as limited in their daily functioning.
OBJECTIVE: To test and compare the capability of 3 multimorbidity-based models to predict outcomes in early childhood among infants born with extremely low birth weight (<1000 g, ELBW). STUDY DESIGN: Participants include...OBJECTIVE: To test and compare the capability of 3 multimorbidity-based models to predict outcomes in early childhood among infants born with extremely low birth weight (<1000 g, ELBW). STUDY DESIGN: Participants included 8332 surviving ELBW infants born 2010-2020 in North America who contributed follow-up data at 24-months corrected age to the Vermont Oxford Network. Neonatal morbidities included bronchopulmonary dysplasia, grade 3-4 intraventricular hemorrhage, periventricular leukomalacia, stage 3-4 retinopathy of prematurity, late infection, necrotizing enterocolitis, and spontaneous intestinal perforation. Outcomes included: 1) developmental delay (Bayley score <70 in ≥1 domain), 2) rehospitalization, and 3) therapeutic service use. We compared 3 gestational age-adjusted risk models with the following predictors: 1) morbidity count, 2) count of 3 morbidities (bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity), and 3) multimorbidity-based latent classes. RESULTS: Thirty five percent of the study sample had ≥2 neonatal morbidities. Most (64%) received ≥2 therapeutic services, 36% were re-hospitalized, and 19% had developmental delay at 24-months. Morbidity counts and multimorbidity-based latent classes were associated with increased risk for poor 24-month outcomes compared with no morbidity. However, the predictive ability of all 3 models was modest (area under the receiver operating curve = 0.66). CONCLUSIONS: Neonatal multimorbidity is common among ELBW infants and associated with later health and developmental outcomes. However, diagnosis-based multimorbidity risk models have poor prognostic ability. More robust characterization of multimorbidity symptom severity, physiologic impact, and environmental correlates may improve the clinical utility of future risk models.
OBJECTIVE: To determine the association between subgroups of children with special health care needs (SHCN) and food insufficiency, and assess whether this association varies by income level, and to evaluate how food ins...OBJECTIVE: To determine the association between subgroups of children with special health care needs (SHCN) and food insufficiency, and assess whether this association varies by income level, and to evaluate how food insufficiency trends have changed over the time. STUDY DESIGN: This was a cross-sectional survey study using the 2016-2023 National Surveys of Children's Health. SHCN subgroups were defined as follows: no special health care needs, prescription medication use only, elevated use of services, and functional limitations. The association between SHCN subgroup and food insufficiency was measured using weighted multivariable logistic regression models. Effect modification by income was evaluated. In addition, linear models described significant changes in food insufficiency rates by SHCN subgroup from 2016 to 2023. RESULTS: Compared with children without SHCN, children with SHCN who used medications only (aOR = 1.31; 95% CI 1.21-1.41), had elevated use of services (aOR = 1.54; 95% CI 1.45-1.63), or had functional limitations (aOR 1.97; 95% CI 1.82-2.13) had higher odds of food insufficiency. Effect modification by income was significant for children with functional limitations. From 2016 to 2023, the associations between SHCN and food insufficiency were similar. CONCLUSION: Children with functional limitations are an especially high-risk group who require attention in public health efforts to reduce food insufficiency.
OBJECTIVE: To assess the relationship between availability of pediatric labeling information as well as on-label pediatric safety information and the use of oral targeted anticancer medications (OTAMs) by pediatric patie...OBJECTIVE: To assess the relationship between availability of pediatric labeling information as well as on-label pediatric safety information and the use of oral targeted anticancer medications (OTAMs) by pediatric patients. STUDY DESIGN: We identified all OTAMs first approved by the Food and Drug Administration from January 1, 2007, to September 31, 2021, and assessed their use by children with cancers on the basis of claims data in Optum's deidentified Clinformatics Data Mart from January 1, 2007, to September 31, 2021. RESULTS: Over the study period and across cancer types, 3.8% of patients with childhood cancer received at least 1 OTAM. The majority of OTAMs used (29.4% in 2008 and 51.7% to 88.6% in other years) did not have an indication for the diagnosed pediatric cancers. First OTAM treatment episodes lasted longer (ie, discontinuations happened later) for drugs with pediatric cancer indications and safety information compared with those without the information during the episode of use. From 2007 to 2021, median standard costs of 30-day supplies of OTAMs for patients <18 years old were $6714 and inflation-adjusted, out-of-pocket median spending for a 30-day supply of OTAMs was about $11. CONCLUSIONS: Our results show relatively limited yet increasing pediatric OTAM use over time. We document a greater likelihood of earlier discontinuation and significant financial cost for drugs without on-label pediatric cancer indications and safety information. There is a need for a robust regulatory framework to mandate the timely generation of pediatric population-specific efficacy and safety evidence.
OBJECTIVE: To explore associations between pediatrics residents' experiences with discrimination, burnout, belonging, professional fulfillment, and career plans, including interest in remaining at their training institut...OBJECTIVE: To explore associations between pediatrics residents' experiences with discrimination, burnout, belonging, professional fulfillment, and career plans, including interest in remaining at their training institution. STUDY DESIGN: Between October 2020 and January 2021, a national, cross-sectional study titled PROMISE (PROmoting Med-Ed Insight into Supportive Environments) used a 23-item survey of pediatrics residents through the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network. Descriptive, association, and mediation analyses were conducted for underrepresented in medicine (UIM), Asian and Asian American (AAA), and White residents using multilevel regression and structural equation models. RESULTS: The study included 799 pediatrics residents (20% UIM) from 24 residency programs. UIM and AAA residents experienced higher discrimination. Among UIM residents, staff discrimination was associated with greater interpersonal disengagement (P = .02), work exhaustion (P < .01), and lower professional fulfillment (P = .04). UIM (P < .01) and AAA (P = .01) residents reported lower belonging even after adjusting for discrimination. Greater belonging was associated with higher likelihood of wanting to remain at one's institution (B = 0.46, 95% CI 0.34-0.57; P < .001). Belonging and professional fulfillment mediated associations between discrimination and intent to stay among UIM residents; for AAA residents, only belonging was a significant mediator. CONCLUSIONS: UIM and AAA pediatric residents reported disproportionately higher discrimination, which was associated with increased burnout and reduced belonging. Institutional efforts to address discrimination are critical for promoting resident well-being and retention in academic medicine.
OBJECTIVE: To evaluate how adolescents and young adults with cerebral palsy (AYACP) make mobility-related health care decisions and seek their perspectives on making decisions about mobility-related health care intervent...OBJECTIVE: To evaluate how adolescents and young adults with cerebral palsy (AYACP) make mobility-related health care decisions and seek their perspectives on making decisions about mobility-related health care interventions. STUDY DESIGN: We purposively recruited AYACP ages 13-21 years from an academic medical center to participate in qualitative semistructured individual interviews. Interview questions explored mobility-related health care interventions and decision-making. We recorded, transcribed, coded, and analyzed interviews using thematic analysis. RESULTS: AYACP described multiple mobility-related health care decisions and cycling between testing out and choosing interventions. The research team identified four themes: balancing autonomy and support; connecting evolving knowledge and goals to intervention outcomes motivates decision participation; limited agency; and desire for options that effectively address AYACPs' individual needs. AYACPs want to participate in decision-making about interventions to address their mobility-related goals but describe needing support from adults. AYACP also described their knowledge and goals as evolving throughout adolescence, which often motivated their participation in decisions and treatment plans. In contrast, some AYACP lacked agency in decision-making, which negatively influenced their participation. AYACP have a wide range of individual needs and struggle with finding mobility-related health care interventions that optimally address their individual needs. CONCLUSIONS: AYACP need support in developing knowledge and decision-making skills about mobility-related health care interventions that address their goals. AYACP would benefit from decision support to develop skills for transitioning to adult health care and engaging in decision making.
OBJECTIVE: To test whether cumulative parental impulsivity exposure across childhood is associated with greater accelerated epigenetic age across adolescence. STUDY DESIGN: Data were drawn from the Future of Families and...OBJECTIVE: To test whether cumulative parental impulsivity exposure across childhood is associated with greater accelerated epigenetic age across adolescence. STUDY DESIGN: Data were drawn from the Future of Families and Child Wellbeing Study, a population-based birth cohort (1998-2000) study of 4898 families across 20 major US cities. We analyzed data from families who provided self-reported survey data on maternal and paternal impulsivity when children were in early childhood (between the ages of 1 and 5 years); scores of parental impulsivity were created for each parent. Youth provided saliva samples to assess adolescent accelerated epigenetic age at ages 9 and 15 years old using 3 epigenetic clocks: PhenoAge, GrimAge, and DunedinPACE (n = 1971). Analyses jointly modeled the associations between maternal and paternal impulsivity during childhood and longitudinal change in accelerated epigenetic age using a latent variable constructed from these clocks in the structural equation modeling framework. We also conducted analyses using the individual clocks as the dependent variables. The autoregressive effect of age 9 accelerated epigenetic age was included to model residualized change from age 9 to 15. RESULTS: Maternal impulsivity during early childhood, but not paternal impulsivity, was significantly associated with greater residualized change in the latent factor of accelerated epigenetic age (β = 0.06, P = .03) at age 15 years. Maternal impulsivity was also associated with greater residualized change in accelerated aging using the individual clocks (GrimAge: β = 0.06, P < .001, PhenoAge: β = 0.04, P = .06, DunedinPACE: β = 0.05, P = .01). CONCLUSIONS: Maternal impulsivity may constitute an environmental stressor that is correlated with greater accelerated epigenetic aging across adolescence. Variations in maternal impulsivity should be considered within the broader constellation of social and ecological factors as parental behavior may reflect adaptations to the broader contexts in which both parents and children reside.
OBJECTIVE: To assess the role of the maternal-fetal environment (MFE) on early neurodevelopmental and clinical outcomes in children with single ventricle heart disease (SVHD). STUDY DESIGN: We performed a retrospective,...OBJECTIVE: To assess the role of the maternal-fetal environment (MFE) on early neurodevelopmental and clinical outcomes in children with single ventricle heart disease (SVHD). STUDY DESIGN: We performed a retrospective, single-center study of patients with a prenatal diagnosis of SVHD from 2011-2022. Impaired MFE was defined as exposure to diabetes, pre-eclampsia, tobacco, or chronic or gestational hypertension in utero. Neurodevelopmental outcomes were assessed using the Bayley Scales of Infant and Toddler Development-III and 4 between 12 and 36 months of age. RESULTS: Among 160 patients with SVHD (117 hypoplastic left heart and 43 hypoplastic right heart), 78 completed neurodevelopmental testing. Exposure to an impaired MFE was associated with lower cognitive scores (P = .030), although this association became nonsignificant after adjustment for clinical covariates. Impaired MFE was also associated with lower language and receptive communication scores after clinical adjustment (P = .023 and P = .040, respectively) but became nonsignificant after further adjustment for the Child Opportunity Index. No significant differences were observed in fine or gross motor scores, neonatal complications, hospital or intensive care unit stay, and 1-year mortality or transplantation between groups. CONCLUSIONS: Among patients with SVHD, exposure to an impaired MFE was associated with lower cognitive and language outcomes, although these associations were attenuated after accounting for clinical and socioeconomic factors. These findings highlight the importance of early identification and monitoring of children with adverse prenatal exposures.
Östman M, Stene LC, Tapia G
… +4 more, Kivelä L, Kurppa K, Størdal K, Human Exposomic Determinants of Immune Mediated Diseases (HEDIMED) Investigator Group
OBJECTIVE: To study the association between rotavirus vaccination and risk of celiac disease, which remains debated. STUDY DESIGN: We conducted a nationwide register-based study including 740 744 children born during 200...OBJECTIVE: To study the association between rotavirus vaccination and risk of celiac disease, which remains debated. STUDY DESIGN: We conducted a nationwide register-based study including 740 744 children born during 2007-2019 from the Norwegian Birth Registry individually linked to the Norwegian Patient Registry for celiac disease diagnosis. With follow-up until 5 years of age, 2795 were diagnosed with celiac disease. The main analysis was an interrupted time series analysis to assess break in trend of celiac disease incidence before compared with after vaccine introduction in September 2014. Furthermore, we linked the cohort to the Norwegian Immunization Register and compared the risk of celiac disease between fully vaccinated and nonvaccinated children. In sensitivity analyses, we excluded children born 1 year before to 1 year after vaccine introduction to mitigate the effect of herd immunity. RESULTS: There was no significant break in trend after rotavirus vaccine introduction (P = .46). Hazard ratio (HR) of celiac disease was 0.96 (95% CI 0.89-1.04) if born after compared with before vaccination started, and 1.00 (95% CI 0.92-1.09) when excluding children born in 2013-2015. In fully vaccinated compared with nonvaccinated the HR was 0.99 (95% CI 0.92-1.07), consistent in robustness analyses. Including a requirement for gluten-free diet support in the celiac disease case definition gave similar results (HR 1.06, 95% CI 0.98-1.15). CONCLUSIONS: This study did not find an association between rotavirus vaccine and the risk of early-onset celiac disease.
OBJECTIVES: To assess knowledge of the American Academy of Pediatrics (AAP) safe sleep recommendations, identify barriers to education, and explore strategies to improve education delivery in the acute care setting among...OBJECTIVES: To assess knowledge of the American Academy of Pediatrics (AAP) safe sleep recommendations, identify barriers to education, and explore strategies to improve education delivery in the acute care setting among pediatric emergency department (ED) clinicians and trainees. STUDY DESIGN: We conducted a cross-sectional survey of pediatric ED clinicians and trainees at a tertiary care children's hospital. The survey assessed knowledge of AAP safe sleep recommendations, current counseling practices, perceived barriers, and suggested interventions. Descriptive statistics and stratified analyses were performed. RESULTS: Of 226 eligible clinicians and trainees, 182 responded (80.5%). Most were pediatric residents (47.5%) or nurses (33.9%). Knowledge was high (mean score: 5.5/6, standard deviation: 0.7), with no significant differences across roles or experience levels. Major barriers to counseling included time constraints (86.3%) and competing clinical priorities (77.6%), followed by language or cultural barriers (38.3%). Although 71.0% provided education when observing unsafe sleep practices, only 29.5% documented counseling. Clinician and trainees endorsed system-level supports such as multilingual resources (65.0%), provision of cribs or sleep sacks (56.3%), electronic medical record prompts (53.0%), and referral pathways for safe sleep resources (53.6%). CONCLUSIONS: Although pediatric ED clinicians and trainees demonstrate strong knowledge of AAP recommendations, system-level barriers limit consistent counseling. Addressing these barriers represents a critical opportunity to reduce the heightened risk of sleep-related infant death during illness. Embedding safe sleep education into ED workflows may strengthen sudden unexpected infant death prevention efforts and reduce infant mortality.
OBJECTIVES: To describe postextubation noninvasive respiratory support (NRS) use, and its variation based on clinical variables and institution, to identify factors associated with failure to liberate from NRS ≤ 48 hours...OBJECTIVES: To describe postextubation noninvasive respiratory support (NRS) use, and its variation based on clinical variables and institution, to identify factors associated with failure to liberate from NRS ≤ 48 hours postextubation, and to explore the association between postextubation NRS use and patient-centered outcomes. STUDY DESIGN: A retrospective cohort study of patients aged ≤ 18 years exposed to invasive mechanical ventilation (IMV) via endotracheal tube for ≥ 24 hours between January 1, 2013 and December 31, 2022, in the Virtual Pediatric Systems multicenter quality improvement database. Failure to liberate from NRS ≤ 48 hours postextubation was the primary outcome. Mixed-effects logistic regression models were developed for patient-centered outcomes. RESULTS: A total of 132,712 encounters from 158 institutions were included. High-flow nasal cannula was the most common NRS modality followed by bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) with rescue deployment more common than planned. Older age, later study year, high-risk primary diagnostic category, use of BiPAP or CPAP, and IMV duration ≥ 7 days were associated with higher odds of failure to liberate from NRS ≤ 48 hours. Patients who failed to be liberated from NRS ≤ 48 hours postextubation had longer NRS duration, longer intensive care unit and hospital lengths of stay, and higher pediatric intensive care unit all-cause mortality. Younger age, high-risk primary diagnostic category, use of rescue CPAP, use of planned as well as rescue BiPAP, and IMV duration ≥ 7 days were associated with higher odds of extubation failure ≤ 48 hours and 7 days. CONCLUSIONS: Postextubation NRS use is highly prevalent and most commonly deployed as a rescue strategy. Failure to liberate from NRS ≤ 48 hours postextubation is associated with worse patient-centered outcomes. Optimizing the postextubation NRS deployment and titration is an important gap in need of research and quality improvement interventions which may lead to improved patients' outcomes.