OBJECTIVE: To examine whether necrotizing enterocolitis (NEC) is associated with time to shunt failure (revision or infection) in infants born premature who have posthemorrhagic hydrocephalus (PHH) and cerebrospinal flui...OBJECTIVE: To examine whether necrotizing enterocolitis (NEC) is associated with time to shunt failure (revision or infection) in infants born premature who have posthemorrhagic hydrocephalus (PHH) and cerebrospinal fluid ventriculoperitoneal shunting. STUDY DESIGN: In this retrospective, case-control study using the Hydrocephalus Clinical Research Network Core Data Project registry, we identified children <6 months of age who underwent shunt placement for PHH. The outcomes were time to shunt failure, frequency of shunt failure at 6, 12, and 24 months, and reasons for failure. RESULTS: Among the 412 patients identified, 76 were diagnosed with NEC (18%). NEC was not associated with time to shunt failure (P = .353) and was not an independent predictor of shunt failure (P = .68). Similar percentages of children experienced shunt failure at 6 (P = .12), 12 (P = .26), and 24 (P = .35) months. The reasons for shunt failure did not differ between cohorts. CONCLUSIONS: Our study did not demonstrate differences in shunt survival between children <6 months of age requiring cerebrospinal fluid diversion secondary to PHH who had NEC and those who did not. Thus, peritoneal shunt placement may be suitable for children with NEC despite having abdominal interventions.
OBJECTIVE: To determine the impact of different feeding strategies in children born moderate-and-late preterm (MLPT) on later neurosensory impairment. STUDY DESIGN: Children born MLPT (32-35 weeks) recruited to the Diffe...OBJECTIVE: To determine the impact of different feeding strategies in children born moderate-and-late preterm (MLPT) on later neurosensory impairment. STUDY DESIGN: Children born MLPT (32-35 weeks) recruited to the Different Approaches to Moderate & Late Preterm Nutrition: Determinants of Feed Intolerance, Body Composition, and Development (DIAMOND) factorial randomized trial from New Zealand neonatal units were randomized to intravenous amino acids vs intravenous dextrose, exclusive maternal breastmilk vs milk supplement, and taste/smell of milk before gastric tube feeds or not. Neurosensory impairment (blindness, deafness, cerebral palsy, or developmental delay [Bayley III composite cognitive/language/motor scores <85]) was assessed at 2 years of corrected age. Outcomes were compared using generalized linear mixed models. RESULTS: Of 529 eligible children, 425 were assessed at mean (SD) 25.6 (1.9) months. Rates of neurosensory impairment were similar in amino acids vs dextrose and in milk supplement vs maternal breastmilk only groups, but impairments were less frequent in children randomized to taste/smell of milk (43/203 [21%] vs 68/220 [31%]; adjusted risk ratio 0.7; 95% CI 0.5-0.9; P = .02). This difference was primarily attributable to mild developmental delay, particularly language delay (35/199 [18%] vs 61/218 [28%]; adjusted risk ratio 0.6; 95% CI 0.4-0.9; P = .01). Growth, general health, and behavior were similar between groups. CONCLUSIONS: Early parenteral and enteral nutrition strategies in children born MLPT did not alter outcomes at 2 years. However, exposure to taste/smell of milk before gastric tube feeds was associated with a lower risk of neurosensory impairment. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12616001199404 (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371006&isReview=true).
Lee R, Wilson N, Le AD
… +11 more, Lubaczewski C, Boyce J, Resnick D, Uwazie CC, Manoranjithan S, Modi R, Smith K, Nguyen A, Schumacher H, Dooley DG, Attisha E
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) rates are higher in children than adults, for whom PEP prophylaxis with rectal indomethacin is standard of care. We analyzed the records of children...Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) rates are higher in children than adults, for whom PEP prophylaxis with rectal indomethacin is standard of care. We analyzed the records of children undergoing endoscopic retrograde cholangiopancreatographies performed during indomethacin unavailability and found the PEP rate was 11.1% when this medication was unavailable vs 3.6% when it was used (P < .001) in age- and complexity-matched groups. Rectal administration of indomethacin appears safe and effective for pediatric PEP prophylaxis.
Lee HC, Costa-Nobre D, Katheria AC
… +6 more, Mausling R, Nakwa FL, Schmölzer GM, Weiner GM, Liley HG, International Liaison Committee on Resuscitation Neonatal Life Support Task Force
OBJECTIVE: To use a natural experiment to investigate the effect of antenatal corticosteroids on the risk of cerebral palsy. STUDY DESIGN: We included singleton livebirths with a maternal admission for delivery from 31 +...OBJECTIVE: To use a natural experiment to investigate the effect of antenatal corticosteroids on the risk of cerebral palsy. STUDY DESIGN: We included singleton livebirths with a maternal admission for delivery from 31 + 0 through 36 + 6 weeks of gestation, in British Columbia, Canada, between 2000 and 2015. Guidelines recommended antenatal corticosteroids through 33 + 6 weeks, and we estimated the effect of the corresponding sharp drop in the proportion treated at 34 + 0 weeks on the risk of a composite of death before age 2 or cerebral palsy. We defined cerebral palsy using diagnostic codes in hospital and physician-billing records before age 5 years and corrected for misclassification using external estimates of the sensitivity and specificity. We used logistic regression to estimate marginal effects at 34 + 0 weeks. RESULTS: There were 20 009 children in our study sample. The crude and misclassification-corrected risks of cerebral palsy were 6.2 and 5.6 per 1000, respectively. The risk of death before age 2 or cerebral palsy declined with increasing gestational age at maternal admission for delivery, but we found no convincing evidence of an abrupt change just before vs just after 34 + 0 weeks (risk ratio: 0.98, 95% confidence interval: 0.50 to 1.98). Results were similar using a composite outcome of in-hospital newborn death or cerebral palsy, and using cerebral palsy alone. CONCLUSIONS: We did not find evidence that the lower likelihood of being treated with antenatal corticosteroid at 34 + 0 weeks affected the risk of cerebral palsy, but the estimates were imprecise and compatible with benefits or harms.
OBJECTIVE: To create a clinical model to predict presence of a high-volume, hemodynamically significant patent ductus arteriosus (PDA) in premature infants. STUDY DESIGN: A single-center retrospective cohort analysis was...OBJECTIVE: To create a clinical model to predict presence of a high-volume, hemodynamically significant patent ductus arteriosus (PDA) in premature infants. STUDY DESIGN: A single-center retrospective cohort analysis was conducted in infants < 27 weeks gestational age who received targeted neonatal echocardiography (TNE) screening for hemodynamically significant PDA. TNEs were categorized as high-volume shunt (score ≥ 9) or no PDA/low-volume shunt (score ≤ 2) using the modified Iowa PDA score. Continuous vital sign data were evaluated in 5-minute increments for the hour preceding each TNE. A Fourier transform of the arterial blood pressure waveform was used to extract features quantifying the waveform shape. Predictor variables were used to create a logistic regression model to classify each 5-minute window as high-volume PDA or no PDA/low-volume shunt. RESULTS: The model included 173 TNEs (37 high-volume shunt, 136 no PDA/low-volume shunt) from 90 patients. Mean airway pressure was higher in the high-volume shunt group (P < .01), but other variables were similar. Once the best model was identified, further training 1000 times resulted in a mean testing area under the curve of 0.8891 (95% CI 0.8858, 0.8924). CONCLUSIONS: Identification of a high-volume PDA shunt is possible with high accuracy using logistic regression modeling. Further work should focus on identification of moderate-volume shunts and correlation with clinical outcomes.
OBJECTIVE: To improve gaps in our understanding of the impact of metabolic bariatric surgery (MBS) on pediatric metabolic dysfunction-associated steatotic liver disease (MASLD) biochemical and histologic outcomes. METHOD...OBJECTIVE: To improve gaps in our understanding of the impact of metabolic bariatric surgery (MBS) on pediatric metabolic dysfunction-associated steatotic liver disease (MASLD) biochemical and histologic outcomes. METHODS: We conducted a longitudinal study to determine biochemical and histologic outcomes of MASLD in adolescents undergoing MBS. RESULTS: In total, 101 adolescents (mean age 17.5 ± 2.1 years, 68% female, 46% Hispanic, body mass index 47.1 ± 8.4 kg/m) underwent MBS. At MBS, 76% had an elevated alanine transaminase (ALT), 61% histologically confirmed MASLD, and 45% fibrosis. Patients with more severe histologic MASLD and fibrosis had greater ALT levels at MBS (P < .05). One-year post-MBS, patients had a mean body mass index decrease of 12.9 ± 7.9 kg/m. ALT levels decreased from 41 ± 38 to 27 ± 33 IU/L, with 35% still having an elevated ALT. One-year post-MBS, 23 patients had repeat liver biopsy; 50% of patients experienced histologic resolution of MASH and half resolved all fibrosis, with the remainder having mild fibrosis post-MBS (P < .001). CONCLUSIONS: The significant improvements in both biochemical and histologic MASLD observed in this study lend further credence to the utility of MBS in pediatric patients with severe obesity and MASLD.
Cohen DM, Helwig S, Poonai N
… +6 more, Mistry RD, Mintegi S, Craig S, Roland D, Shavit I, Pediatric Emergency Research Networks (PERN) PAINT Study Group
OBJECTIVE: To compare discharge strategies following successful ileocolic intussusception (ICI) reduction: inpatient hospitalization vs emergency department (ED) observation/discharge. STUDY DESIGN: This was a planned se...OBJECTIVE: To compare discharge strategies following successful ileocolic intussusception (ICI) reduction: inpatient hospitalization vs emergency department (ED) observation/discharge. STUDY DESIGN: This was a planned secondary analysis of children ages 4 months to 4 years with successful ICI from 86 pediatric centers in 14 countries between January 1, 2017 and December 31, 2019. We evaluated associations between discharge strategy for outpatient recurrent ICI (re-ICI). The primary outcome was ED return for re-ICI <48 hours and the secondary within the study period. RESULTS: We analyzed 2686 cases of ICI; 1588 (59%) admitted to hospital and 1098 (41%) discharged from ED with median (IQR) age of 18 (9, 28) months. During the study period 238 (8.9%) returned to the ED for ICI; 10.2% (112/1098) were discharged from the ED and 7.9% (126/1588) after inpatient hospitalization. Among these 238 patients, 66 (2.5%) returned <48 h most of whom had been discharged directly from the ED with a higher odds of a return visit <48 hours compared with those admitted (odds ratio [OR] = 4.27, CI = 2.50, 7.68; adjusted OR = 3.43, CI = 1.72, 7.29), and increased odds of returning within the study period (OR = 1.32, 95% CI 1.01, 1.72; adjusted OR = 1.48, 95% CI 1.03, 2.13). Upon return, the ICI re-reduction success rate was equally high in each group, ranging from 83.9% to 94.1%. CONCLUSIONS: Few children return to the ED with outpatient recurrent ICI, following successful reduction. Although the odds of return <48 hours due to re-ICI appear higher among patients discharged from the ED vs hospitalized, both groups have equally high rates of successful re-reduction. These findings suggest that clinicians should holistically weigh the risks and benefits, taking individual circumstances into account, to help reduce unnecessary hospitalizations.
OBJECTIVE: To create a simple scoring system to stratify likelihood of shunt failure in the emergency department. STUDY DESIGN: We conducted a retrospective cohort study of all children presenting to the pediatric emerge...OBJECTIVE: To create a simple scoring system to stratify likelihood of shunt failure in the emergency department. STUDY DESIGN: We conducted a retrospective cohort study of all children presenting to the pediatric emergency department with concern for ventricular shunt failure from 2017 to 2022. A separate dataset from 2022 to 2023 was used for validation. The main predictors of shunt revision were determined using univariate and multivariable regression models, and a scoring system utilizing the top predictors of ventricular shunt malfunction was created. RESULTS: There were 1167 neurosurgical consultations for shunt malfunction during the study period which resulted in 285 shunt revisions. Utilizing the 10 variables most associated with revision (increased ventricle size, abnormal shunt series, bradycardia, lethargy, altered mental status, vomiting, headache, shorter time interval from last shunt surgery, seizure, and the presence of upper respiratory symptoms), a SMaRT score was developed. For Shunt Malfunction and Revision Triage (SMaRT) score <4, we achieved a receiver-operating characteristic area under the curve of 0.87 with sensitivity of 0.93, specificity of 0.58, positive predictive value of 0.42, and negative predictive value of 0.96. This was confirmed in a separate validation set of 119 patients. A similar analysis excluding imaging data yielded a significant decrease in the discrimination of the scoring system, dropping the receiver-operating characteristic area under the curve to 0.71. CONCLUSIONS: The SMaRT score provides a data-driven tool to determine the utility of a neurosurgical consult for shunt malfunction with a high negative predictive value for shunt malfunction in its lowest tier. Use of this tool has the potential to improve triage and resource utilization in the emergency department.
Tauzin M, Tribolet S, Goro S
… +18 more, Durrmeyer X, Chevallier M, Roué JM, Milesi C, Chabernaud JL, Barois J, Chary Tardy AC, Bedu A, Zayat N, Beissel A, Bellanger C, Desenfants A, Boukhris R, Loose A, Jung C, Wang X, Berenguer D, Walter-Nicolet E
OBJECTIVE: To evaluate the implementation of the 2023 French Society of Neonatology (SFN) guidelines for premedication before laryngoscopy in neonates without life-threatening emergencies. STUDY DESIGN: A prospective, ob...OBJECTIVE: To evaluate the implementation of the 2023 French Society of Neonatology (SFN) guidelines for premedication before laryngoscopy in neonates without life-threatening emergencies. STUDY DESIGN: A prospective, observational cohort study was conducted across 141 French and Belgian neonatal units. Laryngoscopy data from intubation or less invasive surfactant administration in neonates <45 weeks postmenstrual age were collected. The primary outcome was the proportion of premedication consistent with SFN guidelines. Factors associated with guideline compliance were analyzed using multivariable mixed-effects logistic regression adjusted for neonatal and procedural characteristics. RESULTS: Six hundred seventy-three laryngoscopies were included. The mean (SD) gestational age was 30.1 (4.8) weeks. Of 506 intubations, 110 (21.7%) were immediate life-threatening emergencies. Among 396 non-life-threatening intubations, 357 (90.1%) were preceded by premedication with 169 (42.7%) consistent with SFN guidelines (propofol alone [n = 149, 37.6%]; a fast-acting opioid + muscle blocker [n = 20, 5.1%]). Independent factors associated with SFN guidelines compliance were non-emergent intubation (adjusted odds ratio 3.1 [95% CI 1.4-7.0]) and absence of hemodynamic compromise (adjusted odds ratio 31.0 [95% CI 6.4-150.3). Propofol and ketamine were the most frequent premedications before intubation, followed by opioids and/or anesthetics. Of the 167 less invasive surfactant administration procedures, 151 (90.4%) were preceded by a specific premedication including propofol (n = 84, 50.3%), consistent with SFN guidelines. CONCLUSIONS: Ninety percent of non-life-threatening laryngoscopies were preceded by a premedication but fewer than half complied with SFN guidelines. Further studies on efficacy and tolerance of neonatal anesthetics and drugs associations are needed.
OBJECTIVE: To identify the incidence and risk factors for neurodevelopmental delay in a longitudinal cohort of children with congenital diaphragmatic hernia (CDH) with and without support with extracorporeal membrane oxy...OBJECTIVE: To identify the incidence and risk factors for neurodevelopmental delay in a longitudinal cohort of children with congenital diaphragmatic hernia (CDH) with and without support with extracorporeal membrane oxygenation (ECMO). STUDY DESIGN: We prospectively followed until March 2022 those children who underwent open CDH repair between 2009 and 2018 at a single institution. Standardized assessments of cognitive, language, and motor development were conducted from 6 months to 6 years of age. Delays were defined using SD thresholds. Univariable and multivariable logistic regression analyses identified risk factors for neurodevelopmental delay. RESULTS: Of 278 patients (130 ECMO, 148 non-ECMO), 784 assessments were completed. Cognitive delays were more common in the ECMO group; language and motor outcomes were similar. Most delays were mild. Most children had no delays in any domain by 6 years of age. In multiple regression analyses, risk factors for delays varied at different timepoints. Reoperation during the first year was negatively associated with 2-4-year cognitive function (OR 3.5, 95% CI: 1.3-9.8), expressive language (OR 2.7, 95% CI: 1.0-7.2), and motor delays (OR 2.4; 95% CI: 1.1-5.1). At 4 years, motor delays were associated with antenatal fetoscopic endoluminal tracheal occlusion (OR 4.9, 95% CI: 1.2-20.1) and abdominal wall patch (OR 4.8, 95% CI: 1.7-13.9). CONCLUSIONS: Most children with CDH achieved normal neurodevelopment by school age. ECMO use was associated with early cognitive delays. Disease severity and surgical factors were associated with increased risk of delays, suggesting that meticulous surgical technique may protect neurodevelopmental outcomes. Timely support and standardized neurological follow-up may help to prevent or reduce long-term problems.
OBJECTIVES: To describe writhing General Movements Assessment (GMA) classification and General Movement Optimality Score-Revised (GMOS-R) profiles in the general population; to explore relationships between GMOS-R scores...OBJECTIVES: To describe writhing General Movements Assessment (GMA) classification and General Movement Optimality Score-Revised (GMOS-R) profiles in the general population; to explore relationships between GMOS-R scores and GMA classification, age of assessment and infant socio-demographic factors; and to establish the inter-rater reproducibility of writhing age GMA classification and GMOS-R. STUDY DESIGN: A cross-sectional study of 1861 infants recruited from the general population in Perth, Western Australia, including 7.5% born preterm. Parent-recorded videos were collected between 41- and 45-weeks post-menstural age, when writhing movements are typically observed. General movements (GMs) classification and GMOS-R were assessed independently by at least 2 experienced advanced-trained clinicians. RESULTS: The majority of infants' GMs were classified as normal (66.8%) or poor repertoire (33.2%), with one infant's movements classified as cramped synchronized (0.1%). The median GMOS-R score was 33 (interquartile range 27-36). The GMOS-R differentiated GMA classifications. Lower gestational age, any nursery admission, minority ethnicity, and older age at video collection were each associated with a small but statistically significant reduction in GMOS-R scores. GMA classification had excellent inter-rater reliability and agreement. Total GMOS-R had excellent inter-rater reliability and moderate agreement. CONCLUSIONS: Although most infants had normal GMs there was a high prevalence of poor repertoire GMs in the general population. GMOS-R scores effectively differentiated movement quality within the poor repertoire classification. This study provides population-based percentile ranks for interpreting individual post-term GM assessments and as a reference for future research.