OBJECTIVE: To define nutritional provisions in infants admitted to the neonatal intensive care unit with severe bronchopulmonary dysplasia (sBPD) and concurrent diagnosis of infection. STUDY DESIGN: Fifty instances of in...OBJECTIVE: To define nutritional provisions in infants admitted to the neonatal intensive care unit with severe bronchopulmonary dysplasia (sBPD) and concurrent diagnosis of infection. STUDY DESIGN: Fifty instances of infection over 4 years among 32 infants with sBPD were reviewed retrospectively from a level IV neonatal intensive care unit. Nutritional provisions (total daily energy and proportions from fat, carbohydrate, protein, and enteral feeds, as well as sodium, potassium, magnesium, phosphorous, calcium, acetate, and chloride) were assessed for 7 days prior to and after infection diagnosis and analyzed using general linear mixed models. RESULTS: Across 50 total infections, nutritional provisions were similar before and after infection diagnosis. However, after diagnosis of a bloodstream infection (BSI; 12 infections), infants received a 28.4% increase in proportion of energy from fat (P = .0029) and 24% more chloride (P = .018) compared with before the BSI diagnosis. Infants after BSI diagnosis also received an 8.6% decrease in proportion of energy from carbohydrates (P = .049), 4.8% decrease in proportion of energy from protein (P = .049), 15.5% less potassium (P < .001), 26.7% less calcium (P = .001), and 18.9% less phosphorous (P = .0025). CONCLUSIONS: In this cohort of infants with sBPD, nutritional provisions differed after the diagnosis of BSI, indicating that providers appear to manage the nutrition of acutely infected infants in a manner distinct from their management before diagnosis. These findings highlight how the biologic and clinical interactions between sBPD, infection, recovery, nutrition, and growth require further investigation.
OBJECTIVE: To describe trends and variation in testing, treatment, and disposition of febrile infants aged 61-90 days evaluated in US emergency departments (EDs). STUDY DESIGN: For this retrospective cohort study, we inc...OBJECTIVE: To describe trends and variation in testing, treatment, and disposition of febrile infants aged 61-90 days evaluated in US emergency departments (EDs). STUDY DESIGN: For this retrospective cohort study, we included noncritically ill, previously healthy infants aged 61-90 days with temperatures ≥ 38°C evaluated at 12 Pediatric Emergency Care Applied Research Network Registry EDs during 2017-2023 (trends analysis) and 17 EDs in 2022-2023 (variation analysis). Outcomes included urine, blood, cerebrospinal fluid, and respiratory viral testing; antibiotic administration; hospitalization; and invasive bacterial infections. RESULTS: We included 9041 infants in the trends analysis and 4448 in the variation analysis. From 2017-2023, urine testing (53.8% to 45.7%; P < .01), blood cultures (35.0% to 18.9%; P < .01), cerebrospinal fluid testing (3.8% to 1.1%; P < .01), hospitalizations (22.6% to 16.9%; P < .01), and parenteral antibiotics (10.2% to 5.8%; P < .01) decreased. Conversely, respiratory viral testing (13.4% to 63.3%; P < .01) and procalcitonin use increased (1.6% to 14.2%; P < .01). In 2022-2023, a median 46.3% of infants had urine testing (range: 32.2%-73.9% across hospitals), 21.1% had blood cultures (range: 8.0%-51.1%), and 16.2% were hospitalized (range: 7.9%-26.1%). Respiratory viral testing (median 71.8%; range: 34.7%-95.5%) and procalcitonin use (median 13.4%; range: 0%-37.0%) also varied. The prevalence of invasive bacterial infections was similarly low across hospitals (median 0.3%; range: 0%-1.2%). CONCLUSIONS: There has been significant change over time in testing and disposition of febrile infants aged 61-90 days, although with substantial interhospital variation. Implementation of decision support tools is needed to standardize management and reduce practice variations.
OBJECTIVE: To assess the variation in the duration of antibiotic prophylaxis prescribed for patients with asplenia among US pediatric subspecialists. METHODS: A survey was e-mailed to pediatric infectious diseases, hemat...OBJECTIVE: To assess the variation in the duration of antibiotic prophylaxis prescribed for patients with asplenia among US pediatric subspecialists. METHODS: A survey was e-mailed to pediatric infectious diseases, hematology/oncology, cardiology, and surgery providers at US academic medical centers. Questions addressed prescribing practices in patients with asplenia/hyposplenia. RESULTS: There were 58 respondents who managed antibiotic prophylaxis in patients with asplenia/hyposplenia. Thirty-nine managed patients with nonsurgical disorders of the spleen; most prescribed prophylaxis until 5 years of age for patients with sickle cell disease, but duration varied for congenital anatomic asplenia, situs inversus, polysplenia, and hereditary spherocytosis. Thirty-three managed patients who had undergone surgical splenectomy due to a medical condition. Thirty-five managed patients who had undergone surgical splenectomy due to trauma. Duration of prophylaxis was longer for patients who were younger at the time of splenectomy. Respondents were more likely to prescribe prophylaxis for patients who underwent surgical splenectomy for a medical reason compared with trauma. Thirty-seven institutions were represented; 17 had ≥2 respondents. There was practice variation among individuals from the same institution. Ninety-three percent of all respondents reported their clinical practice would benefit from consensus guidance. CONCLUSIONS: There is wide practice variation in the duration of antibiotic prophylaxis prescribed for patients with asplenia or hyposplenia. These varying practice patterns illustrate the need for outcomes research and expert consensus guidance.
OBJECTIVE: To assess the safety and efficacy of high-dose, oral cholecalciferol supplementation in children and young adults with inflammatory bowel disease treated with infliximab or vedolizumab. STUDY DESIGN: This was...OBJECTIVE: To assess the safety and efficacy of high-dose, oral cholecalciferol supplementation in children and young adults with inflammatory bowel disease treated with infliximab or vedolizumab. STUDY DESIGN: This was a prospective, longitudinal (1 year), open-label study of directly observed high-dose oral cholecalciferol administered every 4-8 weeks. Participants received either 100 000 IU every 4-6 weeks or 200 000 IU every 6-8 weeks, depending on the participant's infusion schedule. Dosing was titrated to a goal 25-hydroxyvitamin D (25-OHD) trough level of 40-60 ng/mL. Safety was assessed by spot urinary calcium and creatinine, and serum calcium levels. RESULTS: Participants' serum 25-OHD levels increased by a mean of 18.1 ng/mL (P < .001). At study conclusion, 58% (P < .001) and 91% (P < .001) of participants had 25-OHD levels greater than 40 ng/mL and 30 ng/mL, respectively. The response to cholecalciferol did not differ between patients with Crohn's disease or ulcerative colitis (P = .74). No adverse effects were observed, including changes in serum or urinary calcium levels. Mean spot urinary calcium to creatinine ratio 0.10 at baseline and 0.09 at study conclusion (P = .26). CONCLUSIONS: High-dose, intermittent cholecalciferol is a safe and effective approach to achieving and maintaining adequate 25-OHD in young patients with inflammatory bowel disease. TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT04331639.
Moschovis PP, Sharfi A, Chaudhury S
… +12 more, Sharma A, Wiens MO, Kumbakumba E, Keneema O, Nyehengane D, Kabakyenga J, Ansermino JM, Kissoon N, Christiani DC, Dzik W, Kiwanuka JP, Hibberd PL
OBJECTIVE: To examine the effect of anemia on mortality among children hospitalized with severe pneumonia in Uganda. STUDY DESIGN: This prospective cohort study enrolled children aged 6 to 59 months admitted with severe...OBJECTIVE: To examine the effect of anemia on mortality among children hospitalized with severe pneumonia in Uganda. STUDY DESIGN: This prospective cohort study enrolled children aged 6 to 59 months admitted with severe pneumonia to 2 hospitals in western Uganda. Severe pneumonia was diagnosed based on World Health Organization criteria, and anemia was diagnosed by hemoglobin (Hb) measured at admission. RESULTS: Among 212 children with severe pneumonia, with a median age of 13.3 months, 67.5% had at least mild anemia (Hb < 11 g/dL) and 9.0% had severe anemia (Hb < 7 g/dL). A lower mean Hb was observed among children who died during hospitalization (8.5 vs 10.2 g/dL; mean difference 1.7 g/dL [95% CI: 0.6, 2.7]). Adjusting for age and oxygen saturation, Hb concentration was inversely associated with mortality. For every 1 g/dL increase in Hb, we observed a 28% lower odds of death (OR: 0.72 [95% CI: 0.57, 0.89]). We also calculated the product of Hb and oxygen saturation (saturated Hb); no child with a saturated Hb > 12 g/dL died, compared with 28% of children with saturated Hb < 6 g/dL. CONCLUSIONS: Among children hospitalized with severe pneumonia, a dose-dependent and independent association was observed between anemia and risk of mortality, with an even greater effect among children with hypoxemia. Public health and clinical interventions that target prevention, early detection, and prompt treatment of anemia may improve outcomes of children with pneumonia, particularly in low-income settings. CLINICAL TRIAL REGISTRATION: NCT02466672 (observational study registration).
OBJECTIVE: To compare prehospital and emergency department (ED)-based vital sign assessments for children with out-of-hospital emergencies and to evaluate the relationships between vital signs and mental status assessmen...OBJECTIVE: To compare prehospital and emergency department (ED)-based vital sign assessments for children with out-of-hospital emergencies and to evaluate the relationships between vital signs and mental status assessment on patient mortality or intensive care unit (ICU) admission. STUDY DESIGN: We performed a retrospective, multiagency and multicenter study of pediatric transports from the scene to the hospital within an integrated health system between 2014 and 2023. We compared 3 sets of vital signs (first prehospital, last prehospital, and first ED). We evaluated the multivariable association of vital signs with outcomes of ICU admission and in-hospital mortality. RESULTS: We included 68 489 children. ICU admission occurred in 2.4%, and in-hospital mortality in 0.1%. All vital signs demonstrated high agreement between the first prehospital, last prehospital, and ED phases of care (Gwet's AC1 > 0.80). For ICU admission, the area under the receiver operator characteristic curve of the initial prehospital model (0.79, 95% CI: 0.77-0.80) was lower than the last prehospital (0.81, 95% CI: 0.80-0.83) and first-ED model (0.83, 95% CI: 0.82-0.85). Models predicting ICU admission had moderate accuracy (sensitivities of 0.72-0.79; specificities of 0.80-0.87). The area under the receiver operator characteristic curve for models predicting mortality based on prehospital vital signs and ED vital signs reached highly accurate criteria (initial prehospital: 0.91, 95% CI: 0.85-0.97; last prehospital: 0.95, 95% CI: 0.91-0.99; first ED: 0.96, 95% CI: 0.93-0.99). Models for mortality demonstrated high sensitivity (0.90-0.98) and specificity (0.90-0.97). Across models, altered mental status showed the strongest associations with both outcomes, and predictive performance improved modestly from initial prehospital to ED assessment. CONCLUSIONS: Prehospital and ED vital signs are predictive of in-hospital outcomes. Following prospective evaluation, these findings may inform pediatric clinical decision-making in prehospital and initial hospital management. These results support the use of age-adjusted physiologic measures together with mental status assessment to strengthen early risk stratification of children transported by emergency medical services.
OBJECTIVE: To evaluate whether the HOUsing-based SocioEconomic Status (HOUSES) index, a validated individual-level proxy derived from property data, predicts the risk of mental, behavioral, and developmental disorders (M...OBJECTIVE: To evaluate whether the HOUsing-based SocioEconomic Status (HOUSES) index, a validated individual-level proxy derived from property data, predicts the risk of mental, behavioral, and developmental disorders (MBDDs). STUDY DESIGN: We performed a retrospective cohort study of live births (2010-2021) using the Rochester Epidemiology Project. The exposure, HOUSES index at birth, was categorized into quartiles (Q1 = lowest; Q4 = highest). The primary outcome was MBDD diagnosis by age 9. We used Cox proportional hazards models to assess risk, adjusting for prematurity. RESULTS: Of 79 444 children (median follow-up 6.2 years), 18 078 (22.8%) received an MBDD diagnosis. Risk increased in a dose-response manner as socioeconomic status decreased: compared with the highest quartile (Q4), adjusted hazard ratios (aHRs) were 1.11 (Q3), 1.21 (Q2), and 1.35 (95% CI 1.29-1.41) for Q1 (lowest). Comparing Q1 vs Q4, risks were pronounced for autism spectrum disorder (aHR 1.98; 95% CI 1.62-2.41), attention deficit hyperactivity disorder (aHR 1.60; 95% CI 1.43-1.80), stress-associated disorders (aHR 1.57; 95% CI 1.24-1.99), and developmental speech or language disorders (aHR 1.20; 95% CI 1.12-1.29). In time-varying analyses accounting for residential mobility, the overall risk for Q1 compared with Q4 increased further (HR 1.69; 95% CI 1.64-1.75). In addition, children in Q1 had higher emergency department utilization rates (incidence rate ratio 1.44; 95% CI 1.41-1.48) compared with Q4. Conversely, no significant difference was observed for inpatient admissions across quartiles. CONCLUSIONS: Housing-based socioeconomic status is a robust, independent predictor of MBDD diagnosis. The HOUSES index reflects social drivers of health associated with neurodevelopment, facilitating early identification of at-risk populations.
RetCam screening for detection of retinopathy of prematurity (ROP) allows for better documentation of digital images, understanding of disease progression, and earlier intervention. We describe the successful implementat...RetCam screening for detection of retinopathy of prematurity (ROP) allows for better documentation of digital images, understanding of disease progression, and earlier intervention. We describe the successful implementation of a RetCam ROP screening program in a large tertiary academic center for 887 exams over a 21-month period.
Extracorporeal membrane oxygenation (ECMO) is only available in specialized medical centers. We conducted a geospatial analysis and found state- and region-level variation in the supply of ECMO centers, and the number of...Extracorporeal membrane oxygenation (ECMO) is only available in specialized medical centers. We conducted a geospatial analysis and found state- and region-level variation in the supply of ECMO centers, and the number of children who had access to ECMO. These findings may help target areas for the development of new ECMO programs.
OBJECTIVE: To test the effect of different schedules of repeated exposure to a novel food on infants' consumption of the novel food. STUDY DESIGN: Fifty-nine infants (mean [SD] age = 11 months [2]; 41% female) caregiver...OBJECTIVE: To test the effect of different schedules of repeated exposure to a novel food on infants' consumption of the novel food. STUDY DESIGN: Fifty-nine infants (mean [SD] age = 11 months [2]; 41% female) caregiver (age = 32 years [4]; 20% Hispanic) dyads were enrolled in the Healthy Starts Study and randomly assigned to 1 of 3 repeated exposure schedules with artichoke as the novel food: (1) 10 exposures over 2 weeks (standard), (2) 5 exposures over 2 weeks, a 2-week break, then 5 more exposures over 2 weeks (take-a-break); or (3) 10 exposures over a 6-week period (extended). Consumption (g) was measured in a laboratory setting at baseline, postintervention, and after a 6-week extinction period. Mixed-effects models tested schedule effect on change in amount consumed between baseline and postintervention, with adjustment for child age and sex. RESULTS: Fifty-four dyads completed all visits (standard = 17, take-a-break = 20, extended = 17; 91% retention). At baseline, consumption did not differ among repeated exposure schedules. At postintervention, consumption in the standard schedule did not change (26.8 g [∼1.8 tbsp] to 22.9 g [∼1.5 tbsp]), whereas infants in the take-a-break and extended schedules significantly increased consumption (P = .024; baseline to postintervention; take-a-break: 21.1 g [∼1.4 tbsp] to 43.6 g [∼3.0 tbsp]; extended: 20.7 g [∼1.4 tbsp] to 33.6 g [∼2.0 tbsp]). CONCLUSIONS: Standard, intense exposure did not change consumption, yet less frequent exposure over a longer duration resulted in sustained increases in children's consumption of the novel food. Thus, persistence, rather than intensity of exposure, may offer greater benefit for improving infants' acceptance of novel foods. TRIAL REGISTRATION: Healthy Starts Study, ClinicalTrials.gov: NCT05639361.
OBJECTIVE: To assess disparities in both individual and neighborhood measures of opportunity across multiple critical junctures in the health care system journey of pediatric head trauma patients. STUDY DESIGN: Using the...OBJECTIVE: To assess disparities in both individual and neighborhood measures of opportunity across multiple critical junctures in the health care system journey of pediatric head trauma patients. STUDY DESIGN: Using the Minds Matter Registry, which includes all patients evaluated for head trauma across emergency department and outpatient locations in a tertiary care pediatric health care network, we evaluated disparities by age, sex, race, ethnicity, and insurance status, and both the overall and domain scores of the neighborhood Child Opportunity Index among: (1) patients presenting to the emergency department with head trauma and diagnosed with concussion, (2) patients diagnosed with concussion referred to specialty care, and (3) patients referred to specialty care for concussion and attending at least one appointment. RESULTS: Overall, we included 22 344 patients, 5998 diagnosed with concussion, 1142 referred to specialty care, and 504 attending a specialty visit. Across the 3 junctures, we saw stepwise increase in age (median 7.0 years overall sample vs 12.0 diagnosed with concussion vs 13.0 referred to specialty care vs 14.0 attending a specialty visit), race and ethnicity (% identifying as non-Hispanic White 33% vs 40% vs 43% vs 48%), insurance (% possessing private insurance 46% vs 53% vs 56% vs 61%), and overall Child Opportunity Index (median 40 vs 55 vs 63 vs 74). CONCLUSIONS: We identified a "leaky pipeline of injury," with multiple increasing disparities present at each juncture along the health care journey of children with head trauma. Although our findings are specific to head injury, this study likely applies to other injuries and disease processes in the pediatric population, helping to identify key targets for future interventions.
OBJECTIVE: To develop and evaluate a machine learning model to forecast treatment-related changes in cranial vault asymmetry index (CVAI) and cranial index (CI) in infants undergoing cranial orthosis therapy for deformat...OBJECTIVE: To develop and evaluate a machine learning model to forecast treatment-related changes in cranial vault asymmetry index (CVAI) and cranial index (CI) in infants undergoing cranial orthosis therapy for deformational plagiocephaly (DP) and/or deformational brachycephaly (DB). STUDY DESIGN: This retrospective analysis used serial measurements of CVAI and CI for 6694 infants with DP and/or DB at initiation and throughout cranial orthosis therapy from April 1, 2012 to October 31, 22 across cranial orthosis health services in 9 US states. Extreme Gradient Boosting was employed to predict CVAI and CI at the end of therapy based on initial cranial measurements, patient age, and duration of treatment. RESULTS: At initial presentation for helmet therapy, the median (IQR) age of infants in months was 6 (5-8), with 36.5% (n = 2446) having isolated DP, 9.0% (n = 600) isolated DB, and 54.5% (n = 3648) both DP and DB. Initial median CVAI and CI were 7.6% (IQR: 6.2%-9.4%) and 95% (IQR: 92.6%-98.5%), respectively. The Extreme Gradient Boosting models demonstrated high predictive accuracy for final CVAI (explaining 79.4% of the variance [R = 0.794] and a mean absolute error of 0.756) and CI (86.4% of the variance [R = 0.864] with a mean absolute error of 0.936). CONCLUSIONS: A large, retrospective cohort analysis of patients undergoing cranial molding therapy for DP and/or DB enabled development of a machine learning-based model that forecasts treatment-related changes in cranial shape during helmet therapy. Further investigation is needed to assess how this predictive tool may assist in clinical decision-making and informed parental counseling regarding cranial orthosis for DP and/or DB.
In a retrospective cohort study, we evaluated the test characteristics of C-reactive protein, alone and in combination with other inflammatory markers, for invasive bacterial infection in well-appearing, febrile infants...In a retrospective cohort study, we evaluated the test characteristics of C-reactive protein, alone and in combination with other inflammatory markers, for invasive bacterial infection in well-appearing, febrile infants aged 8-60 days. The combination of procalcitonin and C-reactive protein demonstrated a sensitivity of 91.4% (95% confidence interval: 84.7-95.8) and specificity of 76.5% (95% confidence interval: 75.3-77.6).
OBJECTIVE: To estimate the effectiveness of nirsevimab against respiratory syncytial virus (RSV)-associated acute otitis media (AOM) in ambulatory care. STUDY DESIGN: We conducted a test-negative design study, post hoc a...OBJECTIVE: To estimate the effectiveness of nirsevimab against respiratory syncytial virus (RSV)-associated acute otitis media (AOM) in ambulatory care. STUDY DESIGN: We conducted a test-negative design study, post hoc analysis using data from the prospective Oursyn study involving 37 primary care pediatricians across France from 2020 to 2025. Nasopharyngeal sampling for RSV was performed in infants younger than 1 year diagnosed with AOM during the first 2 RSV seasons with introduction of nirsevimab passive immunization (October 2023 to February 2024 and October 2024 to January 2025). The main outcome of the study was the detection of RSV status in infants with AOM. We performed a multivariable logistic regression with nirsevimab adjusted for age, sex, underlying chronic condition, prematurity, type of childcare, month, year, and geographic region of inclusion. Sensitivity analyses were performed as well. RESULTS: A total of 236 AOM events were included over the study period: 141 during the first season of nirsevimab implementation and 95 during the second season. Among infants with AOM, 41 (29.1%) and 15 (15.8%), respectively, tested positive for RSV. Nirsevimab-adjusted effectiveness was estimated to be 78.2% (95% CI 44.4-92.4) for the prevention of RSV-AOM in this sample. Sensitivity analyses found similar results. CONCLUSIONS: These findings highlight the broader protective effect of nirsevimab on complications of respiratory tract infections in infants. TRIAL REGISTRATION: NCT04743609.
This multi-institutional, natural language processing-based analysis of 273 children with neurofibromatosis 1-associated optic pathway gliomas examines the impact of ancestral background on clinical presentation and prog...This multi-institutional, natural language processing-based analysis of 273 children with neurofibromatosis 1-associated optic pathway gliomas examines the impact of ancestral background on clinical presentation and progression. We report that White children had a greater prevalence of optic pathway glioma than Black or Asian children, but clinical features and outcomes did not differ across groups.
OBJECTIVE: To describe the epidemiology of acute, non-COVID-19 myocarditis in hospitalized children and to evaluate the association of administration of intravenous immunoglobulin (IVIg) and/or steroids with hospital mor...OBJECTIVE: To describe the epidemiology of acute, non-COVID-19 myocarditis in hospitalized children and to evaluate the association of administration of intravenous immunoglobulin (IVIg) and/or steroids with hospital mortality. STUDY DESIGN: We conducted a retrospective cohort study using the Pediatric Health Information System database. Children (ages 0-18 years) coded for myocarditis from 2012 to 2022 were included. Patients missing pharmacy data or those with a diagnosis of COVID-19 were excluded. Data included demographics, complex chronic conditions, medications, and clinical course. Patients were divided into 4 treatment categories: (1) no IVIg or steroids, (2) steroids, (3) IVIg, and (4) both IVIg and steroids. RESULTS: A total of 2294 children were included. Treatment groups were (1 - none) 8% (189/2294); (2-steroids) 20% (450/2294); (3-IVIg) 25% (578/2294); and (4-IVIg and steroids) 47% (1077/2294). In-hospital mortality was 8%. The proportion of patients who received IVIg alone decreased significantly over the study period (tau = -0.527, P = .03). After adjusting for sex, race, hospital region, age at admission, length of stay, need for intensive care, presence of a complex chronic condition, and use of antiarrhythmic medication, the receipt of IVIg alone (OR 0.24, 95% CI 0.13-0.42) or the combination of IVIg and steroids (OR 0.60, 95% CI 0.42-0.87) was independently associated with decreased mortality compared with steroid use alone. These associations were also seen in a subgroup of children with acute fulminant myocarditis. CONCLUSIONS: In-hospital mortality from acute myocarditis in children remains significant. Although IVIg use has decreased over time, IVIg with or without steroids is associated with improved survival.