Journals

Pediatrics

Pediatrics

PEDIATRICS current issue

  • Successful Management of Chylothorax With Etilefrine: Case Report in 2 Pediatric Patients
    Chylothorax is defined as the accumulation of chyle within the pleural space. Originally described in 1917 by Pisek, it is the most common cause of pleural effusion in the neonatal period. The leading cause of chylothorax is laceration of the thoracic duct during surgery, which occurs in 0.85% to 6.6% of children undergoing cardiothoracic surgery. Few authors of reports in the literature have looked at etilefrine, a relatively unknown sympathomimetic, as an option for the medical treatment of chylothorax. In this case report, we review the clinical course of 2 infants with type III esophageal atresia who developed chylothorax after thoracic surgery and were successfully treated with intravenous etilefrine after failing initial dietary and pharmacological management.


  • Preventive Behavioral Health Programs in Primary Care: A Systematic Review
    CONTEXT:
    Early childhood is a critical period for socioemotional development. Primary care is a promising setting for behavioral health programs.
    OBJECTIVES:
    To identify gaps in the literature on effectiveness and readiness for scale-up of behavioral health programs in primary care.
    DATA SOURCES:
    PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Evidence-Based Medicine Reviews, and Scopus databases were searched for articles published in English in the past 15 years. Search terms included terms to describe intervention content, setting, target population, and names of specific programs known to fit inclusion criteria.
    STUDY SELECTION:
    Inclusion criteria were: (1) enrolled children 0 to 5 years old, (2) primary care setting, (3) measured parenting or child behavior outcomes, and (4) clinical trial, quasi-experimental trial, pilot study, or pre-post design.
    DATA EXTRACTION:
    Data were abstracted from 44 studies. The rigor of individual studies and evidence base as a whole were compared with the Society of Prevention Research’s standards for efficacy, effectiveness, and scale-up research.
    RESULTS:
    Gaps in the literature include: study findings do not always support hypotheses about interventions’ mechanisms, trust in primary care as a mediator has not been sufficiently studied, it is unclear to which target populations study findings can be applied, parent participation remains an important challenge, and the long-term impact requires further evaluation.
    LIMITATIONS:
    Potential limitations include publication bias, selective reporting within studies, and an incomplete search.
    CONCLUSIONS:
    Targeting gaps in the literature could enhance understanding of the efficacy, effectiveness, and readiness for scale-up of these programs.


  • Facilitating the Timely Discharge of Well Newborns by Using Quality Improvement Methods
    BACKGROUND AND OBJECTIVES:
    Discharges are a key driver of hospital throughput. Our pediatric hospitalist team sought to improve newborn nursery throughput by increasing the percentage of newborns on our service with a discharge order by 11 am. We hypothesized that implementing a discharge checklist would result in earlier discharge times for newborns who met discharge criteria.
    METHODS:
    We identified barriers to timely discharge through focus groups with key stakeholders, chart reviews, and brainstorming sessions. We subsequently created and implemented a discharge checklist to identify and address barriers before daily rounds. We tracked mean monthly discharge order times. Finally, we performed chart reviews to determine causes for significantly delayed discharge orders and used this information to modify rounding practices during a second plan-do-study-act cycle.
    RESULTS:
    During the 2-year period before the intervention, 24% of 3224 newborns had a discharge order entered by 11 am. In the 20 months after the intervention, 39% of 2739 newborns had a discharge order by 11 am, a 63% increase compared with the baseline. Observation for group B Streptococcus exposure was the most frequent reason for a late discharge order.
    CONCLUSIONS:
    There are many factors that affect the timely discharge of well newborns. The development and implementation of a discharge checklist improved our ability to discharge newborns on our pediatric hospitalist service by 11 am. Future studies to identify nonphysician barriers to timely newborn discharges may lead to further improvements in throughput between the labor and delivery and maternity suites units.


  • Should a Teenager Be Allowed to Leave the Hospital AMA to Attend His Fathers Funeral?
    What should physicians do when an adolescent wishes to risk his physical health and leave the hospital to attend the funeral of his late father? What if the young man’s mother, and only remaining guardian, both supports and encourages such a decision? In this Ethics Rounds discussion, we examine the legality, morality, and safety of discharging a minor under such conditions.


  • An 18-Year-Old With Acute-on-Chronic Abdominal Pain
    An 18-year-old woman with a complex past medical history presented with 2 days of vomiting and lower abdominal pain. She had been admitted for the majority of the previous 5 months for recurrent pancreatitis and had undergone a cholecystectomy. Additional symptoms included nausea, anorexia, constipation, and a 40-lb weight loss over 4 months. She appeared uncomfortable, and an examination was remarkable for tachycardia, hypertension, and diffuse abdominal tenderness to light palpation. Her initial laboratory test results revealed mildly elevated liver enzymes (aspartate aminotransferase 68 U/L, alanine aminotransferase 80 U/L) and a normal lipase. She was admitted for pain control and nutritional support. Over the next few days, the lipase increased to 1707 U/L. Despite optimizing her management for acute pancreatitis, the patient’s symptoms persisted. Further history gathering and laboratory testing ultimately revealed her diagnosis. Our expert panel reviews her hospital course and elucidates the management of our eventual diagnosis.


  • Improving Anaphylaxis Care: The Impact of a Clinical Pathway
    BACKGROUND:
    Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation.
    METHODS:
    In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision.
    RESULTS:
    The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand.
    CONCLUSIONS:
    By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.


  • Neighborhood Child Opportunity and Individual-Level Pediatric Acute Care Use and Diagnoses
    OBJECTIVES:
    Although health care providers and systems are increasingly interested in patients’ nonmedical needs as a means to improve health, little is known about neighborhood conditions that contribute to child health problems. We sought to determine if a novel, publicly available measure of neighborhood context, the Child Opportunity Index, was associated with pediatric acute care visit frequency and diagnoses.
    METHODS:
    This cross-sectional study included San Francisco residents


  • Antibiotic Allergy in Pediatrics
    The overlabeling of pediatric antibiotic allergy represents a huge burden in society. Given that up to 10% of the US population is labeled as penicillin allergic, it can be estimated that at least 5 million children in this country are labeled with penicillin allergy. We now understand that most of the cutaneous symptoms that are interpreted as drug allergy are likely viral induced or due to a drug–virus interaction, and they usually do not represent a long-lasting, drug-specific, adaptive immune response to the antibiotic that a child received. Because most antibiotic allergy labels acquired in childhood are carried into adulthood, the overlabeling of antibiotic allergy is a liability that leads to unnecessary long-term health care risks, costs, and antibiotic resistance. Fortunately, awareness of this growing burden is increasing and leading to more emphasis on antibiotic allergy delabeling strategies in the adult population. There is growing literature that is used to support the safe and efficacious use of tools such as skin testing and drug challenge to evaluate and manage children with antibiotic allergy labels. In addition, there is an increasing understanding of antibiotic reactivity within classes and side-chain reactions. In summary, a better overall understanding of the current tools available for the diagnosis and management of adverse drug reactions is likely to change how pediatric primary care providers evaluate and treat patients with such diagnoses and prevent the unnecessary avoidance of antibiotics, particularly penicillins.




  • Unmet Rehabilitation Needs After Hospitalization for Traumatic Brain Injury
    OBJECTIVES:
    In this study, we describe unmet service needs of children hospitalized for traumatic brain injury (TBI) during the first 2 years after injury and examine associations between child, family, and injury-related characteristics and unmet needs in 6 domains (physical therapy, occupational therapy, speech therapy, mental health services, educational services, and physiatry).
    METHODS:
    Prospective cohort study of children age 8 to 18 years old admitted to 6 hospitals with complicated mild or moderate to severe TBI. Service need was based on dysfunction identified via parent-report compared with retrospective baseline at 6, 12, and 24 months. Needs were considered unmet if the child had no therapy services in the previous 4 weeks, no physiatry services since the previous assessment, or no educational services since injury. Analyses were used to compare met and unmet needs for each domain and time point. Generalized multinomial logit models with robust SEs were used to assess factors associated with change in need from pre-injury baseline to each study time point.
    RESULTS:
    Unmet need varied by injury severity, time since injury, and service domain. Unmet need was highest for physiatry, educational services, and speech therapy. Among children with service needs, increased time after TBI and complicated mild TBI were associated with a higher likelihood of unmet rather than met service needs.
    CONCLUSIONS:
    Children hospitalized for TBI have persistent dysfunction with unmet needs across multiple domains. After initial hospitalization, children with TBI should be monitored for functional impairments to improve identification and fulfillment of service needs.


  • Disparities for LGBTQ and Gender Nonconforming Adolescents
    OBJECTIVES:
    To identify patterns of childhood adversity in a sample of adolescents and assess disparities in these experiences for lesbian, gay, bisexual, transgender, and questioning adolescents and by level of gender nonconformity.
    METHOD
    By using the cross-sectional, statewide, anonymous 2016 Minnesota Student Survey, 81 885 students were included in the current study (50.59% male; mean age = 15.51). Participants were enrolled in grades 9 and 11 in a total of 348 schools.
    RESULTS:
    Four patterns of childhood adversity were identified with sex-stratified latent class analyses (entropy = 0.833 males; 0.833 females), ranging from relatively low levels of abuse (85.3% males; 80.1% females) to polyvictimization (0.84% males; 1.98% females). A regression analysis showed that compared with heterosexual adolescents, gay, lesbian, bisexual, and questioning adolescents were more likely to be classified into profiles characterized by polyvictimization (odds ratio [OR] 1.81–7.53) and psychological and/or physical abuse (OR 1.29–3.12), than no or low adversity. Similarly, compared with nontransgender adolescents, transgender adolescents were more likely to be classified into profiles characterized by patterns of polyvictimization (OR 1.49–2.91) and psychological and/or physical abuse (OR 1.23–1.96). A higher level of gender nonconformity predicted a higher likelihood of being classified into each adversity profile compared with the no or low adversity profile (OR 1.14–1.45).
    CONCLUSIONS:
    Sexual minority adolescents and adolescents with high levels of gender nonconformity are vulnerable to experience adversity. The disparities for lesbian, gay, bisexual, transgender, and questioning adolescents and adolescents with high gender nonconformity highlight the variation in patterns of childhood adversity that these youth are at risk of experiencing. The findings reveal the need for further research on the benefits and harm of screening for childhood adversity by physicians and pediatricians.


  • Uropathogens and Pyuria in Children With Neurogenic Bladders
    BACKGROUND:
    A recent study revealed that specific uropathogens are associated with lower odds of pyuria in a general pediatrics population. Children with neurogenic bladders who require clean intermittent catheterization (CIC) frequently have pyuria. Our objective with this study was to determine if an association exists between pyuria and type of uropathogen in CIC-dependent children.
    METHODS:
    We obtained urinalysis and urine culture results from electronic medical records from January 2008 through December 2014 for patients ≤18 years of age with neurogenic bladders managed at a single institution. Cultures without concurrent urinalyses were excluded from analysis, as were cultures that yielded no growth, fungal growth, or growth of unidentified mixed organisms. We used logistic regression to determine the association of pyuria and leukocyte esterase with specific uropathogens.
    RESULTS:
    We included 2420 cultures in this analysis. The growth of Enterococcus on urine culture was associated with lower odds of both pyuria and leukocyte esterase. In contrast, the growth of more than 100 000 colony-forming units per milliliter of Proteus mirabilis was associated with increased odds of both pyuria and leukocyte esterase, and the growth of Pseudomonas aeruginosa was associated with increased odds of leukocyte esterase but not pyuria. Certain etiologies of neurogenic bladder, such as bladder exstrophy and cloacal malformations, were also associated with increased odds of pyuria compared with neurogenic bladder due to myelomeningocele.
    CONCLUSIONS:
    In children with neurogenic bladders who require CIC, Enterococcus may grow in urine culture without pyuria or positive leukocyte esterase. Accordingly, urine cultures should be obtained in symptomatic children, regardless of urinalysis results.


  • Safety and Immunogenicity of a Recombinant Influenza Vaccine: A Randomized Trial
    OBJECTIVES:
    The recombinant influenza vaccine is well established in adults ≥18 years of age for preventing seasonal influenza disease. In this randomized controlled trial, we compared the safety and immunogenicity of the quadrivalent, recombinant influenza vaccine (RIV4) versus the inactivated influenza vaccine in children and adolescents 6 to 17 years of age.
    METHODS:
    Two age cohorts were enrolled sequentially: 159 subjects aged 9 to 17 years and, after reviewing for safety, 60 children aged 6 to 8 years. Enrollment of the younger children was halted prematurely at the onset of the influenza season. Subjects in each cohort were randomly assigned 1:1 to the RIV4 or inactivated vaccine. Hemagglutination inhibition antibody titers were obtained before and 28 days after vaccination. Tolerability and safety were monitored for 7 days and 6 months after vaccination, respectively.
    RESULTS:
    Both vaccines were well tolerated in both age groups, and long-term follow-up revealed no vaccine-related adverse events. Overall, immunogenicity (geometric mean titers and seroconversion rate differences) provided comparable antibody responses to most antigens in both vaccines in the older subjects. Low responses to the influenza B Victoria lineage in both vaccines made interpretation difficult. Immunogenicity in younger children was similar, but the truncated sample size was insufficient to support noninferiority comparisons.
    CONCLUSIONS:
    Despite low responses to influenza B lineages in both vaccines, the RIV4 provided safety and immunogenicity that were comparable to those of the licensed inactivated vaccine in pediatric subjects, which was most convincing in those aged 9 to 17 years. Future confirmatory clinical efficacy trials may be used to support the recombinant influenza vaccine as an alternative for the pediatric age group of ≥6 years.



  • Neurodevelopmental Impairment Among Extremely Preterm Infants in the Neonatal Research Network
    OBJECTIVES:
    Evaluate the spectrum of neurodevelopmental outcome in a contemporary cohort of extremely preterm infants. We hypothesize that the rate of severe neurodevelopmental impairment (NDI) decreases over time.
    METHODS:
    Retrospective analysis of neurodevelopmental outcome of preterm infants ≤27 weeks’ gestational age (GA) from a Neonatal Research Network center that completed neurodevelopmental follow-up assessments between April 1, 2011, and January 1, 2015. The Bayley Scales of Infant Development-III (BSID III) and a standardized neurosensory examination were performed between 18 and 26 months’ adjusted age. Outcome measures were neurologic examination diagnoses, BSID III cognitive and motor scores, sensory impairment, and the composite outcome of NDI, based on the BSID III cognitive score (analyzed by using a cutoff of


  • Perceptions of Health Care Transition Care Coordination in Patients With Chronic Illness
    OBJECTIVES:
    Expert consensus jointly authored in 2011 by the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians supports the use of health care transition (HCT) care coordination (CC). Although gaps in care are addressed in these practice-based implementation recommendations, such recommendations have never undergone rigorous assessment. We assessed the effectiveness of implementation on quality of chronic illness care and CC during HCT for adolescents and young adults.
    METHODS:
    Adolescents and young adults with special health care needs were enrolled in a randomized HCT CC intervention. Intervention participants received HCT CC as outlined in the 2011 clinical report. Perceptions of chronic illness care quality and CC were assessed at 0, 6, and 12 months.
    RESULTS:
    Intervention participants had a Patient Assessment of Chronic Illness Care score at 12 months of 3.6 vs 3.3 compared with participants in the control group (P = .01). Intervention participants had higher average scores for patient activation (3.7 vs 3.4; P = .01), problem solving (3.8 vs 3.4; P = .02), and coordination/follow-up (3.0 vs 2.5; P < .01). The Client Perceptions of Coordination Questionnaire revealed that intervention participants had 2.5 times increased odds to endorse mostly or always receiving the services they thought they needed and had 2.4 times increased odds to have talked to their provider about future care (P < .01).
    CONCLUSIONS:
    Implementing recommended HCT CC practices improved patient or patient caregiver perception of quality of chronic illness care and CC especially among the most complex patients.


  • A Multicomponent Early Intervention Program and Trajectories of Behavior, Cognition, and Health
    OBJECTIVES:
    To investigate the developmental impact of a prenatal–to–age-5 multicomponent early intervention program targeting families living in low socioeconomic conditions.
    METHODS:
    Pregnant women from a disadvantaged Irish community were randomly assigned into a treatment group (home visits, baby massage, and parenting program; n = 115) or control group (n = 118). Children’s behavioral problems (externalizing, internalizing), cognitive skills (general, vocabulary), and health service use (number of health clinic visits), were regularly assessed (6 months to 4 years of age). Children’s developmental trajectories were modeled by using latent class growth analyses to test whether certain subgroups benefited more than others.
    RESULTS:
    High and low developmental trajectories were identified for each outcome. Treated children were more likely to follow the high-level trajectory for cognition (odds ratio = 2.89; 95% confidence interval = 1.55–5.50) and vocabulary skills (odds ratio = 2.02; 95% confidence interval = 1.08–3.82). There were no differences by treatment condition in the risk of belonging to a high externalizing or high health clinic visit trajectory. However, within the high externalizing trajectory, treated children had lower scores than controls (Hedges’ g range (2–4 years) = 0.45–0.58; P < .05) and, within the high health clinic visit trajectory, only children in the control group experienced an increasing number of visits.
    CONCLUSIONS:
    This program revealed moderate positive impacts on trajectories of cognitive development and number of health clinic visits for all children, whereas positive impacts on externalizing behavior problems were restricted to children with the most severe problems.


  • Relapsing Pityriasis Rosea With HHV-7 Reactivation in an 11-Year-Old Girl
    Pityriasis rosea (PR) usually presents as acute exanthema with oval erythematous-squamous lesions localized on the trunk, arms, and legs with spontaneous remission. We present an unusual case of PR with frequent relapses during a period of 7 years. An 11-year-old white female patient presented with many pruritic erythematous oval lesions on her trunk. A second episode followed 2 years later with several pruritic erythematous lesions on her lower limbs. During the following 5 years, the patient had several relapses per year, with 1 to 3 lesions on changing localizations. PR was diagnosed on the basis of the clinical presentation and detection of human herpesvirus 7 DNA. Spontaneous remission occurred without treatment in each episode. Relapsing PR is a rare form of PR characterized by a lower number of lesions and smaller sized lesions compared with the classic form of PR. Pediatricians should consider the diagnosis of relapsing PR even if only a single or few erythematous lesions are present.


  • Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods
    BACKGROUND AND OBJECTIVES:
    Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months.
    METHODS:
    We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children’s hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures.
    RESULTS:
    The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found.
    CONCLUSIONS:
    Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.


  • An Adaptable Pediatrics Faculty Mentoring Model
    An effective faculty mentoring program (FMP) is 1 approach that academic departments can use to promote professional fulfillment, faculty retention, and mitigate the risks of faculty burnout. Mentoring has both direct benefits for junior faculty mentees as they navigate the academic promotion process with their mentors, in addition to broader departmental and institutional benefits, with regard to recruitment, retention, and academic productivity. We describe a successful FMP model that has been adapted for use in 6 other pediatrics departments, summarizing the key personnel, mentoring process, and program evaluation methods. Important lessons learned and a generalizable mentoring “model” are provided. Program evaluation indicates a positive effect for the FMP on enhanced faculty self-efficacy, job satisfaction, and career development. The importance of communication, oversight, feedback, accountability, and valuing all faculty members is emphasized. Strategies to promote faculty engagement and the critical role of departmental leadership in prioritizing mentorship are discussed. The success of academic medical departments is inextricably linked to its commitment to the career development of individual faculty members at all levels and in all academic pathways. With our findings, we support the positive impact of a formal FMP in promoting enhanced self-efficacy and career satisfaction, which directly benefits the department and institution through enhanced productivity, retention, successful promotion, and overall professional fulfillment.


  • Copper Deficiency Anemia and Neutropenia Due to Ketogenic Diet
    Copper deficiency is an uncommon cause of hematologic abnormalities in children that is often overlooked or misdiagnosed. Although cases have been reported because of malabsorption syndromes or after gastrointestinal surgeries, we report a case of copper deficiency–associated anemia and neutropenia in a child because of dietary restrictions, specifically, transitioning from a formula-based ketogenic diet to a pureed food–based ketogenic diet. On copper supplementation, the patient’s anemia and neutropenia resolved. To our knowledge, this report is the first revealing copper deficiency anemia and neutropenia developing because of a ketogenic diet.


  • Sexual Orientation and Depressive Symptoms in Adolescents
    OBJECTIVES:
    Sexual orientation disparities in adolescent depressive symptoms are well established, but reasons for these disparities are less well understood. We modeled sexual orientation disparities in depressive symptoms from late adolescence into young adulthood and evaluated family satisfaction, peer support, cyberbullying victimization, and unmet medical needs as potential mediators.
    METHODS:
    Data were from waves 2 to 6 of the NEXT Generation Health Study (n = 2396), a population-based cohort of US adolescents. We used latent growth models to examine sexual orientation disparities in depressive symptoms in participants aged 17 to 21 years, conduct mediation analyses, and examine sex differences.
    RESULTS:
    Relative to heterosexual adolescents, sexual minority adolescents (those who are attracted to the same or both sexes or are questioning; 6.3% of the weighted sample) consistently reported higher depressive symptoms from 11th grade to 3 years after high school. Mediation analyses indicated that sexual minority adolescents reported lower family satisfaction, greater cyberbullying victimization, and increased likelihood of unmet medical needs, all of which were associated with higher depressive symptoms. The mediating role of cyberbullying victimization was more pronounced among male than female participants.
    CONCLUSIONS:
    Sexual minority adolescents reported higher depressive symptoms than heterosexual adolescents from late adolescence into young adulthood. Collectively, low family satisfaction, cyberbullying victimization, and unmet medical needs accounted for >45% of differences by sexual orientation. Future clinical research is needed to determine if interventions targeting these psychosocial and health care–related factors would reduce sexual orientation disparities in depressive symptoms and the optimal timing of such interventions.


  • Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis
    CONTEXT:
    Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high.
    OBJECTIVE:
    Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization.
    DATA SOURCES:
    Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991–November 16, 2016) and bibliographies of retrieved articles.
    STUDY SELECTION:
    Interventional studies in English of inpatient-initiated asthma QI work.
    DATA EXTRACTION:
    Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions.
    RESULTS:
    Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06–14.47)


  • Infant Pulmonary Function Testing and Phenotypes in Severe Bronchopulmonary Dysplasia
    BACKGROUND:
    The definition of severe bronchopulmonary dysplasia (sBPD) is based on respiratory support needs. The management of a patient with sBPD remains empirical and is highly variable among providers. Our objective in this study was to test the hypothesis that infant pulmonary function testing (iPFT) would reveal distinct phenotypes in patients with established sBPD during the initial NICU stay.
    METHODS:
    A prospective cohort study with data prospectively collected on infants with sBPD from May 1, 2003, to June 30, 2016. iPFT data were used to classify the patients as obstructive, restrictive, or mixed.
    RESULTS:
    The median gestational age at birth was 25 weeks (interquartile range [IQR], 24–27 weeks) and the median birth weight was 707 g (IQR, 581–925 g). At the time of iPFT, the median postmenstrual age was 52 weeks (IQR, 45–63 weeks), and the median weight was 4.4 kg (IQR, 3.7–6.0 kg). There were 56 (51%) patients with obstructive, 44 (40%) with mixed, and 10 (9%) with restrictive phenotypes. Moderate or severe obstruction was seen in 86% of the obstructive group and 78% of the mixed group. Of the restrictive patients, 70% had moderate and 30% had mild restriction. Bronchodilator response was seen in 74% of obstructive, 63% of mixed, and 25% of restrictive patients.
    CONCLUSIONS:
    Our findings reveal that sBPD as it is currently defined includes distinct phenotypes. Future researchers of diagnostic approaches to this population should consider the development of bedside tests to define phenotypes, and researchers in future therapeutic trials should consider the use of pulmonary function phenotyping in patient recruitment.



  • Reading Aloud, Play, and Social-Emotional Development
    OBJECTIVES:
    To determine impacts on social-emotional development at school entry of a pediatric primary care intervention (Video Interaction Project [VIP]) promoting positive parenting through reading aloud and play, delivered in 2 phases: infant through toddler (VIP birth to 3 years [VIP 0–3]) and preschool-age (VIP 3 to 5 years [VIP 3–5]).
    METHODS:
    Factorial randomized controlled trial with postpartum enrollment and random assignment to VIP 0–3, control 0 to 3 years, and a third group without school entry follow-up (Building Blocks) and 3-year second random assignment of VIP 0–3 and control 0 to 3 years to VIP 3–5 or control 3 to 5 years. In the VIP, a bilingual facilitator video recorded the parent and child reading and/or playing using provided learning materials and reviewed videos to reinforce positive interactions. Social-emotional development at 4.5 years was assessed by parent-report Behavior Assessment System for Children, Second Edition (Social Skills, Attention Problems, Hyperactivity, Aggression, Externalizing Problems).
    RESULTS:
    VIP 0–3 and VIP 3–5 were independently associated with improved 4.5-year Behavior Assessment System for Children, Second Edition T-scores, with effect sizes (Cohen’s d) ~–0.25 to –0.30. Receipt of combined VIP 0–3 and VIP 3–5 was associated with d = –0.63 reduction in Hyperactivity (P = .001). VIP 0–3 resulted in reduced “Clinically Significant” Hyperactivity (relative risk reduction for overall sample: 69.2%; P = .03; relative risk reduction for increased psychosocial risk: 100%; P = .006). Multilevel models revealed significant VIP 0–3 linear effects and age x VIP 3–5 interactions.
    CONCLUSIONS:
    Phase VIP 0–3 resulted in sustained impacts on behavior problems 1.5 years after program completion. VIP 3–5 had additional, independent impacts. With our findings, we support the use of pediatric primary care to promote reading aloud and play from birth to 5 years, and the potential for such programs to enhance social-emotional development.


  • Imaging in Pediatric Concussion: A Systematic Review
    CONTEXT:
    Pediatric mild traumatic brain injury (mTBI) is a common and poorly understood injury. Neuroimaging indexes brain injury and outcome after pediatric mTBI, but remains largely unexplored.
    OBJECTIVE:
    To investigate the differences in neuroimaging findings in children/youth with mTBI. Measures of behavior, symptoms, time since injury, and age at injury were also considered.
    DATA SOURCES:
    A systematic review was conducted up to July 6, 2016.
    STUDY SELECTION:
    Studies were independently screened by 2 authors and included if they met predetermined eligibility criteria: (1) children/youth (5–18 years of age), (2) diagnosis of mTBI, and (3) use of neuroimaging.
    DATA EXTRACTION:
    Two authors independently appraised study quality and extracted demographic and outcome data.
    RESULTS:
    Twenty-two studies met the eligibility criteria, involving 448 participants with mTBI (mean age = 12.7 years ± 2.8). Time postinjury ranged from 1 day to 5 years. Seven different neuroimaging methods were investigated in included studies. The most frequently used method, diffusion tensor imaging (41%), had heterogeneous findings with respect to the specific regions and tracts that showed group differences. However, group differences were observed in many regions containing the corticospinal tract, portions of the corpus callosum, or frontal white-matter regions; fractional anisotropy was increased in 88% of the studies.
    LIMITATIONS:
    This review included a heterogeneous sample with regard to participant ages, time since injury, symptoms, and imaging methods which prevented statistical pooling/modelling.
    CONCLUSIONS:
    These data highlight essential priorities for future research (eg, common data elements) that are foundational to progress the understanding of pediatric concussion.


  • Variability of Very Low Birth Weight Infant Outcome and Practice in Swiss and US Neonatal Units
    OBJECTIVES:
    Outcomes of very preterm infants vary considerably between health care facilities. Our objective was to compare outcome and practices between the Swiss Neonatal Network (SNN) and US members of the Vermont Oxford Network (US-VON).
    METHODS:
    Retrospective observational study including all live-born infants with a birth weight between 501 and 1500 g as registered by SNN and US-VON between 2012 and 2014. We performed multivariable and propensity score-matched analyses of neonatal outcome by adjusting for case-mix, race, prenatal care, and unit-level factors, and compared indirectly standardized practices.
    RESULTS:
    A total of 123 689 infants were born alive in 696 US-VON units and 2209 infants were born alive in 13 SNN units. Adjusted risk ratios (aRRs) for the composite “death or major morbidity” (aRR: 0.56, 95% confidence interval: 0.51–0.62) and all other outcomes were either comparable or lower in SNN except for mortality, for which aRR was higher (aRR: 1.28, 95% confidence interval: 1.09–1.50). Propensity score matching and restricting the analysis to infants for which we expect no survival bias, because both networks routinely initiate intensive care at birth, revealed comparable aRR. Variations in observed practices between SNN and US-VON were large.
    CONCLUSIONS:
    The SNN units had a significantly lower risk ratio for death or major morbidity. Despite higher mortality, this difference is independent of survival bias. The higher delivery room mortality reflects the SNN practice to favor primary nonintervention for infants born


  • Antibiotic Use After Removal of Penicillin Allergy Label
    BACKGROUND:
    Penicillin allergy is commonly reported in the pediatric emergency department. We previously performed 3-tier penicillin allergy testing on children with low-risk symptoms, and 100% tolerated a penicillin challenge without an allergic reaction. We hypothesized that no serious allergic reactions would occur after re-exposure to penicillin and that prescription practices would change after testing.
    METHODS:
    We performed a follow-up case series of 100 children whose test results were negative for penicillin allergy. Research staff administered a brief follow-up phone survey to the parent and primary care provider of each patient tested. We combined the survey data and summarized baseline patient characteristics and questionnaire responses. We then completed a 3-tier economic analysis from the prescription information gathered from surveys in which cost savings, cost avoidance, and potential cost savings were calculated.
    RESULTS:
    A total of 46 prescriptions in 36 patients were reported by the primary care provider and/or parents within the year after patients were tested for penicillin allergy. Twenty-six (58%) of the prescriptions filled were penicillin derivatives. One (4%) child developed a rash 24 hours after starting the medication; no child developed a serious adverse reaction after being given a penicillin challenge. We found that the cost savings of delabeling patients as penicillin allergic was $1368.13, the cost avoidance was $1812.00, and the total potential cost savings for the pediatric emergency department population was $192 223.00.
    CONCLUSIONS:
    Children with low-risk penicillin allergy symptoms whose test results were negative for penicillin allergy tolerated a penicillin challenge without a severe allergic reaction developing. Delabeling children changed prescription behavior and led to actual health care savings.


  • Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders
    BACKGROUND:
    Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT.
    METHODS:
    We reviewed subjects


  • The Grief of Mothers After the Sudden Unexpected Death of Their Infants
    BACKGROUND:
    The loss of a child is associated with elevated grief severity, and sudden infant death syndrome (SIDS) is the leading cause of postneonatal mortality in the United States. The diagnosis of prolonged grief disorder (PGD) has gained broader acceptance and use. Little is known about PGD in mothers after SIDS.
    METHODS:
    Between May 2013 and July 2016, we assessed 49 SIDS-bereaved mothers living in informal settlements near Cape Town, South Africa, and on the Pine Ridge Indian Reservation and 359 SIDS-bereaved mothers affiliated with SIDS parent-support organizations in the United States, United Kingdom, Australia, New Zealand, and the Netherlands. We examined PGD symptom severity and diagnostic prevalence rates between the samples and other significant grief indicators during the period 2 to 48 months after the deaths of their infants.
    RESULTS:
    Extremely high, persistent, and similar rates of PGD were found in both samples at every time interval. The prevalence of PGD was 50.0% in either sample (mean months from loss: 20.5 vs 24.9). Daily, intrusive emotional pain or yearning was found in 68.1% of subjects; yearning was significantly associated with emotional pain (P < .0001). Role confusion and anger were the most prevalent symptoms, reported by the majority at every time interval. Rates of role confusion, anger, and diminished trust in others remained constant. Acceptance was less prevalent than other grief indicators at every interval.
    CONCLUSIONS:
    Severe symptoms and heightened risk for PGD was seen in mothers after their infants died of SIDS, with discernible symptom profiles. Given their involvement with families after SIDS, pediatricians may have a unique role in identifying this problem and helping address its consequences.



  • Electronic Cigarettes and Future Marijuana Use: A Longitudinal Study
    BACKGROUND:
    Cigarettes have been strongly associated with subsequent marijuana use among adolescents, but electronic cigarettes (e-cigarettes) are now rapidly replacing traditional cigarettes among youth. This study examines associations between youth e-cigarette use and subsequent marijuana use in a national sample.
    METHODS:
    Youth (aged 12–17 years) never marijuana users at wave 1 (n = 10 364; 2013–2014) from the Population Assessment of Tobacco and Health study were followed-up in 1 year (wave 2, 2014–2015). Multivariable logistic regressions were performed to evaluate associations between e-cigarette use at wave 1 and ever/heavy marijuana use in the past 12 months (P12M) and at wave 2.
    RESULTS:
    Among never marijuana users, e-cigarette ever use (versus never use) at wave 1 was associated with increased likelihood of marijuana P12M use (adjusted odds ratio [aOR] = 1.9; 95% confidence interval [CI]: 1.4–2.5) at wave 2. There was a significant interaction between e-cigarette use and age (P < .05) with aOR = 2.7 (95% CI: 1.7–4.3) for adolescents aged 12 to 14 and aOR = 1.6 (95% CI: 1.2–2.3) for adolescents aged 15 to 17. The association with heavy marijuana use was significant among younger adolescents (aOR = 2.5; 95% CI: 1.2–5.3) but was not among older adolescents. Heavier e-cigarette use at wave 1 yielded higher odds of P12M and heavy marijuana use at wave 2 for younger adolescents.
    CONCLUSIONS:
    E-cigarette use predicts subsequent marijuana use among youth, with a stronger associations among young adolescents. Reducing youth access to e-cigarettes may decrease downstream marijuana use.


  • Hip Synovial Fluid Cell Counts in Children From a Lyme Disease Endemic Area
    BACKGROUND:
    Patients with septic hip arthritis require surgical drainage, but they can be difficult to distinguish from patients with Lyme arthritis. The ability of synovial fluid white blood cell (WBC) counts to help discriminate between septic and Lyme arthritis of the hip has not been investigated.
    METHODS:
    We assembled a retrospective cohort of patients ≤21 years of age with hip monoarticular arthritis and a synovial fluid culture obtained who presented to 1 of 3 emergency departments located in Lyme disease endemic areas. Septic arthritis was defined as a positive synovial fluid culture result or synovial fluid pleocytosis (WBC count ≥50 000 cells per µL) with a positive blood culture result. Lyme arthritis was defined as positive 2-tiered Lyme disease serology results and negative synovial fluid bacterial culture results. All other patients were classified as having other arthritis. We compared median synovial fluid WBC counts by arthritis type.
    RESULTS:
    Of the 238 eligible patients, 26 (11%) had septic arthritis, 32 (13%) had Lyme arthritis, and 180 (76%) had other arthritis. Patients with septic arthritis had a higher median synovial fluid WBC count (126 130 cells per µL; interquartile range 83 303–209 332 cells per µL) than patients with Lyme arthritis (53 955 cells per µL; interquartile range 33 789–73 375 cells per µL). Eighteen patients (56%) with Lyme arthritis had synovial fluid WBC counts ≥50 000 cells per µL. Of the 94 patients who underwent surgical drainage, 13 were later diagnosed with Lyme arthritis.
    CONCLUSIONS:
    In Lyme disease endemic areas, synovial fluid WBC counts cannot always help differentiate septic from Lyme arthritis. Rapid Lyme diagnostics could help avoid unnecessary operative procedures in patients with Lyme arthritis.


  • Allergen-Specific Immunotherapy in the Treatment of Pediatric Asthma: A Systematic Review
    CONTEXT:
    Treatment options for allergic asthma include allergen avoidance, pharmacotherapy, and allergen immunotherapy.
    OBJECTIVES:
    Summarize and update current evidence for the efficacy and safety of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) in pediatric allergic asthma.
    DATA SOURCES:
    PubMed, Embase, Cochrane Central Register of Controlled Trials (January 1, 2005, through May 8, 2017), ClinicalTrials.gov, and the US Food and Drug Administration Adverse Event Reporting System. We reevaluated trials from our 2013 systematic review.
    STUDY SELECTION:
    We included studies with children ≤18 years of age in which researchers reported on prespecified outcomes and had an intervention arm receiving aeroallergen SCIT or SLIT. Only randomized controlled trials (RCTs) were included for efficacy. RCTs and non-RCTs were included for safety outcomes.
    DATA EXTRACTION:
    Two reviewers extracted data. We included 40 studies (17 SCIT trials, 11 SLIT trials, 8 non-RCTs for SCIT safety, and 4 non-RCTs for SLIT safety).
    RESULTS:
    We found moderate-strength evidence that SCIT reduces long-term asthma medication use. We found low-strength evidence that SCIT improves asthma-related quality of life and forced expiratory volume in 1 second. There was also low-strength evidence that SLIT improves medication use and forced expiratory volume in 1 second. There was insufficient evidence on asthma symptoms and health care use.
    LIMITATIONS:
    There were no trials in which researchers evaluated asthma symptoms using a validated tool. Study characteristics and outcomes were reported heterogeneously.
    CONCLUSIONS:
    In children with allergic asthma, SCIT may reduce long-term asthma medication use. Local and systemic allergic reactions are common, but anaphylaxis is reported rarely.


  • Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers
    BACKGROUND:
    Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions.
    METHODS:
    Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3–9 years old) and adolescents (10–17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date.
    RESULTS:
    Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4–82) to 144 (95% CI 36–1248). The corresponding range for suicidal ideation was 25 (95% CI 14–45) to 54 (95% CI 18–218).
    CONCLUSIONS:
    TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.



  • Neurobehavioral Outcomes 11 Years After Neonatal Caffeine Therapy for Apnea of Prematurity
    BACKGROUND AND OBJECTIVES:
    Caffeine is effective in the treatment of apnea of prematurity. Although caffeine therapy has a benefit on gross motor skills in school-aged children, effects on neurobehavioral outcomes are not fully understood. We aimed to investigate effects of neonatal caffeine therapy in very low birth weight (500–1250 g) infants on neurobehavioral outcomes in 11-year-old participants of the Caffeine for Apnea of Prematurity trial.
    METHODS:
    Thirteen academic hospitals in Canada, Australia, Great Britain, and Sweden participated in this part of the 11-year follow-up of the double-blind, randomized, placebo-controlled trial. Measures of general intelligence, attention, executive function, visuomotor integration and perception, and behavior were obtained in up to 870 children. The effects of caffeine therapy were assessed by using regression models.
    RESULTS:
    Neurobehavioral outcomes were generally similar for both the caffeine and placebo group. The caffeine group performed better than the placebo group in fine motor coordination (mean difference [MD] = 2.9; 95% confidence interval [CI]: 0.7 to 5.1; P = .01), visuomotor integration (MD = 1.8; 95% CI: 0.0 to 3.7; P < .05), visual perception (MD = 2.0; 95% CI: 0.3 to 3.8; P = .02), and visuospatial organization (MD = 1.2; 95% CI: 0.4 to 2.0; P = .003).
    CONCLUSIONS:
    Neonatal caffeine therapy for apnea of prematurity improved visuomotor, visuoperceptual, and visuospatial abilities at age 11 years. General intelligence, attention, and behavior were not adversely affected by caffeine, which highlights the long-term safety of caffeine therapy for apnea of prematurity in very low birth weight neonates.


  • A Modified Algorithm for Critical Congenital Heart Disease Screening Using Pulse Oximetry
    OBJECTIVES:
    Determine the performance of the American Academy of Pediatrics (AAP) critical congenital heart disease (CCHD) newborn screening algorithm and the impact of an alternative algorithm.
    METHODS:
    Screening was performed on term infants without a known CCHD diagnosis at or near 24 hours of age at a tertiary birth hospital by using the AAP algorithm from 2013 to 2016. Retrospective review from the birth hospital and the area’s sole pediatric cardiac center identified true- and false-positives and true- and false-negatives. A simulation study modeled the results of a modified screening algorithm with a single repeat pulse oximetry test instead of 2.
    RESULTS:
    Screening results were collected on 77 148 newborns . By using the current AAP algorithm, 77 114 (99.96%) infants passed screening, 18 infants failed for an initial saturation of


  • Timing and Location of Emergency Department Revisits
    BACKGROUND:
    Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED.
    METHODS:
    We studied ED discharges for children


  • The Tobacco Industry and Childrens Rights
    The manufacture, use, and marketing of tobacco present a serious threat to children’s right to health. This makes the Convention on the Rights of the Child a potentially powerful tobacco-control tool and the United Nations Children’s Fund (UNICEF), which oversees the convention’s implementation, a potential leader in tobacco control. UNICEF actively supported tobacco control initiatives in the late 1990s, but since the early 2000s UNICEF’s role in tobacco control has been minimal. Using the Truth Tobacco Industry Documents library, an online collection of previously secret tobacco industry documents, we sought to uncover information on the tobacco industry’s ties with UNICEF. We found that from 1997 to 2000, when UNICEF was actively promoting tobacco control to support children’s rights, the tobacco industry saw children’s rights and UNICEF as potentially powerful threats to business that needed to be closely monitored and neutralized. The industry then positioned itself as a partner with UNICEF on youth smoking prevention initiatives as a way to avoid meaningful tobacco control measures that could save children’s lives. After UNICEF’s corporate engagement guidelines were loosened in 2003, tobacco companies successfully engaged with UNICEF directly and via front groups, including the Eliminating Child Labour in Tobacco Growing Foundation. This was part of an overall tobacco industry strategy to improve its corporate image, infiltrate the United Nations, and weaken global tobacco-control efforts. As part of its mission to protect children’s rights, UNICEF should end all partnerships with the tobacco industry and its front groups.


  • Mortality After Pediatric Arterial Ischemic Stroke
    OBJECTIVES:
    Cerebrovascular disease is among the top 10 causes of death in US children, but risk factors for mortality are poorly understood. Within an international registry, we identify predictors of in-hospital mortality after pediatric arterial ischemic stroke (AIS).
    METHODS:
    Neonates (0–28 days) and children (29 days–












  • School Bus Transportation of Children With Special Health Care Needs
    School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation provided by the school system. A plan to provide the most current and proper support to children with special transportation needs should be developed by the Individualized Education Program team, including the parent, school transportation director, and school nurse, in conjunction with physician orders and recommendations. With this statement, we provide current guidance for the protection of child passengers with specific health care needs. Guidance that applies to general school transportation should be followed, inclusive of staff training, provision of nurses or aides if needed, and establishment of a written emergency evacuation plan as well as a comprehensive infection control program. Researchers provide the basis for recommendations concerning occupant securement for children in wheelchairs and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidance for restraint systems for children with special needs and by remaining informed of new resources. Pediatricians can also play an important role at the state and local level in the development of school bus specifications.




  • Interpretation of Do Not Attempt Resuscitation Orders for Children Requiring Anesthesia and Surgery
    This clinical report addresses the topic of pre-existing do not attempt resuscitation or limited resuscitation orders for children and adolescents undergoing anesthesia and surgery. Pertinent considerations for the clinician include the rights of children, decision-making by parents or legally approved representatives, the process of informed consent, and the roles of surgeon and anesthesiologist. A process of re-evaluation of the do not attempt resuscitation orders, called “required reconsideration,” should be incorporated into the process of informed consent for surgery and anesthesia, distinguishing between goal-directed and procedure-directed approaches. The child’s individual needs are best served by allowing the parent or legally approved representative and involved clinicians to consider whether full resuscitation, limitations based on procedures, or limitations based on goals is most appropriate.