Pediatrics最新文献

Objectives: A previous study reported that increased state and local government expenditures were associated with decreased infant mortality rates (IMRs). However, reported estimates of the association between expenditures and IMR represented the degree to which the association changed each year, not the main effect. We reproduced the original results, reporting this main effect and replicated the analysis using improved methodology and updated data.

Methods: For the reproduction analysis, we used methods and data identical to the original study: A publicly-posted, state-level data set of expenditures from 2000 to 2014 US Census Bureau survey data linked to 2-year lagged IMR data with a random intercept model including an interaction between time and expenditures. For the replication analysis, we added 5 years of data and adjusted for fixed state differences and inflation.

Results: In the reproduction, the main effects of total, environmental, and educational expenditures on IMR were much larger than the interaction effects previously reported as the main effects. For example, a 1-SD increase in per-capita total expenditures was associated with a reduction of 0.35 infant deaths per 1000 live births instead of 0.02 deaths per 1000 live births originally reported. In the updated replication, the main effects were generally even larger (eg, -0.51 deaths per 1000 per SD increase in total expenditures). Increased total expenditures were associated with absolute but not relative reductions in Black-white IMR gaps.

Conclusions: State and local government expenditures are associated with greater reductions in IMR than previously reported, underscoring the importance of continued public investment.

Decisions to initiate long-term ventilation (LTV) in children with severe neurologic impairment have recently been subject to candidacy determinations by home ventilation teams that exclude patients based on their neurologic status alone. Determinations of whether decisions are inappropriate require careful analysis of specific clinical circumstances and attention to the family's values. In this Ethics Rounds, we present a case of a previously healthy child who sustained an acute severe anoxic brain injury and was assessed by the medical team to have a high likelihood of remaining minimally conscious or unconscious. It was determined that he was not a candidate for LTV based on the severity of neurologic impairment. The family disagreed and declined withdrawal of ventilatory support. Drawing upon our backgrounds in intensive care, pulmonology, and bioethics, we offer commentary on utilizing a candidacy-based approach for LTV decisions in children with severe neurologic impairment from variable perspectives, including clinical determinations of inappropriate care, ablest biases and discrimination, and obligations to maintain a just process.

Background and objectives: Diet quality has improved over time for US adults and youth aged ≥2 years. Trends over time and disparities in the diet quality of toddlers 12 through 23 months old have not been documented. Our objective was to investigate the direction and magnitude of toddler diet quality trends from 1999 to 2018 overall and by household socioeconomic status.

Methods: This serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data was performed with 2541 toddlers from 10 NHANES cycles from 1999 to 2018. Dietary intake was measured by NHANES study staff using proxy-reported 24-hour recalls. Healthy Eating Index-Toddlers-2020 total scores (0-100 points, higher scores indicate healthier diets) and component scores were calculated from the 24-hour dietary recalls using the population ratio method. Multivariable linear regression was used to evaluate the association between time in years (measured as the midpoint of each NHANES cycle) and diet quality.

Results: Toddler diet quality improved significantly from 1999 to 2018 (P < .001), from 63.7 points on average in 1999-2000 to 67.7 points in 2017-2018. A significant positive linear trend in total diet quality was observed for all socioeconomic status groups (P < .05). Several dietary component scores improved, as follows: Whole Fruits (P < .001), Whole Grains (P = .016), Fatty Acids (P = .002), Refined Grains (P = .009), and Added Sugars (P < .001). Scores did not significantly change for Total Fruit, Total Vegetables, Greens and Beans, Dairy, Total Protein Foods, Seafood and Plant Proteins, Sodium, or Saturated Fats.

Conclusions: From 1999 to 2018, toddler diet quality improved significantly, but mean scores still fell short of dietary guidance.

Adverse childhood experiences (ACEs) are common and can impact health across the life course. Thus, it is essential for professionals in child- and family-serving roles, including pediatric and adult primary care clinicians, to understand the health implications of childhood adversity and trauma and respond appropriately. Screening for ACEs in health care settings has received attention as a potential approach to ACEs identification and response. Careful examination of the existing evidence on ACEs screening and consideration, from a clinical and ethical perspective, of the potential benefits, challenges, and harms is critical to ensuring evidence-informed practice. In this critical appraisal, we synthesize existing systematic and scoping reviews on ACEs screening, summarize recent studies on the ability of ACEs to predict health outcomes at the individual level, and provide a comprehensive overview of potential benefits, challenges, and harms of ACEs screening. We identify gaps in the existing evidence base and specify directions for future research. We also describe trauma-informed, relational care as an orientation and perspective that can help pediatric and primary care clinicians to sensitively assess for and respond to ACEs and other potentially traumatic experiences. Overall, we do not yet have sufficient evidence regarding the potential benefits, challenges, and harms of ACEs screening in health care and other settings. In the absence of this evidence, we cannot assume that screening will not cause harm and that potential benefits outweigh potential harms.

A previously healthy 17-year-old female patient initially presented with symptoms of anterior neck pain. After multiple emergency department visits, she was found to have unilateral enlargement of her thyroid gland. Laboratory studies were consistent with hyperthyroidism. Symptoms were initially attributed to subacute thyroiditis, and she was discharged with steroids and propranolol. She presented again 1 week later with complaints of nausea, vomiting, abdominal pain, and shortness of breath. She was readmitted and developed sepsis with multiorgan system infection and Lemierre syndrome. Further imaging revealed acute suppurative thyroiditis as the likely source. Direct laryngoscopy and bronchoscopy revealed ulceration of the anterior esophageal wall, a fistulous tract to the thyroid, and copious purulent drainage. Esophageal biopsies with immunostaining established a diagnosis of herpes simplex virus esophagitis as the likely cause of esophageal perforation, fistula development, and acute suppurative thyroiditis.

Context: The prevention of urinary tract infection recurrence (UTI) in children has been a challenge yet to be solved. Current practice in children with recurrent UTI (RUTI) suggests that antibiotic prophylaxis may prevent further episodes of UTI and future complications.

Objective: To conduct a systematic review and meta-analysis of randomized controlled trials comparing prophylaxis options for the prevention of UTI and kidney scarring in children with a history of RUTI.

Data sources: We conducted a systematic literature search through major electronic databases (PubMed/Medline, Scopus and Cochrane Library) up to November 26th, 2023. Mean difference and SD were used for continuous outcomes and odds ratio for dichotomous outcomes.

Study selection: Our meta-analysis included 3335 participants from 23 studies.

Data extraction: The primary outcome was the effect of the different prophylaxis options on the incidence of symptomatic UTI in children with RUTI during prophylactic treatment.

Results: Cranberry products and nitrofurantoin lead to lower odds of symptomatic UTI episodes during prophylaxis compared with the control group and control, trimethoprim-sulfamethoxazole, or trimethoprim groups accordingly. Nitrofurantoin may be the best option for UTI incidence reduction compared with all available documented interventions.

Limitations: No prophylaxis option has been shown to reduce kidney scarring.

Conclusions: Nitrofurantoin and cranberry products may decrease the incidence of symptomatic UTI episodes in pediatric patients with a history of RUTI. Future randomized control trials studying nonantibiotic prophylaxis options focusing on children with UTI recurrence and the risk for kidney scarring are needed to draw further conclusions.

Pediatric obesity is a major public health problem, affecting nearly 20% of children and adolescents living in the United States. In 2023, the American Academy of Pediatrics released its first clinical practice guideline for the evaluation and management of child and adolescent obesity and recommended integrating health behavior and lifestyle interventions with pharmacological treatment when medically indicated. However, there is a limited evidence base to guide antiobesity medication treatment decisions in clinical practice and limited data on long-term safety during this critical period of growth and development in youth. Thus, in November of 2023, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored a workshop to identify knowledge gaps and opportunities for research on the use of pharmacotherapy for obesity in children and adolescents. Leading scientific and clinical experts in obesity pathophysiology and treatment, pharmacotherapy, clinical trial design, and health equity and disparities, among others, identified gaps in clinical trial design, guidance for clinical use of medications in children and adolescents, additional treatment outcomes beyond body fat or weight, and improvement in care delivery. Adolescent patients and caregivers with lived experience of obesity and weight management were also invited to participate in a panel discussion, providing personal perspectives on living with obesity, clinical care considerations, and research needs. This article summarizes the workshop proceedings on the state of the science and identifies gaps and opportunities for future research to inform optimal and equitable medical management of children and adolescents with obesity.

Objectives: Sexual- and gender-diverse youth face unique stressors that negatively impact their health. The objective of this study was to use National Fatality Review-Case Reporting System data to epidemiologically describe fatalities among identified sexual- and gender-diverse youth to inform future prevention efforts.

Methods: We used 2015 to 2020 data from the National Fatality Review-Case Reporting System to identify deaths among sexual- and gender-diverse youth and compare their characteristics to a matched sample of youth from these same data who were not known to be sexual- and gender-diverse. Demographic, injury, death, history, and life stressor characteristics were analyzed using descriptive statistics.

Results: During the study period, 176 fatalities were identified among sexual- and gender-diverse youth. Decedents' mean age was 15.3 years. A greater proportion of deaths was attributed to suicide among sexual- and gender-diverse youth (81%) compared with nonsexual- and gender-diverse youth (54%). Receiving prior (69%) and/or current (49%) mental health services was more common among sexual- and gender-diverse youth, compared with nonsexual- and gender-diverse youth (50% and 31%, respectively). Sexual- and gender-diverse youth were significantly more likely to experience problems in school or be victims of bullying, compared with nonsexual- and gender-diverse youth (63% versus 47% and 28% versus 15%, respectively).

Conclusions: Suicide was the most common manner of death for sexual- and gender-diverse youth, despite many decedents receiving current or prior mental health services. These findings indicate the need to improve and diversify interventions to prevent these deaths.

Background and objectives: The challenge of identifying preterm infants with bronchopulmonary dysplasia (BPD) that need tracheostomy placement may delay goals of care (GOC) discussions. By identifying infants with a low probability of ventilation liberation, timely GOC discussions may reduce the time to tracheostomy. Our SMART aim was to reduce the postmenstrual age (PMA) of GOC discussions by 20% in infants with BPD and prolonged invasive ventilatory requirement by October 2020.

Methods: Our group conducted a quality improvement initiative at the University of Alabama at Birmingham. Infants were included if born at <32 weeks' gestation and exposed to invasive ventilation for ≥2 weeks beyond 36 weeks' PMA. Interventions included (1) consensus of BPD infants at risk for tracheostomy dependence, (2) monthly multidisciplinary tracheostomy meetings, and (3) development and utilization of tracheostomy educational content for families. Statistical process control charts were used for all analyses.

Results: A total of 79 infants were included in analyses, of which 44 infants either received a tracheostomy or died. From X-mR control chart analysis, there was special cause variation in the time to GOC discussions, which decreased from 62 to 51 weeks' PMA related to monthly multidisciplinary conferences. The average PMA at tracheostomy decreased from 80 weeks to 63 weeks with no change in the frequency of tracheostomy placement or discordant GOC discussions in which infants survived to hospital discharge without a tracheostomy.

Conclusions: In infants with ventilator-dependent BPD, standardization of GOC discussions reduced the PMA of GOC discussions and tracheostomy.