Pediatrics最新文献

Objective: Children with certain underlying conditions are at higher risk for severe influenza-related complications. In the United States, annual influenza vaccination is recommended for all children aged 6 months and older, yet vaccine effectiveness (VE) in children with underlying conditions remains less understood. We assessed VE against laboratory-confirmed influenza in children with and without underlying conditions presenting to emergency departments or admitted to hospitals.

Methods: We enrolled US children aged 6 months to 17 years at 7 pediatric medical centers within the New Vaccine Surveillance Network during 5 influenza seasons (2015-2020). Influenza status was confirmed by molecular testing and vaccination status was verified using state immunization registries or from health care clinicians. Underlying conditions were abstracted from medical records or self-reported by parents/guardians. VE was estimated by comparing the odds of vaccination among influenza-positive cases vs controls, adjusting for age, site, and calendar time.

Results: Of the 15 875 children included, 2821 (18%) tested positive for influenza. Overall, VE against influenza-associated emergency department visits or hospitalizations was 43% (95% CI: 35%-50%) for children with underlying conditions and 53% (95% CI: 47%-59%) for those without, and there was significant effect measure modification by the presence of underlying conditions (P = .04). VE was lowest among children with respiratory conditions (31%, 95% CI: 19%-42%).

Conclusion: Influenza vaccination provided protection in both children with and children without underlying conditions. Efforts to improve influenza vaccination coverage and to initiate early treatment for influenza, particularly in populations at increased risk for severe influenza, are essential to reducing influenza-associated complications.

Context: Cystic fibrosis-related diabetes significantly impacts health outcomes of people with cystic fibrosis (CF). Understanding the effects of CF transmembrane conductance regulator modulator (CFTRm) therapy on glycemic control is crucial for improving overall health in CF.

Objective: To evaluate the impact of CFTRm therapy on glycemic control in people with CF.

Data sources: A comprehensive literature search was conducted from January 1, 2011, to September 19, 2024, in PubMed, Embase, and Cochrane Central Register of Controlled Trials.

Study selection: Eligible studies included interventional trials comparing CFTRm therapy to no treatment or placebo and observational studies reporting glycemic outcomes-assessed by oral glucose tolerance test or continuous glucose monitoring-pretherapy and on therapy or between treated individuals and controls.

Data extraction: Two authors independently extracted data with full adherence to the Cochrane Handbook.

Results: Elexacaftor/tezacaftor/ivacaftor therapy (ETI) significantly improved 120-minute glucose levels (mean difference, -24.30 mg/dL; 95% CI, -44.82 to -3.96) and lowered hemoglobin A1c (HbA1c) levels (mean difference, -0.44%; 95% CI, -0.75 to -0.13). Regression analyses showed that earlier ETI therapy initiation was associated with lower HbA1c values (P = .03). In contrast, lumacaftor/ivacaftor, tezacaftor/ivacaftor, and ivacaftor monotherapy were not associated with significant changes in any assessed outcomes.

Limitations: Our analyses may underestimate the endocrine effects of CFTRm therapies, as most included papers assessed pre- and on-therapy outcomes in the same patients, potentially overlooking the gradual deterioration of glycemic control.

Conclusions: ETI therapy significantly improves glycemic control in CF, particularly when initiated at a young age. Further research is needed to confirm and detail these findings.

This month's Ethics Rounds presents a case of an adolescent and her parent who object to the presence of a transgender adolescent in an established sexual trauma support group. To what extent do clinicians have a duty to consider the most beneficial therapeutic setting for all attendees? To what extent should the religious beliefs of a cisgender adolescent or the identity of a transgender attendee impact the group attendance of others? The case raised an opportunity for ethicists, therapists, an adolescent medicine physician, a social worker, a chaplain, an attorney and conflict mediator, and a palliative physician to consider gender identity and religious nondiscrimination as an ethics stance while also noting respect for persons, dignity, religious freedom, and therapeutic benefit ratios. It is important to foster ethically aligned and equitable care models in a nation increasingly polarized by different "bedrock beliefs."

Objective: Quality improvement collaborations have documented a lack of sustained mortality and morbidity reductions in very low birth weight infants. We calculated mortality/morbidity/hospital stay metrics and major morbidity counts from an affiliated group of neonatal intensive care units (NICUs).

Methods: Sixteen NICUs provided Vermont Oxford Network data on births of 401 to 1500 g and/or at most 29 6/7 weeks from 2010 to 2023 to calculate composite mortality, risk-adjusted morbidity, and hospital stay metrics ascertaining proficiency (Benefit Metric) and efficiency (Value Metric).

Results: In 11 795 infants, median age 28.7 (IQR, 26.4-30.6) weeks, the group Benefit Metric did not improve (P = .59). Only 1 NICU improved their Benefit Metric; 2 worsened. Six morbidity rates were unchanged. Chronic lung disease increased (P < .004). Morbidity counts increased with decreasing gestation. Overall, 37% of infants had at least 1 morbidity. Of infants aged 25 0/7 to 27 6/7 weeks, 57% had at least 1 morbidity, and 21% had at least 2. Of infants aged at most 24 6/7 weeks, 55% had at least 2 morbidities, and 23% had at least 3. Mortality excluding early deaths decreased only for infants born at 28 weeks or more (P < .01). All NICUs demonstrated increasing survivor total hospital length of stay (64-71 days, P < .0001). The group NICUs' Value Metric declined (P < .0001).

Conclusions: The Benefit Metric proficiency score from 16 affiliated NICUs showed no progress 2010 to 2023. The Value Metric efficiency score declined because survivor length of stay increased. To improve mortality, morbidity rates, and cost proxies of resource expenditure will require scalable potentially better practices, robust adherence measurements of evidence-based structures and processes, identification of influential culture/environment factors, extensive shared experience, and development of more comprehensive risk-adjustment methodologies that enhance accurate, meaningful NICU comparisons.

Objective: Prognostic communication is vital to high-quality care for children with serious illness. Yet clinicians often struggle to balance honesty with preservation of hope-especially when prognosis is poor or uncertain. Patients and parents cite hope and uncertainty as central themes in their communication needs, but guidance for clinicians is lacking. This study aimed to characterize patient, parent, and oncologist recommendations for strategies to navigate hope and uncertainty during prognostic discussions.

Methods: Semistructured interviews were conducted with pediatric patients with poor-prognosis cancer (n = 25), parents of patients on therapy (n = 30), bereaved parents (n = 10), and pediatric oncologists (n = 20) from 6 institutions across 5 US states. Participants were asked whether oncologists could support hope while discussing poor prognosis and how oncologists should discuss uncertain prognostic information. Rapid analysis yielded themes in participant recommendations.

Results: Nearly all participants agreed that oncologists can support hope while discussing poor prognosis. Participants emphasized that honesty-about prognosis and uncertainty-can support, rather than diminish, hope. Most participants described recommended strategies for how to navigate hope and uncertainty during prognostic communication. Four themes were identified in recommendations: (1) prioritize honesty, (2) provide leadership, guidance, and expertise, (3) provide compassionate, individualized support, and (4) acknowledge inherent uncertainty as space for hope.

Conclusion: Providing honest, individualized communication can foster hope and manage uncertainty for children with cancer and their families. Results will guide development of communication tools to strengthen education and bedside care, equipping clinicians to meet the diverse needs and preferences of families facing childhood cancer.

Background: Prematurity may place young children at increased risk for severe respiratory syncytial virus (RSV) disease because of differences in lung development. We describe characteristics of children aged less than 2 years hospitalized with RSV by prematurity and bronchopulmonary dysplasia (BPD) status and examine both as risk factors for severe in-hospital outcomes.

Methods: During 2016-2023, population-based surveillance was conducted at 7 medical centers for hospitalizations with RSV-associated acute respiratory illness in children. Poisson regression with robust variance was used to estimate adjusted relative risks (aRRs) of prolonged hospitalization (≥3 days), intensive care unit (ICU) admission, and assisted ventilation by age in children with prematurity without and with BPD compared with term children after adjustment for surveillance site and palivizumab receipt.

Results: Among 5844 children, 4626 (79.2%) were term and 1218 (20.8%) were premature, including 1138 (93.4%) without BPD and 80 (6.6%) with BPD. Compared with term children, all premature children had greater risks for prolonged hospitalization (aRR = 1.3; 95% CI, 1.2-1.5), ICU admission (aRR = 1.4; 95% CI, 1.2-1.6), and assisted ventilation (aRR = 2.0; 95% CI, 1.4-2.8) at chronological age less than 6 months. Premature children with BPD also had greater risk for prolonged hospitalization at all ages through 23 months.

Conclusions: Premature children accounted for 1 in 5 hospitalizations among children aged less than 2 years hospitalized with RSV. Compared with term children, all premature children had increased risk for severe in-hospital outcomes in early infancy, and those with BPD remained at increased risk of prolonged hospitalization through age 23 months.

Background and objectives: Humans use storytelling to create meaning from suffering, including after the death of a child. The elicitation of and response to stories remains underused in medicine, and in particular, within parental bereavement. Thus, we sought to explore how bereaved parents choose to share the story of their child.

Methods: This is a secondary analysis of a dual site, survey-based study of parents' experiences following their child's death from cancer 6 to 24 months earlier. Our qualitative inquiry focuses on inductive, iterative analysis of free-text responses to the following question: "If you would be willing to share, please tell us about your child. What would you like us to know about him/her?"

Results: A total of 128 parents completed the survey; 101 parents (79%) representing 81 children shared stories about their child. Responses took the form of narratives that varied in terms of structure (eg, verb tense, subject, narrative arc) and content (eg, character development, narration/voice). Parents highlighted their child's appearance, traits, and passions. Most did not detail cancer history or death. Parent narratives progressed through themes of medicalization, humanization, and supernaturalization in the "character development" of their child, who was frequently characterized as "otherworldly."

Conclusions: Bereaved parents whose child died of cancer have a desire to tell their child's story. When given the opportunity, nearly 80% of parents in this study chose to share. Thematic progression may be a framework for narrative repair. Parental narratives of their deceased child provide new insights into their bereavement experience and may help to develop novel supportive interventions.