Pediatrics Current

Errors occurred in the article by Hoffmann JA et al, titled “Supporting Children’s Mental Health Needs in Disasters”, published in the January 2025 issue of Pediatrics (2025;155(1):e2024068076; doi: 10.1542/peds.2024-068076).

BACKGROUND AND OBJECTIVESAdolescence is a critical period for cognitive, social, and emotional development. Existing data on dose-dependent associations between cannabis use and adverse psychosocial development indicators in adolescence are limited, particularly for low-frequency users. We describe relationships between cannabis use frequency and psychosocial indicators.METHODSThis cross-sectional study used a US nationally representative sample of 8th, 10th, and 12th grade students from the 2018-2022 Monitoring the Future surveys. Participants were categorized for nonuse and noncurrent, monthly, weekly, and near-daily cannabis use. We describe demographically adjusted odds of cannabis use frequency and cognitive, social, and emotional indicators.RESULTSAmong 162 532 respondents (mean age, 16.0 years [SD, 1.7]; 45.8% male; racially and ethnically diverse), 42 601 (26.2%) were cannabis users: 7515 (4.6%) were near-daily, 5853 (3.6%) were weekly, 7802 (4.8%) were monthly, and 21 431 (13.2%) were noncurrent users. Compared with nonusers, noncurrent and monthly users had greater odds of poor academic performance (adjusted odds ratio [aOR], 1.30–2.20), poor impulsivity and self-regulation (aOR, 1.26–2.19), and adverse emotional states (aOR, 1.1–1.42). Adjusted odds of all adverse psychosocial categories, excluding low social engagement, showed a consistent dose-response trend. Effect sizes were small for poor academic performance (d = 0.39–0.44), small to medium for poor impulsivity and self-regulation (d = 0.43–0.55), small for adverse emotional state (d = 0.33–0.40), and none to small (d = 0.03–0.18) for low social engagement. Younger users (aged <16 years) showed greater susceptibility for academic and emotional indicators.CONCLUSIONIn this nationally representative sample, dose-dependent associations of frequency of cannabis use with adverse academic and emotional functioning were observed, even among monthly users, underscoring the importance of routinely inquiring about cannabis use in adolescents.

OBJECTIVEHealth insurance gaps are common among publicly insured children, undermining health care access and health. The Families First Coronavirus Response Act halted Medicaid disenrollments during the COVID-19 public health emergency (PHE), offering an opportunity to study the impact of continuous Medicaid eligibility on child health insurance coverage, health care access and use, and health.METHODSUsing 2016–2022 National Survey of Children’s Health data (n = 182 910), we applied a difference-in-differences approach to compare changes in health insurance coverage gaps, health care access (unmet health care needs [any, mental health, and specialist]), health care use (preventive care, emergency department [ED]), and general health status before and during the PHE between publicly (“treated”) and privately (“untreated”) insured children. Adjusted models included child demographics, household characteristics, and state of residence. We also conducted subgroup analyses by child age and special health care need status.RESULTSContinuous Medicaid eligibility was associated with a 3.1 percentage point (pp) decrease in health insurance coverage gaps (95% CI, −3.9 to −2.3) and a 3.9 pp decrease in ED use (95% CI, −5.7 to −2.0) among publicly insured children. Among children with special health care needs (CSHCN), continuous eligibility was associated with a larger decrease in ED use (−7.5 pp, 95% CI, −11.3 to −3.7) and was additionally associated with a 6.4 pp increase (95% CI, 2.7–10.1) in excellent general health status compared with children without special health care needs. No significant associations were observed with other indicators of health care access or use.CONCLUSIONPolicies promoting continuous Medicaid eligibility may improve child health care use and health through improved coverage consistency, particularly among CSHCN.

Differentiating viral from bacterial infections is one of the greatest challenges in pediatrics. As our awareness of the harms associated with antibiotic use in children has increased, the tension between the desire to avoid unnecessary antibiotics and the imperative to identify and treat invasive bacterial infections, including bacteremia and meningitis, in a timely fashion has escalated. Countless algorithms, guidelines, recommendations, and tests have been developed to support clinical decision-making around antibiotic use. Yet, we still struggle.

10.1542/6378834658112Video AbstractPEDS-VA_2024-0699616378834658112OBJECTIVEEvaluate impact of MeMed BV (MMBV) host-protein test on clinical decision-making for children with acute infection in urgent care centers (UCCs).METHODSPragmatic study examining real-world use of MMBV by physicians trained to order the test when facing diagnostic uncertainty in suspected pediatric infections. Study assessed MMBV’s impact on 2 decisions: whether to refer to the emergency department (ED), and, for discharged patients, whether to prescribe antibiotics. MMBV scores from 65 to 100 indicated a bacterial infection (or coinfection) and from 0 to 35 indicated viral/nonbacterial. Physicians filled pre- and post-test questionnaires. The outcomes included ED referrals, alignment between prescription and MMBV results, and 7-day post-UCC hospitalizations and antibiotic prescriptions.RESULTSThe MMBV was ordered for 2171 patients. According to post-test questionnaires (n = 1677), MMBV results encouraged referral in 3.9% and discouraged referral in 26.0% of cases. Hospitalization rates were similar when the MMBV result did not impact vs when it discouraged referral (5.5% vs 4.6%; P = .53). Among 1713 nonreferred patients, the prescription aligned with MMBV results in 80.5%. Physicians reported that MMBV results changed or supported prescription decisions in 82.0% of cases. When physicians were undecided pretest, 80.6% of bacterial MMBV and 15.9% of viral MMBV cases were managed. When physicians were likely to prescribe but MMBV results were viral, 61.7% of patients were not treated. Post-UCC hospitalizations (3.3% vs 1.5%; P = .49) and prescriptions (14.7% vs 16%; P = .74) were comparable between not treated vs treated. When unlikely to prescribe but the MMBV results were bacterial, 77.1% of patients were treated. Post-UCC prescriptions were higher among cases not managed at a UCC (33.3% vs 13.2%; P = .02).CONCLUSIONSMMBV aided safe clinical decision-making for pediatric acute infections in UCCs.

Therapeutic drug monitoring (TDM) is indicated for drugs with narrow therapeutic indices, whereby clinicians can adjust drug dosing to promote efficacy while limiting toxicity risk. Such monitoring is particularly important in managing infectious diseases, as both patient- and organism-specific factors must be considered to achieve optimal clinical responses. Innovation in pediatric TDM lags behind adults, largely due to a paucity of data and feasibility issues with lab draws and pharmacy resources. Emerging techniques in pharmacokinetic (PK) modeling, PK study design, flexible sampling strategies, and reduced sample volume requirements are particularly promising for TDM advancement in neonates and children. In this article, we discuss recent advancements in vancomycin TDM as a model case. Vancomycin is commonly used to treat serious gram-positive infections in children, and monitoring was historically performed using trough concentration–based guidance. Emerging data suggest that vancomycin troughs are not reliable surrogates for efficacy or toxicity and that trough-based monitoring is associated with increased risk of nephrotoxicity without clinical benefits. The area under the concentration-time curve (AUC) is the optimal pharmacokinetic-pharmacodynamic metric to measure overall vancomycin exposures, and consensus infectious diseases and pharmacist society guidance has formally recommended a shift toward AUC-based monitoring and away from trough-based monitoring in all age groups—including in neonates and children. We compare approaches to TDM in infectious diseases and summarize the body of literature describing application of vancomycin AUC-guided monitoring in children and neonates. Finally, we highlight opportunities and potential barriers to implementation of AUC-guided TDM in pediatric populations.

A 13-year-old girl presented for evaluation of pulmonary hypertension after symptoms of dyspnea and exercise intolerance. Full evaluation was negative except for abdominal ultrasonography with splenomegaly and esophageal varices suggestive of portal hypertension. Cardiac and hepatic vein catheterization confirmed portopulmonary hypertension. Liver biopsy demonstrated sinusoidal dilatation, nodularity, and minimal fibrosis, which was interpreted as possible nodular regenerative hyperplasia but not cirrhosis. Radiographic imaging, including computed tomography venography, demonstrated an elongated and severely stenotic extrahepatic portal vein, and portal hypertension was presumed to be secondary to congenital portal vein hypoplasia. She was treated with ambrisentan with initial improvement in symptoms and estimated pulmonary pressure. Whole-exome sequencing revealed a likely pathogenic missense mutation in Delta-like canonical Notch ligand 4 associated with Adams-Oliver syndrome. After 2 years, pulmonary hypertension and right heart failure symptoms worsened, along with liver failure. She then had fulminant liver failure and cardiorespiratory arrest. Resuscitative efforts included extracorporeal membranous oxygenation (ECMO), but because of hypoxic brain injury, care was compassionately withdrawn. Autopsy limited to the thorax and abdomen revealed high-grade pulmonary plexiform arteriopathy, splenomegaly, esophageal varices, and large splenorenal shunt. The liver was small with a nodular surface but not fibrotic. The entire length of the extrahepatic portal vein was severely stenotic, and intrahepatic portal veins were missing or diminutive—findings diagnostic of hepatoportal sclerosis. Noncirrhotic portopulmonary hypertension is rare and should include evaluation of immunologic, infectious, toxic, thrombotic, and genetic etiologies. Unfortunately, there is no known treatment of hepatoportal sclerosis.

10.1542/6380059087112Video AbstractPEDS-VA_2025-0713226380059087112OBJECTIVEThis study aimed to evaluate associations of a narrative film with community perspectives toward persons with disabilities (PWDs) in western Kenya.METHODSSix locations were selected for the film intervention in Uasin Gishu County, Kenya. Focus group discussions (FGDs) were conducted before, immediately after, and 3 months following the film to understand perspectives on disability. Thematic analysis was used to identify emerging themes and concepts.RESULTSA total of 506 community members attended the film screening, and 114 were randomly selected for FGDs. In preintervention FGDs, participants attributed the cause of disability to an accident or a curse or witchcraft, as occurring from birth, or being related to disease. Many participants noted that the community viewed PWDs as overlooked, feared, and burdensome. Treatment of PWDs was described as discriminatory, describing children being hidden, neglected, and abused. After the film, many individuals described PWDs as blessings, important, and capable members of the community. Participants described that the family, community, and government have shared roles in bringing their children with disabilities outside of the home; providing educational opportunities; and finding ways to support, protect, and love them. Three months after the film, participants described working toward more inclusion but noted that limited resources, uncertainty, lack of awareness, and PWDs’ families’ fear of being exploited were all challenges to implementing change in their communities.CONCLUSIONSA narrative film about stigma regarding disability may improve perspectives among community members toward PWDs. Evidence of community-based action and advocacy were demonstrated even 3 months after viewing the film.

BACKGROUND AND OBJECTIVEEmergency department (ED) crowding and prolonged boarding times negatively impact care. Our objective was to decrease the average ED boarding time for patients admitted from the ED to any inpatient (IP) acute care unit at our main campus by 35% over 24 months.METHODSOur multidisciplinary team used the Model for Improvement to identify inefficiencies within the existing admission process and created a key driver diagram to guide intervention design. Serial Plan-Do-Study-Act cycles tested and refined interventions initially piloted on one high-volume IP unit before implementation across the institution. Interventions focused on creating shared knowledge of the admission process, optimizing IP room preparation, improving communication between process stakeholders, and streamlining the admission process. We used statistical process control charts to measure the impact of our interventions over time. Our outcome measure was ED boarding time. Very rapid transfer rate, or patients transferred to an intensive care unit within 3 hours of admission, and ED length of stay (LOS) were balancing measures. Our left without being seen (LWBS) rate served as a measure of care access.RESULTSOur average ED boarding time decreased by 40% from 169 to 102 minutes, accompanied by a decrease in ED LOS and LWBS rate. There was no change in our very rapid transfer rate.CONCLUSIONSEngaged institutional and site of care leadership was integral to our project success. By understanding our system, creating clear expectations for process timelines, and streamlining communication, we were able to meaningfully improve transitions of care.

10.1542/6382808433112Video AbstractPEDS-VA_2025-0734916382808433112BACKGROUNDThe Korea Early Childhood Home-visiting Intervention (KECHI), a nurse-led program, was developed in 2020 to support maternal and child health. This study evaluated the program’s impact on the home environment and maternal outcomes at 6 months postpartum.METHODSA randomized controlled trial was conducted with individual-level 1:1 allocation across 25 district public health centers between 2021 and 2025. Pregnant women under 37 weeks’ gestation with a risk factor score greater than or equal to 2 of sociodemographic, psychosocial, and health risk factors and trauma experiences were randomly assigned to the intervention or control group. The intervention group received 11.24 visits on average from intervention providers, beginning during pregnancy and continuing through 6 months postpartum. The control group received usual care. Primary outcomes included scores on the Infant/Toddler Home Observation for Measurement of the Environment (IT-HOME), breastfeeding duration, and maternal self-rated health. Secondary outcomes included maternal knowledge, mental health, and parenting behaviors.RESULTSOutcome data were obtained for 395 of 408 (96.8%) participants in the intervention group and 385 of 392 (98.2%) in the control group. Compared with the control group, the intervention group demonstrated significantly greater parental involvement on the IT-HOME scale (Cohen’s d effect size [ES], 0.14; 95% CI, 0.00 to 0.27), higher safety knowledge (ES, 0.17; 95% CI, 0.02 to 0.32), and fewer depressive symptoms measured by the Patient Health Questionnaire-9 (ES, –0.17; 95% CI, –0.32 to –0.02) and the Edinburgh Postnatal Depression Scale (ES, –0.21; 95% CI, –0.36 to –0.05). Adjusted odds ratios were 0.55 (95% CI, 0.35 to 0.86) for postnatal depression and 0.50 (95% CI, 0.30 to 0.85) for suicidal ideation. No effect on breastfeeding duration was detected.CONCLUSIONSKECHI improved the home environment and maternal mental health at 6 months postpartum. The upcoming 2-year results will offer further insight into KECHI’s impact and support its national scale-up.

In the current issue of Pediatrics, Khang et al report outcomes from a randomized clinical trial of a program of nurse–home-visiting that begins during pregnancy and continues through child-age–two conducted in Korea.1 The program was adapted from the Australian Maternal and Early Childhood Sustained Home-visiting (MECSH) program to align with the Korean context. Findings covered in this report are through child-age 6 months and are promising: intervention-group mothers exhibited greater parental involvement with their children on the Infant/Toddler Home Observation for Measurement of the Environment, greater knowledge of child safety, and fewer maternal mental health problems than those assigned to the usual-care control group.

Codeveloped by the American Heart Association and the American Academy of Pediatrics, this publication presents the 2025 guidelines for basic life support during cardiopulmonary resuscitation and emergency cardiovascular care of the pediatric patient, excluding the newborn infant, and represents the first comprehensive update of treatment recommendations since 2020. Incorporating the results of structured evidence reviews from the International Liaison Committee on Resuscitation, these guidelines are for lay rescuers and health care professionals with recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. Existing guidelines remain relevant unless specifically updated in this publication. Topics reviewed include the initiation of cardiopulmonary resuscitation; pulse check; components of high-quality cardiopulmonary resuscitation; chest compression technique; support surfaces for cardiopulmonary resuscitation; opening the airway; coordination of shock and cardiopulmonary resuscitation; types of defibrillators or automated external defibrillators; defibrillator paddle or pad size, type, position; treatment of inadequate breathing with a pulse; and foreign-body airway obstruction. Key topics that are new, are substantially revised, or have significant new literature include the elimination of 2-finger chest compressions in infants due to ineffectiveness of achieving proper depth with a recommendation of 1-hand or 2 thumb–encircling hands technique; the immediate application and use of an automated external defibrillator with a pediatric attenuator if available for cardiac arrest; and in infants with severe foreign-body airway obstruction repeated cycles of 5 back blows alternating with 5 chest thrusts (no abdominal thrusts), and in children with severe foreign-body airway obstruction repeated cycles of 5 back blows alternating with 5 abdominal thrusts.Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • chest compressions • defibrillator • foreign body airway obstruction • heart arrest • shockable rhythm • ventilation

The guidelines in this document from the American Heart Association and the American Academy of Pediatrics focus upon optimal care of the newborn infant, including those who are proceeding to a normal transition from the fluid-filled uterine environment to birth. Newborn infants who are proceeding to normal transition can benefit from deferred cord clamping for at least 60 seconds in most instances, skin-to-skin with their parent soon after birth, and appropriate assistance with thermoregulation. Some newborn infants require assistance during transition, with interventions ranging from warming and tactile stimulation to advanced airway management, assisted ventilation, oxygen therapy, intravascular access, epinephrine, and volume expansion. In this context, individuals, teams, and health care settings that care for newborn infants should be prepared and have access to appropriate training and resources for neonatal resuscitation. The newborn chain of care provides guidance on considerations that may lead to optimal outcomes for newborn infants starting from prenatal care to recovery and follow-up.Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • laryngeal mask • neonatal resuscitation • neonate • oxygen • umbilical cord management • ventilation

The American Heart Association and the American Academy of Pediatrics provide these pediatric advanced life support guidelines focusing on resuscitation during cardiopulmonary resuscitation and emergency cardiovascular care. These guidelines are intended to be a resource for health care professionals to identify and treat infants and children up to 18 years of age (excluding newborn infants) in the prearrest, intra-arrest, and post–cardiac arrest states as well as select other emergency care situations. These guidelines apply to infants and children in various settings, including the community, prehospital environments, and hospital environments. Topics presented include ventilation and advanced airway strategies during cardiopulmonary resuscitation; drug administration and weight-based dosing of medications during cardiopulmonary resuscitation; energy doses for defibrillation; measuring cardiopulmonary resuscitation physiology and quality; extracorporeal cardiopulmonary resuscitation; post–cardiac arrest care related to management of core temperature, blood pressure, oxygenation/ventilation, neurologic monitoring, and seizures; neurological prognostication post–cardiac arrest; post–cardiac arrest survivorship; family presence during cardiopulmonary resuscitation; evaluation of sudden unexplained cardiac arrest; management of shock types; airway/intubation management; arrhythmia management including bradycardia and tachycardia (narrow and wide complex); treatment of myocarditis/cardiomyopathies; resuscitation of patients with single ventricle congenital heart disease; management of pulmonary hypertension; and management of traumatic cardiac arrest. Lastly, important gaps in resuscitation science knowledge are identified, aiming to encourage further scientific inquiry and provide additional evidence for future pediatric advanced life support guidelines.Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • child • epinephrine • heart arrest • pediatric • prognosis

The International Liaison Committee on Resuscitation continually reviews new, peer-reviewed cardiopulmonary resuscitation science and publishes comprehensive reviews every 5 years. The Neonatal Life Support chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations addresses all published resuscitation evidence reviewed by the Neonatal Life Support Task Force science experts since 2020. This summary addresses 40 questions on population, intervention, comparator, and outcomes, addressing all parts of the Neonatal Resuscitation Algorithm. The summary includes 4 new systematic reviews, 2 new scoping reviews, and evidence updates for other topics. Members of the Neonatal Life Support Task Force have assessed, discussed, and debated the quality of the evidence on the basis of Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task force are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task force lists priority knowledge gaps for further research.Key Words: AHA Scientific Statements • cardiopulmonary resuscitation • ILCOR • infant • neonatal resuscitation

The International Liaison Committee on Resuscitation conducts continuous review of new peer-reviewed published cardiopulmonary resuscitation science and publishes annual summaries. More comprehensive reviews are published every 5 years. The Pediatric Life Support Task Force chapter of the 2025 International Liaison Committee on Resuscitation Consensus on Science With Treatment Recommendations addresses all published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Pediatric Life Support Task Force members in the past year, as well as brief summaries of topics reviewed since 2020, to provide a more comprehensive update. In total, 39 questions related to pre-arrest, intra-arrest, and postarrest resuscitation phases of pediatric cardiac arrest are included, including systematic reviews, scoping reviews, and evidence updates. Members of the task force assessed, discussed, and debated the quality of evidence, based on Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into deliberations of the task force are provided in the Justification and Evidence-to-Decision Framework Highlights sections. The task force has also listed priority knowledge gaps for further research.Key Words: AHA Scientific Statements • cardiac arrest • cardiopulmonary arrest • cardiopulmonary resuscitation • children • ILCOR • pediatrics • resuscitation

Early childhood development and subsequent adult health outcomes are influenced by the relational environments in which children grow, learn, and play. A child who is living in an environment with positive, nurturing, and supportive relationships and consistent routines is more likely to develop well-functioning neurodevelopmental and biological systems, including brain circuits, that promote positive development and lifelong health.1 The American Academy of Pediatrics’ clinical report on trauma-informed care promotes a relational-health framework including promoting positive parenting skills and safe, stable nurturing relationships and environments.2 An emerging theme from the available literature is that investing in early relational health (ERH) yields returns for children, families, and communities across generations.3

BACKGROUND AND OBJECTIVESDespite longstanding efforts to design, implement, and study parenting interventions early in life to address disparities in school readiness, gaps remain related to understanding their long-term effects and pathways of influence on child development. Here we describe sustained impacts at child age 6 of the innovative, tiered birth to age 3 Smart Beginnings (SB) model.METHODSWe performed a single-blind, 2-site randomized clinical trial of the SB model. SB integrates PlayReadVIP, a universal, pediatric primary care–based program, and Family Check-Up, a targeted secondary home-based parenting intervention. Mother-infant dyads (N = 403) were randomized at birth to standard pediatric care or the SB model. In line with SB’s theory of change that supporting parents will promote their children’s development, single and serial mediation pathways evaluated intervention effects of SB on age 6 child academic skills through parental cognitive stimulation at age 2 and child academic functioning at age 4.RESULTSWe found significant single and serially mediated indirect effects of SB on academic outcomes through parental cognitive stimulation in toddlerhood and preacademic skills in preschool. The total indirect pathways were positive and statistically significant for all academic outcomes at age 6, including receptive vocabulary (effect size [ES] = 0.04, P = .04), oral comprehension (ES = 0.05, P = .04), letter-word recognition (ES = 0.04, P = .04), phonemic decoding (ES = 0.04, P = .04), and applied problems (ES = 0.05, P = .04).CONCLUSIONSFindings build on the demonstrated scalability of the SB model, support the cumulative process of academic functioning in childhood, and offer a promising model to address disparities early in life.

In this issue of Pediatrics, Raol et al1 report on a prospective mixed-methods study conducted at a large urban tertiary care hospital in Hyderabad, India. Their study enrolled 476 maternal-infant dyads within 48 hours of birth and compared breastfeeding outcomes and perceived breastfeeding difficulties among 366 infants who did not have ankyloglossia (“tongue-tie”) and 110 who did, based on clinical assessment with the Bristol Tongue Assessment Tool (BTAT).2 Their study is unique in that none of the infants had a frenotomy or other surgical treatment of their ankyloglossia, and exclusive breastfeeding was assessed at 2–4 weeks, 3 months, and 6 months after delivery. Surprisingly, there were no differences in rates of exclusive breastfeeding at any time point, including at 6 months (82.3% [no ankyloglossia] vs 73.5% [assessed with ankyloglossia]; P = .25), and no differences in infant growth velocity at any time point. The only factor associated with lower odds of exclusive breastfeeding at 6 months after delivery was maternal concern about milk supply at the 2–4 weeks phone call (odds ratio, 0.22; P < .003). In structured interviews of 36 mothers with a spectrum of experiences in this study, reports of nipple pain (commonly associated with ankyloglossia3) did not differ between those with and without either early breastfeeding cessation or ankyloglossia.

10.1542/6380111573112Video AbstractPEDS-VA_2024-0705316380111573112BACKGROUNDAnkyloglossia may cause breastfeeding difficulties, potentially leading to early cessation of exclusive breastfeeding (EBF). However, increases in rates of frenotomy have not resulted in increases in EBF rates, and, in some regions, ankyloglossia is not regarded as a major barrier to successful breastfeeding. We sought to elucidate the contribution of untreated ankyloglossia to early cessation of EBF.METHODSWe conducted a sequential explanatory mixed-methods study at an urban tertiary care hospital for women and children in Hyderabad, India. We evaluated for ankyloglossia and breastfeeding difficulties in mother–infant dyads recruited within 48 hours after birth. Primary outcomes of EBF and infant weight gain were compared between infants with (tongue-tie [TT]) or without (No-TT) ankyloglossia. Semistructured interviews were conducted to identify reasons contributing to early cessation.RESULTSA total of 476 dyads were recruited over 3 months. There was no significant difference in rates of EBF at 6 months (No-TT 81.4% vs TT 78.6%; P = .6) or infant weight gain velocity from 0 to 3 months (No-TT 26.3 g/d vs TT 26 g/d; P = .86) or from 3 to 6 months (19.3 g/d vs 20.4 g/d; P = .49). Maternal concern for inadequate supply was associated with lower EBF odds at 6 months (odds ratio 0.22; P = .003). Mothers with early cessation in either group rarely reported issues with infant breastfeeding skill or nipple pain.CONCLUSIONSAlthough ankyloglossia may affect breastfeeding experiences, ankyloglossia alone does not appear to affect breastfeeding maintenance or infant weight gain. Improving breastfeeding outcomes should include multidisciplinary management to focus on all potential causes and not only ankyloglossia.

BACKGROUND AND OBJECTIVESThe developmental trajectories and stability of delayed sleep phase (DSP) are poorly known. We investigated how behavioral and psychiatric characteristics, circadian thermoregulation, and the amount and intensity of physical activity (PA) were associated with the continuity of DSP from late adolescence to early adulthood.METHODSWe created a population-based longitudinal study in which 1374 adolescents (mean age, 16.8 years; SD, 0.6; 66% girls) self-reported their sleep and psychiatric and behavioral symptoms at timepoint 1 (T1). A DSP-weighted subsample at T2 (7 months from T1; N = 315) and at T3 (19 months from T1; N = 207) provided sleep, PA (GENEActiv actigraphy, 8 days and nights), and skin temperature data (iButton 1922L thermologgers; 3 days and nights) twice.RESULTSCluster analysis indicated 2 behavioral profiles underlying DSP: 1 pointing to game addiction alone and the other to widely spread behavioral challenges. The stability of DSP was 70%, such that poor self-control, attention-deficit hyperactivity disorder symptoms, and alcohol use together accounted for 18%. Alcohol use and poor self-control accounted for 16% of the emergence of DSP over time. Circadian thermoregulation or the duration or intensity of PA did not associate with the continuity of DSP.CONCLUSIONSDSP is a highly stable condition from late adolescence to early adulthood. Behavioral challenges related to self-control, attention-deficit hyperactivity disorder symptoms, and alcohol use underlie the trajectories of DSP over time. The outcomes emphasize behavioral over the potential physiological components of DSP measured in this study and give clear directions to develop new interventional targets to overcome DSP.

We report a rare presentation of posterior reversible encephalopathy syndrome with spinal cord involvement (PRES-SCI) in a 14-year-old girl presenting with severe symptomatic hypertension secondary to bilateral renal dysplasia and grade 4 hypertensive retinopathy causing near blindness in her right eye. Magnetic resonance imaging of the brain and spine showed patchy T2 hyperintensity in the basal ganglia, brainstem, and cerebellum and extensive longitudinal central gray and white matter T2 hyperintensity in the spinal cord from the cervical cord to the conus. Despite extensive neuroimaging changes, she had no neurological signs apart from a visual acuity of 3/95 (20/400 Snellen) of the right eye. The imaging changes completely resolved on follow-up neuroimaging with blood pressure control, although a visual acuity deficit persisted. This case report and review of the literature highlights the rare presentation of PRES-SCI in the pediatric population and emphasizes the need for early recognition and treatment to ensure good neurological outcome and to avoid misdiagnoses.

Over the past generation, US hospital payment policy and hospital-based care for children have undergone significant transformations. In 1983, Medicare introduced prospective payment systems (PPS), which are predetermined fixed payment amounts for hospitalizations within diagnosis-related groups (DRGs), regardless of the true costs of care.1 As hospitals were pressured to shorten inpatient stays, observation units and an observation status billing designation emerged.2–4 By the 1990s, PPS were being adapted for pediatrics.5,6 Payment reform grew in the 2000s with pay-for-performance programs tied to measures of hospital quality.7,8 In 2013, the Centers for Medicare & Medicaid Services (CMS) implemented the “Two-Midnight Rule,” limiting inpatient care and its higher level of reimbursement to stays expected to cross 2 midnights; commercial payers soon followed suit. Concurrently, the pediatric workforce has evolved. Pediatric emergency medicine was formally recognized as a subspecialty in 1992,9 and pediatric hospital medicine attained subspecialty status in 2020.10 These and other pediatric subspecialties are increasingly concentrated at academic centers and are in short supply relative to their demand.11

OBJECTIVETo evaluate how availability of pediatric-capable hospitals has changed over 2 decades.METHODSWe studied US acute care hospitals from 2003 to 2022 using the Healthcare Cost and Utilization Project Kids’ Inpatient Database. We determined the annual proportion of hospitals by pediatric capability level from 1 to 4, defined by which of 24 services were provided (level 1: broadest range; level 4: minimal services). We used Poisson models adjusting for hospital characteristics to evaluate changes from 2003 to 2022. We also measured changes in provision of each specific service.RESULTSWe analyzed a mean 3927 hospitals per year, which in 2022 were 67.3% nonprofit, 39.7% urban teaching, 47.0% small, and 37.4% in the South. The number of high-capability hospitals decreased over time. Adjusting for hospital characteristics, level 1 hospitals decreased 38% (95% CI, 27–48), level 2 hospitals decreased 54% (95% CI, 47–60), level 3 hospitals decreased 48% (95% CI, 43–53), and level 4 hospitals increased 137% (95% CI, 119–156). For 17/24 (71%) capabilities, fewer hospitals were capable in 2022 than 2003. The steepest declines of hospital-level specific services were for moderate-intensity services including appendectomy (−50.5%), pneumonia hospitalization (−42.3%), and asthma hospitalization (−41.1%). The smallest changes were for extracorporeal membrane oxygenation (+0.8%), organ transplant (0.0%), and Fontan surgery (−0.1%).CONCLUSIONSLow-capability hospitals more than doubled over 2 decades, corresponding to substantial losses in hospitals at all higher levels of pediatric capability. This would be expected to limit child access to care across a range of conditions and complexity.

Globally, 18% of births occur to adolescent women, with higher rates in low- and middle-income countries.1 In this issue of Pediatrics, Bell et al. used linked administrative data from Western Australia to examine the impact of maternal incarceration on rates of teenage motherhood.2 In the study population, 34% of teenage mothers experienced their own mother’s incarceration before the birth of their child. Adolescents who experienced maternal incarceration had a 1.7 times higher risk of teenage motherhood than those whose mothers were not incarcerated, demonstrating an association between maternal incarceration and increased risk of teenage pregnancy. The authors stratified the analysis by Aboriginal and non-Aboriginal background to account for higher rates of incarceration and adolescent pregnancy within Aboriginal communities in Western Australia. Maternal incarceration was more strongly associated with an increased risk of teenage motherhood among non-Aboriginal adolescents.

OBJECTIVESThis study examined the risk of teenage motherhood among females whose mothers were incarcerated.METHODSUsing linked administrative data from Western Australia, we examined 3 generations of individuals. Starting with the second generation, we identified 6218 adolescent females whose mothers had been incarcerated, matched 3:1 with 18 654 females whose mothers had not. The first generation comprised the 19 076 mothers of the second generation, and the third generation comprised the 3384 babies born to second-generation females aged 12 to 19 years. Additional data captured sociodemographic characteristics and adversity exposures, including incarceration, mental illness, and substance use among first-generation mothers, and second-generation females’ experiences of child maltreatment and family and domestic violence. We calculated rates and hazard ratios for births to second-generation teenage females whose mothers were or were not incarcerated, adjusting for adversity exposures and stratified by Aboriginal ethnicity.RESULTSOf teenage mothers, 34% had experienced their own mother’s incarceration prior to the birth of their child. The unadjusted rate of births to second-generation females whose mothers were incarcerated was 1.67 (95% CI, 1.56–1.80) times higher than the rate among unexposed females. After adjustment for sociodemographic and adversity factors, maternal incarceration was associated with an increased risk of teenage motherhood among second-generation females for both non-Aboriginal (adjusted hazard ratio [aHR], 1.63; 95% CI, 1.22–2.17) and Aboriginal (aHR, 1.17; 95% CI, 1.05–1.29) females.CONCLUSIONSIncarceration of mothers is associated with an increased risk of teenage motherhood in the next generation. Addressing the circumstances that precipitate teenage pregnancy may help improve child and maternal health and well-being and disrupt intergenerational cycles of disadvantage.

BACKGROUNDNone of the legislative and regulatory advances shaping pediatric drug development explicitly mandate the marketing of pediatric formulations. This study explores the availability of commercial products at the time of, and after, pediatric labeling.METHODSOrally administered drugs with new pediatric labeling between 1998 and 2024 were evaluated for formulations marketed at the time of labeling, current marketing status, and generic availability.RESULTSSix hundred eleven labeling changes representing 425 drugs available as 567 marketed formulations were reviewed. One hundred eighty-eight (44%) drugs were marketed with pediatric-friendly (PF) formulations; the remainder were available only as solid dosage forms. The rate of change in pediatric labeling significantly outpaced the rate of PF formulation development. For 329 (54%) labeling changes, the only marketed formulation was a solid dosage, although this varied by age group. Standalone PF formulations were discontinued at rates comparable to adult formulations (28% vs 30%) but were 2 to 3 times more likely to have no available generic alternative. Where both an adult and PF formulation were marketed, discontinuation rates for PF formulations were 4 times more likely than discontinuation of the adult formulations when PF forms were still marketed (13% vs 3%) and PF formulations were 2 to 5 times more likely to have no generic alternative. Where PF formulations were not marketed, only 56% of labels provided guidance on manipulation of the adult formulation.CONCLUSIONSInadequate PF formulation development and lack of sustained accessibility represent barriers to safe and appropriate pharmacotherapy for children. Key stakeholders should collaborate to improve medication options for pediatric patients.

CONTEXTChildren with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) level III-V are at risk of reduced bone strength and low-trauma fractures.OBJECTIVEThis systematic literature review aimed to identify fracture rates, locations, and risk factors in this population.DATA SOURCESFive databases (MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO) were searched up until November 2024.STUDY SELECTIONStudies were included if they involved children younger than 18 years with CP (GMFCS III-V). Included study designs were cross-sectional, cohort, case-control, or experimental, including both randomized control trials and quasi-experimental, which reported baseline data separately. The Newcastle Ottawa Scale was used to assess methodological quality.DATA EXTRACTIONStudy characteristics, population characteristics, fracture rate, location, and risk factors identified were extracted.RESULTSOut of 2220 studies, 30 were included. The fracture rate ranged from 2.2 to 4.8 per 100 child-years, and lifetime prevalence estimates were between 9.4% and 15.5%. The most frequently reported fracture location was in the lower extremities, particularly the femur (54.1%). Risk factors for fracture supported by high-quality evidence were low bone mineral density, epilepsy, and weight imbalance; factors with mixed-quality evidence were anticonvulsant use, feeding difficulties, reduced weight bearing, history of fracture, and increasing age.LIMITATIONSVariability in methodological quality across studies and inconsistent reporting limited the generalizability of findings.CONCLUSIONSChildren with CP functioning at GMFCS III-V are prone to fragility fractures in the lower extremities with several modifiable risk factors identified, including poor nutrition, weight imbalance, uncontrolled seizures, and limited weight-bearing activity.

This case study uses a hospital family safety reporting intervention, coproduced with key partners, with the aim to garner lessons for developing complex, hospital-based interventions. Health equity, communication science, health literacy, and organizational behavior principles were utilized to develop a family safety reporting intervention consisting of a family safety reporting tool, staff and family education, and a process for reviewing and sharing family reports with unit and hospital leaders. We evaluated intervention training rates and hospital impact (comparing family-reported safety incidents received by the hospital through voluntary incident reports at baseline to incidents received through voluntary incident reports and after the intervention). Additionally, we analyzed field notes and minutes to describe lessons learned from applying these principles in complex, hospital-based interventions. We trained 208 families, 149 nurses, 42 resident physicians, and 7 attending physicians in the intervention. After implementing the intervention, the frequency of families from whom the hospital documented safety concerns increased from an average of 0.4 per month at baseline to 4.4 per month after the intervention. Four key lessons emerged: (1) Build deep and regular partnerships across all intervention key partners, including initial skeptics. (2) Tailor the intervention message to each audience. (3) Embrace flexibility and a growth mindset when weighing suggestions and adapting interventions. (4) Equity is an investment, not a checkbox. We conclude that health equity, communication science, health literacy, and organizational behavior can inform inclusive, effective, complex hospital-based interventions but require deep partnerships, tailored messaging, flexibility, a growth mindset, and a commitment to equity.

BACKGROUND AND OBJECTIVEChildren with complex chronic disease (CCD) are at high risk for poor hospital-to-home transition and unplanned urgent health care use. Existing measures of transition effectiveness have rarely included families of children with CCD in their development and validation. We sought to identify patient- and family-reported outcomes (PROs) of transition effectiveness that matter most to families of children with CCD and to assess the feasibility, acceptability, and variation in each family-identified PRO among recently discharged families.METHODSWe recruited family members of children with CCD to participate in design sessions to review existing and develop new PRO measures. We then conducted a prospective cohort study of hospitalized children with CCD, collecting transition measures 7 days after discharge. These measures were compared with 30-day unplanned readmission rates using Somers’ D test of ordinal correlation.RESULTSFamilies endorsed existing transition effectiveness measures and co-created a Return to Baseline measure assessing progress toward prehospital baseline. In a prospective cohort of 102 children with CCD, families rated transition measures highly, although children often were not at baseline health by 7 (64.7%) or 30 days (62.4%). Return to baseline at 7 days with regards to child health, child routine, work schedule, and sleep was moderately correlated with unplanned 30-day readmission.CONCLUSIONSFamilies of children with CCD endorsed several transition measures as family-centered. Many reported their child’s health had not returned to baseline 7 and even 30 days after hospitalization. Future trials of hospital-to-home transition interventions in this population should include PROs and health utilization outcomes.