Pediatrics最新文献

Objectives: The prevalence of gastroschisis has been increasing for decades globally across all ages and races/ethnicities and is one of few birth defects with rising prevalence in both developing and developed countries. However, there are some indications that rates in the United States may be declining. We aim to investigate national gastroschisis prevalence with 3 independent large-scale databases. We hypothesize that from 2016-2022, the data will congruently reveal a decline in gastroschisis prevalence in the United States.

Methods: This study is a retrospective cross-sectional database review of 3 national datasets: 1 clinical outcomes-based dataset (the American College of Surgeons [ACS] National Surgical Quality Improvement Program-Pediatric [NSQIP-P] dataset), 1 administrative dataset (the Healthcare Cost and Utilization Project-National Inpatient Sample [HCUP-NIS]), and 1 public health-based dataset (the Center for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research [CDC WONDER]). Datasets were analyzed from 2016-2021/2022 for gastroschisis prevalence.

Results: From 2016-2022, the ACS NSQIP-P dataset revealed a decline in gastroschisis frequency from 0.32 to 0.19 per 100 infants. The HCUP-NIS dataset demonstrated a decline from 3.32 to 2.46 per 10 000 births. CDC WONDER data revealed a decline from 2.43 to 1.60 per 10 000 births.

Conclusion: From 2016-2022, 3 large-scale national datasets congruently reveal a decline in gastroschisis prevalence in the United States for the first time in decades. The cause is likely multifactorial and should be further investigated.

Background and objectives: Children aged 9 years and older visit dental providers more frequently than medical providers. Routine dental visits include screenings for human papillomavirus (HPV)-related oropharyngeal cancers and provide opportunities for HPV vaccination. The objective of this project was to implement a medical-dental integration (MDI) program to enhance HPV vaccine administration among children aged 9 to 17 years being seen at dental clinics.

Methods: Between June 1, 2021, and May 31, 2023, we conducted a quality improvement initiative at dental clinics within a large, integrated, safety-net health care system in Denver, Colorado. We implemented an MDI program in which dental professionals recommended the HPV vaccine and integrated medical staff administered the vaccine during the appointment. The primary outcome assessed was the HPV vaccine receipt on the same day as the dental visit. We used interrupted time series and multivariate regression models to assess the intervention's effectiveness.

Results: During the intervention period, this program reached 2781 dental visits, with 77% of children covered by Medicaid and 21% uninsured. Among them, 60% identified as Hispanic, 23% identified as Black, and 40% preferred to speak Spanish. Interrupted time series analysis revealed an immediate 9.8% improvement. The overall vaccination rate at eligible visits increased from 5.3% to 13.9% during the 1-year intervention. The adjusted odds ratio (aOR) of HPV vaccination at a dental visit was 4 times higher during the intervention (aOR, 4.37; 95% CI, 3.22-5.92) compared with preintervention.

Conclusions: MDI was an effective intervention to increase HPV vaccination rates at a safety-net health care system.

Background and objectives: Children from lower-income households lose less weight in family-based weight management interventions, likely due to barriers to treatment attendance and adherence. The CHECK randomized controlled trial tested whether delivering pediatric weight management interventions in the home improves weight loss outcomes relative to clinic-delivered intervention.

Methods: Enrolled families included 269 children (137 boys) who were aged 6 to 12 years, had overweight/obesity, and lived in lower-income English- or Spanish-speaking households in Chicago, Illinois (2017-2022). All families received a 12-month pediatric weight management intervention with 18 planned in-person sessions and 12 planned telephone contacts. The sole difference between arms was the location (home vs clinic) of in-person intervention sessions. Intention-to-treat analyses compared treatment arms on 12-month change in BMI z-score (zBMI), intervention session attendance and contact time, and secondary clinical outcomes.

Results: Twelve-month zBMI change did not differ (P = .58) between the home-delivered (n = 133; -0.031, SD = 0.26) and clinic-delivered arms (n = 136; -0.002, SD = 0.30). Across both arms, session attendance and total contact time predicted larger decreases in zBMI. Both variables were higher in the home-delivered arm (median = 11 sessions, 500 minutes) than the clinic-delivered arm (median = 6.5 sessions, 315.5 minutes; P values < .001). Post hoc analyses indicated that home-delivered (vs clinic-delivered) intervention led to 0.03 (SE = 0.008, P = .0004) greater zBMI reductions across time points prior to the COVID-19 pandemic, but not after.

Conclusions: Home delivery did not improve overall 12-month weight loss outcomes. Home-delivered intervention did increase session attendance and contact time and may have had beneficial weight loss effects prior to the COVID-19 pandemic.

Obesity remains highly prevalent among children in the United States and is associated with an ever-increasing burden of obesity-related diseases. Effective pediatric obesity prevention and treatment will require both societal interventions and health care system innovation. One recent advancement is the approval of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for use in adolescents. GLP-1RAs are notable for their effectiveness in weight management and in their ability to ameliorate obesity-related diseases. GLP-1RAs can be an important part of a comprehensive treatment plan for pediatric patients seeking obesity care, and we will review the pediatric clinician's considerations for their effective use. We discuss the history of obesity pharmacology and development of GLP-1RAs. We review the indications for use and common adverse reactions. We highlight the importance of mental health care for obesity treatment, with a focus on disordered eating behaviors and their intersection with obesity and pharmacologic treatment of obesity. Nutrition remains an important issue for obesity prevention and management, and we highlight nutritional concerns during GLP-1RA therapy. Finally, we discuss health inequities in obesity, the dangers of perpetuating these inequities if GLP-1RA access remains biased, and the opportunities for improvement.

Objectives: Children with neurologic impairment (CNI) are commonly hospitalized with pneumonia but are often excluded from practice guidelines. We sought to develop evidence-based, expert-panel endorsed recommendations for the care of CNI hospitalized with pneumonia.

Methods: We conducted an extensive literature search that formed the basis of drafted candidate recommendations for diagnostic testing, antimicrobial treatment, airway clearance, and discharge criteria. We convened a national panel of individuals with expertise in nursing, pediatric medicine (infectious diseases, pulmonology, hospital medicine, complex care), and family advocacy. Using the RAND/University of California Los Angeles Appropriateness Method, including a moderated panel meeting, panelists rated recommendations for appropriateness in 2 sequential rounds.

Results: The panel assessed 73 drafted recommendations for diagnostic testing, antimicrobial treatment, airway clearance, and discharge criteria for CNI hospitalized with pneumonia. After modifications to 2 of the drafted recommendations, the panel reached agreement on the appropriateness of 72 recommendations. Recommendations include management that minimizes the use of broad-spectrum antibiotics. Recommendations further emphasize collaboration with respiratory therapists for airway clearance and with families, outpatient managing physicians, and homecare providers for discharge. The recommendations for pneumonia diagnosis and management account for heterogeneity in the patient population, including comorbidities and risk factors (eg, aspiration risk), as well as severity of presenting illness.

Conclusion: Recommendations for appropriate diagnostic testing, antimicrobial treatment, airway clearance, and discharge criteria for CNI hospitalized with pneumonia can be used to inform clinical care. The effect of these recommendations on patient- and family-centered outcomes should be studied.

The shortage of novel pediatric devices that accommodate the unique needs of children exists due to several scientific, clinical, regulatory, and financial barriers. This global unmet need is being addressed in the United States by multiple stakeholders including the Food and Drug Administration (FDA) and its Pediatric Device Consortia (PDC) grant program. One critical area of interest is the suboptimal medical device clinical trial infrastructure that currently exists in academic medical centers and compounded at children's hospitals. Although pediatric drug clinical trial infrastructure is often well developed at many children's hospitals, these capabilities do not necessarily translate to pediatric device trials. The chief challenge to address is the recognition of differences in conducting device vs drug trials. We need to shift the paradigm by introducing best practices and a set of tools and job aids to assist the stakeholders of device trials at children's hospitals. Pediatric medical device clinical trial support has unique infrastructure needs and barriers compared to trials carried out of adult medical devices and drugs. Well-coordinated cross-sector collaboration is needed to advance the state of pediatric medical devices. To assess these gaps and challenges, surveys and interviews were conducted with key leaders at each of the children's hospitals primarily associated with the 5 FDA-supported PDCs. Reviews of pediatric device clinical trials were performed at each institution with the goal of identifying the common denominators and specifics of best practices, challenges, and areas of improvement for conducting and supporting pediatric device trials.

Background: The American Academy of Pediatrics recommends up to 7 days of observation for neonatal opioid withdrawal syndrome (NOWS) in infants with chronic opioid exposure. However, many of these infants will not develop NOWS, and infants with seemingly less exposure to opioids may develop severe NOWS that requires in-hospital pharmacotherapy. We adapted and validated a prediction model to help clinicians identify infants at birth who will develop severe NOWS.

Methods: This prognostic study included 33 991 births. Severe NOWS was defined as administration of oral morphine. We applied logistic regression with a least absolute shrinkage selection operator approach to develop a severe NOWS prediction model using 37 predictors. To contrast the model with guideline screening criteria, we conducted a decision curve analysis with chronic opioid exposure defined as the mother receiving a diagnosis for opioid use disorder (OUD) or a prescription for long-acting opioids before delivery.

Results: A total of 108 infants were treated with oral morphine for NOWS, and 1243 infants had chronic opioid exposure. The model was highly discriminative, with an area under the receiver operating curve of 0.959 (95% CI, 0.940-0.976). The strongest predictor was mothers' diagnoses of OUD (adjusted odds ratio, 47.0; 95% CI, 26.7-82.7). The decision curve analysis shows a higher benefit with the model across all levels of risk, compared with using the guideline criteria.

Conclusion: Risk prediction for severe NOWS at birth may better support clinicians in tailoring nonpharmacologic measures and deciding whether to extend birth hospitalization than screening for chronic opioid exposure alone.

Background and objectives: Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic.

Methods: A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children's hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis.

Results: Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0-16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients.

Conclusions: Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children's hospitals.