OBJECTIVE: To compare Functional Disability Inventory (FDI) between adolescents with chronic orthostatic intolerance (COI) and postural orthostatic tachycardia syndrome (POTS). STUDY DESIGN: This cross-sectional study in...OBJECTIVE: To compare Functional Disability Inventory (FDI) between adolescents with chronic orthostatic intolerance (COI) and postural orthostatic tachycardia syndrome (POTS). STUDY DESIGN: This cross-sectional study included adolescents ≤19 years with orthostatic symptoms >3 months referred to a tertiary pediatric autonomic clinic (August 2024-March 2025) and classified as POTS or COI based upon active stand testing. Self- and parent-reported FDI scores were collected. Group comparisons used chi-square and Wilcoxon-Mann-Whitney tests. Univariable and multivariable linear regression models compared FDI scores, adjusting for age, sex, and body mass index. Adjusted means were estimated using post-fit marginal estimation. RESULTS: Ninety-two adolescents were included (46 POTS, 46 COI). Groups were similar in age, sex, and body mass index, but differed in heart rate response by definition. Self-reported FDI scores did not differ between COI and POTS in unadjusted (22.9 vs 22.4; P = .81) or adjusted analyses (adjusted mean difference 1.0, 95% CI -3.0 to 4.9; P = .63). Parent-reported FDI scores were also comparable in unadjusted (23.1 vs 22.3; P = .70) and adjusted analyses (adjusted mean difference 0.4, 95% CI -3.4 to 4.2; P = .85). Differences were well below the prespecified threshold for clinical significance. CONCLUSION: There was no evidence for a difference in functional disability in adolescents with COI, regardless of tachycardia-based POTS classification. This suggests that heart rate response is not associated with functional differences in pediatric orthostatic intolerance.
OBJECTIVE: To develop models within pediatric telemedicine that identify potentially "sick" cases for additional safety checks and integrate those models into electronic clinical decision support tools. STUDY DESIGN: We...OBJECTIVE: To develop models within pediatric telemedicine that identify potentially "sick" cases for additional safety checks and integrate those models into electronic clinical decision support tools. STUDY DESIGN: We conducted a secondary analysis of paired virtual and in-person examinations across 3 consecutive implementation studies conducted at a telemedicine and medication delivery service in Haiti. Artificial intelligence/machine learning (XGBoost) was applied to derive models focused on identifying "sick" patients (moderate or severe) and those requiring escalation. Given the limited sample size, we used an ensemble method based on gradient boosted decision trees. The area under the receiver operating characteristic curve (AUC) was the primary outcome measure. RESULTS: A total of 683 paired records were available for this secondary analysis from 2225 participants enrolled. The median age was 15 months and 47% were female. For prediction of a "sick" child, we found an AUC of 0.82 (95% confidence interval [CI]: 0.78-0.86) after 5-fold cross-validation; calibration slope and intercept were 1.09 (95% CI: 0.91-1.26) and 0.16 (95% CI: 0.03-0.35), respectively. For prediction of escalation, we found an AUC of 0.77 (95% CI: 0.73-0.81); calibration slope and intercept were 0.81 (95% CI: 0.66-0.96) and 0.08 (95% CI: 0.11-0.26), respectively. CONCLUSIONS: These methods and findings offer an innovative and important proof-of-concept for how to aid clinical decision-making within pediatric telemedicine environments. The models require external validation prior to electronic clinical decision support integration and deployment. Once validated, the models will provide a critical safety check for experienced providers and digitally convey expertise to new providers.
OBJECTIVE: To assess whether the timing of ischemic stroke onset demonstrates circadian variability in children. STUDY DESIGN: We performed a retrospective cohort study evaluating children with arterial ischemic stroke a...OBJECTIVE: To assess whether the timing of ischemic stroke onset demonstrates circadian variability in children. STUDY DESIGN: We performed a retrospective cohort study evaluating children with arterial ischemic stroke and known time of stroke onset who were enrolled in a large, multicenter pediatric stroke registry. Clinical and radiographic features were compared according to 4 time epochs-6:00-11:59 (morning), 12:00-17:59 (afternoon), 18:00-23:59 (evening), and 00:00-5:59 (night)-using Kruskal-Wallis and chi-square tests. Pairwise comparisons were conducted when needed. RESULTS: A total of 478 patients were included, with 54% male and a mean age of 9.9 ± SD 5.7 years. We observed a rise in stroke frequency in the morning that plateaued around 10:00, with a sustained high frequency into the early afternoon; most strokes occurred in the afternoon (n = 185, 38.7%), followed by the morning (n = 156, 32.6%). Arteriopathy risk factors were more prevalent in nighttime strokes (23/36, P = .034). Patients in the <2, 2-5, and 6-11-year-old age groups had a higher proportion of strokes in the afternoon (42%, 38%, and 45%, respectively). There was a trend for better median 6-month pediatric stroke outcome measure scores after evening strokes (0.5, IQR 0-1.5) compared with morning strokes (1, IQR 0.5-2) and afternoon strokes (1, IQR 0.5-3), P = .033, but this was not statistically significant after adjustment for multiple comparisons. CONCLUSIONS: Circadian influence on stroke timing appears to differ between adults and children. These findings could influence stroke systems of care and treatment strategies for pediatric stroke.
OBJECTIVE: To produce objective predictions of neurodevelopmental outcomes after perinatal hypoxic-ischemic insult for the full spectrum of severity of hypoxic-ischemic encephalopathy (HIE) using a machine learning model...OBJECTIVE: To produce objective predictions of neurodevelopmental outcomes after perinatal hypoxic-ischemic insult for the full spectrum of severity of hypoxic-ischemic encephalopathy (HIE) using a machine learning model incorporating only magnetic resonance imaging (MRI)-based radiomic measures. STUDY DESIGN: This was a retrospective cohort study of infants born between January 2018 and January 2022 who experienced HIE. Neonates with a gestational age of ≥35 weeks and a diagnosis of neonatal encephalopathy were treated with therapeutic hypothermia, after which post-rewarming brain MRIs were acquired. At 18 months of age, developmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development. The MRI data were preprocessed, and radiomic measures were extracted from labels covering the entire brain. The radiomic measures together with the outcome measures were provided to an elastic-net penalized linear regression model to predict the outcomes within a 10-fold cross-validation framework. RESULTS: A total of 167 neonates were included. Across cognitive, language, and motor domains, the mean correlation between the predicted outcomes and the observed outcomes was 0.94, and the mean predictive R-square was 0.87. CONCLUSIONS: A machine learning model using only MRI-based radiomic measures from infants with HIE can reliably predict their 18-month developmental outcomes with high accuracy across motor, cognitive, and language domains, regardless of the severity of their brain injury. In addition, our approach allowed us to produce atlases of the brain regions responsible for the developmental impairments, which may prove useful in the search for novel interventions.
OBJECTIVE: To investigate whether slower reaction time (RT) was associated with higher concussion odds among middle school female soccer players. STUDY DESIGN: We performed a retrospective cohort study, analyzing pre-par...OBJECTIVE: To investigate whether slower reaction time (RT) was associated with higher concussion odds among middle school female soccer players. STUDY DESIGN: We performed a retrospective cohort study, analyzing pre-participation computerized neurocognitive data (Immediate Postconcussion and Cognitive Testing) for 10-14-year-old female soccer players. We compared composite RT scores between those who did/did not sustain a concussion during the following year using Welch's t-test. We used binary logistic regression to determine the association between RT and subsequent concussion, adjusting for covariates. RESULTS: A cohort of 2489 female soccer players were included (mean age = 13.2 ± 1.0 years; 12% with prior concussion). Of these, 226 (9.1%) athletes sustained a concussion. On univariable analysis, those who sustained a subsequent concussion demonstrated faster RT than those who did not (633.8 ± 87.2 vs 649.3 ± 90.1 milliseconds; Cohen's d = 0.17). After covariate adjustment, slower RT was associated with lower subsequent concussion odds (OR = 0.997, 95% CI: 0.996-0.999). Prior concussion was significantly associated with subsequent concussion (OR = 2.48, 95% CI: 1.73-3.52). CONCLUSIONS: Contrary to our hypothesis, slower pre-participation RT was associated with lower odds of subsequent concussion, with a 3% decrease in concussion odds for every 10-millisecond RT increase. Prior concussion was the strongest predictor of subsequent concussion, consistent with past work.
OBJECTIVE: To study the impact of a combined intervention using Buzzy plus simultaneous distraction (playing video games on a tablet) on the incidence of postvaccination presyncope and syncope. STUDY DESIGN: We performed...OBJECTIVE: To study the impact of a combined intervention using Buzzy plus simultaneous distraction (playing video games on a tablet) on the incidence of postvaccination presyncope and syncope. STUDY DESIGN: We performed a randomized-controlled trial of a combined intervention designed to reduce presyncope, which is more common than syncope, and has served as a surrogate for syncope in previous studies. Adolescents 10-14 years-old receiving ≥1 intramuscular vaccine were randomized 1:1 to a combined intervention group including Buzzy (vibration/cool pack device to reduce injection site pain) and a video game (distraction) or a standard of care control group. The primary outcome was the efficacy of the combined intervention to decrease presyncope. Secondary outcomes included changes in prevaccination and postvaccination state anxiety; postvaccination pain; and participant acceptability of the intervention. RESULTS: We enrolled 332 adolescents and included all in the modified intention to treat group. Presyncope was lower in the intervention group (36%) compared with the control group (48%, P = .02). Pain at 1-3 minutes was also decreased in the intervention group compared with the standard of care group with mean postvaccine Wong-Baker Faces Pain Scores of 3.3 vs 2.5 (P = .006), respectively. CONCLUSIONS: We identified an acceptable clinic-based intervention that reduces presyncope in young adolescents receiving routine vaccines. This efficacy was likely driven by decreases in postvaccination pain. TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT04772755.
OBJECTIVES: To evaluate the incidence, pathogens, clinical characteristics, and outcomes of neonatal sepsis at a single, level IV, neonatal intensive care unit from 2014 to 2024, and compare results with historical, inst...OBJECTIVES: To evaluate the incidence, pathogens, clinical characteristics, and outcomes of neonatal sepsis at a single, level IV, neonatal intensive care unit from 2014 to 2024, and compare results with historical, institutional data. STUDY DESIGN: A retrospective cohort study was undertaken of infants with a documented bloodstream infection from 2014 to 2024. Episodes were documented prospectively, and data were collected retrospectively and assessed via univariate and multiregression analyses. Data were compared between epochs 1 (2004-2013) and 2 (2014-2024) and trends since 1928 analyzed. RESULTS: In total, 250 episodes of sepsis occurred in 233 infants from 2014 to 2024. Early-onset sepsis (EOS) attributed to gram-negative organisms increased in epoch 2, as did identification of historically uncommon organisms associated with EOS. Escherichia coli(E coli)-related EOS increased between epochs in neonates born late preterm and term (13%-36%; 173% increase) and in very low birth weight infants (58%-64%; 10% increase). Although a lower rate of late-onset sepsis (LOS) was observed in epoch 2, mean gestational age was lower and disease severity greater. Forty percent of LOS episodes were attributed to gram-negative bacteria, with an increase noted from 32% of episodes (2014-2019) to 50% (2020-2024). LOS-related mortality increased in epoch 2 (11%-25%; 127% increase), with overall sepsis-related mortality increasing steadily over 3 decades. Predictors of sepsis-related mortality included lower birth weight, need for pressors, concurrent necrotizing enterocolitis, and thrombocytopenia. CONCLUSIONS: Pathogen distribution for EOS and LOS revealed a sustained increase in gram-negative organisms, predominantly E coli. This trend coupled with decreasing gestational age and increasing baseline illness severity likely contributed to increased sepsis-related mortality.
OBJECTIVE: To examine the effects of PlayReadVIP, a pediatric primary care intervention promoting early relational health, on child behaviors. STUDY DESIGN: A factorial randomized controlled trial enrolled mother-child d...OBJECTIVE: To examine the effects of PlayReadVIP, a pediatric primary care intervention promoting early relational health, on child behaviors. STUDY DESIGN: A factorial randomized controlled trial enrolled mother-child dyads postpartum. PlayReadVIP was delivered in 2 phases: birth to 3 years (PlayReadVIP 0-3) and 3-5 years (PlayReadVIP 3-5). At enrollment, dyads were assigned to PlayReadVIP 0-3 or control. At age 3, dyads were rerandomized to PlayReadVIP 3-5 or control. Analyses included dyads with a second randomization and complete data on the mediators and child outcomes. In PlayReadVIP, dyads attended one-on-one sessions with a parent coach, in which they received child development information, learning materials, and real-time, strengths-based feedback on brief video recordings of parent-child interactions. Cognitive stimulation and harsh discipline were reported by mothers. Child behaviors were assessed using the Behavior Assessment System for Children, Second Edition. RESULTS: A total of 143 dyads, primarily immigrant, Latino/Hispanic, and low-socioeconomic status, comprised the analytic sample. Mothers in PlayReadVIP vs control had higher cognitive stimulation at 54 months, which resulted in reduced problem behaviors (aggression and attention problems) and better social skills in their children in second grade. No significant indirect effects through harsh discipline were found. CONCLUSIONS: PlayReadVIP leads to sustained but small improvements in child behaviors by enhancing maternal cognitive stimulation, emphasizing the potential of early intervention in pediatric primary care for promoting child mental health in disadvantaged populations.
OBJECTIVE: To investigate whether large language models (LLMs) can assist with maternal and neonatal health care in low- and middle-income countries. STUDY DESIGN: We evaluated the ability of GPT-4o to generate accurate...OBJECTIVE: To investigate whether large language models (LLMs) can assist with maternal and neonatal health care in low- and middle-income countries. STUDY DESIGN: We evaluated the ability of GPT-4o to generate accurate answers across countries in 4 domains related to maternal and neonatal health: (1) prevalence of conditions when generating medical case examples; (2) prevalence of conditions in countries without reliable national prevalence data; (3) standardized medical examination questions; and (4) subjective health-related questions. We used the GPT-4o Application Programming Interface except for domain 2, for which we used ChatGPT, and used repeated prompts to guarantee statistical significance of answers. We utilized publicly available data from 6 WHO regions and 204 countries. RESULTS: We observed challenges for LLMs to provide accurate answers on a global scale. Medical cases generated by GPT-4o did not reflect true prevalences of outcomes, over-representing the Americas. GPT-4o demonstrated explicit bias, giving lower rankings for subjective health-related topics to countries with high infant mortality rates. In 44% of cases, GPT-4o provided pregnancy-related statistics in regions where those statistics were not available, while not acknowledging the uncertainty, and nearly half (46.7%) of the source citations were erroneous. GPT-4o answered the majority (79%) of pregnancy-related medical examination questions correctly but made errors when answering based on prevalent health issues in specific regions while overlooking symptoms. CONCLUSIONS: Identified challenges in using GPT-4o highlight important limitations in applying general-purpose LLMs to guide maternal and neonatal healthcare in low- and middle-income countries. These findings can guide further studies and solutions in fine-tuning LLMs on contextualized data.
OBJECTIVE: To compare the overall safety, efficacy, and resource utilization of ultra-low-dose computed tomography (ULDCT) with multiview chest x-ray (CXR) in children presenting with suspected foreign body aspiration (F...OBJECTIVE: To compare the overall safety, efficacy, and resource utilization of ultra-low-dose computed tomography (ULDCT) with multiview chest x-ray (CXR) in children presenting with suspected foreign body aspiration (FBA). STUDY DESIGN: A single-center, retrospective chart review was conducted for patients ≤17 years of age with concern for FBA and presenting between January 1, 2018, and July 31, 2024. Computed tomography (CT) studies were categorized as standard, low, and ultra-low dose, based on reported CT dose index volume. Measures of diagnostic performance, estimated effective doses, and total variable costs per patient encounter were compared between imaging modalities. RESULTS: Three hundred thirty patients were evaluated for FBA with CXR only (n = 171), CT only (n = 47), or both modalities (n = 112). One hundred thirty-two patients underwent bronchoscopy with 107 foreign bodies discovered. Negative bronchoscopy rates ranged from 11% (n = 1) in patients evaluated with CT only to 21% (n = 18) in patients evaluated with CXR only. Seven patients evaluated with CXR only were later found to have missed airway foreign bodies. The sensitivity and specificity of ULDCT for tracheobronchial foreign bodies were 100%, respectively. Sensitivity and specificity were 74% and 83% for two-view CXR and 82% and 67% for four-view CXR. Mean effective dose of ULDCT was 0.18 mSv higher than four-view CXR (P < .001). Median total variable costs were similar among patients initially evaluated with CXR and CT (P = .21). CONCLUSIONS: Reduced-dose CT showed greater sensitivity and specificity than CXR to diagnose FBA and can be delivered without a clinically significant increase in radiation exposure or hospital expenditure.
OBJECTIVES: To evaluate whether preterm birth is associated with impaired airway and parenchymal lung function and whether early physiological phenotypes change or are sustained during follow-up during infancy. STUDY DES...OBJECTIVES: To evaluate whether preterm birth is associated with impaired airway and parenchymal lung function and whether early physiological phenotypes change or are sustained during follow-up during infancy. STUDY DESIGN: We included125 infants born preterm who underwent forced expiratory flow at 75% (FEF), expired forced vital capacity, lung diffusion (D), and alveolar volume measured longitudinally after discharge from the neonatal intensive care unit. RESULTS: The average gestational age of the cohort was 31 weeks (range, 25-36), 52% were female, and 36% were diagnosed with bronchopulmonary dysplasia. Length and lung function were evaluated at mean corrected ages of 5.4 and 13.6 months, visit 1 and visit 2, respectively. Significant increases occurred in body length (11.82 cm), FEF (94.3 mL/s), forced vital capacity (149 mL), D (147 mL/min/mm Hg), and alveolar volume (254 mL) (P < .01 for each parameter). When quantified by z-scores based on full-term infants, the Δz-length increased significantly (P < .01); however, there were significant decreases in Δz-FEF and Δz-D (P < .01). Lower FEF and D values at visit 1 were associated with lower values at visit 2, but were not associated with gestational age or bronchopulmonary dysplasia. CONCLUSIONS: After preterm birth, absolute values for lung function increased during infancy; however, when expressed as z-scores, values were persistently impaired and became more negative relative to full-term infants. Airway and parenchymal function may be established early after preterm birth and may contribute to impaired trajectories or dysanapsis later in life.
This reflective essay tells of the dramatic story of the discovery of nonconvulsive status epilepticus in a previously-healthy 11 year old girl who presented to our children's hospital with confusion and personality chan...This reflective essay tells of the dramatic story of the discovery of nonconvulsive status epilepticus in a previously-healthy 11 year old girl who presented to our children's hospital with confusion and personality changes. The piece also attempts to capture the striking divide between the emotion present in the room when she was given medications to abort the seizures and returned to normal and the sterile description of the encounter that lives on in the electronic medical record.
Jaekel J, Wolke D, Esser G
… +9 more, Woodward LJ, Spittle A, Cheong J, van Baar AL, Verhoeven M, Gueron-Sela N, Atzaba-Poria N, Anderson PJ, Treyvaud K
OBJECTIVES: To assess variations in children's cognitive and language test scores according to observed dyadic maternal sensitivity and the child's gestational age, after adjustment for known confounders. STUDY DESIGN: S...OBJECTIVES: To assess variations in children's cognitive and language test scores according to observed dyadic maternal sensitivity and the child's gestational age, after adjustment for known confounders. STUDY DESIGN: Systematic review and a one-stage individual participant data meta-analysis of harmonized data from 7 birth cohorts across 5 countries (n = 2560) using mixed effects linear regression. Maternal sensitivity and child cognition and language test scores were z-standardized relative to contemporary cohort-specific term-born controls. Models were adjusted for child sex, multiple birth, small for gestational age, age at outcome assessment, mother's education, mother's age at the child's birth, single mother status, and child neurodevelopmental impairment. RESULTS: Maternal sensitivity was associated with subsequently assessed cognition (0.20; 95% CI, 0.14-0.26; P < .001) and language (0.15; 95% CI, 0.08-0.22; P < .001). A significant interaction between gestational age and sensitivity on cognition (-0.01; 95% CI, -0.02 to -0.01; P = .001) was observed; the association between sensitive parenting and later cognition was stronger among children born at younger gestational ages. Sensitivity analyses adjusting for children's neurodevelopment impairments produced similar findings. CONCLUSIONS: High maternal sensitivity is a potential protective factor for cognitive and language functioning for children born preterm, especially among those born at earlier gestational ages.