Association between postoperative ibuprofen exposure and acute kidney injury after pediatric cardiac surgery

BACKGROUND

Acute kidney injury (AKI) is a common complication after pediatric cardiac surgery and is associated with worse outcomes. Ibuprofen is widely used in the perioperative period and can affect kidney function in children. However, the association between ibuprofen exposure and AKI after pediatric cardiac surgery has not been determined yet.

METHODS

In this retrospective cohort study, children undergoing cardiac surgery with cardiopulmonary bypass were studied. Exposure was defined as given ibuprofen in the first 7 days after surgery. Postoperative AKI was diagnosed using the KDIGO criteria. A multivariable Cox regression model was used to assess the association between ibuprofen exposure and postoperative AKI by taking ibuprofen as a time-varying covariate.

RESULTS

Among 1,112 included children, 198 of them (17.8%) experienced AKI. In total, 396 children (35.6%) were exposed to ibuprofen. AKI occurred less frequently among children who were administered ibuprofen than among those who were not (46 of 396 [11.6%] vs. 152 of 716 [21.2%], p < 0.001). Using the Cox regression model accounting for time-varying exposures, ibuprofen treatment was not associated with AKI (adjusted HR, 0.99; 95% CI 0.70-1.39, p = 0.932). This insignificant association was consistent across the sensitivity and subgroup analyses.

CONCLUSIONS

Postoperative ibuprofen exposure in pediatric patients undergoing cardiac surgery was not associated with an increased risk of AKI.

Use of donepezil for neurocognitive recovery after brain injury in adult and pediatric populations: a scoping review

There are few pharmacologic options for the treatment of cognitive deficits associated with traumatic brain injury in pediatric patients. Acetylcholinesterase inhibitors such as donepezil have been evaluated in adult patients after traumatic brain injury, but relatively less is known about the effect in pediatric populations. The goal of this review is to identify knowledge gaps in the efficacy and safety of acetylcholinesterase inhibitors as a potential adjuvant treatment for neurocognitive decline in pediatric patients with traumatic brain injury. Investigators queried PubMed to identify literature published from database inception through June 2023 describing the use of donepezil in young adult traumatic brain injury and pediatric patients with predefined conditions. Based on preselected search criteria, 340 unique papers were selected for title and abstract screening. Thirty-two records were reviewed in full after eliminating preclinical studies and papers outside the scope of the project. In adult traumatic brain injury, we review results from 14 papers detailing 227 subjects where evidence suggests donepezil is well tolerated and shows both objective and patient-reported efficacy for reducing cognitive impairment. In children, 3 papers report on 5 children recovering from traumatic brain injury, showing limited efficacy. An additional 15 pediatric studies conducted in populations at risk for cognitive dysfunction provide a broader look at safety and efficacy in 210 patients in the pediatric age group. Given its promise for efficacy in adults with traumatic brain injury and tolerability in pediatric patients, we believe further study of donepezil for children and adolescents with traumatic brain injury is warranted.

Feasibility study of micronutrient status and body mass index of newly diagnosed pediatric oncology patients: Research commentary

We conducted a feasibility study to evaluate micronutrients and body mass index (BMI). Fat soluble vitamins A, D, E and trace elements copper (Cu), selenium (Se), and zinc (Zn) levels were evaluated. Weight, height, BMI, and Z-scores were recorded. Side effects or specific adverse events were documented. No patient had a Z-score for height, weight, or BMI of less than 2 SD or greater than 2 SD. Ninety percent of patients had one or more micronutrient levels below normal. These results suggest that micronutrient abnormalities are common despite no obvious evidence of malnutrition. Side effects of chemotherapy may be exacerbated by micronutrient depletion.

Beyond traditional venous access: Midline catheter use in pediatric apheresis

The objective of this study was to assess the use of midline catheters as venous access for apheresis procedures in pediatric patients. A retrospective analysis of medical records was conducted from September 2019 to June 2022 to evaluate the safety and efficacy of midline catheters for therapeutic pediatric apheresis. During the study period, a total of 121 procedures were inserted in 22 unique patients. The age of the subjects ranged from 2.7 to 21 years. The blood flow rates achieved with midline catheters met or exceeded the recommended rates for apheresis in children (40 mL/min), by the Wilcoxon signed-rank test (p < 0.0001). There was one episode of catheter-related thrombosis, but no cases of bloodstream infection or catheter dislodgement were reported. In conclusion, this study supports the use of midline catheters as a safe and effective alternative for venous access during therapeutic and donor apheresis procedures in pediatric patients.

Septic shock: an atypical complication of alimentary tract duplication

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

Excellent response to treatment with hydroxychloroquine in pediatric patients with SLE-related immune thrombocytopenia

BACKGROUND

Pediatric immune thrombocytopenia (ITP) may precede systemic autoimmune disorders. In adolescent patients with ITP, routine screening for systemic lupus erythematosus (SLE) may be performed by testing for antinuclear antibody (ANA) titer. Hydroxychloroquine (HCQ) is a safe and effective immunomodulatory drug in patients with SLE but rarely used in ITP. We analyzed the platelet count response and safety of HCQ in treating pediatric patients with SLE-related ITP.

METHODS

A retrospective study including pediatric patients with ITP and definite or incomplete SLE, who were treated with HCQ during 2010-2021. SLE was defined by ANA titer ≥ 1:160 as measured by immunofluorescence and ≥10 points according to the 2019 EULAR/ACR 2019 classification criteria, while patients with incomplete SLE achieved a score < 10. Complete response (CR) of the platelet count was defined as platelet count > 100 × 109/L; partial response (PR) as platelet count 30-100 × 109/L and exceeding ≥ twice baseline counts.

RESULTS

Of the 17 patients included (median age 15.5 years; IQR 3.6), 15 (88.2%) were female, 13 had definite SLE, and four had incomplete SLE. HCQ was initiated at a median of 17 months after ITP diagnosis with a median platelet count of 38 × 109/L (IQR 28). At 8 weeks, 8 (47.1%) patients responded, including 6 (35.3%) achieving CR. After one year, the overall response was 82.4%, with the remaining patients having stable platelet counts requiring no additional ITP therapy. The response was maintained at a median follow-up of 42 months. No adverse effects to HCQ were noted.

CONCLUSION

Pediatric patients with SLE-related ITP may benefit from treatment with HCQ.

The RAS-signaling-pathway-mutation-related prognosis in B-cell acute lymphoblastic leukemia: A report from South China children's leukemia group

The next-generation sequencing technologies application discovers novel genetic alterations frequently in pediatric acute lymphoblastic leukemia (ALL). RAS signaling pathway mutations at the time of relapse ALL frequently appear as small subclones at the time of onset, which are considered as the drivers in ALL relapse. Whether subclones alterations in the RAS signaling pathway should be considered for risk group stratification of ALL treatment is not decided yet. In this work, we investigate the RAS signaling pathway mutation spectrum and the related prognosis in pediatric ALL. We employed an NGS panel comprising 220 genes. NGS results were collected from 202 pediatric ALL patients. 155 patients (76.7%) harbored at least one mutation. The incidences of RAS signaling pathway mutations are different significantly between T-ALL and B-ALL. In B-ALL, the RAS pathway is mostly involved, and NRAS (17.6%), KRAS (22.7%), and PTPN11 (7.7%) were the three most frequently mutated genes. Co-occurring mutations of CREBBP and NRAS, FLT3, or PTPN11 (p = 0.002, p = 0.009, and p = 0.003, respectively) were found in this cohort. The 3-year RFS rates for the RAS signaling pathway mutation-positive and negative cases was 76.5 % versus 89.7 % (p = 0.012). Four cases relapsed in the lately 3 years were RAS signaling pathway mutation-positive. RAS signaling pathway mutation is an important biomarker for poorer relapse-free survival in pediatric B-ALL patients despite good early MRD levels.

A Mobile Application for Child-Focused Tonsillectomy Education: Development and User-Testing

OBJECTIVE

Patient education is central to Enhanced Recovery After Surgery protocols, but child-focused materials are lacking. We developed and piloted a mobile application to support accessible, interactive patient and caregiver education about pediatric tonsillectomy.

METHODS

Thirty children ages 5-12 who were preparing for tonsillectomy, their caregivers, and six attending otolaryngologists participated in a user-testing trial of a web-based prototype. The trial measured feasibility, fidelity, and patient-centered outcomes. Patients and caregivers rated usability/likeability on the mHealth App Usability Questionnaire. Otolaryngologists rated quality on the Mobile App Rating Scale. The full mobile application, "Ready for Tonsillectomy," was then developed for iOS and Android.

RESULTS

Enrollment was 88.2%, retention was 90.0%, and use was 96.3%. Mean (SD) patient ratings for usability/likeability were 6.3 (1.1) out of 7; caregiver ratings were 6.5 (1.1). In common themes from open-ended feedback, patients described the application as helpful and appealing, and caregivers described it as informative, easy to understand, calming, and easy to use. Among caregivers who used the application during recovery, 92.3% reported that it helped them manage their child's pain. Providers would recommend the application to many or all of their patients (mean [SD]: 4.7 [0.5] out of 5). Mean provider ratings for domains of engagement, functionality, aesthetics, information quality, subjective quality, and app-specific value ranged from 4.1 to 4.8 out of 5.

CONCLUSION

Feasibility and fidelity were high. Families and otolaryngologists endorsed the resource as an engaging, informative tool that supports positive coping. Our mobile application offers a patient-centered solution readily scalable to other surgeries.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2455-2463, 2024.

Cost-of-illness and Economic Evaluation of Interventions in Children and Adolescents With Chronic Pain: A Systematic Review

OBJECTIVES

Chronic pain in children and adolescents (CPCA) is widespread with an increasing prevalence. It is associated with a decreased quality of life and an increased parental work loss. Accordingly, CPCA may pose a substantial economic burden for patients, health care payers, and society. Therefore, this systematic review aimed to synthesize (1) the results of existing cost-of-illness studies (COIs) for CPCA and (2) the evidence of economic evaluations (EEs) of interventions for CPCA.

METHODS

The systematic literature search was conducted in EMBASE, MEDLINE, PsycINFO, NHS EED, and HTA Database until February 2023. Title, abstract, and full-text screening were conducted by 2 researchers. Original articles reporting costs related to CPCA published in English or German were included. Study characteristics, cost components, and costs were extracted. The quality of studies was assessed using standardized tools. All costs were adjusted to 2020 purchasing power parity US dollars (PPP-USD).

RESULTS

Fifteen COIs and 10 EEs were included. The mean annual direct costs of CPCA ranged from PPP-USD 603 to PPP-USD 16,271, with outpatient services accounting for the largest share. The mean annual indirect costs ranged from PPP-USD 92 to PPP-USD 12,721. All EEs reported a decrease in overall costs in treated patients.

DISCUSSION

The methodology across studies was heterogeneous limiting the comparability. However, it is concluded that CPCA is associated with high overall costs, which were reduced in all EEs. From a health-economic perspective, efforts should address the prevention and early detection of CPCA followed by specialized pain treatment.

Real-world experience of direct oral anticoagulant use in a single pediatric center

BACKGROUND

Pediatric venous thromboembolism has increased by 130%-200%, specifically in hospitalized children, and direct oral anticoagulants (DOACs) offer several therapeutic advantages.

METHODS

This study aims to evaluate the real-world epidemiological and outcome data from a retrospective review of pediatric patients treated with DOACs from January 1, 2013 to December 31, 2022. In this single-center, IRB-approved study, 65 patients were identified and analyzed using SPSS statistical software, and a descriptive statistical analysis was conducted.

RESULTS

Of the 65 patients, 37% were on apixaban, 61.5% were on rivaroxaban, and 1.5% were on dabigatran. Per the 2023 ISTH outcome definitions, one (2%) patient had a major bleeding episode, six (9%) had clinically relevant non-major bleeding, three (5%) patients had patient-important heavy menstrual bleeding (HMB), and one (1.5%) patient had minor bleeding. Seven (19%) of 37 postmenarchal patients had evidence of HMB. Six (9.2%) patients had recurrent venous thromboembolism while on a DOAC (one was on apixaban, and five were on rivaroxaban) and were transitioned to other forms of anticoagulation.

CONCLUSION

Thus, bleeding rates after DOAC therapy are comparable to previous DOAC trials, as well as other anticoagulants in pediatrics. HMB is an important outcome measure and should continue to be investigated. This study reports a higher rate of recurrent thrombosis (9.2%) compared to other trials. However, this observation may be attributed to patients who had ongoing risk factors, as well as a longer duration of study follow-up. Additional multicentered outcome studies evaluating DOAC use in children are needed to determine long-term recurrence and HMB risks.

Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium

BACKGROUND

Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. There is a paucity of large-scale pediatric-specific data regarding AMR treatment outcomes.

METHODS

Data were obtained from 14 centers within the Pediatric Nephrology Research Consortium. Kidney transplant recipients aged 1-18 years at transplant with biopsy-proven AMR between 2009 and 2019 and at least 12 months of follow-up were included. The primary outcome was graft failure or an eGFR <20 mL/min/1.73 m2 at 12 months following AMR treatment. AMR treatment choice, histopathology, and DSA class were also examined.

RESULTS

We reviewed 123 AMR episodes. Median age at diagnosis was 15 years at a median 22 months post-transplant. The primary outcome developed in 27.6%. eGFR <30 m/min/1.73 m2 at AMR diagnosis was associated with a 5.6-fold higher risk of reaching the composite outcome. There were no significant differences in outcome by treatment modality. Histopathology scores and DSA class at time of AMR diagnosis were not significantly associated with the primary outcome.

CONCLUSIONS

In this large cohort of pediatric kidney transplant recipients with AMR, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.

Impact of prophylactic echinocandin on the development of neurological complications in patients receiving busulfan-containing conditioning regimens for stem cell transplantation: A single-center retrospective study

BACKGROUND

Although neurotoxicity is a major adverse event associated with busulfan, little information is available regarding the association between drug interactions and neurological symptoms during busulfan-based regimens. This study evaluated the association between prophylactic echinocandins and neurological complications in patients receiving busulfan-containing conditioning regimens for stem cell transplantation.

METHODS

We retrospectively included consecutive patients who administered intravenous busulfan as a conditioning regimen at our facility between 2007 and 2022. Prophylactic echinocandin use was defined as the use of an echinocandin antifungal drug to prevent invasive fungal disease in SCT recipients. The primary outcome was the incidence of neurological complications within 7 days of busulfan initiation and was compared between the echinocandin group (patients received prophylactic echinocandin) and nonechinocandin group (patients received prophylactic antifungal drugs other than echinocandin and those without antifungal prophylaxis).

RESULTS

Among the 59 patients included in this study, the incidence of neurological complications in the echinocandin (n = 26) and nonechinocandin groups (n = 33) was 30.8% and 63.6%, respectively. We observed a negative association between prophylactic echinocandin use and the development of neurological complications after adjusting for the propensity score for receiving prophylactic echinocandins (adjusted odds ratio 0.294, 95% confidence interval 0.090 to 0.959). We observed a lower incidence of neurological complications in the echinocandin group than in the nonechinocandin group.

CONCLUSION

Our results suggested that the choice of antifungal prophylaxis is associated with busulfan neurotoxicity.

Free-Breathing Compressed Sensing Cine Cardiac MRI for Assessment of Left Ventricular Strain by Feature Tracking in Children

BACKGROUND

Cardiac MRI feature-tracking (FT) with breath-holding (BH) cine balanced steady state free precession (bSSFP) imaging is well established. It is unclear whether FT-strain measurements can be reliably derived from free-breathing (FB) compressed sensing (CS) bSSFP imaging.

PURPOSE

To compare left ventricular (LV) strain analysis and image quality of an FB CS bSSFP cine sequence with that of a conventional BH bSSFP sequence in children.

STUDY TYPE

Prospective.

SUBJECTS

40 children able to perform BHs (cohort 1 [12.1 ± 2.2 years]) and 17 children unable to perform BHs (cohort 2 [5.2 ± 1.8 years]).

FIELD STRENGTH/SEQUENCE

3T, bSSFP sequence with and without CS.

ASSESSMENT

Acquisition times and image quality were assessed. LV myocardial deformation parameters were compared between BH cine and FB CS cine studies in cohort 1. Strain indices and image quality of FB CS cine studies were also assessed in cohort 2. Intraobserver and interobserver variability of strain parameters was determined.

STATISTICAL TESTS

Paired t-test, Wilcoxon signed-rank test, intraclass correlation coefficient (ICC), and Bland-Altman analysis. A P-value <0.05 was considered statistically significant.

RESULTS

In cohort 1, the mean acquisition time of the FB CS cine study was significantly lower than for conventional BH cine study (15.6 s vs. 209.4 s). No significant difference were found in global circumferential strain rate (P = 0.089), global longitudinal strain rate (P = 0.366) and EuroCMR image quality scores (P = 0.128) between BH and FB sequences in cohort 1. The overall image quality score of FB CS cine in cohort 2 was 3.5 ± 0.5 with acquisition time of 14.7 ± 2.1 s. Interobserver and intraobserver variabilities were good to excellent (ICC = 0.810 to 0.943).

DATA CONCLUSION

FB CS cine imaging may be a promising alternative technique for strain assessment in pediatric patients with poor BH ability.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 1.

Trends in telemedicine visits among pediatric asthma patients during COVID-19

Background

Environmental and social factors, including lack of access to asthma care, contribute to persistent inequities in asthma outcomes among children from historically marginalized ethnoracial groups. Telemedicine, which expanded rapidly during the coronavirus disease 2019 (COVID-19) pandemic, may be an approach to augment access to pediatric asthma care.

Objectives

We sought to describe characteristics of pediatric (0-17 years) telemedicine users with asthma and characterize use trends throughout the COVID-19 pandemic.

Methods

We conducted a retrospective analysis using electronic health record data of pediatric patients with asthma seen at University of California, Los Angeles, Medical Center between March 2019 to March 2022 describing telemedicine user characteristics, trends of asthma-related telemedicine use, and associations between user characteristics and having a telemedicine visit.

Results

Among 6,777 patients with asthma, the percentage of asthma-related telemedicine visits peaked early in the pandemic, comprising 74.3% of visits, before decreasing to 13.6% in 2022. Compared to White patients, Black patients had lower odds of an asthma telemedicine visit (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.26, 0.94). Those with public insurance (OR, 1.7; 95% CI, 1.19, 2.43), severe persistent asthma (OR, 3.03; 95% CI, 1.70, 5.42), or comorbidities (OR, 1.59; 95% CI, 1.08, 2.33) had higher odds. Time to first emergency department visit and hospitalization comparing those with at least one telemedicine visit to those with none were similar.

Conclusions

More pediatric asthma patients are using telemedicine since the COVID-19 pandemic, particularly those with medical complexity and comorbidities, and outcomes appear similar. However, Black patients at our institution have lower odds of using telemedicine.

A randomized, double-blind, dose-controlled study of the use of dexmedetomidine alone for procedural sedation of children and adolescents undergoing MRI scans

BACKGROUND

Dexmedetomidine is a selective α2-adrenergic agonist originally approved for sedation of adults in the intensive care unit and subsequently approved for procedural sedation in adults undergoing medical procedures. Dexmedetomidine is widely used off-label for procedural sedation in children.

AIMS

To evaluate efficacy and safety of monotherapy dexmedetomidine for magnetic resonance imaging procedural sedation of children ≥1month-<17years across three ascending doses.

METHODS

Randomized, double-blind, dose-ranging study of procedural sedation recruited patients at USA and Japanese sites from February 2020 to November 2021. Patients were stratified into Cohort A (≥1month-<2years) or Cohort B (≥2-<17years). Cohort A loading doses/maintenance infusions: 0.5 mcg/kg/0.5 mcg/kg/h, 1.0 mcg/kg/1.0 mcg/kg/h, and 1.5 mcg/kg/1.5 mcg/kg/h. Cohort B loading doses/maintenance infusions: 0.5 mcg/kg/0.5 mcg/kg/h, 1.2 mcg/kg/1.0 mcg/kg/h, and 2.0 mcg/kg/1.5 mcg/kg/h. Primary endpoint was percentage of overall patients completing MRI without rescue propofol at the high versus low dose. Key secondary endpoint was percentage in each age cohort who did not require propofol at the high versus low dose.

RESULTS

One hundred twenty-two patients received high- (n = 38), middle- (n = 42), or low-dose (n = 42) dexmedetomidine. A greater percentage completed MRI without propofol rescue, while receiving high- versus low-dose dexmedetomidine (24/38 [63.2%] vs. 6/42 [14.3%]) (odds ratio: 10.29, 95% confidence interval: 3.47-30.50, p < .001). Similar results were seen in both age cohorts. The most common adverse events were bradypnea, bradycardia, hypertension, and hypotension, and the majority were of mild-to-moderate severity.

CONCLUSIONS

Dexmedetomidine was well tolerated. The high dose was associated with meaningfully greater efficacy compared with lower doses. Based on these results, the recommended starting dose for procedural sedation in children ≥1month-<2years is loading dose 1.5 mcg/kg/maintenance infusion 1.5 mcg/kg/h; children ≥2-<17years is loading dose 2.0 mcg/kg/maintenance infusion 1.5 mcg/kg/h.

Radiopaque marker colonic transit study in the pediatric population BSPGHAN Motility Working Group consensus statement

Functional constipation (FC) is a common condition in childhood in the United Kingdom and worldwide. Various radiological approaches have been established for diagnostic purposes. The radiopaque marker study (ROMS) is universally accepted and used to assess colonic transit time (CTT) in children with FC. Despite being widely used, there is a lack of standardization with various technical protocols, reproducibility of different populations, the purpose for using investigation, variance in the number of markers used, the amount of study days and calculations, the need to empty the colon before performing the test, and whether to perform on medication or off, or the use of specific diets. As part of the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) motility working group (MWG), we decided to explore further into the evidence, in order to provide guidance regarding the use of ROMS in dealing with FC in the pediatric population.

Factors associated with the disinfection of devices attached to peripheral intravenous catheters performed by the nursing team in pediatric units

Background

Peripheral intravenous catheterization, as well as drug administration through it, represents one of the most performed procedures by the Nursing team and, for that, precautions need to be adopted to offer harm-free care.

Objective

To verify the association of Nursing professionals' work shift and training time with proper disinfection of intravenous catheter devices in pediatric units.

Methods

A cross-sectional and analytical study conducted between June and August 2021 in three hospitalization units of a Pediatric Hospital. The inclusion criterion was drug administration via peripheral intravenous catheters performed by Nursing professionals. The data were analyzed according to inferential statistics, adopting p ≤ .05 as significance level.

Results

There were a total of 385 observations of drug administration procedures. The device was not disinfected in 60.3% of the cases, there was no friction at the suitable time in 86.3%, and the disinfectant was not allowed to dry in 72.5%. The work shift exerted no influence on performance of the disinfection procedure (p = .376). However, longer training time was associated with a lower rate in performing such procedure (p < .001).

Conclusion

Performing friction below the recommended time can cause a false sense of prevention of catheter-associated bloodstream infection; therefore, training sessions and strategies for adherence to the disinfection procedures should be considered, mainly for professionals with more training time.

Postconcussion Moderate to Vigorous Physical Activity Predicts Anxiety Severity among Adolescent Athletes

PURPOSE

This study aimed to examine how moderate-to-vigorous physical activity (MVPA) during concussion recovery influences self-reported anxiety symptoms at follow-up assessment. We hypothesized that more MVPA after concussion would be associated with lower anxiety rating at follow-up.

METHODS

We performed a prospective study of participants aged 13-18 yr initially assessed within 14 d of diagnosed concussion. Participants rated concussion symptoms using the Post-Concussion Symptom Inventory and were provided a wrist-worn actigraphy device to track activity for 1 wk after assessment. At follow-up assessment, participants rated anxiety symptoms using the four-question Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety subscale. Each question ranged from 1 (never) to 5 (almost always), with an overall score range of 4-20. For univariable analysis, we calculated correlation coefficients between MVPA and PROMIS anxiety subscale scores. We then created a multiple linear regression model with follow-up PROMIS anxiety subscale score as the outcome and MVPA, sex, initial symptom severity, and preconcussion anxiety as predictors.

RESULTS

We enrolled and initially tested 55 participants, and 48 were included in the final analysis (age, 14.6±2.7 yr; 56% female; initial assessment, 7.3± 3.1 d; follow-up assessment, 42.0±29.7 d). We observed an inverse and low correlation between MVPA and follow-up PROMIS anxiety subscale T-scores ( r = -0.30, P = 0.04). Multivariable regression results indicated that MVPA ( β = -5.30; 95% confidence interval (CI), -10.58 to -0.01), initial Post-Concussion Symptom Inventory score ( β = 0.11; 95% CI, 0.03 to 0.19), and preconcussion anxiety ( β = 5.56; 95% CI, 0.12 to 11.0), but not sex ( β = -2.60; 95% CI, -7.14, to 1.94), were associated with follow-up PROMIS anxiety subscale T-scores.

CONCLUSIONS

After adjusting for covariates, more MVPA early after concussion predicted lower PROMIS anxiety subscale scores at follow-up. Although initial concussion symptom severity and preconcussion anxiety were also associated with follow-up PROMIS anxiety subscale score, MVPA represents a modifiable factor that may contribute to lower anxiety symptoms.

Accelerometer-based sedentary time, light physical activity, and moderate-to-vigorous physical activity from childhood with arterial stiffness and carotid IMT progression: A 13-year longitudinal study of 1339 children

AIMS

We examined the longitudinal associations of sedentary time (ST), light physical activity (LPA), and moderate-to-vigorous PA (MVPA) from childhood with carotid-femoral pulse wave velocity (cfPWV), a measure of arterial stiffness and carotid intima-media thickness (cIMT).

METHODS

We studied 1339 children, aged 11 years from Avon Longitudinal Study of Parents and Children, UK, followed up for 13 years. Accelerometer-based ST, LPA, and MVPA were assessed at ages 11, 15, and 24 years clinic visits. cfPWV and cIMT were measured with Vicorder and ultrasound, respectively, at ages 17 and 24 years.

RESULTS

Among 1339 [56.4% female] participants, mean ST increased from ages 11 through 24 years, while mean LPA and MVPA decreased. Persistently high ST tertile from childhood was associated with increased cfPWV progression, effect estimate 0.047 m/s; [(95% CI 0.005 to 0.090); p = 0.030], but not cIMT progression. Persistently high LPA tertile category was associated with decreased cfPWV progression in males -0.022 m/s; [(-0.028 to -0.017); p < 0.001] and females -0.027 m/s; [(-0.044 to -0.010); p < 0.001]. Cumulative LPA exposure decreased the odds of progressively worsening cfPWV [Odds ratio 0.994 (0.994-0.995); p < 0.0001] and cIMT. Persistent exposure to ≥60 min/day of MVPA was paradoxically associated with increased cfPWV progression in males 0.053 m/s; [(0.030 to 0.077); p < 0.001] and females 0.012 m/s; [(0.002 to 0.022); p = 0.016]. Persistent exposure to ≥60 min/day of MVPA was inversely associated with cIMT progression in females -0.017 mm; [(-0.026 to -0.009); p < 0.001].

CONCLUSION

LPA >3 h/day from childhood may attenuate progressively worsening vascular damage associated with increased ST in youth.

Efficacy and safety of azacitidine in pediatric patients with newly diagnosed advanced myelodysplastic syndromes before hematopoietic stem cell transplantation in the AZA-JMML-001 trial

Here we report efficacy, pharmacokinetics, and safety data obtained in treatment-naive, pediatric patients with newly diagnosed advanced MDS receiving azacitidine in the AZA-JMML-001 study. The primary endpoint was response rate (proportion of patients with complete response [CR], partial response [PR], or marrow CR, sustained for ≥4 weeks). Of the 10 patients enrolled, one had an unconfirmed marrow CR and none had confirmed responses after three cycles; the study was therefore closed after stage 1. Azacitidine was well tolerated. The lack of efficacy of azacitidine in pediatric patients with newly diagnosed advanced MDS highlights the need for effective new treatments in these patients.

Grief and Bereavement Support for Parents in Low- or Middle-Income Countries: A Systematic Review

INTRODUCTION

The death of a child may be the most traumatic event a family can experience. Bereavement care for parents is essential for their physical and mental well-being and is a psychosocial standard of care. Childhood mortality is higher in low- or middle-income countries (LMICs); however, little is known regarding bereavement support or interventions for parents in LMICs.

AIM

To identify programs, services, initiatives, or interventions offered to bereaved parents in LMICs in hospital settings.

METHODS

A systematic search was executed following the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles from LMICs describing interventions, programs, or resources provided to parents after the death of a child (0-18 years old) from any cause were included. Extracted data was categorized by demographics, study design, outcomes, and quality assessment using the McGill Mixed Methods Appraisal Tool (MMAT).

RESULTS

We retrieved 4428 papers and screened their titles and abstracts, 36 articles were selected for full-text assessment, resulting in nine articles included in the final analysis. Most interventions described support for parents whose child died during the prenatal or neonatal period. The primary interventions included psychological counseling, creating mementos (such as photographs or footprints), and bereavement workshops. Only one paper described a fully established bereavement program for parents. Eight of the papers met high-quality criteria.

DISCUSSION

Although bereavement care is crucial for parents whose child has died, only a few studies have documented bereavement interventions in LMICs. More research may help with bereavement program implementation and improved care for bereaved parents in LMICs.

Immunophenotypes of Newborns From SARS-CoV-2-infected Mothers

BACKGROUND

Little is known about the neonatal immunologic response to a maternal SARS-CoV-2 infection present during childbirth. Here we analyze a cohort of 75 neonates from SARS-CoV-2-infected mothers.

METHODS

The SARS-CoV-2 infection status was laboratory assessed by real-time reverse transcription polymerase chain reaction on nasopharyngeal swabs (NPS) in both mothers during childbirth and neonates within 24 hours of life. Immunophenotypes of peripheral blood mononucleated cells and SARS-CoV-2 antispike IgA, IgM and IgG of the newborns were recorded. Ten (13.3%) of 75 neonates had positive NPS for SARS-CoV-2; 17 of 75 (23%) were SARS-CoV-2-IgG seropositive, of which one with positive NPS. All the newborns resulted seronegative for SARS-CoV-2 IgA and IgM and were asymptomatic. Our cohort of newborns was divided into groups according to IgG seropositivity (IgG+/-) and NPS results (NPS+/-).

RESULTS

The count and proportion of lymphocyte subsets (evaluated measuring CD3, CD4, CD8 and CD19 markers) and of natural killer cells (evaluated by measuring the CD3-/CD16+/CD56+ subset) were all in the normal range, with no statistical differences among groups. We found a significant expansion of the T cell (CD3+) subset in the IgG+ group interpreted as the result of immune effects triggered by trained immunity in these newborns, but a decrease in CD4+ T cells for NPS+ neonates. It is therefore difficult to conclude that the decrease in CD4 can certainly be caused by an infection.

CONCLUSIONS

A maternal SARS-CoV-2 infection resulted in an expansive effect of CD3+ T cells in IgG+ newborns; nonetheless, it seems not to affect structural and functional development of the newborn immune system.

Cerebral Oximetry During Pediatric In-Hospital Cardiac Arrest: A Multicenter Study of Survival and Neurologic Outcome

OBJECTIVES

To determine if near-infrared spectroscopy measuring cerebral regional oxygen saturation (crS o2 ) during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in children.

DESIGN

Multicenter, observational study.

SETTING

Three hospitals in the pediatric Resuscitation Quality (pediRES-Q) collaborative from 2015 to 2022.

PATIENTS

Children younger than 18 years, gestational age 37 weeks old or older with in-hospital cardiac arrest (IHCA) receiving cardiopulmonary resuscitation greater than or equal to 1 minute and intra-arrest crS o2 monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was ROSC greater than or equal to 20 minutes without extracorporeal membrane oxygenation. Secondary outcomes included SHD and favorable neurologic outcome (FNO) (Pediatric Cerebral Performance Category 1-2 or no change from prearrest). Among 3212 IHCA events (index and nonindex), 123 met inclusion criteria in 93 patients. Median age was 0.3 years (0.1-1.4 yr) and 31% (38/123) of the cardiopulmonary resuscitation events occurred in patients with cyanotic heart disease. Median cardiopulmonary resuscitation duration was 8 minutes (3-28 min) and ROSC was achieved in 65% (80/123). For index events, SHD was achieved in 59% (54/91) and FNO in 41% (37/91). We determined the association of median intra-arrest crS o2 and percent of crS o2 values above a priori thresholds during the: 1) entire cardiopulmonary resuscitation event, 2) first 5 minutes, and 3) last 5 minutes with ROSC, SHD, and FNO. Higher crS o2 for the entire cardiopulmonary resuscitation event, first 5 minutes, and last 5 minutes were associated with higher likelihood of ROSC, SHD, and FNO. In multivariable analysis of the infant group (age < 1 yr), higher crS o2 was associated with ROSC (odds ratio [OR], 1.06; 95% CI, 1.03-1.10), SHD (OR, 1.04; 95% CI, 1.01-1.07), and FNO (OR, 1.05; 95% CI, 1.02-1.08) after adjusting for presence of cyanotic heart disease.

CONCLUSIONS

Higher crS o2 during pediatric IHCA was associated with increased rate of ROSC, SHD, and FNO. Intra-arrest crS o2 may have a role as a real-time, noninvasive predictor of ROSC.

Postoperative outcomes of acute-on-chronic liver failure in infants and children with biliary atresia

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is associated with increased mortality and morbidity in patients with biliary atresia (BA). Data on impact of ACLF on postoperative outcomes, however, are sparse.

METHOD

We performed a retrospective analysis of patients with BA aged <18 years who underwent LT between 2011 and 2021 at our institution. ACLF was defined using the pediatric ACLF criteria: ≥1 extra-hepatic organ failure in children with decompensated cirrhosis.

RESULTS

Of 107 patients (65% female; median age 14 [9-31] months) who received a LT, 13 (12%) had ACLF during the index admission prior to LT. Two (15%) had Grade 1; 4 (30%) had Grade 2; and 7 (55%) had Grade ≥3 ACLF. ACLF cohort was younger at time of listing (5 [4-8] vs. 9 [6-24] months; p < .001) and at LT (8 [8-11] vs. 16 [10-40] months, p < .001) compared to no-ACLF group. Intraoperatively, ACLF patients had higher blood loss (40 [20-53] vs. 10 [6-19] mL/kg; p < .001) and blood transfusion requirements (33 [21-69] vs. 18 [7-25] mL/kg; p = .004). Postoperatively, they needed higher vasopressor support (31% vs. 10.6%; p = .04) and had higher total hospital length of stay (106 [45-151] vs. 13 [7-30] days; p = .023). Rate of return to the operating room, hospital readmission rates, and 1-year post-LT survival rates were comparable between the groups.

CONCLUSION

Despite higher perioperative complications, survival outcomes for ACLF in BA after LT are favorable and comparable to those without ACLF. These encouraging data reiterate prioritization during organ allocation of these critically ill children for LT.

Approach for defining human adenovirus infection and disease for central review adjudication in clinical studies

BACKGROUND

Pediatric allogeneic hematopoietic cell transplant (allo-HCT) recipients are at risk for morbidity and mortality from human adenovirus (HAdV). HAdV can be detected in an asymptomatic state, referred to as infection or with signs or symptoms of illness, referred to as disease. Standardized case definitions are needed to distinguish infection from disease and allow for consistent reporting in both observational cohort studies and therapeutic clinical trials.

METHODS

A working group of experts in virology, transplant infectious disease, and HCT was assembled to develop HAdV infection and disease definitions with the degree of certainty (i.e., possible, probable, and proven). Definitions were further refined through an iterative process and independently applied by two central review committees (CRCs) to 20 pediatric allo-HCT recipients with at least one HAdV-positive PCR.

RESULTS

Initial HAdV infection and disease definitions were developed and updated through an iterative process after reviewing clinical and virological details for 81 subjects with at least one positive HAdV PCR detected in a clinical specimen. Independent application of final definitions to 20 HAdV positive allo-HCT recipients by two CRCs yielded similar number of HAdV infection or disease events but with variation of degree of certainty for some events.

CONCLUSIONS

Application of definitions by a CRC for a study of HAdV infection and disease is feasible and can provide consistency in the assignment of outcomes. Definitions need further refinement to improve reproducibility and to provide guidance on determining clinical improvement or worsening after initial diagnosis of HAdV infection or disease.

Let's Stop the Pain: A Trauma-Informed Care Approach to Pediatric Vaccination

Exposure to pain during routine vaccinations and other injections can cause lifelong anxiety for pediatric patients that may persist into adulthood. Teaching pediatric providers and staff to use intentional and humane approaches to pain management, including distraction, positioning, and use of purposeful language can help to mitigate these fears. We share our experience with assessing pre and post changes to pain management in our pediatric outpatient setting caring for underserved patients and implementing a trauma-informed care approach.

Pediatric en bloc kidney transplant from donors <15 kg: An excellent approach to expand the pediatric deceased donor pool

INTRODUCTION

Most kidneys from small pediatric donors are transplanted to adult recipients because of the perceived risk of surgical complications and graft thrombosis. In this study, we aim to demonstrate our favorable outcomes in transplanting pediatric kidneys from donors <15 k into pediatric recipients.

METHODS

This study retrospectively analyzes the outcomes of seven pediatric recipients of en block kidney transplants from pediatric donors weighing <15 kg performed at King Fahad Specialist Hospital-Dammam from December 2014 to January 2018. Baseline characteristics of donors and recipients were collected. The incidences of surgical complication, immediate, and intermediate graft function were the primary outcomes.

RESULTS

The study included seven recipients monitored for a mean duration of 6.86 ± 1.35. Donors' and recipients' mean weights were 7.4 ± 3.2 kg and 20.7 ± 9.2 kg, respectively. Ureteric stricture occurred in one patient. There was a substantial improvement of 1-year estimated glomerular filtration rate (eGFR) compared to the 1-week mark (106.7 ± 26.38 mL/min. 1.73 m2 vs. 63.7 ± 22.92 mL/min/1.73 m2, p = .0069). The observed improvement in renal function persisted at the 5-year mark and during the last follow-up, with eGFR of 70.3 ± 40.7 mL/min/1.73 m2, and 79.8 ± 30.8 mL/min/1.73 m2, respectively. There was also increase of 27.9% in the size of the en bloc kidney observed at the 6 months.

CONCLUSION

In a specialized transplant center with highly skilled surgeons, the utilization of en bloc kidney transplant from donors weighing less than 15 kg is an effective strategy for expanding the donor pool and ensuring favorable graft outcomes.

Effect of pre-emptive rituximab on EBV DNA levels and prevention of post-transplant lymphoproliferative disorder in pediatric kidney transplant recipients: A case series from the pediatric nephrology research consortium

BACKGROUND

There are scant data on the effect of rituximab on EBV DNA levels and prevention of post-transplant lymphoproliferative disorder (PTLD) in pediatric kidney transplant recipients with EBV DNAemia.

METHODS

Kidney transplant recipients with EBV DNAemia treated with rituximab to prevent PTLD between 7/1999 and 7/2019 at five pediatric centers were included. Those with confirmed PTLD at the onset of rituximab were excluded. Primary outcomes included percentage change in EBV DNAemia and occurrence of PTLD post rituximab.

RESULTS

Twenty-six pediatric kidney transplant recipients were included. Median age at transplant was 4 years (IQR 2.1-10.3). EBV DNA load monitoring by qPCR was performed at 1-3 month intervals. EBV DNAemia onset occurred at a median of 73 days post-transplant (IQR 52-307), followed by DNAemia peak at a median of 268 days (IQR 112-536). Rituximab was administered at a median of 9 days post peak (IQR 0-118). Rituximab regimens varied; median dose 375 mg/m2 (IQR 375-439) weekly for 1-4 doses per course. Following rituximab, EBV DNA load decreased to <10% of baseline at 120 days in 20/26 patients; however, only 30% achieved complete resolution at last follow-up (median 2094 days post-transplant [IQR 1538-3463]). Two (7%) developed PTLD at 915 and 1713 days post rituximab. All recipients had functioning grafts. One death occurred in a child with PTLD following remission due to unrelated reasons.

CONCLUSIONS

In the largest pediatric kidney transplant recipient case series with EBV DNAemia given rituximab to prevent PTLD, rituximab achieved a short-term reduction in DNA load; however, recurrent DNAemia is common.

Recurrent Peritonsillar Abscess Caused by Vaginal Flora: A Common Problem From a Unique Source

Peritonsillar abscesses (PTAs) are typically caused by group A Streptococcus or mixed oral flora. Gardnerella vaginalis is a part of the normal vaginal microbiome, and overgrowth can cause bacterial vaginosis. We present a case of recurrent PTA with G. vaginalis superinfection, which occurred after the patient performed oral sex on a female after incision and drainage of her initial PTA. The patient continued to have recurrent PTAs until G. vaginalis was identified, and antibiotic coverage was broadened to cover both group A Streptococcus and G. vaginalis. This case highlights the importance of culturing PTA aspirate for directed antibiosis in persistent or recurrent infections. The rare superinfection also raises the question of advising abstinence from oral-genital contact after oral procedures to minimize risk of superinfection.

Long-Term Globus Pallidus Internus Deep Brain Stimulation in Pediatric Non-Degenerative Dystonia: A Cohort Study and a Meta-Analysis

BACKGROUND

The evidence in the effectiveness of deep brain stimulation in children with medication-refractory non-degenerative monogenic dystonia is heterogeneous and long-term results are sparse.

OBJECTIVES

The objective is to describe long-term outcomes in a single-center cohort and compare our results with a meta-analysis cohort form literature.

METHODS

We performed a retrospective single-center cohort study including consecutive pediatric patients with non-degenerative genetic or idiopathic dystonia treated with globus pallidus internus deep brain stimulation at our center and a systematic review and individual-patient data meta-analysis with the same inclusion criteria. The primary outcome was the change from baseline in the Burke-Fahn-Marsden Dystonia Rating Scale-movement (BFMDRS-M) score.

RESULTS

The clinical cohort included 25 patients with a mean study follow-up of 11.4 years. The meta-analysis cohort included 224 patients with a mean follow-up of 3 years. Overall, the BFMDRS-M mean improvements at 1 year and at last follow-up were 41% and 33% in the clinical cohort and 58.9% and 57.2% in the meta-analysis cohort, respectively. TOR1A-dystonia showed the greatest and most stable BFMDRS-M improvement in both cohorts at 1 year and at last follow-up (76.3% and 74.3% in the clinical cohort; 69.6% and 67.3% in the meta-analysis cohort), followed by SGCE-dystonia (63% and 63.9% in the meta-analysis cohort). THAP1-dystonia (70.1% and 29.8% in the clinical cohort; 52.3% and 42.0% in the meta-analysis cohort) and KMT2B-dystonia (33.3% and 41.3% in the clinical cohort; 38.0% and 26.7% in the meta-analysis cohort) showed a less pronounced or sustained response.

CONCLUSION

Globus pallidus deep brain stimulation long-term treatment seems effective with a possible gene-specific differential effect. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems

OBJECTIVE

To describe the frequency and observed trends for all Indian Health Service (IHS) and tribal emergency department (ED) transfers to a pediatric referral center from January 1, 2017, to December 31, 2020, with a secondary analysis to describe trends in final dispositions, lengths of stay (LOS), and the most common primary ICD-10 diagnoses.

METHODS

We performed a retrospective chart review of IHS and tribal ED transfers to a pediatric referral center from 2017 to 2020 (n = 2433). The data were summarized using frequencies and percentages and we used generalized estimating equations to analyze patient characteristics over time.

RESULTS

IHS and tribal ED transfers accounted for 6.5%-7.1% of all transfers each year between 2017 and 2020 without significant changes over time. Within this group, 60% were admitted and 62% experienced a LOS greater than 24 h. The most common diagnostic code groups for these patients were respiratory conditions, injuries and poisonings, nonspecific abnormal clinical findings and labs, digestive system diseases, and nervous system diseases.

CONCLUSIONS

This study addresses important knowledge gaps regarding transfers from IHS and tribal EDs, highlights potential high-impact areas for pediatric readiness, and emphasizes the need for more granular data to inform resource allocation and educational interventions. Further studies are needed to delineate potentially avoidable transfers seen within this population.

Sofosbuvir-velpatasvir in children 3-17 years old with hepatitis C virus infection

BACKGROUND

The safety and efficacy of sofosbuvir-velpatasvir in children aged 3-17 years with chronic hepatitis C virus (HCV) infection of any genotype were evaluated.

METHODS

In this Phase 2, multicenter, open-label study, patients received once daily for 12 weeks either sofosbuvir-velpatasvir 400/100 mg tablet (12-17 years), 200/50 mg low dose tablet or oral granules (3-11 years and ≥17 kg), or 150/37.5 mg oral granules (3-5 years and <17 kg). The efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Dose appropriateness was confirmed by intensive pharmacokinetics in each age group.

FINDINGS

Among 216 patients treated, 76% had HCV genotype 1% and 12% had genotype 3. Rates of SVR12 were 83% (34/41) among 3-5-year-olds, 93% (68/73) among 6-11-year-olds, and 95% (97/102) among 12-17-year-olds. Only two patients experienced virologic failure. The most common adverse events were headache, fatigue, and nausea in 12-17-year-olds; vomiting, cough, and headache in 6-11-year-olds; and vomiting in 3-5-year-olds. Three patients discontinued treatment because of adverse events. Four patients had serious adverse events; all except auditory hallucination (n = 1) were considered unrelated to study drug. Exposures of sofosbuvir, its metabolite GS-331007, and velpatasvir were comparable to those in adults in prior Phase 2/3 studies. Population pharmacokinetic simulations supported weight-based dosing for children in this age range.

INTERPRETATION

The pangenotypic regimen of sofosbuvir-velpatasvir is highly effective and safe in treating children 3-17 years with chronic HCV infection.

Serum Phosphorus as a Driver of Skeletal Morbidity in Fibrous Dysplasia

CONTEXT

Fibrous dysplasia (FD) results in fractures, pain, and deformities. Abnormal osteoprogenitor cells overproduce FGF23, leading to hyperphosphaturia in most patients and frank hypophosphatemia in a subset. Studies suggest hypophosphatemia is associated with increased FD-related morbidity. However, the relationship between phosphorus and skeletal complications has not been investigated, and the optimal therapeutic target has not been determined.

OBJECTIVE

Characterize the impact of serum phosphorus on FD-related morbidity and identify levels associated with increased skeletal complications.

METHODS

Natural history study with 240 subjects at a clinical research center who had ≥1 fasting phosphorus level, determined as age- and sex-adjusted Z-scores. Subjects were categorized based on frank hypophosphatemia (Z-score ≤ -2; n = 48); low-normophosphatemia (> -2 to ≤ -1; n = 66); and high-normophosphatemia (> -1 to ≤ 2; n = 125). Main outcomes were fractures, orthopedic surgeries, and scoliosis.

RESULTS

Subjects with frank and low-normophosphatemia had increased fracture and surgery rates vs high-normophosphatemia. The prevalence of moderate to severe scoliosis was similarly higher in the frank and low-normophosphatemia groups. In a subanalysis of patients matched for Skeletal Burden Score ≥35, fracture and surgery rates remained higher in the frank hypophosphatemia group, suggesting association between phosphorus and skeletal complications is not explained by differences in FD burden alone.

CONCLUSION

Both frank hypophosphatemia and low-normophosphatemia are associated with increased FD-related complications. This supports FGF23-mediated hypophosphatemia as a driver of skeletal morbidity, which may impact a larger proportion of the FD/McCune-Albright syndrome population than previously recognized. These findings enable clinicians to identify at-risk patients and will inform development of prospective studies to determine optimal therapeutic targets.

Co-Development of Three Dietary Indices to Facilitate Dietary Intake Assessment of Pediatric Crohn's Disease Patients

Literature on dietary behaviours of the pediatric Crohn's Disease (CD) population and the relationship between dietary intake and CD activity is limited. Three dietary indices were developed and tested to conduct dietary pattern analysis in pediatric patients with CD consuming a free diet following remission induction via exclusive enteral nutrition (n = 11). Index scores underwent descriptive and inferential analysis. The mean adjusted scores (out of 100) for the Pediatric Western Diet Index, Pediatric Prudent Diet Index, and Pediatric-Adapted 2010 Alternate Healthy Eating Index (PA2010-AHEI) were 29.82 ± 15.22, 34.25 ± 15.18, and 51.50 ± 11.69, respectively. The mean Western-to-Prudent ratio was 0.94 ± 0.55. A significant correlation (r = -0.71) and relationship (F[1, 9] = 9.04, P < 0.05, R2 = 0.501) between the Western-to-Prudent ratio and PA2010-AHEI was found. The results suggest participants were not following a Western or Prudent diet, and were consuming foods not captured by the indices. More research is needed to describe dietary intake of individuals with CD, validate dietary indices in diverse samples, and explore the utility of these indices in CD assessment and treatment. The co-authors hope this work will stimulate/inspire subsequent interprofessional, dietitian-led research on this topic.

Feasibility and Effectiveness of Repeat Laparoscopic Pyeloplasty for Recurrent Ureteropelvic Junction Obstruction in Pediatric Patients

Objective: To assess the outcomes of redo laparoscopic pyeloplasty (RLP) in pediatric patients with recurrent ureteropelvic junction obstruction (UPJO) in contrast to redo open pyeloplasty (ROP). In addition, evaluate the feasibility and efficacy of RLP as a treatment modality for recurrent UPJO in children. Materials and Methods: The data of 44 patients from March 2012 to March 2022, who underwent redo pyeloplasty, were retrospectively reviewed. In Group RLP, the children underwent RLP, whereas ROP was attempted in Group ROP. Demographics, clinical manifestations, surgical duration, hospitalization duration, complication rates, and treatment success were examined within the respective groups. Moreover, preoperative and postoperative measurements of anterior-posterior diameter of the renal pelvis (APD), preoperative assessment of differential renal function (DRF), and the percentage of improvement in DRF (PI-DRF) were subject to analysis. Results: The study included 28 patients who underwent RLP (Group RLP), and 16 patients who underwent ROP (Group ROP). In all cases, the Anderson-Hynes technique was employed. There was no significant difference between the two groups regarding age, body mass index, gender distribution, affected side, preoperative APD, postoperative APD, and preoperative DRF. In comparison to Group ROP, Group RLP exhibited a shorter hospitalization duration, a longer surgical procedure duration, and a higher percentage improvement in PI-DRF. The median follow-up period for Group RLP was 25 months, whereas it was 25.5 months for Group ROP. Notably, the success rates were similar between the two groups, with a success rate of 89.2% in RLP and 87.5% in ROP (p = 0.634). Conclusion: RLP has a comparable success rate to ROP and is a safe, effective, and feasible procedure for the treatment of failed pyeloplasty in children.

Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.

Laryngeal clefts in Prader-Willi syndrome: Feeding difficulties and aspiration not always caused by hypotonia

Feeding difficulties, aspiration, and failure to thrive in infancy are commonly seen in patients with Prader-Willi Syndrome (PWS) and attributed to hypotonia. Patients with PWS and laryngeal clefts were identified by review of medical records at three tertiary care children's hospitals between 2017 and 2022. We present three patients with PWS with feeding difficulties who were also found to have laryngeal clefts which likely contributed to their feeding difficulties. Additional factors such as airway anomalies should be considered in patients with PWS, especially when swallowing dysfunction, dysphagia, or abnormal swallow evaluations are present.

Bladder Exstrophy Consortium (MIBEC) After 8 Years: The Short and Intermediate Term Outcomes

BACKGROUND

Bladder exstrophy (BE) poses challenges both during the surgical repair and throughout follow-up. In 2013, a multi-institutional BE consortium was initiated, which included utilization of unified surgical principles for the complete primary repair of exstrophy (CPRE), real time coaching, ongoing video capture and review of video footage, prospective data collection, and routine patient data analysis, with the goal of optimizing the surgical procedure to minimize devastating complications such as glans ischemia and bladder dehiscence while maximizing the rate of volitional voiding with continence and long term protection of the upper tracts. This study reports on our short term complications and intermediate term continence outcomes.

METHODS

A single prospective database for all patients undergoing surgery with a bladder exstrophy epispadias complex diagnosis at three institutions since February 2013 was used. For this study, data for children with a diagnosis of classic BE who underwent primary CPRE from February 2013 to February 2021 were collected. Data recorded included sex, age at CPRE, adjunct surgeries, including ureteral reimplantations and hernia repairs at the time of CPRE, osteotomies and immobilization techniques, and subsequent surgeries. Data on short term postoperative outcomes, defined as those occurring within the first 90 days after surgery, were abstracted. In addition, intermediate term outcomes were obtained for patients operated on between February 2013 and February 2017 to maintain a minimum follow-up of 4 years. Outcomes included upper tract dilation on renal and bladder ultrasound (RBUS), presence of vesicoureteral reflux (VUR), cortical defects on nuclear scintigraphy (DMSA), and continence status. Bladder emptying was assessed with respect to spontaneous voiding ability, need for clean intermittent catheterization (CIC), and duration of dry intervals. All operating room encounters that occurred subsequent to initial CPRE were recorded.

RESULTS

CPRE was performed in 92 classic BE patients in the first 8 years of the collaboration (62 boys), including 46 (29 boys) during the first 4 years. In the complete cohort, the median (IQR) age at CPRE was 79 (50.3) days. Bilateral iliac osteotomies were performed in 89 (97%) patients (42 anterior and 47 posterior). Of those undergoing osteotomies 84 were immobilized in a spica cast (including the 3 who did not have an osteotomy), 6 in modified Bryant's traction, and 2 in external fixation with Bucks traction). Sixteen (17%) patients underwent bilateral ureteral reimplantations at the time of CPRE. Nineteen (21%) underwent hernia repair at the time of CPRE, 6 of which were associated with orchiopexy. Short term complications within 90 days occurred in 31 (34%), and there were 13 subsequent surgeries within the first 90 days. Intermediate term outcomes were available for 40 of the 46 patients who have between 4 and 8 years of follow up, at a median of 5.7 year old. Thirty-three patients void volitionally, with variable dry intervals, demonstrated in the summary table.

CONCLUSIONS

Cumulative efforts of prospective data collection have provided granular data for evaluation. Short term outcomes demonstrate no devastating complications, that is, penile injury or bladder dehiscence, but there were other significant complications requiring further surgeries. Intermediate term data show that boys in particular show encouraging spontaneous voiding and continence status post CPRE, while girls have required modification of the surgical technique over time to address concerns with urinary retention. Overall, 40% of children with at least 4 years of follow up are voiding with dry intervals of > 1 hour.

First Accuracy and User-Experience Evaluation of New Continuous Glucose Monitoring System for Hypoglycemia Due to Hyperinsulinism

INTRODUCTION

Patients with congenital hyperinsulinism (HI) require constant glucose monitoring to detect and treat recurrent and severe hypoglycemia. Historically, this has been achieved with intermittent self-monitoring blood glucose (SMBG), but patients are increasingly using continuous glucose monitoring (CGM). Given the rapidity of CGM device development, and increasing calls for CGM use from HI families, it is vital that new devices are evaluated early.

METHODS

We provided two months of supplies for the new Dexcom G7 CGM device to 10 patients with HI who had recently finished using the Dexcom G6. Self-monitoring blood glucose was performed concurrently with paired readings providing accuracy calculations. Patients and families completed questionnaires about device use at the end of the two-month study period.

RESULTS

Compared to the G6, the G7 showed a significant reduction in mean absolute relative difference (25%-18%, P < .001) and in the over-read error (Bland Altman +1.96 SD; 3.54 mmol/L to 2.95 mmol/L). This resulted in an improvement in hypoglycemia detection from 42% to 62% (P < .001). Families reported an overall preference for the G7 but highlighted concerns about high sensor failure rates.

DISCUSSION

The reduction in mean absolute relative difference and over-read error and the improvement in hypoglycemia detection implies that the G7 is a safer and more useful device in the management of hypoglycemia for patients with HI. Accuracy, while improved from previous devices, remains suboptimal with 40% of hypoglycemia episodes not detected.

Securing the oral and enteral oncopediatric chemotherapy process in pediatric oncology: Introduction of the ENFit™ standard in a controlled-atmosphere area and implementation of a dispensing service of medications to outpatients circuit with advice on proper use

INTRODUCTION

Oral chemotherapies pediatrics are manufactured from injectable specialties in a controlled-atmosphere area. Packaged in Luer-Lock syringes, the transition to an ENFit™ connector became crucial to enable administration in surveyed patients. In parallel, a study was carried out to optimize and secure patient care by setting up a retrocession circuit.

OBJECTIVE

To introduce the ENFit™ range of devices into the manufacturing process for oral or enteral chemotherapy syringes. Secondly, establish a retrocession circuit, validate its economic relevance and implement and evaluate efforts to promote proper use.

METHODS

ENFit™ meeting the specifications were sourced and then evaluated. Research was conducted on the legislative framework governing the retrocession of masterful preparations made from injectable specialties. A 2021 retrospective economic study enabled the assessment of the financial balance generated by a potential retrocession circuit. Meetings to promote the good use of medication were conducted. Satisfaction questionnaires were created for caregivers and medical staff in the pediatric department.

RESULTS

All ENFit™ ranges have been referenced within the Fresenius laboratory. Retrocession has been set up in accordance with legislation. The economic study highlighted a potential revenue of EUR 69,900 in 2021. Three good-use booklets and a dosage plan were created to promote good use. Ten families and 12 caregivers responded to the questionnaire, with satisfaction rates of 81.1% and 71.9%, respectively.

CONCLUSION

ENFit™ devices has enabled oral and enteral administration of chemotherapy. The retrocession circuit includes all the good-use elements required for optimal patient care. The results of the satisfaction survey are positive, certain areas for improvement have been identified.

Pediatric Population Management Classification for Children with Medical Complexity

Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.

Establishing a pediatric reference interval for plasma calprotectin

Plasma calprotectin is a promising new biomarker of inflammatory activity and has been found to correlate well with clinical and endoscopic activity in children and adolescents with inflammatory bowel disease. A pediatric reference interval for plasma calprotectin has not been established for the Phadia 250 EliA™ Calprotectin fluoroenzyme immunoassay. In studies regarding pre-analytical properties, excellent precision and stability was found. However, sensitivity to hemolysis was demonstrated. We identified pediatric blood samples from apparently healthy children who were referred by their general practitioner for blood sampling including measurement of hemoglobin (Hb) and C-reactive protein (CRP). We excluded samples from children who had undergone additional blood sampling within 2 months before or after the index sample, if Hb was outside of local reference ranges or CRP levels were above the lower limit of the measuring interval (LLM), and any samples with a hemolysis above 0.02 mmol/L. Using this algorithm, we identified 141 blood samples. No outliers were identified. We established the following reference intervals according to CLSI C28-A3 using non-parametric statistics: 1-17 years: 16-246 µg/L. Our results may prove useful for further utilization of plasma calprotectin as a marker of inflammation in children and adolescents with inflammatory disorders.

Geographic, Sociodemographic, and Clinical Factors Associated With Parental Self-Efficacy in Pediatric Patients With Hearing Loss

OBJECTIVE

To identify geographic, sociodemographic, and clinical factors associated with parental self-efficacy in a diverse cohort of deaf or hard-of-hearing (DHH) children.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary children's hospital.

METHODS

Four hundred forty parents of DHH children aged 0 to 17 completed the 25-item Scale of Parental Involvement and Self-Efficacy (SPISE) survey from 2014 to 2022. Residential addresses were geocoded and assigned Area Deprivation Index and Social Vulnerability Index rankings, and univariable and multivariable analyses were conducted using sociodemographic and clinical variables, including sex, race/ethnicity, insurance type, survey language, age at the survey, comorbidities, newborn hearing screening results, and hearing loss laterality and severity.

RESULTS

Compared to English and Spanish-speaking parents, Chinese-speaking parents were associated with overall lower parental self-efficacy and involvement (regression coefficient = -0.518, [-0.929, -0.106]), Cohen's d = 0.606) and lower scores on items related to their ability to affect multiple aspects of their child's development and expression of thoughts as well as competency in checking and putting on their child's sensory device. Across univariable and multivariable analyses, besides Chinese language, all other sociodemographic, clinical, and geographic variables were not associated with SPISE score.

CONCLUSION

To achieve the best patient outcomes, care teams can use the SPISE to evaluate parental self-efficacy and provide targeted support to parents at risk for having lower knowledge and confidence scores about critical skills necessary to facilitate their child's auditory access and language development. Notably, this study found similar reports of parental efficacy across various sociodemographic, clinical, and geographic variables but significantly lower SPISE scores in Chinese-speaking families.

Advancing Pediatric Care: The virtualKIDS Experience in Nursing-Led Audio-Visual Clinical Services

During the COVID-19 pandemic, the escalating trend of pediatric patients, particularly non-urgent cases, going to the emergency departments (EDs) in New South Wales, Australia, prompted the establishment of virtualKIDS, a nursing-led telehealth service. This service, initiated in June 2021, operates 24/7 and provides comprehensive care through audio-visual consultations emphasizing a patient-centered approach. Three elements-COVID-19 Outpatient Response Team (CORT), virtualKIDS Acute Review (vKAR), and Virtual Urgent Care (VUC)-addressed specific needs during and beyond the pandemic, showcasing the adaptability and impact of virtual care. vKAR focuses on post-discharge support, allowing families access to telehealth for up to three days. Preliminary data indicates a 44% reduction in ED visits within 48 h. VUC employs nursing-led triaging paired with audiovisual assessment, demonstrating a 69% hospitalization avoidance rate. Hybrid ambulatory models such as a sleep study at home project, day-only tonsillectomies, and arthroscopic knee surgeries showcase innovative approaches to reducing hospital admissions and enhancing patient outcomes. This paper presents the evolution and diverse models of care implemented by the virtualKIDS service, offering insights into its potential as a nursing-led alternative to ED visits in acute-care pediatrics.

Infant microbes and metabolites point to childhood neurodevelopmental disorders

This study has followed a birth cohort for over 20 years to find factors associated with neurodevelopmental disorder (ND) diagnosis. Detailed, early-life longitudinal questionnaires captured infection and antibiotic events, stress, prenatal factors, family history, and more. Biomarkers including cord serum metabolome and lipidome, human leukocyte antigen (HLA) genotype, infant microbiota, and stool metabolome were assessed. Among the 16,440 Swedish children followed across time, 1,197 developed an ND. Significant associations emerged for future ND diagnosis in general and for specific ND subtypes, spanning intellectual disability, speech disorder, attention-deficit/hyperactivity disorder, and autism. This investigation revealed microbiome connections to future diagnosis as well as early emerging mood and gastrointestinal problems. The findings suggest links to immunodysregulation and metabolism, compounded by stress, early-life infection, and antibiotics. The convergence of infant biomarkers and risk factors in this prospective, longitudinal study on a large-scale population establishes a foundation for early-life prediction and intervention in neurodevelopment.

Increased Pediatric Respiratory Syncytial Virus Case Counts Following the Emergence of Severe Acute Respiratory Syndrome Coronavirus 2 Can Be Attributed to Changes in Testing

BACKGROUND

Respiratory syncytial virus (RSV) circulation dropped markedly early in the COVID-19 pandemic, followed by a resurgence with heightened case counts. The "immunity debt" hypothesis proposes that the RSV-naїve pediatric population increased during the period of low transmission. However, the evidence supporting this hypothesis is limited, and the role of changing testing practices in the perceived surge has not been comprehensively evaluated.

METHODS

We conducted a multicenter, retrospective analysis of 342 530 RSV encounters and 980 546 RSV diagnostic tests occurring at 32 US pediatric hospitals in 2013-2023. We used interrupted time series analysis to estimate pandemic-associated changes in RSV patient and test volume and to quantify changes in the proportions of patients requiring hospitalization, intensive care, or mechanical ventilation. We quantified the fraction of the shifts in case counts and in the age of diagnosed patients attributable to changes in testing.

RESULTS

RSV patient volume increased 2.4-fold (95% confidence interval [CI]: 1.7, 3.5) in 2021-2023 relative to the pre-pandemic phase and was accompanied by an 18.9-fold increase (95% CI: 15.0, 23.9) in RSV test volume. Shifts in patient volume and in patient age were largely attributable to increased testing. The proportions of patients with RSV that required hospitalization, intensive care, or mechanical ventilation declined significantly across all patient age groups.

CONCLUSIONS

A surge in RSV testing, rather than in viral circulation, likely underlies the increased case counts observed in 2021-2023. These findings warrant a critical assessment of the immunity debt hypothesis and highlight the importance of considering the testing denominator when surveillance strategies are dynamic.

Evaluation of Balance with Computerized Dynamic Posturography in Children with Otitis Media

BACKGROUND

Otitis media with effusion (OME) frequently leads to vestibular symptoms in children. However, young children face difficulty expressing their symptoms due to their limited language abilities.

METHODS

The balance of study and patient group evaluated with computer dynamic posturography, single-leg stance test with eyes closed and regular Head Impulse Test. The study group was assessed once again after the insertion of a ventilation tube two months later.

RESULTS

In the Sensory Organization Test, the scores for conditions 5, 6, and composite equilibrium of the preoperative patient group were notably lower compared with both the control and postoperative patient groups (p < 0.05). Additionally, a significant correlation was found between single-leg stance test with eyes closed results and conditions 5, 6, and composite equilibrium scores.

CONCLUSION

The impact of OME on the vestibular system is negative. This effect can be objectively assessed using Computer Dynamic Posturography and following tube insertion, there is a notable improvement in vestibular function. Furthermore, the single-leg stance (SLS) test with eyes closed has shown its reliability in assessing balance disorders, notably in children with OME.

LEVEL OF EVIDENCE

Level 2 Laryngoscope, 2024.

Reliability of the Clinical Measurement of Joint Motion and Muscle Length in the Upper and Lower Extremities of Children with Cerebral Palsy: A Systematic Review

Reliability of joint motion and muscle length measurement in children with cerebral palsy was examined. Twenty-one studies of intraobserver and/or interobserver reliability were reviewed: joint motion of upper extremities in four and lower extremities in 13; muscle length of upper extremities in one and lower extremities in 15. Intraclass correlation coefficients for goniometric interobserver reliability varied widely for joint motion (range 0.38-0.92) and muscle length (range 0.20-0.95). Inclusion of an error measurement to provide clinicians with a value indicating true change was limited. Further research is required to determine intraobserver and interobserver reliability for these important pediatric clinical measurements.

Immunogenicity and Vaccine Shedding After 1 or 2 Doses of rVSVΔG-ZEBOV-GP Ebola Vaccine (ERVEBO®): Results From a Phase 2, Randomized, Placebo-controlled Trial in Children and Adults

BACKGROUND

The rVSVΔG-ZEBOV-GP vaccine (ERVEBO®) is a single-dose, live-attenuated, recombinant vesicular stomatitis virus vaccine indicated for the prevention of Ebola virus disease (EVD) caused by Zaire ebolavirus in individuals 12 months of age and older.

METHODS

The Partnership for Research on Ebola VACcination (PREVAC) is a multicenter, phase 2, randomized, double-blind, placebo-controlled trial of 3 vaccine strategies in healthy children (ages 1-17) and adults, with projected 5 years of follow-up (NCT02876328). Using validated assays (GP-ELISA and PRNT), we measured antibody responses after 1-dose rVSVΔG-ZEBOV-GP, 2-dose rVSVΔG-ZEBOV-GP (given on Day 0 and Day 56), or placebo. Furthermore, we quantified vaccine virus shedding in a subset of children's saliva using RT-PCR.

RESULTS

In total, 819 children and 783 adults were randomized to receive rVSVΔG-ZEBOV-GP (1 or 2 doses) or placebo. A single dose of rVSVΔG-ZEBOV-GP increased antibody responses by Day 28 that were sustained through Month 12. A second dose of rVSVΔG-ZEBOV-GP given on Day 56 transiently boosted antibody concentrations. In vaccinated children, GP-ELISA titers were superior to placebo and non-inferior to vaccinated adults. Vaccine virus shedding was observed in 31.7% of children, peaking by Day 7, with no shedding observed after Day 28 post-dose 1 or any time post-dose 2.

CONCLUSIONS

A single dose of rVSVΔG-ZEBOV-GP induced robust antibody responses in children that was non-inferior to the responses induced in vaccinated adults. Vaccine virus shedding in children was time-limited and only observed after the first dose. Overall, these data support the use of rVSVΔG-ZEBOV-GP for the prevention of EVD in at-risk children. Clinical Trials Registration. The study is registered at ClinicalTrials.gov (NCT02876328), the Pan African Clinical Trials Registry (PACTR201712002760250), and the European Clinical Trials Register (EudraCT number: 2017-001798-18).