Pediatrics最新文献

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.

A previously healthy 15-year-old female developed sudden onset right lower extremity swelling, pain, and erythematous linear streaking from the ankle to mid-thigh. Duplex venous ultrasound revealed multiple superficial and deep venous thrombi in the right lower extremity. Incidentally, the patient was also noted to have elevated transaminases and a microcytic anemia with significant iron deficiency. Additional evaluation ultimately led to the diagnosis of 2 distinct but interconnected chronic conditions, one of which progressed to requiring liver transplantation.

Background and objectives: Diagnosis of adnexal torsion is challenging due to variable clinical presentations and often inconclusive imaging results. We hypothesized that diagnostic delays are common, leading to prolonged ischemia and subsequent tissue loss. We aimed to identify factors associated with diagnostic delays in pediatric patients with adnexal torsion.

Methods: We performed a multi-institutional retrospective review of females aged 5 to 18 years with confirmed adnexal torsion between 2013 to 2022. Delay to care was defined as prior emergency department discharge within 7 days of operation and/or hospital admission without initial plan for operation.

Results: 862 patients were identified from 10 children's hospitals, with delayed diagnosis in 30%. Patients with delay were less likely to present with emesis or fever, have initial pediatric surgery consultation, or have typical ultrasound findings of torsion compared to those without delay (P < .05). For every unit increase in area deprivation index, the odds of delay increased by 1.3% (odds ratio 1.013, 95% CI, 1.007-1.018). The odds of delay were 81% greater for patients living > 30 miles from the hospital compared with 1-10 miles (odds ratio 1.812, 95% CI, 1.236-2.657). Oophorectomy and salpingectomy rates were 10% and 13%; those with delay had higher risk of oophorectomy (14% vs 7%, P = .002).

Conclusion: Delayed diagnosis of adnexal torsion is common and associated with higher area deprivation index and farther distance from hospital. Risk of oophorectomy was higher in patients with delay. Improved diagnostics and increased awareness of social disparities are critical to decrease time to definitive treatment and improve rates of adnexal salvage.

This report helps pediatric primary care providers quickly identify infants with biliary atresia, which has the potential to improve outcomes and reduce need for liver transplant. The strategy is intended to be used between 2 and 4 weeks of life at the "By 1 month" well-child visit in the Bright Futures/American Academy of Pediatrics "Recommendations for Preventive Pediatric Health Care." The strategy involves examining every infant's eye color, stool color, and prior laboratory results to determine whether measurement of a direct or conjugated bilirubin level is warranted.

Objectives: The TEN-4-FACESp bruising clinical decision rule (BCDR) is a validated screening tool utilizing information about a child's body region bruised, age, and pattern of bruising to predict abuse in children younger than 4 years of age. Our objectives were to (1) evaluate the accuracy of the BCDR in predicting abuse when only 1 bruise was present and (2) identify other characteristics differentiating abusive from accidental injury in young children with a single bruise.

Methods: Patients included in this secondary analysis were those from the BCDR validation study whose only skin finding was a single bruise (including petechiae, subconjunctival hemorrhage, or frenulum injury). Cases were previously classified as abuse, accident, or indeterminate by an expert panel. We compared demographics, clinical characteristics, bruising regions, and psychosocial risk factors (PRFs) between abuse and accident groups.

Results: Of 349 patients with a single bruise, 27 were classified as abuse. The TEN-4-FACESp BCDR performed with 81.5% sensitivity and 87.6% specificity in this sample. Patients with abusive injuries were (1) younger and (2) less likely to present with an injury complaint but more likely to (3) have a bruise in a BCDR-positive region, (4) have a lower Glasgow Coma Score, and (5) have PRFs.

Conclusions: The TEN-4-FACESp BCDR is an effective screening tool for abuse among young children with a single bruise in the pediatric ED. Even 1 BCDR-positive bruise indicated increased risk for abuse. Negative BCDR results must be interpreted with caution given the higher rate of false negatives in this analysis compared with the validation study.