Pediatrics最新文献

Background and objectives: Researchers have not yet collected sufficient prognostic data on the combined use of structural brain MRI (sMRI) with General Movements Assessment (GMA) or Hammersmith Infant Neurological Examination (HINE) in children born preterm for diagnosing cerebral palsy (CP) before 5 months corrected age (CA), particularly for Gross Motor Function Classification System (GMFCS) level I CP. We evaluated the predictive values of sMRI, GMA, and HINE individually and in combination for early CP diagnosis and assessed accuracy across varying GMFCS levels in children born preterm.

Methods: We studied a prospective regional cohort of 395 preterm infants (≤32 weeks' gestation) from 5 NICUs in Greater Cincinnati. The primary outcome was CP diagnosis at 22 to 26 months CA, classified by GMFCS. We calculated sensitivity, specificity, predictive values, and likelihood ratios for CP diagnosis/prediction for an abnormal sMRI (motor tract abnormalities) at 39-44 weeks postmenstrual age and an abnormal GMA (absent fidgety movements) or HINE (score below 56) at 12 to 18 weeks CA.

Results: Of 338 (86%) children with complete follow-up, 39 (11.5%) developed CP (28 GMFCS level I, 11 levels II-V). Combining sMRI and GMA achieved 100% specificity and 22% sensitivity, while sMRI and HINE exhibited 32% sensitivity, 98% specificity. These 2 combinations achieved higher sensitivity (78%-90%) and specificity (98%-100%) for predicting CP levels II to V.

Conclusions: In our preterm cohort, sMRI plus GMA/HINE demonstrated high specificity but low sensitivity in predicting CP, underscoring the need for longer developmental follow-up and more sensitive diagnostic tools for early detection of CP in children born preterm.

Objective: We aimed to assess whether the presence of a therapy dog during 2 dental care sessions could facilitate subsequent dog-free dental care for anxious autistic children who had difficulty cooperating.

Methods: We conducted a parallel-arm randomized trial: control group using usual behavioral strategies only and experimental group using animal-assisted therapy (AAT) strategies combined with usual behavioral strategies. All patients had 3 dental care sessions. In the experimental group, the therapy dog was present during the first 2 dental sessions, and the third dental session was dog-free. The primary outcome was the mean overall anxiety during the dog-free third treatment session. Generalized estimating equations (GEEs) were also used to account for the correlation of repeated measures.

Results: A total of 49 patients were enrolled. The most frequently usual behavioral strategies were positive reinforcement (n = 31; 64%), hypnosis (n = 28; 58%), demystification (n = 26; 52%), and in vivo modeling (n = 25; 51%). AAT-specific strategies included imitating dog (n = 18; 69%), positive supportive reinforcement with dog incentives (n = 14; 54%), and distraction or therapeutic touch (n = 11; 42%). Mean anxiety scores were significantly lower in the experimental group during the third session (mean difference, -1.4; 95% CI, -2.43 to -0.37). GEE analysis showed a significant reduction in anxiety over time in the experimental group compared with controls (P = .0001; β = -1.03).

Conclusion: Dog served mainly as an in vivo model and positive reinforcer. Our findings suggest that AAT could play a key role in helping children acclimate to dental procedures, and, consequently, ease the transition back to conventional, animal-free dental treatments.

This is a revision of the previous joint policy statement titled "Pediatric Readiness in the Emergency Department." This is a joint policy statement from the American Academy of Pediatrics, the American College of Emergency Physicians, the American College of Surgeons, and the Emergency Nurses Association. These updated recommendations are intended to serve as a resource for clinical and administrative leadership of emergency departments as they strive to improve their readiness for the emergency care of children of all ages.

Congenital diaphragmatic hernia (CDH) is a rare defect that most commonly presents in neonates with severe respiratory distress. Late presentation in older children is exceedingly rare and often accompanied by nonspecific symptoms, leading to diagnostic challenges. We report the case of a 9-year-old child who initially presented with nonspecific abdominal pain, nausea, and vomiting. Initial evaluations, including computed tomography (CT) imaging, led to the initial diagnosis of a splenule. Owing to persistent symptoms, repeated imaging 2 weeks later revealed herniation of abdominal contents into the thoracic cavity, confirming a large left-sided CDH. The patient underwent thoracoscopic surgical repair of a Bochdalek defect, leading to resolution of symptoms. This case highlights diagnostic challenges surrounding late-presenting CDH, including its variable clinical presentation ranging from nonspecific gastrointestinal or respiratory symptoms, as well as challenges of radiographic interpretation. This case emphasizes the importance of considering CDH in diagnostic workups in all age groups, even when imaging findings are inconclusive, to ensure timely and accurate diagnosis and treatment.

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."