Journal of Pediatrics最新文献

Objective: To evaluate the incidence of necrotizing enterocolitis (NEC) before probiotic introduction, during probiotic administration, and after its cessation following the 2023 FDA advisory discouraging probiotic use in preterm infants.

Study design: Retrospective cohort study of very low birthweight (VLBW) infants (birthweight <1500 grams), admitted to a level IV neonatal intensive care unit (NICU) from 2014 through 2024. Infants were grouped into three epochs according to Bifidobacterium longum ssp. infantis (B. infantis) EVC001 administration: Pre-EVC001 (no probiotic), EVC001 (routine use), and Post-EVC001 (post-discontinuation). The primary outcome was NEC incidence. Secondary outcomes included NEC-associated mortality, all-cause mortality, NEC severity, and NEC incidence among extremely low birthweight (ELBW; <1000 grams) infants. Multivariable log-binomial and ordinal logistic regression models were used.

Results: Among 733 VLBW infants, NEC incidence was 12% Pre-EVC001, 2.6% EVC001, and 16% Post-EVC001 (p<0.001). NEC risk was higher both Pre-EVC001 (aRR 4.4, 95% CI 2.2-9.0) and Post-EVC001 (aRR 4.5, 95% CI 2.0-9.9; both p<0.001) compared with during EVC001 administration. ELBW infants showed similar trends. EVC001 use was associated with reduced odds of severe NEC compared with epochs without EVC001use (VLBW OR 5.3, 95% CI 2.5-11.0; ELBW OR 5.0, 95% CI 2.2-11.7; both p<0.001). NEC-related mortality was lowest during EVC001 use compared with epochs without EVC001 (0.9%, p=0.05).

Conclusions: NEC incidence was higher before and lower during EVC001 administration and rose then after its discontinuation in this single center retrospective study. There is a need for multicenter trials evaluating B. infantis for NEC prevention.

Objectives: To describe writhing General Movements Assessment (GMA) classification and General Movement Optimality Score-Revised (GMOS-R) profiles in the general population; to explore relationships between GMOS-R scores and GMA classification, age of assessment and infant socio-demographic factors; and to establish the inter-rater reproducibility of writhing age GMA classification and GMOS-R.

Study design: A cross-sectional study of 1,861 infants recruited from the general population in Perth, Western Australia, including 7.5% born preterm. Parent-recorded videos were collected between 1- and 5-weeks post-term age, when writhing movements are typically observed. General movements (GMs) classification and GMOS-R were assessed independently by at least two experienced advanced-trained clinicians.

Results: The majority of infants' GMs were classified as normal (66.8%) or poor repertoire (33.2%), with one infant's movements classified as cramped synchronized (0.1%). The median GMOS-R score was 33 (inter-quartile range 27-36). The GMOS-R differentiated GMA classifications. Lower gestational age, any nursery admission, minority ethnicity, and older age at video collection were each associated with a small but statistically significant reduction in GMOS-R scores. GMA classification had excellent inter-rater reliability and agreement. Total GMOS-R had excellent inter-rater reliability and moderate agreement.

Conclusion: Although most infants had normal GMs there was a high prevalence of poor repertoire GMs in the general population. GMOS-R scores effectively differentiated movement quality within the poor repertoire classification. This study provides population-based percentile ranks for interpreting individual post-term GM assessments and contributes a large, population-based dataset of writhing age GMA as a reference for future research.

Objective: To evaluate neonatal risk factors and the predictive value of prior assessments for language development at age 3 in toddlers born before 32 weeks of gestation.

Study design: Data were acquired retrospectively from infants' hospitalizations (level 3 perinatal center, Medical University of Vienna) and annual assessments (Bayley Scales of Infant and Toddler Development). We included children born in 2012-2020 at <32 weeks of gestation, with annual follow-up, at least one German-speaking parent, and unimpaired hearing. Predictors of 3-year language development were analyzed using Gradient Boost Decision Trees (GBDTs) and interpreted through SHapely Additive exPlanations (SHAP) values.

Results: The cohort comprised 476 children (202 [42.4%] females; mean [SD] gestational age, 27.4 [2.0] weeks). Risk factors were multilingualism (mean|SHAP| = 3.93, P ≤ .001), lower maternal education (mean|SHAP| = 2.51, P ≤ .001), reduced birthweight (mean|SHAP| = 1.92, P = .003), shorter gestational age (mean|SHAP| = 1.64, P = .009), grade of intraventricular hemorrhage (IVH) in the left hemisphere (mean|SHAP| = 1.07, P = .005), severe IVH (mean|SHAP| = 0.80, P = .011, surgical necrotizing enterocolitis (NEC) (mean|SHAP| = 0.80, P = .018) and surgical retinopathy of prematurity (ROP) (mean|SHAP| = 0.59, P = .045).

Conclusions: The identification of SHAP values allowed us to evaluate the additive effect of neonatal and socioeconomic risk factors predicting language impairments in this cohort of children born preterm. Replication in other cohorts will be important, but SHAP analyses may be useful for tailored monitoring and implementation of early language support.

Objective: To determine if children enrolled in the International Pediatric Stroke Study (IPSS) database (4,294 patients enrolled, 2003-2014, neonates through 18 years of age) demonstrate demographic, clinical, radiographic, and therapeutic characteristics that relate to age and development at the time of stroke .

Study design: Participants with arterial ischemic stroke or cerebral sinus venous thrombosis were enrolled using standardized consent and case report forms. Data were entered on-site and electronically transferred to a central data storage site in Toronto, Canada. Children were stratified into 4 age groups for analysis of developmental features: neonates (0-28 days of age); infants (29 days to <2 years of age); young children (2 years to <10 years old), and adolescents (> 10 years to <18 years old). Continuous and categorical variables were examined using appropriate statistical techniques in SAS.

Results: 3,809 children were analyzed: 1,112 (29.2%) neonates, 728 (19.1%) infants, 1,088 (28.6%) young children, and 881 (23.1%) adolescents. Arterial ischemic stroke alone occurred in 3,201 (916 neonates; 2,285 older children) and cerebral sinovenous thrombosis alone occurred in 608 (196 neonates; 412 older children). Age group specific clinical and neuroimaging features that segregate by ischemic stroke type were identified and are reported.

Conclusions: The IPSS database comprises the a very large, structured pediatric stroke database used by investigators to advance the understanding and treatment of pediatric stroke. Developmentally based analyses of IPSS data reveal features of childhood stroke that segregate by ischemic stroke type and age at stroke occurrence. These features should aid in understanding age-related pathophysiology and in clinical stroke recognition.

Objective: To explore potential associations between neighborhood-level factors and early organ dysfunction in critically ill children.

Study design: This retrospective, ecological cohort study assessed the association between neighborhood factors and early organ dysfunction in 8,289 encounters for critically ill children from January 2013 to December 2019 at a quaternary pediatric hospital in an urban setting. The exposures were neighborhood factors, which were measured using three composite indices: Child Opportunity Index (COI), Social Vulnerability Index (SVI), and Neighborhood Disorder Index (NDI). Peak Pediatric Logistic Organ Dysfunction [PELOD]-2 scores in the first 72 hours measured early organ dysfunction as the primary outcome. An adjusted Poisson regression with robust modeling was used to measure the association.

Results: Most encounters were for patients from very low opportunity (28%), very high vulnerability (29%), and very high physical disorder neighborhoods (27%). Median peak PELOD-2 score was 3 (IQR 2-5). No association was identified for COI or NDI with peak PELOD-2 scores; however, there was an association between a very high SVI and higher peak PELOD-2 scores (p=0.004).

Conclusions: No association was found among COI or NDI with higher early organ dysfunction. Very high SVI was associated with higher early organ dysfunction. Further studies should assess whether specific aspects of neighborhoods drive critical illness in organ-specific diseases.

Objective: To test and compare the capability of three multimorbidity-based models to predict outcomes in early childhood among infants born with extremely low birth weight (<1000g, ELBW).

Study design: Participants included 8,332 surviving ELBW infants born 2010-2020 in North America who contributed follow-up data at 24-months corrected age to the Vermont Oxford Network. Neonatal morbidities included: bronchopulmonary dysplasia (BPD), grade 3-4 intraventricular hemorrhage (IVH), periventricular leukomalacia, stage 3-4 retinopathy of prematurity (ROP), late infection, necrotizing enterocolitis, and spontaneous intestinal perforation. Outcomes included: 1) developmental delay (Bayley score <70 in ≥1 domain), 2) rehospitalization, and 3) therapeutic service use. We compared three gestational age-adjusted risk models with the following predictors: 1) morbidity count, 2) count of three morbidities (BPD, IVH, ROP), and 3) multimorbidity-based latent classes.

Results: Thirty five percent of the study sample had ≥2 neonatal morbidities. Most (64%) received ≥2 therapeutic services, 36% were re-hospitalized, and 19% had developmental delay at 24-months. Morbidity counts and multimorbidity-based latent classes were associated with increased risk for poor 24-month outcomes compared with no morbidity. However, the predictive ability of all three models was modest (area under the receiver operating curve=0.66).

Conclusions: Neonatal multimorbidity is common among ELBW infants and associated with later health and developmental outcomes. However, diagnosis-based multimorbidity risk models have poor prognostic ability. More robust characterization of multimorbidity symptom severity, physiologic impact, and environmental correlates may improve the clinical utility of future risk models.

Objective: To explore associations between pediatrics residents' experiences with discrimination, burnout, belonging, professional fulfillment, and career plans, including interest in remaining at their training institution.

Study design: Between October 2020 and January 2021, a national, cross-sectional study titled PROMISE (PROmoting Med-Ed Insight into Supportive Environments) used a 23-item survey of pediatrics residents through the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network. Descriptive, association, and mediation analyses were conducted for underrepresented in medicine (UIM), Asian and Asian American (AAA), and White residents using multilevel regression and structural equation models.

Results: The study included 799 pediatrics residents (20% UIM) from 24 residency programs. UIM and AAA residents experienced higher discrimination. Among UIM residents, staff discrimination was associated with greater interpersonal disengagement (P = .02), work exhaustion (P < .01), and lower professional fulfillment (P = .04). UIM (P < .01) and AAA (P = .01) residents reported lower belonging even after adjusting for discrimination. Greater belonging was associated with higher likelihood of wanting to remain at one's institution (B = 0.46, 95% CI 0.34-0.57; P < .001). Belonging and professional fulfillment mediated associations between discrimination and intent to stay among UIM residents; for AAA residents, only belonging was a significant mediator.

Conclusions: UIM and AAA pediatric residents reported disproportionately higher discrimination, which was associated with increased burnout and reduced belonging. Institutional efforts to address discrimination are critical for promoting resident well-being and retention in academic medicine.

Objectives: To examine neurodevelopmental outcomes at 5.5 years corrected age (CA) in children included in the Systemic hydrocortisone (HC) To Prevent Bronchopulmonary Dysplasia in preterm infants (SToP-BPD) study, and to investigate the neurodevelopmental outcomes and mortality with HC treatment started between 7-14 days after birth compared with placebo in infants born preterm who required mechanical ventilation.

Study design: Data at 5.5 years' CA on cognitive, motor and neurosensory functioning, behavior, schooling ,and general health outcomes were derived from regular follow-up visits. The primary outcome was death or moderate-severe neurodevelopmental impairment (NDI, complete case analysis), with NDI defined as a disability in at least one of the domains of cognition, motor development, vision or hearing. Other outcomes included neurologic and behavioral assessments as well as parent reports of service utilization and school function.

Results: NDI was assessed in 213 of the 277 (77%) surviving children. Children attending follow-up were more likely to have highly educated or non-smoking parents and had better neurodevelopmental outcomes at two years' CA than non-attending children. Baseline characteristics of assessed children were comparable between treatment arms. No significant difference was found on the primary outcome (OR 0.75 [95% CI, 0.49-1.14]; P=0.18). All developmental outcomes were comparable between the HC and placebo group.

Conclusions: Treatment with HC started between 7-14 days after birth in infants born preterm at risk of BPD did not affect death or moderate-severe NDI, nor any of the separate developmental outcome measures at 5.5 years' CA.

Objective: To investigate the physical and mental health of a national cohort of Swedish adults born with extremely low birth weight (ELBW, ≤1000 g) and its impact on self-reported health-related quality of life (HRQoL).

Study design: This prospective, follow-up study was conducted on a Swedish national cohort of individuals born between 1990 and 1992 with a birth weight of ≤ 1000 g (N=201), along with a matched control group (N=327) born appropriate for gestational age at term. All participants were between 26 and 29 years old at the time of the study. Data were collected through web-based questionnaires assessing physical and mental health, including the 36-item Short Form Health Survey version 2 (SF-36v2) to evaluate HRQoL. In addition, registered diagnoses were obtained from the Swedish National Board of Health and Welfare. Multivariable linear regressions were performed to investigate factors associated with HRQoL.

Results: Compared with the control group, adult individuals born ELBW had a significantly higher prevalence of physical morbidities. In terms of mental health, developmental and psychiatric conditions were also more prevalent, with the exception of mood disorders. However, there were no significant differences in self-reported HRQoL between ELBW and the control group.

Conclusion: Despite a higher prevalence of impairments, ELBW individuals may not perceive themselves as limited in their daily functioning.