Pediatrics最新文献

Pediatricians play a key role in preparing patients and families for anesthesia and surgery by primarily addressing 2 major areas of concern. The first involves preparation and ensures that the patient is in optimal medical condition for surgery and that the patient and family are emotionally and cognitively ready for surgery. The second category concerns logistics and addresses the necessary communication and prerequisites to enable safe passage through the perioperative process. This revised report updates the recommendations for the pediatrician's role in the perioperative preparation of patients.

Background and objectives: Children with medical complexity are caregiver dependent because of complex, chronic health conditions; functional limitations; technology dependence; and high health care use. Their parental caregivers have suboptimal mental health, yet little is known about the psychiatric profiles of this group. We aimed to describe the clinical and demographic characteristics of parents of children with medical complexity seen by an integrated psychiatry service.

Methods: This is a descriptive case series using retrospective medical record review of electronic medical records from 2020 to 2023. We developed a novel psychiatry service in partnership with a pediatric complex care program for diagnostic assessment and treatment of parental caregivers of children with medical complexity in Toronto, Ontario. We included all parents of children with medical complexity who were seen by the psychiatry service for assessment and treatment of suspected mental illness (n = 57).

Results: Most parents received a new diagnosis (79%); the most common diagnoses were depressive disorders (67%), anxiety disorders (65%), and trauma- and stressor-related disorders (56%). Common treatment recommendations included psychotherapy (95%) and medication (75%). The sample was 84% female with a mean age of 42 years (SD 6 years). All consultations occurred virtually.

Conclusions: We identified a high number of treatable psychiatric illnesses in the referred parents. Partnerships between pediatric complex care teams and psychiatry services and using virtual care may help with timely and accessible mental health care for this at-risk population. Future research could investigate adherence to and efficacy of treatment recommendations for this caregiver population.

We report a case of delayed acute liver injury (ALI) after treatment with delandistrogene moxeparvovec-rokl (DM), an adeno-associated virus-based gene therapy, in a 10-year-old ambulatory boy with Duchenne muscular dystrophy (DMD). The patient had a duplication of exons 8-11 in the DMD gene and was on chronic prednisone. He received prophylactic oral prednisone (1 mg/kg/d) starting 1 day before DM infusion. Baseline alanine aminotransferase (ALT), aspartate aminotransferase (AST), and creatine kinase (CK) levels were elevated, consistent with DMD. On day 34 after infusion, ALT and AST began to rise without gamma-glutamyl transpeptidase (GGT) elevation. By day 41, transaminases were more than 7× baseline with elevated GGT and bilirubin, prompting hospitalization. He was treated with intravenous methylprednisolone, increased oral prednisone, and sirolimus. Liver enzymes rapidly improved and returned to baseline by day 69. Immunologic studies revealed CD8+ T-cell activation and innate immune activation via mildly elevated IL-18 that normalized without additional immunosuppression. The patient remained clinically stable. Infectious workup, liver ultrasonogram, and coagulation studies were unremarkable. Notably, the ALT/CK ratio increased more than 10-fold 1  week before GGT elevation and before ALT exceeded the 95% CI predicted by a CK- and age-adjusted model, suggesting its potential as an early biomarker of liver injury in DMD. This case highlights the challenges of interpreting liver enzymes in DMD, the potential utility of the ALT/CK ratio for early detection of ALI, and the role of immunophenotyping in guiding immunosuppressive therapy. Early recognition and timely escalation, including use of sirolimus, may help mitigate serious liver toxicity after gene therapy.

Objective: Compared with first-generation antihistamines (FGAs), second-generation antihistamines (SGAs) are equally effective, longer acting, and better tolerated. We aimed to reduce the proportion of patients receiving FGAs among all receiving antihistamines from baselines of 74% in the pediatric emergency department (PED) and 54% in inpatient units by 50% within 6 months and sustain this change for 6 months.

Methods: This multidisciplinary quality improvement initiative was conducted between 2022-2024. Implemented interventions were clinician education, flyers, ensuring cetirizine availability, and clinical pathways updates. The outcome measures were the proportion of patients receiving FGAs (diphenhydramine or hydroxyzine) or SGAs (cetirizine) among all receiving antihistamines. The process measures were educational sessions, knowledge assessments, and clinical pathways usage. The balancing measures were emergency department revisit within 48 hours, median inpatient length of stay, and antihistamine cost. We assessed improvement using statistical process control charts.

Results: The proportion of patients receiving FGAs decreased from 74% to 28% in the PED and from 54% to 36% in inpatient units. Reductions were sustained for 8.5 and 9 months, respectively. Cetirizine use increased from 31% to 75% in the PED and from 54% to 74% in inpatient units. Knowledge scores doubled posteducation. Clinical pathways usage increased from 36 to 44 clinicians monthly. Emergency department revisits and length of stay remained stable. Monthly median antihistamine costs increased in the PED from $53 to $177 and inpatient from $57 to $104.

Conclusions: Using the Model for Improvement, we reduced FGA use and increased cetirizine use in the PED and inpatient setting.

Objectives: Children with medical complexity (CMC) are a growing population of pediatric patients with disabling multisystem conditions leading to reliance on medical devices and disposable supplies. These products are essential for CMC, but prior research has linked problems with home devices to emergency care and hospitalizations. We aimed to understand parent experiences with in-home devices and identify opportunities for improvement.

Methods: A cross-sectional qualitative study of English and Spanish-speaking parents of CMC was conducted using semistructured interviews. Parents could also opt to send pictures with descriptions of their children's home device use. Applied thematic analysis and content analysis were used to identify key themes and preferred design attributes.

Results: We conducted 17 semistructured interviews with parents of CMC. Eight parents submitted 97 total pictures. Five main themes emerged: (1) lack of communication and education about product availability; (2) frequent, major device design flaws, often with safety and health risks; (3) parents of CMC often addressed unmet device needs and flaws with improvised problem-solving strategies; (4) structural barriers reduce access to efficacious and high-quality in-home devices; and (5) parents of CMC value a variety of medical devices design attributes.

Conclusions: Parents of CMC reported that the current landscape of medical devices functionally available to CMC for life at home and in the community is inadequate. These findings raise concerns that medical device design flaws can pose safety risks and negatively impact the health of CMC. Future work should incorporate user input into tailoring both medical product design and coverage.

Opioid overdose deaths are a leading cause of death for adolescents and young adults in the United States. Many young people, however, are not aware of basic harm reduction principles like overdose recognition, naloxone administration, and protections provided by Good Samaritan laws. This article describes advocacy efforts to create peer-to-peer opioid education and naloxone distribution (OEND) in a high school setting. Through the recruitment of multidisciplinary partners, the team created a novel student-led initiative in a high school setting to provide peer education. The high school students leveraged their existing relationships with teachers and peers to promote their classroom didactics, and they were able to provide overdose prevention education to 46 classes. In a focus group at the end of the school year, the peer educators stated that they were prepared to teach about overdose prevention, the student-led design was appreciated by their peers, and they planned to spread their model for OEND programming to local high schools. There was an increase in naloxone distribution following the student-led initiatives, with 94 kits distributed, a 247% increase from baseline distribution efforts at the beginning of the year. Ultimately, the high school health center was able to distribute 150 kits of free naloxone throughout the school year. This model serves as an example for using existing school resources, and particularly partnering with school-based health centers, to create a model for youth-led programs addressing overdose awareness in adolescents.

Background and objectives: On social media, people are expected to disclose any sponsored content. However, celebrities who own alcohol brands and make posts promoting their brands may circumvent these disclosure policies, potentially exposing young audiences to alcohol marketing. This study examined the extent to which celebrities promoted their own alcohol brands on Instagram, whether they disclosed the content as sponsored, and whether the posts were visible to underage users.

Methods: Through systematic Google searches, we identified 112 celebrities who own alcohol brands. We retrieved 85 673 of their Instagram posts published between January 1, 2020, and December 31, 2023. Alcohol-brand posts were identified through text-pattern matching. We checked the accessibility of alcohol-brand posts to underage users using a simulated 15-year-old account.

Results: Among 112 celebrities (mean age = 50.8 years; 72.3% male), 42 (37.5%) explicitly mentioned their brand in their Instagram bio, and 84 (75%) referenced their own alcohol brand in at least 1 post during the study period. Of the 85 673 total posts, 3.4% mentioned a celebrity's alcohol brand. Concerningly, only 1.7% of these alcohol-brand posts included a clear disclosure in the caption and 98% (646/660) of sampled alcohol-brand posts were visible to a simulated 15-year-old account.

Conclusions: Celebrities' posts about their own alcohol brands were common and accessible to underage users. Policymakers should implement stricter regulations on alcohol promotions on social media to protect adolescents from exposure to alcohol-related content.