Pediatrics最新文献

The unconsolidated motor and cognitive skills that are typical of the early childhood period place infants, toddlers, and preschoolers at risk for a variety of traumatic injuries. Such injuries may include mild traumatic brain injury or concussion. Knowledge regarding the risk, diagnosis, outcomes, and management of early childhood concussion is limited, especially compared with what is known about concussion in school-age children, adolescents, and adults. This state-of-the-art review aims to provide current knowledge on the epidemiology, physical signs, behavior, and clinical outcomes associated with early childhood concussion. Research on this condition has been challenged by the need to adapt methods to the unique physical, behavioral, and developmental characteristics of young children. We provide information on observable symptoms associated with concussion, recommended approaches to care, and suggestions for overcoming barriers to research in this area. Developmentally appropriate efforts are needed to improve our ability to identify, evaluate, and treat early childhood concussion.

Background and objectives: The 20-valent pneumococcal conjugate vaccine (PCV20) was developed to expand protection for pneumococcal disease. It contains all 13-valent pneumococcal conjugate vaccine (PCV13) components plus conjugates for 7 additional serotypes. Our primary objective with this study was to evaluate PCV20 tolerability and safety.

Methods: In this phase 3, multi-country, double-blind study, healthy infants born at ≥34 weeks' gestation were randomly assigned 2:1 to receive PCV20 or PCV13 at 2, 4, 6, and 12 to 15 months of age. Safety assessments included local reactions and systemic events within 7 days after each vaccination, adverse events (AEs) from dose 1 to 1 month after dose 3 and from dose 4 to 1 month after dose 4, and serious AEs and newly diagnosed chronic medical conditions from dose 1 through 6 months after the last dose.

Results: Participants received PCV20 (N = 1000) or PCV13 (N = 504); 91.7% received all 4 doses. The frequencies of local reactions and systemic events were generally similar in PCV20 and PCV13 groups, with most reported as mild or moderate. The most common local reaction was injection site pain (PCV20, 24.7% to 40.5%; PCV13, 26.8% to 42.0%); irritability was the most common systemic event (PCV20, 54.8% to 68.2%; PCV13, 54.7% to 68.5%). AE frequencies were similar in both groups. No serious AEs were related to study vaccines. Few newly diagnosed chronic medical conditions were reported (2.8% in both groups). PCV20 was safe across multiple countries, in late preterm infants, and when administered with other vaccines.

Conclusions: A 4-dose series of PCV20 had a tolerability and safety profile similar to that of PCV13.

The National Fatality Review Case Reporting System (NFR-CRS) is a web-based data collection tool for child death review and fetal and infant mortality review teams. The NFR-CRS captures information from the multidisciplinary review, including the social and community risk factors that may have impacted the death. The NFR-CRS is a nimble data system that has evolved throughout the past 20 years. The most recent enhancements include a life stressors section focused on collecting contextual information such as racism and poverty, revised cause of death sections to better align data collected with risk factors identified in the research, and enhanced data visualizations. The NFR-CRS has improved data quality since the launch of a data quality initiative in 2015. As a result of the data quality initiative, the completeness, consistency, accuracy, and timeliness of the NFR-CRS data have improved. Limitations for the NFR-CRS include the fact that data entered are not population-based, data fields have evolved over time, and there are high percentages of missing and unknown data. Despite its limitations, the NFR-CRS remains a valuable research tool, especially when paired with other data sources.

Background: Leaving the hospital against medical advice (AMA) reflects a breakdown in the family-clinician relationship and creates ethical dilemmas in inpatient pediatric care. There are no national data on frequency or characteristics of leaving AMA from US children's hospitals.

Methods: We performed a retrospective cohort study of hospital discharges for children under 18 years old from January 1, 2018 to December 31, 2022 in 43 children's hospitals in the Pediatric Health Information System (PHIS) database. The primary outcome was leaving AMA. Exposures were demographic, geographic, and clinical characteristics. We used multivariable mixed effects logistic regression models to assess independent factors associated with leaving AMA and all-cause 14-day hospital readmission.

Results: Among 3 672 243 included inpatient encounters, 2972 (0.08%) ended in leaving AMA. Compared with non-Hispanic white patients, non-Hispanic Black patients had higher odds of leaving AMA (adjusted odds ratio [aOR] 1.31 [95% confidence interval (CI) 1.19-1.44]), whereas Hispanic patients (aOR 0.66 [95% CI 0.59-0.75]) had lower odds of leaving AMA. Hospitalizations for patients with noncommercial insurance were more likely to end in leaving AMA. Leaving AMA was associated with increased odds of 14-day inpatient readmission (aOR 1.41 [95% CI 1.24-1.61]) compared with patients who did not leave AMA. There was substantial interhospital variability in standardized rates of leaving AMA (range 0.18-2.14 discharges per 1000 inpatient encounters).

Conclusions: Approximately 1 in 1235 inpatient encounters ended in leaving AMA. Non-Hispanic Black patients had increased odds of leaving AMA. Leaving AMA was associated with increased odds of 14-day readmission.

Objectives: Pediatric patients with life-limiting diagnoses frequently seek care in the pediatric emergency department (PED) during times of acute illness, or at end-of-life (EOL) . Although the population of patients with life-limiting diagnoses is heterogenous, clinician expertise in EOL communication is essential to providing family-centered care. In this study, we explored PED physician and nurse experiences with communication when eliciting EOL values, including factors specified to the PED environment, clinician perceptions of family supports and preferences, and clinicians' self-reflection of their skills and challenges in this sphere.

Methods: We performed a prospective qualitative study using semistructured interviews of PED physicians and nurses recruited from a quaternary care center. Thematic content analysis was performed on the transcribed interviews to identify codes and, ultimately, themes.

Results: We interviewed 17 emergency department clinicians, including 10 physicians and 7 nurses. Thematic content analysis revealed 6 salient themes. The first theme related to contextual factors of the emergency department environment. Two additional themes related to patient and family characteristics, including unique patient and family factors and clinician interpretation of parental/family needs. Lastly, we found 3 clinician-focused themes including knowledge gaps in EOL communication, communication styles and priorities in EOL conversations with families, and coping with ethical challenges.

Conclusions: PED clinicians report communication-related challenges to providing optimal care for families and patients with life-limiting diagnoses. Participants self-identified gaps in communication skills in this area. Future studies should focus on clinician educational interventions on the basis of this needs assessment and include family perspectives to develop best practice.

Objectives: To describe sudden unexpected infant deaths (SUIDs) occurring in safe sleep environments and explore differences in selected characteristics.

Methods: We examined SUID from 22 jurisdictions from 2011 to 2020 and classified them as unexplained, no unsafe sleep factors (U-NUSF). Data were derived from the Sudden Unexpected Infant Death and Sudden Death in the Young Case Registry, a population-based Centers for Disease Control and Prevention surveillance system built on the National Center for Fatality Review and Prevention's child death review program. SUID classified as U-NUSF included infants who were (1) awake, under supervision, and witnessed to become unresponsive or (2) found unresponsive in a safe sleep environment after sleep (unwitnessed). We calculated frequencies and percentages for demographics, birth and environmental characteristics, medical history, and death investigation findings.

Results: Most of the 117 U-NUSF SUID occurred before 4 months of age. Witnessed deaths most commonly occurred at <1 month of age (28%), whereas unwitnessed deaths most commonly occurred at ages 2 to 3 months (44%) Among all U-NUSF, 69% occurred in the infant's home (62% witnessed, 77% unwitnessed). All unwitnessed deaths occurred in a crib; most witnessed deaths occurred while being held (54%) or in a car seat traveling (18%). Most infants (84%) had no history of abuse or neglect. Abnormal autopsy findings were reported in 46% of deaths (49% witnessed, 42% unwitnessed).

Conclusions: Characterizing these deaths is key to advancing our knowledge of SUID etiology. Our study revealed a heterogeneous group of infants, suggesting physiologic, genetic, or environmental etiologies.

Sudden unexpected infant death (SUID) is the leading cause of postneonatal infant mortality in the United States, with disproportionately high rates in Baltimore City and Baltimore County in Maryland. This Advocacy Case Study describes the collaboration between the City and County Child Fatality Review teams to decrease infant mortality. B'more for Healthy Babies, formed in 2009 by the Bureau of Maternal Child Health in Baltimore City with the goal of reducing infant mortality through policy change, service improvements, community mobilization, and behavior change has had a sustained effort to respond to SUID. Recognizing that infants born in Baltimore City often reside in Baltimore County (and vice versa), collaboration with Baltimore County has been essential to increasing B'more for Healthy Babies' scope, reach, and effectiveness. Public health messaging campaigns, creation, and dissemination of a "SLEEP SAFE" testimonial video, and Safe Sleep Summits have involved caregivers, healthcare providers, and community partners. Outcomes of this ongoing collaboration demonstrate a decrease in sleep-related infant mortality rates. Our findings also highlight the need for continued, real time monitoring of sleep-related infant mortality trends with a coordinated, multidisciplinary, and crossjurisdictional response. This initiative can serve as a model of cross-sector communication that can be replicated in other similar geographic locations to further reduce SUID.

Objectives: Contextual factors that contribute to firearm injuries among children aged 0 to 10 are not well understood.

Methods: A retrospective review of the National Fatality Review-Case Reporting System was conducted for firearm deaths of children aged 0 to 10 from 2004 to 2020. Descriptive analyses characterized child and parent demographics, incident details, firearm characteristics, and firearm use. Cluster analysis identified key clustering of contextual variables to inform prevention efforts.

Results: Within the study timeframe, 1167 child firearm deaths were reported (Mage = 4.9; 63.2% male; 39.4% urban). At the time of the incident, 52.4% of firearms were reported unlocked and 38.5% loaded. Firearm deaths occurred primarily at the child's home (69.0%) or a friend or relative's home (15.9%), with most involving a handgun (80.6%). Children were supervised in 74.6% of incidents, and 38.4% of child supervisors were impaired during the incident. Cluster analysis identified incident contextual factors clustering in distinct groups, including unsupervised firearm play, long gun discharge while cleaning, hunting, or target shooting, supervised discharge within the child's home, murder-suicide events, deaths occurring in the context of intimate partner violence, and community violence firearm deaths.

Conclusions: Data highlight the importance of primary prevention through secure firearm storage to prevent child firearm deaths. Efforts focused on identifying and reducing intimate partner violence, addressing community violence (eg, community greening), and implementing policy that limit firearm access (eg, domestic violence restraining orders, background checks), may reduce child firearm deaths.