Journals

Pediatrics

Pediatrics

PEDIATRICS current issue


  • Cardiometabolic Risk Factors at 5 Years After Omega-3 Fatty Acid Supplementation in Infancy
    BACKGROUND:
    Omega-3 long-chain polyunsaturated fatty acid (n-3 LCPUFA) supplementation during infancy may reduce adult cardiovascular risk as observed in animals. We assessed the effect of n-3 LCPUFA supplementation in infancy on growth, body composition, and cardiometabolic risk factors at 5 years of age.
    METHODS:
    Infants were randomly assigned to a daily supplement of n-3 LCPUFA or olive oil (control) from birth to 6 months (n = 420). Measurements included weight, length, cord blood adipokines at birth and anthropometry, skinfolds, blood pressure, heart rate, fasting blood adipokines, and biochemistry at 5 years.
    RESULTS:
    The infants who received n-3 LCPUFA had a smaller waist circumference at 5 years (coefficient: 1.1 cm; 95% confidence interval [CI]: 0.01 to 2.14), which remained significant after adjustments for confounders (coefficient: 0.8 cm; 95% CI: 0.19 to 1.30). Five-year-old boys who received n-3 LCPUFA supplementation as infants had a 21% reduction in insulin concentrations (ratio: 0.79; 95% CI: 0.66 to 0.94) and a 22% reduction in insulin resistance (ratio: 0.78; 95% CI: 0.64 to 0.95) compared with the control group. There were no other differences in growth and cardiometabolic risk factors between the groups for the whole cohort at birth, 2.5, or 5 years.
    CONCLUSIONS:
    Supplementation with n-3 LCPUFA in infancy revealed a reduction in waist circumference at 5 years. Boys in the n-3 LCPUFA group showed reduced insulin concentrations and insulin resistance at 5 years, which may have beneficial outcomes for later health. No effects were seen in girls. Longer term follow-up of the cohort is warranted to determine whether these differences are maintained into adolescence.


  • Comparison of Collaborative Versus Single-Site Quality Improvement to Reduce NICU Length of Stay
    BACKGROUND:
    There is unexplained variation in length of stay (LOS) across NICUs, suggesting that there may be practices that can optimize LOS.
    METHODS:
    Three groups of NICUs in the California Perinatal Quality Care Collaborative were followed: (1) collaborative centers participating in an 18-month collaborative quality improvement project to optimize LOS for preterm infants; (2) individual centers aiming to optimize LOS; and (3) nonparticipants. Our aim in the collaborative project was to decrease postmenstrual age (PMA) at discharge for infants born between 27 + 0 and


  • Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative
    BACKGROUND AND OBJECTIVES:
    Acute pharyngitis is a common diagnosis in ambulatory pediatrics. The Infectious Diseases Society of America (IDSA) clinical practice guideline for group A streptococcal (GAS) pharyngitis recommends strict criteria for GAS testing to avoid misdiagnosis and unnecessary treatment of children who are colonized with group A Streptococcus. We sought to improve adherence to the IDSA guideline for testing and treatment of GAS pharyngitis in a large community pediatrics practice.
    METHODS:
    The Model for Improvement was used, and iterative Plan-Do-Study-Act cycles were completed. The quality improvement project was approved for American Board of Pediatrics Part 4 Maintenance of Certification credit. Interventions included provider education, modification of existing office procedure, communication strategies, and patient and family education. Outcomes were assessed by using statistical process control charts.
    RESULTS:
    An absolute reduction in unnecessary GAS testing of 23.5% (from 64% to 40.5%) was observed during the project. Presence of viral symptoms was the primary reason for unnecessary testing. Appropriate antibiotic use for GAS pharyngitis did not significantly change during the project; although, inappropriate use was primarily related to unnecessary testing. At the end of the intervention period, the majority of providers perceived an improvement in their ability to communicate with families about the need for GAS pharyngitis testing and about antibiotic use.
    CONCLUSIONS:
    The majority of GAS pharyngitis testing in this practice before intervention was inconsistent with IDSA guideline recommendations. A quality improvement initiative, which was approved for Part 4 Maintenance of Certification credit, led to improvement in guideline-based testing for GAS pharyngitis.


  • Home Extubation in a Neonate
    End-of-life care for many infants involves the withdrawal of mechanical ventilation. Usually this takes place in the hospital environment, but sometimes parents request that their infant dies at home. Facilitating this has significant practical and resource implications and raises both logistical and ethical questions. In this article, we report a neonatal case involving home extubation, explaining the processes involved as well as providing an ethical context.


  • When a Mother Changes Her Mind About a DNR
    Generally, wide latitude is granted to parents when making decisions for their child on the basis of the wide acceptance of the special relationship between parent and child and the important role played by parents in the lives of children. However, when high-risk decisions are made, health care teams serve as an important societal safeguard that questions whether a parent is an appropriate decision-maker for their child. Child advocacy is an essential function of the pediatric health care team. In this ethics rounds, we examine a case of an infant with a complex medical condition requiring prolonged hospitalization that results in a clash of understanding between a mother and medical team when the mother abruptly requests removal of life-sustaining treatment. We present an ethical decision-making framework for such cases and examine the impact of barriers and unconscious bias that can exclude parents from their rightful role in directing care for their child.


  • The Collaborative Role of North American Departments of Pediatrics in Global Child Health
    Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA–LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC–NA partnerships can contribute to reductions of child mortality and morbidity globally.


  • A Toddler With Treatment-Resistant Iron Deficiency Anemia
    A 19-month-old girl with a history of asthma and atopic dermatitis presented to her pediatrician because of parental concerns of pallor and fatigue. On dietary history, it was discovered that she was a picky eater and consumed 26 oz of homogenous milk daily. Her physical examination was unremarkable aside from pallor, and both her height and weight plotted between the 50th and 75th percentile for age. Therefore, she was investigated for iron deficiency anemia and indeed her blood work was consistent. Despite appropriate iron supplementation and dietary milk restriction, there was no improvement in her hemoglobin or iron studies. Our expert panel examines the case and offers a differential diagnosis for a child presenting with treatment-resistant iron deficiency anemia.


  • An International Comparison of Death Classification at 22 to 25 Weeks Gestational Age
    OBJECTIVES:
    To explore international differences in the classification of births at extremely low gestation and the subsequent impact on the calculation of survival rates.
    METHODS:
    We used national data on births at 22 to 25 weeks’ gestation from the United States (2014; n = 11 144), Canada (2009–2014; n = 5668), the United Kingdom (2014–2015; n = 2992), Norway (2010–2014; n = 409), Finland (2010–2015; n = 348), Sweden (2011–2014; n = 489), and Japan (2014–2015; n = 2288) to compare neonatal survival rates using different denominators: all births, births alive at the onset of labor, live births, live births surviving to 1 hour, and live births surviving to 24 hours.
    RESULTS:
    For births at 22 weeks’ gestation, neonatal survival rates for which we used live births as the denominator varied from 3.7% to 56.7% among the 7 countries. This variation decreased when the denominator was changed to include stillbirths (ie, all births [1.8%–22.3%] and fetuses alive at the onset of labor [3.7%–38.2%]) or exclude early deaths and limited to births surviving at least 12 hours (50.0%–77.8%). Similar trends were seen for infants born at 23 weeks’ gestation. Variation diminished considerably at 24 and 25 weeks’ gestation.
    CONCLUSIONS:
    International variation in neonatal survival rates at 22 to 23 weeks’ gestation diminished considerably when including stillbirths in the denominator, revealing the variation arises in part from differences in the proportion of births reported as live births, which itself is closely connected to the provision of active care.


  • Psychiatric Diagnoses and Weight Loss Among Adolescents Receiving Sleeve Gastrectomy
    BACKGROUND AND OBJECTIVES:
    Severe obesity is associated with higher risk of psychiatric difficulties. Bariatric surgery is the most effective treatment of severe obesity. Few guidelines exist regarding the association of psychiatric diagnoses in adolescents and outcomes after surgery because of the lack of longitudinal research. Our objective is to evaluate the rates of psychiatric diagnoses in adolescents undergoing surgery compared with those not receiving surgery and the association of preoperative psychiatric diagnoses with postsurgical weight loss outcomes.
    METHODS:
    Adolescents (N = 222) referred for psychological evaluation at one institution for bariatric surgery (2009–2017) completed semistructured clinical interviews to assess the presence and number of psychiatric diagnoses. Comparison analyses were conducted between those who did not end up receiving surgery (N = 53) and those who did (N = 169). Using longitudinal modeling, we assessed the association of preoperative diagnoses with weight loss outcomes between 3 and 12 months after surgery.
    RESULTS:
    Seventy-one percent of adolescents qualified for a psychiatric disorder. There were no differences in rates of specific disorders or numbers of diagnoses between those receiving surgery and those not receiving surgery. The presence or absence or number of diagnoses before surgery was not associated with weight loss outcomes after surgery.
    CONCLUSIONS:
    Psychiatric diagnoses are prevalent among adolescents with severe obesity. These diagnoses are not associated with weight loss outcomes. The presurgical psychological evaluation serves as an opportunity to identify adolescents experiencing psychiatric problems and provide them with care but should not necessarily be considered a contraindication to surgery.


  • Intimate Partner Violence, Depression, and Child Growth and Development
    BACKGROUND:
    Evidence on the relationship between maternal depression and exposure to intimate partner violence (IPV) with child physical growth and development is equivocal. Our aim in the current study is to examine these relationships among women and their children in Tanzania.
    METHODS:
    The Bayley Scales of Infant Development and anthropometric measures were used to assess children 18 to 36 months of age (n = 1031). Maternal exposure to IPV and depression were assessed using the Tanzania Demographic and Health Survey questionnaire and the Patient Health Questionnaire-9, respectively. We used linear regression models to calculate standardized mean differences (SMDs) for developmental outcomes and generalized linear models to estimate the associations with nutritional status.
    RESULTS:
    Mild depressive symptoms in mothers (Patient Health Questionnaire-9 ≥5) and exposure to physical and sexual IPV were associated with lower SMDs for motor skills (–0.14 [P = .023] and –0.23 [P < .01], respectively), expressive communication (–0.13 [P = .187] and –0.23 [P < .01], respectively), receptive communication (–0.19 [P < .009] and –0.16 [P = .03], respectively), and cognitive development (–0.08 [P = .245] and –0.12 [P = .07], respectively). Exposure to physical and sexual IPV was associated with higher risk for stunting (relative risk = 1.6; P < .001).
    CONCLUSIONS:
    This study reveals that maternal depressive symptoms and IPV are associated with adverse child nutritional and developmental outcomes. Further research is needed to develop programs to address IPV and depression among women and enhance the growth and development of their children.


  • Emergency Department Alcohol Intervention: Effects on Dating Violence and Depression
    OBJECTIVES:
    With this study, we examined secondary outcomes of an emergency department (ED)–based brief intervention (BI) on dating violence perpetration and victimization and depression symptoms over 3, 6, and 12 months.
    METHODS:
    ED patients (14–20 years) were screened for risk drinking. Patients who received positive screen results were randomly assigned to a computer BI (n = 277), therapist BI (n = 278), or control condition (n = 281). After the 3-month assessment, participants were randomly assigned to receive the post-ED BI or control condition. BIs were used to address alcohol consumption and consequences (eg, dating violence and depression symptoms) by using motivational interviewing.
    RESULTS:
    A total of 836 patients were enrolled in the randomized controlled trial of 4389 patients screened and 1054 who reported risky drinking. Regression models were used to examine longitudinal effects of the alcohol BI on dating violence perpetration, dating violence victimization, and depression symptoms. The therapist BI resulted in a significant reduction of dating violence perpetration up to 12 months (incidence rate ratio [IRR] = 0.53; 95% confidence interval [CI]: 0.37–0.77) and depression symptoms up to 3 months (IRR = 0.85; 95% CI: 0.72–1.00) after the intervention. Computer BI resulted in a reduction of dating violence perpetration (IRR = 0.52; 95% CI: 0.35–0.76) and depression symptoms (IRR = 0.78; 95% CI: 0.66–0.94) 6 months postintervention. Post-ED BIs were associated with lower perpetration at 12 months and lower victimization at 6 and 12 months, irrespective of BI intervention randomization at baseline; however, they did not affect depression symptoms.
    CONCLUSIONS:
    A single-session ED BI revealed previously to show promise in reducing underage drinking also demonstrates promise in preventing dating violence perpetration and depression symptoms. These technology-enhanced BIs could be particularly helpful given the potential for more efficient resource usage and ease of future implementation.


  • Preterm Birth/Low Birth Weight and Markers Reflective of Wealth in Adulthood: A Meta-analysis
    CONTEXT:
    Preterm birth and/or low birth weight (PT/LBW) increases the risk of cognitive deficits, which suggests an association between PT/LBW and lower wealth in adulthood. Nevertheless, studies have revealed inconsistent findings so far.
    OBJECTIVE:
    To systematically investigate whether PT/LBW is associated with markers of adulthood wealth.
    DATA SOURCES:
    We searched Medline, PubMed, PsycINFO, Web of Science, and Embase.
    STUDY SELECTION:
    Prospective longitudinal and registry studies containing reports on selected wealth-related outcomes in PT/LBW-born adults compared with term-born controls.
    DATA EXTRACTION:
    Two independent reviewers extracted data on educational qualifications, employment rates, social benefits, and independent living.
    RESULTS:
    Of 1347 articles screened, 23 studies met the inclusion criteria. PT/LBW was associated with decreased likelihood of attainment of higher education qualifications (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.69–0.80), lower employment rate (OR = 0.83; 95% CI = 0.74–0.92), and increased likelihood of receiving social benefits (OR = 1.25; 95% CI = 1.09–1.42). A dose-response relationship according to gestational age was only found for education qualifications. PT/LBW-born adults did not differ significantly from those born at term in independent living.
    LIMITATIONS:
    There was high heterogeneity between studies. There were unequal numbers of studies from different regions in the world.
    CONCLUSIONS:
    PT/LBW is associated with lower educational qualifications, decreased rate of employment, and an increased rate of receipt of social benefits in adulthood. Low educational qualifications were most prevalent in those born very preterm and consistent across geographic regions. However, the findings are less clear for independent living.


  • Buprenorphine Exposures Among Children and Adolescents Reported to US Poison Control Centers
    OBJECTIVE:
    To investigate buprenorphine exposures among children and adolescents ≤19 years old in the United States.
    METHODS:
    Data were analyzed from calls to US poison control centers for 2007–2016 from the National Poison Data System.
    RESULTS:
    From 2007 to 2016, there were 11 275 children and adolescents ≤19 years old exposed to buprenorphine reported to US poison control centers. Most exposures were among children


  • Neonatal Circumcision and Urinary Tract Infections in Infants With Hydronephrosis
    BACKGROUND:
    Boys with urinary tract abnormalities may derive a greater benefit from newborn circumcision for prevention of urinary tract infection (UTI) than the general population. However, the effect of newborn circumcision on UTI is not well characterized across the etiological spectrum of hydronephrosis. We hypothesized that boys with an early diagnosis of hydronephrosis who undergo newborn circumcision will have reduced rates of UTI.
    METHODS:
    The MarketScan data set, an employer-based claims database, was used to identify boys with hydronephrosis or hydronephrosis-related diagnoses within the first 30 days of life. The primary outcome was the rate of UTIs within the first year of life, comparing circumcised boys with uncircumcised boys and adjusting for region, insurance type, year of birth, and infant comorbidity.
    RESULTS:
    A total of 5561 boys met inclusion criteria, including 2386 (42.9%) undergoing newborn circumcision and 3175 (57.1%) uncircumcised boys. On multivariate analysis, circumcision was associated with a decreased risk of UTI in both boys with hydronephrosis and healthy cohorts: odds ratio (OR) 0.36 (95% confidence interval [CI] 0.29–0.44) and OR 0.32 (95% CI 0.21–0.48), respectively. To prevent 1 UTI, 10 patients with hydronephrosis would have to undergo circumcision compared with 83 healthy boys. Among specific hydronephrosis diagnoses, circumcision was associated with a reduced risk of UTI for those with isolated hydronephrosis (OR 0.35 [95% CI 0.26–0.46]), vesicoureteral reflux (OR 0.35 [95% CI 0.23–0.54]), and ureteropelvic junction obstruction (OR 0.35 [95% CI 0.20–0.61]).
    CONCLUSIONS:
    Newborn circumcision is associated with a significantly lower rate of UTI among infant boys with hydronephrosis.



  • Outcomes in Mild to Moderate Isolated Thrombocytopenia
    OBJECTIVES:
    Incidental isolated mild to moderate thrombocytopenia is a frequent laboratory finding prompting a referral to pediatric hematology-oncology. We tested the hypothesis that patients with isolated asymptomatic mild thrombocytopenia would not progress to require an intervention from a pediatric hematologist–oncologist.
    METHODS:
    This is a 5-year retrospective review of 113 patients referred to pediatric hematology–oncology for isolated thrombocytopenia. Initial, lowest, and current platelet counts along with clinical course and need for interventions were recorded. Thrombocytopenia was categorized as mild (platelet count: 101–140 x 103/μL), moderate (platelet count: 51–100 x 103/μL), severe (platelet count: 21–50 x 103/μL), and very severe (platelet count: ≤20 x 103/μL).
    RESULTS:
    Eight of 48 patients (17%) referred for initial mild isolated thrombocytopenia progressed to moderate thrombocytopenia at 1 visit. At present, 2 of these patients have moderate thrombocytopenia, 17 remain with mild thrombocytopenia, and 29 patients have resolved thrombocytopenia. Nine of 65 patients (14%) referred for moderate thrombocytopenia progressed to severe or very severe thrombocytopenia on 1 occasion. At present, no patients have severe thrombocytopenia, 18 remain with moderate thrombocytopenia, 14 improved to mild thrombocytopenia, and 33 have resolved thrombocytopenia. Only 3 patients required interventions from a hematologist, whereas 10 patients required therapy from other subspecialties.
    CONCLUSIONS:
    We only identified 3 patients (3%) with mild to moderate thrombocytopenia who required an intervention from a hematologist to improve platelet counts. Patients with isolated mild thrombocytopenia with a normal bleeding history and physical examination findings frequently have normalized their platelet counts within 1 month.


  • Postdischarge Nurse Home Visits and Reuse: The Hospital to Home Outcomes (H2O) Trial
    BACKGROUND:
    Hospital discharge is stressful for children and families. Poor transitional care is linked to unplanned health care reuse. We evaluated the effects of a pediatric transition intervention, specifically a single nurse home visit, on postdischarge outcomes in a randomized controlled trial.
    METHODS:
    We randomly assigned 1500 children hospitalized on hospital medicine, neurology services, or neurosurgery services to receive either a single postdischarge nurse-led home visit or no visit. We excluded children discharged with skilled home nursing services. Primary outcomes included 30-day unplanned, urgent health care reuse (composite measure of unplanned readmission, emergency department, or urgent care visit). Secondary outcomes, measured at 14 days, included postdischarge parental coping, number of days until parent-reported return to normal routine, and number of “red flags” or clinical warning signs a parent or caregiver could recall.
    RESULTS:
    The 30-day reuse rate was 17.8% in the intervention group and 14.0% in the control group. In the intention-to-treat analysis, children randomly assigned to the intervention group had higher odds of 30-day health care use (odds ratio: 1.33; 95% confidence interval: 1.003–1.76). In the per protocol analysis, there were no differences in 30-day health care use (odds ratio: 1.14; confidence interval: 0.84–1.55). Postdischarge coping scores and number of days until returning to a normal routine were similar between groups. Parents in the intervention group recalled more red flags at 14 days (mean: 1.9 vs 1.6; P < .01).
    CONCLUSIONS:
    Children randomly assigned to the intervention had higher rates of 30-day postdischarge unplanned health care reuse. Parents in the intervention group recalled more clinical warning signs 2 weeks after discharge.


  • Topiramate for Seizures in Preterm Infants and the Development of Necrotizing Enterocolitis
    Neonatal seizures represent a significant health burden on the term and preterm neonatal population and are linked to poor long-term neurodevelopmental outcomes. Currently, there are no US Food and Drug Administration–approved antiepileptic drugs for neonates, and authors of the medical literature have yet to reach a consensus on the most adequate approach to neonatal seizures. Topiramate is readily used in the adult and older pediatric population for the management of migraines and partial-onset seizures. Topiramate continues to gain favor among pediatric neurologists who often recommend this medication as a third-line treatment of neonatal seizures. We report our recent experience with 4 preterm neonates, born between 2015 and 2017, who developed radiographic signs of necrotizing enterocolitis after receiving topiramate for seizures. Each was given oral topiramate for the treatment of electrographic and clinical seizures and developed the subsequent diagnosis of necrotizing enterocolitis, with abdominal distention, hemoccult-positive stools, and radiographic signs of intestinal distention and pneumatosis. More research regarding the risk factors of topiramate use in premature infants is needed.



  • Implementation of Duchenne Muscular Dystrophy Care Considerations
    BACKGROUND:
    Duchenne muscular dystrophy (DMD) is an X-linked disorder characterized by progressive muscle weakness and multisystem involvement. Recent advances in management of individuals with DMD have prolonged survival. Lack of standardized care spurred an international collaboration to develop consensus-based care considerations for diagnosis and management. In this study, we evaluate adherence to considerations at selected sites.
    METHODS:
    We collaborated with the Muscular Dystrophy Surveillance, Tracking, and Research Network. Our sample included males with DMD and Becker muscular dystrophy


  • Ensuring Timely Connection to Early Intervention for Young Children With Developmental Delays
    BACKGROUND AND OBJECTIVES:
    Timely provision of developmental services can improve outcomes for children 0 to 3 years old with developmental delays. Early Intervention (EI) provides free developmental services to children under age 3 years; however, data suggests that many children referred to EI never connect to the program. We sought to ensure that 70% of patients referred to EI from an academic primary care clinic serving a low-income population were evaluated within 120 days of referral.
    METHODS:
    Recognizing that our baseline system of EI referrals had multiple routes to referral without an ability to track referral outcome, we implemented a multifaceted referral process with (1) a centralized electronic referral system used by providers, (2) patient navigators responsible for processing all EI referrals submitted by providers, and (3) a tracking system postreferral to facilitate identification of patients failing to connect with EI.
    RESULTS:
    The percentage of patients evaluated by EI within 120 days increased from a baseline median of 50% to a median of 72% after implementation of the systems (N = 309). After implementation, the centralized referral system was used a median of 90% of the time. Tracking of referral outcomes revealed decreases in families refusing evaluations and improvements in exchange of information with EI.
    CONCLUSIONS:
    Rates of connection to EI improved substantially when referrals were centralized in the clinic and patient navigators were responsible for tracking referral outcomes. Knowledge of EI intake processes and relationships between the practice and the EI site are essential to ensure successful connections.


  • Paracetamol/Acetaminophen During Pregnancy Induces Prenatal Ductus Arteriosus Closure
    Paracetamol or acetaminophen (APAP) is commonly used as a first line treatment of pain and fever in pregnancy. In view of new evidence that reveals that APAP medication during pregnancy may be associated with impaired outcomes, safety of the use of APAP during pregnancy should be questioned. The causality between maternal APAP treatment and prenatal ductus arteriosus closure was qualified as certain by using the World Health Organization Uppsala Monitoring Center causality assessment system in a short series of 2 clinical cases. Because the fetal ductus arteriosus closure can lead to fetal loss or life-threatening cardiac failure in the newborn, the use of APAP, specifically after the sixth month of pregnancy, should be as limited as possible.


  • Preterm Neuroimaging and School-Age Cognitive Outcomes
    BACKGROUND AND OBJECTIVES:
    Children born extremely preterm are at risk for cognitive difficulties and disability. The relative prognostic value of neonatal brain MRI and cranial ultrasound (CUS) for school-age outcomes remains unclear. Our objectives were to relate near-term conventional brain MRI and early and late CUS to cognitive impairment and disability at 6 to 7 years among children born extremely preterm and assess prognostic value.
    METHODS:
    A prospective study of adverse early and late CUS and near-term conventional MRI findings to predict outcomes at 6 to 7 years including a full-scale IQ (FSIQ)


  • Objective Sleep Characteristics and Cardiometabolic Health in Young Adolescents
    BACKGROUND AND OBJECTIVES:
    Shorter sleep duration is associated with childhood obesity. Few studies measure sleep quantity and quality objectively or examine cardiometabolic biomarkers other than obesity.
    METHODS:
    This cross-sectional study of 829 adolescents derived sleep duration, efficiency and moderate-to-vigorous physical activity from >5 days of wrist actigraphy recording for >10 hours/day. The main outcome was a metabolic risk score (mean of 5 sex-specific z-scores for waist circumference, systolic blood pressure, high-density lipoprotein cholesterol scaled inversely, and log-transformed triglycerides and homeostatic model assessment of insulin resistance), for which higher scores indicate greater metabolic risk. Secondary outcomes included score components and dual-energy radiograph absorptiometry fat mass. We measured socioeconomic status, race and/or ethnicity, pubertal status, and obesity-related behaviors (television-viewing and fast food and sugar-sweetened beverage consumption) using questionnaires.
    RESULTS:
    The sample was 51.5% girls; mean (SD) age 13.2 (0.9) years, median (interquartile range) sleep duration was 441.1 (54.8) minutes per day and sleep efficiency was 84.0% (6.3). Longer sleep duration was associated with lower metabolic risk scores (–0.11 points; 95% CI: –0.19 to –0.02, per interquartile range). Associations with sleep efficiency were similar and persisted after adjustment for BMI z score and physical activity, television-viewing, and diet quality. Longer sleep duration and greater sleep efficiency were also favorably associated with waist circumference, systolic blood pressure, high-density lipoprotein cholesterol, and fat mass.
    CONCLUSIONS:
    Longer sleep duration and higher sleep efficiency were associated with a more favorable cardiometabolic profile in early adolescence, independent of other obesity-related behaviors. These results support the need to assess the role of sleep quantity and quality interventions as strategies for improving cardiovascular risk profiles of adolescents.


  • Respiratory Viruses and Treatment Failure in Children With Asthma Exacerbation
    OBJECTIVES:
    Respiratory pathogens commonly trigger pediatric asthma exacerbations, but their impact on severity and treatment response remains unclear.
    METHODS:
    We performed a secondary analysis of the Determinants of Oral Corticosteroid Responsiveness in Wheezing Asthmatic Youth (DOORWAY) study, a prospective cohort study of children (aged 1–17 years) presenting to the emergency department with moderate or severe exacerbations. Nasopharyngeal specimens were analyzed by RT-PCR for 27 respiratory pathogens. We investigated the association between pathogens and both exacerbation severity (assessed with the Pediatric Respiratory Assessment Measure) and treatment failure (hospital admission, emergency department stay >8 hours, or relapse) of a standardized severity-specific treatment. Logistic multivariate regressions were used to estimate average marginal effects (absolute risks and risk differences [RD]).
    RESULTS:
    Of 958 participants, 61.7% were positive for ≥1 pathogen (rhinovirus was the most prevalent [29.4%]) and 16.9% experienced treatment failure. The presence of any pathogen was not associated with higher baseline severity but with a higher risk of treatment failure (20.7% vs 12.5%; RD = 8.2% [95% confidence interval: 3.3% to 13.1%]) compared to the absence of a pathogen. Nonrhinovirus pathogens were associated with an increased absolute risk (RD) of treatment failure by 13.1% (95% confidence interval: 6.4% to 19.8%), specifically, by 8.8% for respiratory syncytial virus, 24.9% for influenza, and 34.1% for parainfluenza.
    CONCLUSIONS:
    Although respiratory pathogens were not associated with higher severity on presentation, they were associated with increased treatment failure risk, particularly in the presence of respiratory syncytial virus, influenza, and parainfluenza. This supports influenza prevention in asthmatic children, consideration of pathogen identification on presentation, and exploration of treatment intensification for infected patients at higher risk of treatment failure.


  • Growth Hormone Deficiency Causing Micropenis: Lessons Learned From a Well-Adjusted Adult
    This report of a 46,XY patient born with a micropenis consistent with etiology from isolated congenital growth hormone deficiency is used to (1) raise the question regarding what degree testicular testosterone exposure to the central nervous system during fetal life and early infancy has on the development of male gender identity, regardless of gender of rearing; (2) suggest the obligatory nature of timely full disclosure of medical history; (3) emphasize that virtually all 46,XY infants with functional testes and a micropenis should be initially boys except some with partial androgen insensitivity syndrome; and (4) highlight the sustaining value of a positive long-term relationship with a trusted physician (R.M.B.). When this infant presented, it was commonly considered inappropriate to gender assign an infant male whose penis was so small that an adult size was expected to be inadequate, even if the karyotype was 46,XY, and testes were functional. Concomitantly, female gender assignment was considered the appropriate decision, believing that parental rearing in the assigned gender was considered the major factor determining established adult gender identity. Full disclosure of medical information was considered inappropriate. Progress in appreciating the complexities of gender identity development, which is not yet completely understood, and sexuality, coping ability, and outcome data has resulted in a change of practice in initial gender assignment. A 46,XY individual with functional testes and verified androgen responsiveness should be assigned and reared as male, regardless of penis size. Without androgen responsiveness, the multiple factors must be carefully considered and disclosed.


  • Safety Surveillance of Diphtheria and Tetanus Toxoids and Acellular Pertussis (DTaP) Vaccines
    OBJECTIVE:
    To assess the safety of currently licensed diphtheria-tetanus-acellular pertussis (DTaP) vaccines in the United States by using data from the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting surveillance system.
    METHODS:
    We searched VAERS for US reports of DTaP vaccinations occurring from January 1, 1991, through December 31, 2016, and received by March 17, 2017. We reviewed available medical records for all death reports and a random sample of reports classified as nondeath serious. We used Empirical Bayesian data mining to identify adverse events that were disproportionally reported after DTaP vaccination.
    RESULTS:
    VAERS received 50 157 reports after DTaP vaccination; 43 984 (87.7%) of them reported concomitant administration of other vaccines, and 5627 (11.2%) were serious. Median age at vaccination was 19 months (interquartile range 35 months). The most frequently reported events were injection site erythema (12 695; 25.3%), pyrexia (9913; 19.8%), injection site swelling (7542; 15.0%), erythema (5599; 11.2%), and injection site warmth (4793; 9.6%). For 3 of the DTaP vaccines, we identified elevated values for vaccination errors using Empirical Bayesian data mining.
    CONCLUSIONS:
    No new or unexpected adverse events were detected. The observed disproportionate reporting for some nonserious vaccination errors calls for better education of vaccine providers on the specific indications for each of the DTaP vaccines.


  • Uropathogen Resistance and Antibiotic Prophylaxis: A Meta-analysis
    CONTEXT:
    Limited data exist regarding uropathogen resistance in randomized controlled trials of urinary tract infection (UTI) prevention and antibiotic prophylaxis.
    OBJECTIVE:
    To assess the effect of prophylaxis on developing a multidrug-resistant first recurrent UTI among children with vesicoureteral reflux.
    DATA SOURCES:
    Cochrane Kidney and Transplant Specialized Register through May 25, 2017.
    STUDY SELECTION:
    Randomized controlled trials of patients ≤18 years of age with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis compared with no treatment or placebo with available antibiotic sensitivity profiles.
    DATA EXTRACTION:
    Two independent observers abstracted data and assessed quality and validity per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Adjusted meta-analyses were performed by using a mixed-effects logistic regression model.
    RESULTS:
    One thousand two hundred and ninety-nine patients contributed 224 UTIs. Patients treated with prophylaxis were more likely to have a multidrug-resistant infection (33% vs 6%, P < .001) and were more likely to receive broad-spectrum antibiotics (68% vs 49%, P = .004). Those receiving prophylaxis had 6.4 times the odds (95% confidence interval: 2.7–15.6) of developing a multidrug-resistant infection. One multidrug-resistant infection would develop for every 21 reflux patients treated with prophylaxis.
    LIMITATIONS:
    Variables that may contribute to resistance such as medication adherence and antibiotic exposure for other illnesses could not be evaluated.
    CONCLUSIONS:
    Prophylaxis increases the risk of multidrug resistance among recurrent infections. This has important implications in the risk-benefit assessment of prophylaxis as a management strategy and in the selection of empirical treatment of breakthrough infections in prophylaxis patients.


  • Prenatal Antidepressant Exposure and Child Motor Development: A Meta-analysis
    CONTEXT:
    There is increasing use of antidepressants in pregnancy and hence children exposed in utero. Contradictory studies exist in the literature in which researchers report on the potential impact of antenatal antidepressant exposure on subsequent child motor development.
    OBJECTIVE:
    Our objective in this systematic review and meta-analysis was to determine whether antenatal antidepressant exposure increases the risk of impaired motor development in children.
    DATA SOURCES:
    We searched PsychINFO, Embase, Medline, PubMed, and Scopus up to July 24, 2017.
    STUDY SELECTION:
    English-language cohort and case control studies in which researchers report primary data from a motor assessment of infants or children after any antidepressant exposure in pregnancy were included.
    DATA EXTRACTION:
    Of the 329 studies identified, there were 160 articles screened, 24 were included in the systematic review, and 18 met inclusion criteria for the meta-analysis.
    RESULTS:
    The total pooled results were based on random effects models and revealed a significant association between exposure to antidepressants during pregnancy and overall occurrence of poorer motor outcomes in children (effect size = 0.22; 95% confidence interval = 0.07 to 0.37) with a moderate degree of heterogeneity (I2 = 56.6%).
    LIMITATIONS:
    There was variation in the measurement both of exposure and motor development across the identified study, and few followed up to later childhood or beyond.
    CONCLUSIONS:
    A small increased risk of poorer motor development may exist for children who are exposed to antidepressant medications during pregnancy. However, the marked methodological variation among studies and the limited control for possible confounds warrants cautious interpretation of these findings.


  • Pain-Relieving Interventions for Retinopathy of Prematurity: A Meta-analysis
    CONTEXT:
    Retinopathy of prematurity eye examinations conducted in the neonatal intensive care.
    OBJECTIVE:
    To combine randomized trials of pain-relieving interventions for retinopathy of prematurity examinations using network meta-analysis.
    DATA SOURCES:
    Systematic review and network meta-analysis of Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and the World Health Organization International Clinical Trials Registry Platform. All databases were searched from inception to February 2017.
    STUDY SELECTION:
    Abstract and title screen and full-text screening were conducted independently by 2 reviewers.
    DATA EXTRACTION:
    Data were extracted by 2 reviewers and pooled with random effect models if the number of trials within a comparison was sufficient. The primary outcome was pain during the examination period; secondary outcomes were pain after the examination, physiologic response, and adverse events.
    RESULTS:
    Twenty-nine studies (N = 1487) were included. Topical anesthetic (TA) combined with sweet taste and an adjunct intervention (eg, nonnutritive sucking) had the highest probability of being the optimal treatment (mean difference [95% credible interval] versus TA alone = –3.67 [–5.86 to –1.47]; surface under the cumulative ranking curve = 0.86). Secondary outcomes were sparsely reported (2–4 studies, N = 90–248) but supported sweet-tasting solutions with or without adjunct interventions as optimal.
    LIMITATIONS:
    Limitations included moderate heterogeneity in pain assessment reactivity phase and severe heterogeneity in the regulation phase.
    CONCLUSIONS:
    Multisensory interventions including sweet taste is likely the optimal treatment for reducing pain resulting from eye examinations in preterm infants. No interventions were effective in absolute terms.


  • Father-Inclusive Perinatal Parent Education Programs: A Systematic Review
    CONTEXT:
    Fathers contribute to their children’s health starting at the beginning of life. Few parent education programs include fathers. Among those that do, there is little effort to report program effects on father outcomes.
    OBJECTIVE:
    In this systematic review, we examined father-inclusive perinatal parent education programs in the United States as they relate to a range of father outcomes.
    DATA SOURCES:
    The databases searched were PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, and PsycINFO.
    STUDY SELECTION:
    Studies were included if they included an evaluation of a parent education program and a report of father outcomes measured within 1 year of the child’s birth and were conducted within the United States.
    DATA EXTRACTION:
    Of 1353 total articles, 21 met study criteria.
    RESULTS:
    The overall state of the father-inclusive perinatal parent education program literature was poor, with few interventions available to fathers. Available programs were associated with increased father involvement, coparenting relationship, partner relationship quality, father’s mental health, and father’s supportive behaviors. Program effects on father-infant interaction, parenting knowledge, and attitudes and parenting self-efficacy were inconclusive. Three programs emerged as best evidence-based interventions.
    LIMITATIONS:
    Risk of bias was high for many studies. Outcome variability, small sample size, and publication bias contributed to the weak evidence base.
    CONCLUSIONS:
    There is a need for more evidence-based interventions to support fathers. Clinicians play a key role in engaging fathers in early parent education programs and health care settings. PROSPERO registration number: CRD42017050099.


  • Selection Bias and Outcomes for Preterm Neonates
    BACKGROUND:
    Reported survival and neurodevelopmental outcomes at 23 weeks’ gestation are based on the infants admitted to NICUs. In this study, we aim to describe the association between clinical characteristics and admission to NICU at 23, 24 and 25 weeks’ gestation.
    METHODS:
    Cohort data from 2 national databases enabled comparison of the clinical characteristics all Australian births and all NICU admissions during 2010–2013 at 23, 24, and 25 weeks’ gestation.
    RESULTS:
    NICU admission occurred in 15% of all births at 23 weeks, in comparison with 49% at 24 weeks and 64% at 25 weeks. At 23 weeks, live-born infants were less likely to be admitted to NICU with birth weight 500 g (13% vs 43%, P < .0001), and boys were admitted less compared with girls (33% vs 43%, P < .018). In contrast, birth weight (including birth weight





  • Diagnosis and Management of Gastroesophageal Reflux in Preterm Infants
    Gastroesophageal reflux (GER), generally defined as the passage of gastric contents into the esophagus, is an almost universal phenomenon in preterm infants. It is a common diagnosis in the NICU; however, there is large variation in its treatment across NICU sites. In this clinical report, the physiology, diagnosis, and symptomatology in preterm infants as well as currently used treatment strategies in the NICU are examined. Conservative measures to control reflux, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of GER in the preterm infant. In addition, preterm infants with clinically diagnosed GER are often treated with pharmacologic agents; however, a lack of evidence of efficacy together with emerging evidence of significant harm (particularly with gastric acid blockade) strongly suggest that these agents should be used sparingly, if at all, in preterm infants.




  • The Prenatal Visit
    A pediatric prenatal visit during the third trimester is recommended for all expectant families as an important first step in establishing a child’s medical home, as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition. As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow general pediatricians to establish a supportive and trusting relationship with both parents, gather basic information from expectant parents, offer information and advice regarding the infant, and may identify psychosocial risks early and high-risk conditions that may require special care. There are several possible formats for this first visit. The one used depends on the experience and preference of the parents, the style of the pediatrician’s practice, and pragmatic issues of payment.