European Journal Of Pediatrics[JOURNAL]
Sun
200 papers
Allergic diseases and atopy in elite swimmers: a cross-sectional study.
Ünal F, Uyan ZS, Öktem S … +4 more , Ersu R, Karakoç F, Dağlı ES, Karadağ B
Eur J Pediatr · 2026 May · PMID 42151687 · Publisher ↗
UNLABELLED: Environmental exposure to irritants may contribute to asthma pathogenesis through increased epithelial permeability. This study aimed to investigate the association between chlorinated swimming pool exposure...
UNLABELLED: Environmental exposure to irritants may contribute to asthma pathogenesis through increased epithelial permeability. This study aimed to investigate the association between chlorinated swimming pool exposure and allergic diseases, as well as its relationship with objective markers of airway inflammation, epithelial permeability, bronchial hyperreactivity, and atopy in elite swimmers. This cross-sectional study was conducted among pediatric swimmers attending a professional swimming club in Istanbul. All eligible participants were invited to complete the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. A subset underwent objective assessments, including exercise-induced bronchoconstriction testing, measurement of fractional exhaled nitric oxide (FeNO), serum surfactant protein-D (SP-D), serum club cell protein (CC16), and total and aeroallergen-specific immunoglobulin E (IgE) measurements. Of the 172 invited children, 169 (98%) completed the questionnaire, and 84 (49%) underwent objective assessments (44% male; mean age 10.0 ± 2.1 years). The median duration of swimming and cumulative pool attendance were 36 months and 1430 h, respectively. The prevalence of atopy was 41.6%. Among the participating swimmers, the prevalence of asthma (ever, current, and physician-diagnosed) was 25%, 9.5%, and 15.5%, respectively. Corresponding prevalences for eczema were 16.7%, 4.8%, and 7.1%, and for allergic rhinitis were 19.0%, 19.0%, and 16.7%. Cumulative exposure to chlorinated swimming pools was not associated with allergic diseases, airway inflammation, epithelial permeability, or bronchial hyperreactivity. However, children who had been swimming for more than 72 months demonstrated higher rates of atopy and current allergic symptoms. CONCLUSION: In this cohort of elite swimmers, cumulative exposure to chlorinated swimming pools was not associated with allergic diseases or objective markers of airway inflammation. However, given the cross-sectional design, these findings should be interpreted with caution. The observed association between longer swimming duration and atopy appears to be exploratory. Overall, chlorinated pool exposure alone may be unlikely to be a major determinant of allergic disease in this population. WHAT IS KNOWN: • Chlorinated pool exposure has been proposed to contribute to asthma and allergic diseases through airway epithelial injury; however, findings in pediatric populations are inconsistent, and many studies rely primarily on questionnaire-based data without objective airway assessments. WHAT IS NEW: • In this cohort of elite swimmers, cumulative pool exposure was not associated with allergic diseases or objective markers of airway inflammation and epithelial integrity. However, longer swimming duration was associated with increased atopy, and subgroup analyses suggested that early-life exposure in combination with tobacco smoke may influence airway inflammation.
Early laboratory indicators of acute metabolic decompensation during emergency presentations in pediatric maple syrup urine disease.
Oral-Cebeci S, Aktuğlu-Zeybek Ç, Aslan B … +4 more , Uysal ÖY, Cansever MŞ, Kıykım E, Zubarioglu T
Eur J Pediatr · 2026 May · PMID 42151652 · Full text
UNLABELLED: Acute metabolic decompensation (AMD) is the most life-threatening complication of maple syrup urine disease (MSUD). Recognizing AMD early in the emergency department (ED) is difficult because the most importa...
UNLABELLED: Acute metabolic decompensation (AMD) is the most life-threatening complication of maple syrup urine disease (MSUD). Recognizing AMD early in the emergency department (ED) is difficult because the most important clinical indicators-neurological manifestations-typically appear late during decompensation, and plasma leucine measurements are frequently delayed. This study aimed to identify laboratory biomarkers that can be obtained quickly and support early AMD detection at ED. This retrospective study included MSUD patients aged 28 days-18 years admitted to a tertiary pediatric ED between 2016 and 2025. Acute neurological deterioration, reduced oral intake, or vomiting with ketosis or plasma leucine levels ≥ 600 µmol/L were defined as AMD. Presenting complaints, duration of hospitalization, treatment modalities, and laboratory investigations were recorded and compared between ED visits with AMD and non-AMD. Among 25 patients, 269 ED visits were analyzed; 79 (29.4%) met AMD criteria. AMD visits were associated with worse clinical outcomes, including higher rates of pediatric intensive care admissions (22% vs. 2.6%) and increased hemodialysis requirements (19% vs. 1.6%). Hyponatremia (p = 0.005) and hyperuricemia (p < 0.001) were more prevalent during AMD. Acid-base parameters did not significantly discriminate AMD. Among primary laboratory tests, only serum uric acid was a clinically meaningful predictor (AUC 0.786). A cutoff value of 4.65 mg/dL for uric acid was identified to predict AMD. CONCLUSION: Serum uric acid is a reliable and clinically practical early predictor of AMD. This readily available marker may enable earlier risk stratification and intervention when leucine results are delayed, potentially improving outcomes in pediatric MSUD. WHAT IS KNOWN: • Acute metabolic decompensation (AMD) in pediatric maple syrup urine disease (MSUD) can rapidly lead to encephalopathy, cerebral edema, and permanent neurologic injury. • Early emergency presentations are clinically nonspecific, and plasma leucine-the diagnostic gold standard-is often not available in real time. WHAT IS NEW: • A cutoff value of 4.65 mg/dL for uric acid was identified to predict AMD. • Respiratory symptoms and fever were significantly more frequent in non-AMD visits, suggesting that infectious symptoms alone do not necessarily indicate metabolic instability in MSUD patients.
Development and validation of an explainable machine learning model for predicting surgical intervention in pediatric intestinal obstruction.
Tang Z, Fu Y, Zhou J … +2 more , Lu D, Kang Q
Eur J Pediatr · 2026 May · PMID 42151627 · Publisher ↗
Pediatric intestinal obstruction, a critical acute abdomen condition, carries a risk of intestinal necrosis. Decisions for urgent surgery lack standardized criteria. This study aimed to develop an explainable machine lea...
Pediatric intestinal obstruction, a critical acute abdomen condition, carries a risk of intestinal necrosis. Decisions for urgent surgery lack standardized criteria. This study aimed to develop an explainable machine learning (ML) model to predict surgical indication, reducing diagnostic variability. A retrospective study included 642 children from our center (split into training/internal validation sets) and 137 from two external centers. Surgical indication was defined based on the presence of one or more of the following: evidence of peritonitis on physical examination, radiographic signs of strangulation, or failure of conservative management for > 24 h; in cases of diagnostic uncertainty, consensus among three senior physicians was used as the adjudication standard. We built models using 35 easily obtainable features across eleven algorithms and evaluated performance via AUC and other metrics. SHapley Additive exPlanations (SHAP) provided model interpretability, and an optimal probability threshold was established for clinical stratification. At the optimal threshold determined by maximizing the Youden index, the model achieved a sensitivity of 89% and a specificity of 99% in the internal validation set. The random forest model demonstrated the highest discriminative performance. A streamlined, interpretable model using the eight most important features (including vital sign dynamics and clinical markers) showed no evidence of overfitting based on the close agreement between training and validation performance metrics. It achieved AUCs of 0.988 (internal validation) and 0.981 (external validation). The model has been translated into a convenient clinical tool.Conclusion: Our explainable ML model demonstrates strong discriminative performance in predicting the need for surgery in pediatric intestinal obstruction and is strongly associated with intestinal necrosis. By mitigating the "black-box" concern through SHAP, it offers transparent, interpretable decision support to clinicians.
Development of a modular neonatal neurological examination: from a short screening test to a detailed assessment of specific aspects of neurological function.
Mercuri E, Ricci D, Cowan FM … +2 more , Haataja LM, Romeo DM
Eur J Pediatr · 2026 May · PMID 42151620 · Full text
UNLABELLED: The neurological examination of the newborn is often perceived as difficult. This paper describes the development of a modular approach, based on the Hammersmith Neonatal Neurological Examination, including a...
UNLABELLED: The neurological examination of the newborn is often perceived as difficult. This paper describes the development of a modular approach, based on the Hammersmith Neonatal Neurological Examination, including a short proforma for routine use, the standard examination and two add-on modules. We report details of the single modules with description of their use in different scenarios. CONCLUSIONS: The modular approach provides a number of options for performing an appropriate level of clinical neurological examinations in all newborns accommodating different needs in clinical and research settings. WHAT IS KNOWN: • Neonatal neurological examinations are often not performed as perceived as difficult. • Detailed examinations are a burden in routine clinical practice and not always needed. WHAT IS NEW: • A modular approach, including a short examination, can be used in clinical routine. • The additional modules, when needed, can help in differential diagnosis.
The effect of virtual reality glasses used during inhaler treatment on anxiety, fear and vital signs in children: a randomized controlled trial.
Güvener YÖ, Kara ŞŞ
Eur J Pediatr · 2026 May · PMID 42151606 · Full text
UNLABELLED: This study aimed to determine the effect of virtual reality (VR) glasses used during inhaler treatment on anxiety, fear and vital signs in children. The study had an experimental, randomized controlled design...
UNLABELLED: This study aimed to determine the effect of virtual reality (VR) glasses used during inhaler treatment on anxiety, fear and vital signs in children. The study had an experimental, randomized controlled design. Participants were assigned to groups using a lottery method based on simple randomization. The random sequence was generated by physically mixing up 30 red (experimental) and 30 white (control) cards. All the data were collected and finalized by two trained researchers (Yasemin Özyer Güvener, a nurse researcher, and Şeyma Şimşirgil Kara, a pediatrician). Participants were recruited using a convenience sampling method from among individuals who met the inclusion criteria. In terms of baseline measurements, the experimental group had significantly higher mean pulse rate, fear scores, and anxiety scores (130.23 ± 14.64, 2.77 ± 1.25, and 4.60 ± 2.04, respectively) compared to the control group (118.83 ± 17.10, 2.07 ± 1.26, and 2.80 ± 2.07, respectively) (p = 0.007, p = 0.035, and p = 0.001, respectively). For post-intervention measurements, the experimental group had significantly lower mean fear and anxiety scores (0.443 ± 0.16 and 0.703 ± 0.22, respectively) compared to the control group (2.39 ± 0.16 and 3.197 ± 0.22, respectively) (p < 0.001 and p = 0.001, respectively). CONCLUSION: It was determined that VR glasses reduced anxiety and fear, increased oxygen saturation, and reduced respiratory and pulse rates. They can thus be used as an alternative method to reduce fear and anxiety levels and balance vital signs during inhalation therapy in children. WHAT IS KNOWN: • Virtual reality (VR) is an effective non-pharmacological method for reducing pain, anxiety, and fear in pediatric patients during various medical procedures. • VR applications create a sense of presence in a virtual world, limiting the impact of anxiety and fear in clinical settings. WHAT IS NEW: • Using VR glasses during the administration of inhaled medication significantly reduces anxiety and fear levels in children compared to traditional methods. • While evidence for VR use during inhalation therapy was previously limited, this study demonstrates its effectiveness as a promising alternative to improve treatment compliance and physiological responses in pediatric patients.
Acromelic dysplasias: similarities and differences in clinical and molecular findings in 12 Turkish patients.
Güneş N, Türk S, Onur H … +6 more , Gür K, Yüksel Elgin C, Çifçi Sunamak E, Uludağ Alkaya D, Eroğlu AG, Tüysüz B
Eur J Pediatr · 2026 May · PMID 42151490 · Full text
UNLABELLED: The purpose of this study is to compare the natural history of clinical and radiologic features in patients with acromelic dysplasias. Twelve patients from nine families with genetically confirmed dysplasia t...
UNLABELLED: The purpose of this study is to compare the natural history of clinical and radiologic features in patients with acromelic dysplasias. Twelve patients from nine families with genetically confirmed dysplasia types with acromelia were included in the study, and eight of them were followed-up for a median of 8.1 years. Monoallelic disease-causing variants were identified in FBN1 (acromicric dysplasia, n = 3) and GNAS (Albright hereditary osteodystrophy (AHO), n = 1). Biallelic disease-causing variants in ADAMTSL2 (geleophysic dysplasia type 1, n = 4), ADAMTS10 (Weill-Marchesani syndrome type 1 (WMS1), n = 3), and ADAMTS17 (Weill-Marchesani syndrome type 4 (WMS4), n = 1) were identified. Five novel variants were detected. Short stature was present in all patients. In all patients with geleophysic dysplasia, height normalized during follow-up, and in two, initial acromelia and broad phalanges on hand radiographs resolved over time. Pseudomuscular build, joint limitations, tiptoe walking, and delayed bone age were common findings in geleophysic dysplasia, while patients with WMS1 also had pseudomuscular build, joint limitations, and delayed bone age. Acromicric dysplasia showed mild joint limitation. Intellectual disability was observed only in the WMS4 patient. Spherophakia was specific to patients with WMS. Heterotopic ossification was present in the AHO patient. CONCLUSION: These findings underscore the clinical and genetic heterogeneity of acromelic dysplasias and emphasize that integrated clinical and molecular evaluation is essential for accurate classification and follow-up. WHAT IS KNOWN: • Acromelic dysplasias are rare connective tissue disorders characterized by short stature, brachydactyly, and joint stiffness, caused by variants in genes involved in extracellular matrix organization and TGF-β- related signaling. WHAT IS NEW: • Five novel variants in ADAMTSL2, ADAMTS10, and ADAMTS17 expand the molecular spectrum of acromelic phenotypes. • Tiptoe walking, in association with early findings including short stature, acromelia, and broad proximal phalanges on radiographs, may suggest ADAMTSL2-related geleophysic dysplasia.
Evidence of the role of Midkine and Pleiotrophin in the pathogenesis of Familial Mediterranean Fever.
Abdallah ZY, Eldeen GN, Sokkar MF … +5 more , Abdelkawy RFM, Lotfy RS, Hussein SH, Hamed K, El-Bassyouni HT
Eur J Pediatr · 2026 May · PMID 42149205 · Full text
Familial Mediterranean Fever (FMF) is a chronic autoinflammatory illness that follows a pattern of periodic attacks; however, the majority of cases experience ongoing subclinical inflammation during the attack-free perio...
Familial Mediterranean Fever (FMF) is a chronic autoinflammatory illness that follows a pattern of periodic attacks; however, the majority of cases experience ongoing subclinical inflammation during the attack-free periods that could lead to the development of anemia, splenomegaly, heart disease, and the major complication, amyloidosis. Midkine/Pleiotrophin (MDK/PTN) are heparin-binding cytokines, with upregulated expression in various inflammatory and malignant diseases. Thus, the present research aims to identify the role of MDK and PTN in the pathogenesis of chronic inflammation and to explore the potential of both cytokines as new markers of subclinical inflammation in FMF. Blood samples from 30 FMF patients and 30 controls were collected to assess gene expression and protein levels of MDK and PTN by qRT-PCR and ELISA, respectively. Statistical correlation between different parameters and bioinformatic analysis to link the MEFV gene to the relevant genes was also performed. The expression of MDK and PTN genes was significantly higher in FMF children than in healthy subjects. Additionally, the serum level of MDK showed a fourfold increase in patients compared to controls (p < 0.001). The levels of PTN were also higher in cases, but without reaching the significance level (p = 0.096). MDK gene expression was inversely related to ESR level and positively correlated to serum level of MDK and anemia occurrence. Conclusion: Collectively, our results disclosed that Midkine could be identified as a useful clinical tool in diagnosing and managing systemic and subclinical inflammation in FMF cases, while Pleiotrophin might provide additional information on acute inflammatory processes.
Accidental arterial PICC placement in neonatal patients: a case series.
Douch C, Duffy D, Shetty S … +2 more , Richards J, Kulkarni A
Eur J Pediatr · 2026 May · PMID 42149194 · Publisher ↗
UNLABELLED: There is a paucity of literature relating to accidental arterial peripherally inserted central catheter (PICC) placement in neonatal patients. We present a series of nine cases from a single centre. A databas...
UNLABELLED: There is a paucity of literature relating to accidental arterial peripherally inserted central catheter (PICC) placement in neonatal patients. We present a series of nine cases from a single centre. A database of point-of-care ultrasound (POCUS) assessments of PICC lines was recorded at a single tertiary neonatal intensive care unit over a 5-year period (2020-25). This database was reviewed and cases of arterial PICC line placement were identified. Of 265 POCUS assessments, intra-arterial PICC placement was identified in 3% (n = 9). High-risk insertion sites include the area posterior to the medial malleolus (n = 3, 33%) and the median cubital fossa (n = 3, 33%). A third of cases (n = 3, 33%) developed no complications. Complications included oozing from the site (n = 3, 33%), high pressure on infusion pumps (n = 2, 22%) and digital ischaemia (n = 3, 33%). All cases of ischemia occurred in lower limb PICCs and the majority (n = 2, 66%) in the contralateral limb to the insertion site, leading to a delay in identification of the arterial placement by 5 to 17 days. CONCLUSION: This series supports the use of routine immediate POCUS for all neonatal PICC lines and consideration of real-time ultrasound-guided PICC placement. Warning signs of intra-arterial placement include abnormal line trajectory on radiographs, insertion site oozing, high pump pressures and limb ischaemia (including contralateral limb involvement). Particularly high-risk neonates include those with congenital diaphragmatic hernia whereby mediastinal shift renders radiographic confirmation of PICC position unreliable. WHAT IS KNOWN: • Neonatal PICC position is usually confirmed by radiography, and accidental arterial cannulation (AAC) is considered rare. WHAT IS NEW: • AAC occurred more frequently than previously reported and was often not detected clinically or on radiographs. • Point-of-care ultrasound improved identification of AAC and may improve neonatal PICC safety.
Clinical impact of toxin detection in children with PCR-confirmed Clostridioides difficile infection.
Demirci B, Vergili GNC, Aydın F … +8 more , Gülhan B, Yücel SP, Erat T, Yahşi A, Özen S, Bayhan Gİ, Özkaya-Parlakay A, Kanık-Yüksek S
Eur J Pediatr · 2026 May · PMID 42144455 · Publisher ↗
UNLABELLED: The diagnosis of Clostridioides difficile infection (CDI) in children is challenging due to high rates of asymptomatic colonization and the limited ability of available assays to differentiate colonization fr...
UNLABELLED: The diagnosis of Clostridioides difficile infection (CDI) in children is challenging due to high rates of asymptomatic colonization and the limited ability of available assays to differentiate colonization from true infection. The relative utility of polymerase chain reaction (PCR) versus stool toxin A/B detection by enzyme immunoassay (EIA) remains uncertain in pediatric practice. This study aimed to evaluate whether stool toxin A/B detection adds incremental clinical value among children with gastrointestinal multiplex PCR positivity for C. difficile toxin genes (tcdA/tcdB) by comparing risk factors, treatment decisions, and outcomes according to toxin status. This retrospective observational study included 103 pediatric patients (< 18 years) with PCR positive for C. difficile toxin genes (tcdA/tcdB) results at a tertiary children's hospital between October 2022 and April 2025. Patients were categorized into three groups: stool toxin A/B not evaluated, stool toxin A/B negative, and stool toxin A/B positive. Demographics, risk factors, clinical characteristics, laboratory findings, treatment decisions, and outcomes were compared across stool toxin A/B groups. Of the 103 patients, 26 (25.2%) had no stool toxin A/B, 63 (61.2%) were stool toxin A/B negative, and 14 (13.6%) were stool toxin A/B positive. More than half of the cohort (54.3%) received CDI treatment, with no significant difference in treatment initiation rates among stool toxin A/B groups. The risk factors-including underlying disease (e.g., malignancies, inflammatory bowel disease, and immunodeficiencies), recent hospitalization, antibiotic exposure, and proton pump inhibitor (PPI) or enteral tube use-were similarly distributed. Clinical severity, laboratory parameters, imaging findings, recurrence, complications (1.0%), ICU admission (4.9%), and mortality (3.9%) did not differ significantly between stool toxin A/B positive and negative patients. Although a statistically significant difference in diarrhea severity was observed across groups, this was driven by the toxin-not-evaluated group. Importantly, stool toxin A/B positivity did not correlate with clinical severity, underlying risk factors, laboratory abnormalities, or outcomes. CONCLUSION: In this pediatric cohort, stool toxin A/B detection did not provide additional clinical value beyond PCR positivity for C. difficile toxin genes (tcdA/tcdB). PCR alone, when interpreted in the context of compatible symptoms and epidemiological risk factors, may be sufficient to guide treatment decisions for suspected pediatric CDI. Given the limited incremental value of stool toxin A/B testing, optimized diagnostic algorithms and further multicenter pediatric studies are warranted. WHAT IS KNOWN: • Pediatric CDI diagnosis is complicated by high asymptomatic colonization; PCR for C. difficile toxin genes (tcdA/tcdB) is sensitive but cannot distinguish colonization from infection. • Stool toxin A/B EIAs are more specific but less sensitive, and guidelines often recommend multistep algorithms. WHAT IS NEW: • In our cohort of pediatric patients with PCR positivity for C. difficile toxin genes (tcdA/tcdB), stool toxin A/B status was not associated with clinical severity, risk factors, laboratory findings, outcomes, or treatment initiation. • When clinical features are compatible, PCR positivity for C. difficile toxin genes (tcdA/tcdB) alone may be sufficient to guide treatment, with limited incremental value of stool toxin A/B testing.
Phenotypic and genotypic analysis of pediatric patients with congenital isolated growth hormone deficiency resulting from biallelic variants in the GHRHR gene: a Belgian registry study.
Van de Velde S, Boros E, Brunelle C … +6 more , Beckers D, Thomas M, Heinrichs C, Vlaeminck J, De Schepper J, Brachet C
Eur J Pediatr · 2026 May · PMID 42143199 · Publisher ↗
UNLABELLED: Pathogenic variants in the growth hormone releasing hormone receptor (GHRHR) gene cause severe isolated growth hormone deficiency (IGHD). Over 82 distinct variants have been described, mostly in South and Eas...
UNLABELLED: Pathogenic variants in the growth hormone releasing hormone receptor (GHRHR) gene cause severe isolated growth hormone deficiency (IGHD). Over 82 distinct variants have been described, mostly in South and East Asia and Northern Brazil. This study characterizes the phenotypic and genotypic variability of children harboring (likely) pathogenic GHRHR variants, included in the Belgian and Luxembourg Registry for Growth Hormone Treated Children. We retrospectively reviewed clinical, biochemical, genetic and neuroimaging data from seven children with severe IGHD carrying biallelic GHRHR variants. Peak growth hormone (GH) concentrations were measured following insulin and glucagon-induced hypoglycemia. Auxological parameters at diagnosis and pituitary magnetic resonance imaging (MRI) findings were obtained from medical records. Three children of Syrian origin from two consanguineous families carried a novel likely pathogenic c.367G > T, p.(Glu123*) variant in a homozygous state. Among the four Belgian-origin patients, one was homozygous for a pathogenic c.674_677delinsGCTGTTGGCAGAAG, p.(Val225Gly*fs165) variant, while two siblings were compound heterozygous including this particular variant and an additional pathogenic c.271dupG, p.(Ala91Glyfs*13) frameshift variant. The other Belgian patient was compound heterozygous for the well described likely pathogenic c.431 T > A, p.(Leu144His) variant and a previously undescribed c.150C > A, p.(Asn50Lys) variant. IGHD was diagnosed between 7 months and 7 years. Height SDS at presentation ranged from - 4.6 to - 3.4. Peak GH levels after stimulation were markedly reduced (0.35-3.4 ng/ml), confirming severe growth hormone deficiency (GHD). No dysmorphic features were observed. Anterior pituitary hypoplasia at MRI was seen in six patients. CONCLUSION: This series expands the geographic spectrum of biallelic GHRHR variants causing severe IGHD. Targeted GHRHR genotyping should be considered in children with early-onset severe IGHD, particularly when anterior pituitary hypoplasia is present and dysmorphic features are absent. WHAT IS KNOWN: • Biallelic GHRHR variants cause severe congenital IGHD with early onset growth failure and markedly reduced GH/IGF-1 (Insulin-like growth factor 1) levels. WHAT IS NEW: • This first Belgian registry series broadens the phenotypic and genotypic spectrum of biallelic GHRHR variants. • Identification of a novel likely pathogenic homozygous c.367G > T, p.(Glu123*) variant in two unrelated Syrian families, suggesting a potential founder effect in the Syrian population, as this variant has not been reported elsewhere.
Prevalence of common respiratory viruses of infants with respiratory tract infections in European countries in the past decade: a systematic review and meta-analysis comparing between the pre-COVID-19, pandemic, and post-COVID-19 periods.
Mapindra MP, Mahindra MP, McNamara P … +4 more , Kartasasmita C, Semple MG, Clark H, Madsen J
Eur J Pediatr · 2026 May · PMID 42142180 · Full text
UNLABELLED: The purpose of this study is. to determine the leading cause of respiratory tract infections over the decade; this review examined the proportions of airway viruses in infants with respiratory tract infection...
UNLABELLED: The purpose of this study is. to determine the leading cause of respiratory tract infections over the decade; this review examined the proportions of airway viruses in infants with respiratory tract infections in Europe before, during, and after the COVID-19 pandemic. The protocol for this systematic review was registered in the PROSPERO database (CRD42024497097). Literature searches in PubMed, Embase, Scopus, and Web of Science (WoS) identified 20,453 studies reporting respiratory viral testing in Europe over the past decade (2012/13-2022/23). Eligible studies were English-language full-text or grey articles with low risk of bias and complete data, and reports that explicitly provided the number of positive airway virus cases (n, virus) and the total infant population (N). Risk of bias was assessed using the Hoy et al. scoring system. Pooled prevalence estimates (pooled proportion [95% CI]) were calculated for pre-, during-, and post-COVID-19 periods using proportional meta-analysis with the MetaProp package in R. Fifty studies before, ten studies during, and 18 studies after the COVID-19 pandemic were eligible for proportional meta-analyses of viral testing in infants. Before the pandemic, the predominant viruses in infants with respiratory infections were Respiratory Syncytial Virus (RSV) (0.48 [0.41-0.56]), Human rhinovirus (HRV) (0.24 [0.18-0.29]), and Influenza virus (IV) (0.08 [0.04-0.12]). Post-pandemic, the leading viruses were RSV (0.63 [0.51-0.75]), HRV (0.25 [0.11-0.40]), and IV (0.10 [0.00-0.20]) again. CONCLUSIONS: RSV and HRV remained the two most identified viruses in infants with respiratory infections, pre- and post-COVID-19 pandemic. Interestingly, both RSV and IV were suppressed during the pandemic. The trajectory dynamics of respiratory viruses were divergent, with resilient viruses (RSV, HRV, and IV) regaining dominance more rapidly than persistently suppressed viruses. WHAT IS KNOWN: • The COVID-19 pandemic induced an infection precautions policy, which reduced the spread of respiratory infectious diseases. • Respiratory Syncytial Virus (RSV) was estimated as one of the most common causes of respiratory infections in infants. Still, there are no reports summarising the geographical distributions of the various viral agents of infant respiratory diseases. WHAT IS NEW: • This meta-analysis shows that the prevalence of RSV and HRV infections in infants remains high in Europe following the COVID-19 pandemic and the associated precautionary policy. Furthermore, RSV proportionally experienced a marked reduction during COVID-19 pandemic (lockdown periods). However, the immunological debt may have led to a re-emergence in RSV positivity after the lockdown periods. • Our proportional meta-analysis indicates the heterogeneous post-pandemic recovery patterns of each respiratory virus commonly identified in infants, where HRV was shown to be resilient whilst RSV was rapidly rebound.
Excessive sedentary behaviour during hospitalisations among children and adolescents: a prospective observational study.
Winther L, Stahlhut M, Curtis DJ … +9 more , Hellum ME, Aaserud KN, Pedersen SV, Christensen J, Kristensen MT, Hjuler T, Frandsen TL, Sørensen JL, Dall CH
Eur J Pediatr · 2026 May · PMID 42142120 · Full text
UNLABELLED: The purpose of this study is to objectively quantify physical activity and sedentary behaviour in children and adolescents during hospital admission using device-based monitoring and investigate the associati...
UNLABELLED: The purpose of this study is to objectively quantify physical activity and sedentary behaviour in children and adolescents during hospital admission using device-based monitoring and investigate the association between sedentary behaviour and pain, constipation, surgery status, movement restrictions, 30-day readmission, and length of stay. Children and adolescents aged 2 ≤ 17 years admitted between March and September 2025 to three paediatric departments at a Danish hospital were eligible for this prospective observational study. Children and adolescents scheduled for day surgery and wheelchair users were excluded. All participants wore two triaxial accelerometers throughout their hospital stay. In total, 103 hospitalised children and adolescents were included. The participants spent 45 min per day (interquartile range 20-125) in upright position (standing and walking time combined) and were sedentary (sitting and lying time combined) for 23.3 h per day (21.8-23.7). Adolescents undergoing spine surgery were sedentary for 23.6 h per day (23.5-23.7), of which 22.6 h (21.8-23.0) were spent lying in bed. Sedentary behaviour was significantly associated with higher age (p < 0.001), opioid consumption beyond standardised analgesia (p = 0.028), and orthopaedic procedures (p < 0.001). No associations between sedentary behaviour and length of stay (p = 0.391), 30-day readmission (p = 0.467), laxative use (p = 0.695), and postoperative movement restrictions (p = 0.637) were found. CONCLUSION: Hospitalised children and adolescents in this study exhibited high levels of sedentary behaviour. The findings highlight that mobilisation strategies are needed across all paediatric surgical procedures, but adolescents, patients undergoing orthopaedic or spine procedures, and those prescribed opioids beyond standardised analgesia require particular attention. There is a need for further evidence of the consequences of sedentary behaviour during hospitalisation among children and adolescents. WHAT IS KNOWN: • Prolonged sedentary behaviour is associated with adverse health outcomes in healthy children and adolescents and in hospitalised adults. • Accelerometery provides objective, validated measurements of physical activity and sedentary behaviour in children and adolescents, with advantages over self-report methods. WHAT IS NEW: • These findings highlight low levels of physical activity (767 steps/day) and high levels of sedentary behaviour (23.3 h/day) among hospitalised children and adolescents. • These patterns remain consistent across surgical procedures and age categories.
Medication self-management during the developmental transition of responsibility among Chinese adolescent liver transplant recipients: a qualitative descriptive study.
Liu F, Chen C, Guo H … +2 more , Yan X, Yi Q
Eur J Pediatr · 2026 May · PMID 42141293 · Publisher ↗
Adolescence is a high-risk period for non-adherence to immunosuppressive therapy after pediatric liver transplantation, especially as medication responsibility shifts from parent-led routines toward increasing adolescent...
Adolescence is a high-risk period for non-adherence to immunosuppressive therapy after pediatric liver transplantation, especially as medication responsibility shifts from parent-led routines toward increasing adolescent participation. However, limited evidence explains how adolescents manage medication demands in daily life within school, family, and peer contexts. We conducted a single-center qualitative descriptive study in a tertiary pediatric liver transplant clinic in Southwest China. Using purposive sampling, we recruited adolescents aged 13-17 years who were at least 1 year post-transplant and remained in pediatric follow-up at the time of interview (N = 12). None had transferred to adult services. Semi-structured one-to-one interviews were conducted between July and August 2025, audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis. Analytic depth was supported through reflexive memoing, post-interview debriefing, preliminary coding during recruitment, dialogic discussion within the research team, and an audit trail. Four interrelated tensions shaped medication self-management during the developmental transition of responsibility: (1) regimen requirements versus school-day routines; (2) growing expectations for autonomy versus uneven readiness for self-management; (3) family and school support that was both enabling and conflict-provoking; and (4) a desire for empowerment and peer normalcy in the context of stigma and limited youth-oriented resources. Participants described overlapping self-management patterns rather than fixed types. In two accounts, episodes of repeated compromise, treatment fatigue, or reduced engagement suggested ongoing vulnerability in particular contexts. Conclusions: Medication non-adherence in adolescence may be shaped by contextual constraints as well as knowledge or motivation. Support should extend beyond standardized education to include individualized medication planning, staged autonomy-building within pediatric follow-up, practical school-day planning, and discreet youth-centered adherence strategies that better fit adolescents' daily lives.
Leveraging artificial intelligence to predict non-adherence to pediatric immunization schedules: a systematic review.
Rey R, L'Huillier AG, Pittet LF
Eur J Pediatr · 2026 May · PMID 42141249 · Publisher ↗
UNLABELLED: Immunization is one of the most effective interventions to prevent infectious diseases. Identifying individuals at risk of non-adherence to immunization schedules could enable early interventions to improve c...
UNLABELLED: Immunization is one of the most effective interventions to prevent infectious diseases. Identifying individuals at risk of non-adherence to immunization schedules could enable early interventions to improve coverage. With the increasing availability of large datasets with sociodemographic, medical, and geographic data, artificial intelligence (AI) offers new possibilities for identifying predictive patterns. We performed a systematic literature review of original studies that used AI to predict immunization non-adherence in children. Searches were conducted in PubMed, Embase, and Web of Science and no restrictions were applied regarding publication year, language, or study design. Study characteristics, dataset size, AI methods, performance metrics, and validation approaches were extracted. Risk of bias was assessed using PROBAST + AI. A total of 843 records were identified; after screening, 12 studies were included. Nine of 12 studies were conducted in low- and middle-income countries, used cross-sectional survey data, and analyzed vaccines from routine immunization schedules. Model performance was generally high; 9/12 studies reported an accuracy or an area under the receiver operating characteristic curve exceeding 80%, but no study conducted external validation. Predictors clustered into seven categories: maternal, paternal, family, child, geographic, wealth, and others. Among maternal and child-related factors, prenatal care and previous immunization history had a high predictive weight. CONCLUSION: AI demonstrates a promising potential for identifying individuals at risk of vaccine non-adherence. However, the lack of external validation raises concerns about model overfitting and limits real-world applicability. Demographic health surveys were routinely repeated across countries and time periods and could therefore represent an ideal resource for external validation. WHAT IS KNOWN: • Geographic, sociodemographic, and medical factors contribute to non-adherence to the immunization schedule. • Identifying these individuals can guide early interventions to improve immunization coverage. WHAT IS NEW: • Artificial intelligence can reveal unknown influential factors; prenatal care and delivery setting emerged as key factors in this systematic review.
Paediatric septic thrombophlebitis secondary to an otogenic infection: a single-centre retrospective case series.
Nobacht A, Loeffen YGT, Smit AL
Eur J Pediatr · 2026 May · PMID 42141231 · Full text
UNLABELLED: Paediatric septic thrombophlebitis secondary to head and neck infections is a rare but life-threatening disease. Although commonly associated with oropharyngeal infections, otogenic cases have also been descr...
UNLABELLED: Paediatric septic thrombophlebitis secondary to head and neck infections is a rare but life-threatening disease. Although commonly associated with oropharyngeal infections, otogenic cases have also been described, yet paediatric literature on their disease course and thrombotic distribution remains sparse. To describe the clinical presentation, thrombotic distribution, management, and outcomes of paediatric septic thrombophlebitis secondary to primary otogenic infections. We conducted a retrospective case series of children aged 0-18 years admitted to a tertiary paediatric referral centre between 2016 and 2021 with septic thrombophlebitis following an otogenic infection. Clinical, microbiological, radiological, and treatment data were extracted from records. Ten patients (median age 4.5 years, 70% male) were included. Most cases presented with primary acute otitis media and mastoiditis. Fusobacterium necrophorum was detected in 50% of cases. Internal jugular vein thrombosis occurred in 80%, sigmoid sinus thrombosis in 60%, and cavernous sinus thrombosis in 30%. All patients received systemic antibiotics and anticoagulant therapy for medians of 42.5 and 46 days, respectively. Surgery, mainly otogenic interventions, such as mastoidectomy, was performed in 90% of patients. Complications other than thrombosis occurred in 70% of cases and encompassed both intra- and extracranial manifestations. Thrombosis resolved or recanalized in 78% of cases on follow-up imaging. CONCLUSION: This case series adds to the limited literature on paediatric septic thrombophlebitis secondary to otogenic infections, highlighting a high rate of internal jugular vein thrombosis and a complicated disease course. WHAT IS KNOWN: • Paediatric thrombophlebitis secondary to an otogenic infections is a rare but life-threatening disease. • These otogenic presentations can be a diagnostic challenge, while carrying a signifi cant risk of severe intracranial or systemic complications. WHAT IS NEW: • This paediatric case-series describes the complicated disease course of septic thrombophlebitis following primary otogenic infections, demonstrating heterogeneity in clinical presentations and thrombotic distributions.
Attitudes toward the use of complementary and alternative medicine in children with gastrointestinal symptoms, a multicenter survey study among parents and pediatricians.
Bloem MN, Baaleman DF, Koppen IJN … +7 more , Bijlsma MW, Vlieger AM, Goede J, Plötz FB, Teklenburg-Roord STA, de Lorijn F, Benninga MA
Eur J Pediatr · 2026 May · PMID 42141218 · Full text
UNLABELLED: Disorders of gut-brain interaction (DGBI) are common in children and often persist despite conventional treatments, leading families to seek complementary and alternative medicine (CAM). However, evidence for...
UNLABELLED: Disorders of gut-brain interaction (DGBI) are common in children and often persist despite conventional treatments, leading families to seek complementary and alternative medicine (CAM). However, evidence for CAM in pediatric DGBI is scarce. This multicenter survey study assessed parents' and pediatricians' experiences with and attitudes toward CAM for children with gastrointestinal symptoms. Parents and pediatricians of children (0-18 years) with gastroesophageal reflux disease (GERD) and DGBI (infant colic (IC), functional abdominal pain, and functional constipation) from six Dutch hospitals were included. GERD diagnosis was based on international guidelines, DGBI on Rome IV criteria. Parental surveys addressed child health, medication, (reasons for) CAM use, and attitudes toward CAM research. Pediatricians' surveys covered experiences and attitudes toward CAM for pediatric DGBI. A total of 677 parents (71%) and 76 pediatricians (79%) responded. Most patients had functional constipation (45%) or abdominal pain (41%), with 8% IC and 6% GERD. Seventy-one percent had symptoms for over a year; 58% used medication, and 49% reported side effects. Overall, 42% of patients used CAM, mainly manual therapies, homeopathy, and natural remedies. Predictors of CAM use included IC, longer symptom duration, higher household income, and positive parental CAM experience. Among pediatricians, 53% recommended CAM. Pediatricians with over 15 years' experience were less likely to recommend CAM. Sixty-five percent of parents were willing to participate in CAM research. CONCLUSION: CAM use is common among children with DGBI or GERD, and over half of pediatricians have recommended CAM, underscoring the need for efficacy studies of frequently used CAM. WHAT IS KNOWN: • Complementary and alternative medicine (CAM) is commonly used among pediatric patients with gastrointestinal symptoms but often excluded in evidence-based guidelines due to insufficient evidence. • Previous research has examined perspectives of patients and families, with limited insight into pediatricians' recommendations. WHAT IS NEW: • In Dutch hospitals, 42% of children with infant colic, reflux, abdominal pain, or constipation used CAM. Most pediatricians (52.6%) recommended some CAM to these patients. • Predictors for CAM use include infant colic, longer symptom duration, positive parental CAM experience, and higher income; pediatricians with > 15 years' experience were less likely to recommend CAM. Parental interest in CAM research is high (65%).
Tuberculosis infection in BCG vaccinated children and adolescents with rheumatological diseases treated by tumor necrosis factor-α inhibitors.
Ademhan Tural D, Doğru D, Özsezen B … +12 more , Karaman A, Sunman B, Nayir Büyükşahin H, Güzelkaş İ, Alboğa D, Erdal MA, Emiralioğlu Ordukaya N, Bilginer Y, Yalçın E, Özçelik U, Özen S, Kiper N
Eur J Pediatr · 2026 May · PMID 42141213 · Full text
UNLABELLED: Tumor necrosis factor-alpha (TNF-α) inhibitors increase the risk of developing active tuberculosis (TB) disease through reactivation of latent TB infection (LTBI). We aimed to analyze TB infections in BCG-vac...
UNLABELLED: Tumor necrosis factor-alpha (TNF-α) inhibitors increase the risk of developing active tuberculosis (TB) disease through reactivation of latent TB infection (LTBI). We aimed to analyze TB infections in BCG-vaccinated children and adolescents with rheumatologic diseases treated with TNF-α inhibitors in a country of moderate risk for TB. This retrospective study included 261 children with a rheumatic disease who were treated with TNF-α inhibitors and followed up on a fixed schedule between January 2018 and December 2022. Demographic and clinical characteristics, as well as TB screening results, were recorded. The mean age of the patients was 14.0 ± 4.1 years; 56.7% were female. The mean age at initiation of TNF-α inhibitors was 11.0 ± 5.1 years, the mean duration of TNF-α inhibitor use was 4.1 ± 2.7 years, and the mean follow-up time was 4.1 ± 2.6 years. During the study period, 75 (29.0%) patients were diagnosed with LTBI: 44% at the initial evaluation and 56% during follow-up. None of them progressed to TB disease. Only two cases of active TB disease were seen without prior documented LTBI. Age and duration of TNF-α inhibitor use were significantly associated with LTBI positivity. CONCLUSION: TB screening is necessary in children and adolescents at the initiation of and during TNF-α inhibitor therapy. The risk of LTBI positivity increases with age and longer use of TNF-α inhibitors. No cases progressed from LTBI to active TB, which may support the effectiveness of current screening and prophylaxis strategies in our country. WHAT IS KNOWN: • TNF-α inhibitors are associated with an increased risk of developing active tuberculosis (TB) disease as a result of the reactivation of latent TB infection (LTBI). WHAT IS NEW: • Screening for LTBI at initiation and during TNF-α inhibitor treatment, along with appropriate LTBI prophylaxis, prevented LTBI reactivation into active TB disease in BCG-vaccinated patients receiving TNF-α inhibitors. • Increasing age and duration of TNF-α inhibitor treatment are associated with the risk of LTBI positivity.
Vitamin D deficiency in newly diagnosed childhood-onset systemic lupus erythematosus: prevalence and clinical associations.
Ratanaphisit T, Sukharomana M, Piyaphanee N … +2 more , Tangcheewinsirikul S, Charuvanij S
Eur J Pediatr · 2026 May · PMID 42141164 · Full text
UNLABELLED: This study aimed to determine the prevalence of vitamin D deficiency and identify its associated factors in patients with newly diagnosed childhood-onset systemic lupus erythematosus (c-SLE). This retrospecti...
UNLABELLED: This study aimed to determine the prevalence of vitamin D deficiency and identify its associated factors in patients with newly diagnosed childhood-onset systemic lupus erythematosus (c-SLE). This retrospective study included patients with c-SLE aged ≤ 18 years treated at an academic tertiary center between January 2013 and December 2023. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25-OHD) level < 20 ng/mL. A total of 192 patients with c-SLE were included (87% female; mean [SD] age, 12.1 [3.0] years). Lupus nephritis (LN) was identified in 92 patients (48.2%). The median serum 25-OHD level was 15 ng/mL (IQR, 11.2-22.8), and vitamin D deficiency was identified in 126 patients (65.6%). Compared to those without vitamin D deficiency, deficient patients were older and had higher body mass index, more frequent LN, and higher urine protein-to-creatinine ratio (UPCR; P < 0.05). These patients also had lower estimated glomerular filtration rate and serum complement 3 levels (P < 0.05). Serum 25-OHD levels were negatively correlated with UPCR (ρ = - 0.38, P < 0.001). On multivariable logistic regression, increased UPCR was independently associated with vitamin D deficiency (adjusted odds ratio, 1.54; 95% CI, 1.15-2.24; P = 0.011). Patients with moderate (SLEDAI-2 K, 7-12) and high disease activity (SLEDAI-2 K ≥ 13) had a higher prevalence of vitamin D deficiency (P = 0.002 and P < 0.001, respectively). CONCLUSION: Vitamin D deficiency was prevalent in newly diagnosed c-SLE and was associated with LN, proteinuria, and moderate to high disease activity. WHAT IS KNOWN: • Childhood-onset systemic lupus erythematosus (c-SLE) is a complex autoimmune connective tissue disease in which vitamin D has been implicated in immune dysregulation. WHAT IS NEW: • Vitamin D deficiency was identified in 65.6% of newly diagnosed Southeast Asian c-SLE. • c-SLE patients with LN had a higher prevalence of vitamin D deficiency than those without LN, particularly those with proteinuria.
Idiopathic recurrent pericarditis in children: a tertiary care cohort highlighting the emergence and effectiveness of interleukin-1 blockade.
Gunalp A, Akay N, Kirali M … +12 more , Torunoglu Z, Aslan E, Gul U, Konte EK, Senturk NGK, Yildiz M, Haslak F, Adrovic A, Sahin S, Barut K, Dedeoglu R, Kasapcopur O
Eur J Pediatr · 2026 May · PMID 42141100 · Full text
UNLABELLED: Idiopathic recurrent pericarditis (IRP) is an increasingly recognized inflammatory condition in children, characterized by recurrent flares and therapeutic challenges, with emerging evidence supporting a role...
UNLABELLED: Idiopathic recurrent pericarditis (IRP) is an increasingly recognized inflammatory condition in children, characterized by recurrent flares and therapeutic challenges, with emerging evidence supporting a role for interleukin-1 (IL-1)-mediated pathways. This study aimed to characterize the clinical features of a pediatric IRP cohort at our center, to examine clinically relevant differences between patients requiring and not requiring anakinra, and to evaluate anakinra effectiveness by assessing changes in disease activity before and after treatment. In this single-center retrospective cohort study, 26 children with IRP were evaluated in terms of demographic, clinical, laboratory, genetic, and treatment characteristics. Patients were stratified according to anakinra requirement, and these characteristics were compared between groups. In patients receiving anakinra, treatment effectiveness was assessed by comparing disease activity before and after therapy using annualized attack rate (AAR) and inflammatory markers. The cohort showed a male predominance (19/26, 73%), with a median age at diagnosis of 114 months (IQR, 48-168). Chest pain was the most common presenting symptom (16/26, 62%). Pericardial effusion was present in all patients (26/26, 100%), while pleural effusion was observed in 12/26 (46%). Despite conventional therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids, steroid dependency developed in 9/22 patients (41%). Anakinra was required in 16 patients (62%) and was associated with a marked reduction in disease activity, with a median relative decrease in AAR of 89.4% (IQR, 56.7-100%); a ≥ 50% reduction in AAR was achieved in 12/16 patients (75%). Significant and concordant reductions in inflammatory markers were observed. Relapse frequently occurred during anakinra dose spacing or discontinuation, while corticosteroid withdrawal was achieved in most treated patients. Patients requiring anakinra had higher baseline disease activity. CONCLUSION: Idiopathic recurrent pericarditis in children represents a heterogeneous and frequently relapsing inflammatory condition in which conventional therapies often fail to achieve sustained disease control. As an IL-1 blockade, anakinra emerges as a key therapeutic option, enabling corticosteroid sparing while effectively achieving disease control through targeting underlying innate immunity pathways. WHAT IS KNOWN: • Idiopathic recurrent pericarditis (IRP) in children is characterized by recurrent inflammatory flares and frequent treatment resistance, with conventional therapies (NSAIDs, colchicine, and corticosteroids) often being insufficient and associated with steroid dependency. • Increasing evidence implicates autoinflammatory pathways in disease pathogenesis, highlighting the potential role of IL-1 inhibition in refractory cases. WHAT IS NEW: • The high prevalence of MEFV-associated variants, frequent steroid dependency, and substantial use of IL-1 inhibitors collectively support an auto inflammatory-driven disease model in pediatric IRP. • Anakinra markedly reduces disease activity even in patients with high baseline inflammatory burden; however, sustained disease control requires continuous therapy, as dose spacing is associated with increased relapse rates.
Association of compliance-normalized airway and transpulmonary mechanical power with mortality in PARDS.
Soydan E, Demirel O, Yay ED … +7 more , Atakul G, Topal S, Colak M, Sarac O, Karaarslan U, Agin H, Ceylan G
Eur J Pediatr · 2026 May · PMID 42133083 · Publisher ↗
UNLABELLED: The prognostic significance of mechanical power (MP) and the optimal normalization strategy in pediatric acute respiratory distress syndrome (PARDS) remains uncertain. We evaluated the association between air...
UNLABELLED: The prognostic significance of mechanical power (MP) and the optimal normalization strategy in pediatric acute respiratory distress syndrome (PARDS) remains uncertain. We evaluated the association between airway and transpulmonary mechanical power normalized using different strategies and 28-day mortality in children with PARDS. In this multicenter retrospective observational study, 128 invasively ventilated subjects with PARDS were included from four tertiary pediatric intensive care units between June 2020 and December 2025. Airway MP and transpulmonary mechanical power (MPL) were calculated during pressure-controlled ventilation and normalized to predicted body weight (PBW), body surface area (BSA), and static respiratory system compliance (Cstat). The primary outcome was 28-day mortality. Associations were examined using multivariable logistic regression adjusted for age, sex, ARDS severity (PALICC-2), and Pediatric Index of Mortality-3 (PIM-3). Discriminative performance was assessed using receiver operating characteristic analysis with DeLong comparisons, and optimal thresholds were identified using the Youden index. The 28-day mortality rate was 20.3%. Absolute airway MP was not associated with mortality. In adjusted analyses, only compliance-normalized airway MP (MP/Cstat) was associated with mortality (adjusted OR 6.8, 95% CI 1.0-44.8; p = 0.044). Compliance-normalized transpulmonary MP (MPL/Cstat) was also associated with mortality (adjusted OR 30.6, 95% CI 1.5-615.7; p = 0.03). PBW- and BSA-normalized indices were not significant. Compliance-normalized indices showed numerically higher AUC values (MP/Cstat 0.68; MPL/Cstat 0.70), although the differences were not significant by DeLong testing. Mortality increased stepwise across MP/Cstat tertiles (p for trend = 0.01). Among MP components, only the compliance-normalized elastic component was significantly associated with mortality. CONCLUSIONS: Mechanical power, normalized to static respiratory system compliance rather than anthropometric parameters, was associated with mortality and showed a graded dose-response relationship in PARDS. Compliance-based normalization may provide additional physiological insight into mechanical power assessment in PARDS. WHAT IS KNOWN: • Mechanical power integrates multiple ventilatory variables and has been associated with outcomes in adult ARDS. • Different normalization approaches, including anthropometric and physiologic methods, have been proposed to account for variability in body size and lung mechanics. The clinical relevance of these normalization strategies in PARDS remains uncertain. WHAT IS NEW: • In a multicenter cohort of subjects with PARDS, mechanical power normalized to static respiratory system compliance was independently associated with 28-day mortality for both airway and transpulmonary measurements. In contrast, normalization to predicted body weight or body surface area was not independently associated with mortality after adjustment. • Mortality increased progressively across tertiles of compliance-normalized airway mechanical power. Among mechanical power components, only the compliance-normalized elastic component was independently associated with mortality.
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