Pediatrics Current

Infants and children with prenatal substance exposure (PSE) experience high rates of child protection system (CPS) involvement.1 Reporting to CPS is often initiated around the time of birth due to concerns about future risk of abuse and neglect, but reporting mandates vary by jurisdiction, state, and/or country and interpretation of these mandates can further vary by hospital and provider.2–5 Few studies have been able to look at cumulative risk of CPS reports, investigations, and substantiated abuse and neglect following PSE throughout childhood because data systems involving administrative claims, CPS data, and substance use records are rarely linked or tracked longitudinally. In this issue of Pediatrics, Powell and colleagues were able to link population-level health, substance use, and CPS data spanning a 12-year period to compare childhood CPS involvement among children with PSE compared with those without in New South Wales (NSW), Australia.6 They found, unsurprisingly, that by age 12 years, when compared with children without documented exposure, children with documented PSE had significantly higher rates of CPS reports that were screened in for investigation (90% vs 18%), CPS cases that were substantiated (61% vs 5%) and out-of-home placement episodes (39% vs 1%).

BACKGROUND AND OBJECTIVESChildren with prenatal substance exposure are at high risk of child protection involvement during infancy. We quantified the risk and timing of child protection system involvement until age 12 years among children with and without prenatal substance exposure.METHODSA whole-population birth cohort (2007–2018) was assembled from data linked for the New South Wales Child E-Cohort, Australia. The prenatal substance exposure population included children with records indicating prenatal substance exposure in hospital, emergency, mental health outpatient, opioid treatment, and/or child protection reports data. We estimated the risk of child protection responses (screened-in reports, investigations, substantiations, and out-of-home care [OOHC]), and child maltreatment types.RESULTS1 161 876 children (17 976 with prenatal substance exposure) and 717 063 mothers were included. By age 1 year, 75% of the prenatal substance exposure population born in 2018 had ≥1 screened-in report, 34% ≥1 substantiation, and 20% ≥1 OOHC placement, compared with 4%, 0.8%, and 0.2% of all other children, respectively. By age 12, 90% of the prenatal substance exposure population born in 2007 had ≥1 screened-in report, 61% ≥1 substantiation, and 39% ≥1 OOHC placement, compared with 18%, 5%, and 1% of all other children, respectively. One-half of the prenatal substance exposure population had neglect recorded by age 12. Health and socioeconomic disadvantage were more common among the prenatal substance exposure population.CONCLUSIONChildren with prenatal substance exposure experienced high child protection involvement early in life. Child protection reports represent an opportunity to mobilize nonstigmatizing substance use in pregnancy and antenatal care to prevent escalating child protection interventions.

We have read with great interest the recent article, Recommendations for pneumonia in hospitalized children with neurologic impairment, by Thomson et al1 and deeply appreciate their efforts in establishing an evidence-based management framework for this special population. The recommendations provided in the article are of significant guiding value. As clinicians in the field of rehabilitation, we wish to build upon the valuable insights of this paper by offering a few supplementary recommendations, specifically focusing on children with mild neurological impairment—a group often overlooked in clinical practice—from the perspectives of functional assessment, rehabilitation intervention, and continuity of care. Our aim is to enhance treatment efficacy and promote antimicrobial stewardship without significantly increasing resource expenditure.

On behalf of the authorship team, I sincerely thank Dr He and colleagues for their thoughtful engagement with our article, Recommendations for pneumonia in hospitalized children with neurologic impairment.1 We deeply appreciate their efforts to extend the conversation on children with neurological impairment—a population that is indeed underrepresented in both research and clinical protocols.

An international panel of 27 experts (pediatric and movement disorder neurologists, psychiatrists, and parent representatives) from all continents participated in a Delphi process to establish international consensus guidelines for the evaluation, diagnosis, and management of children with Sydenham chorea (SC) based on best evidence and expert opinion. In total, 88 recommendations reached consensus. Practitioners should identify key signs of SC (chorea and hypotonia), screen for behavioral, mobility, swallowing, speech, and cognitive impairments, and acute rheumatic fever (ARF) features including carditis. Etiological evaluation will differ according to population ARF risk. At all times, patients, families, and educators should receive support, information, and guidance to minimize the impact of SC on academic and social functioning. Antibiotic treatment is recommended at first presentation. Long-term secondary antibiotic prophylaxis should follow international or local guidelines, and measures to reduce pain and distress associated with intramuscular antibiotics will aid in adherence. Immunotherapy (corticosteroids) is recommended in moderate to severe SC. In those with inadequate recovery, intravenous immunoglobulin or plasma exchange should be given. In SC relapse, repeat clinical assessments, etiological investigation, and antibiotics plus corticosteroid therapy should be considered. This consensus guideline will standardize the evaluation and management of patients with SC and direct future research to improve the lived experience and outcomes of patients and families.

10.1542/6380058992112Video AbstractPEDS-VA_2025-0710516380058992112OBJECTIVEEarly childhood advanced primary care models are promising ways of addressing child and family needs, but there is limited evidence to support short-term sustainability within current Medicaid payment structures. We evaluate claims-based outcomes associated with 3-2-1 IMPACT (IMPACT), an early childhood advanced primary care model, compared with the standard of care.METHODSUsing New York State Medicaid claims, we identified and matched children aged 1 to 35 months receiving care at 3 IMPACT sites and 3 comparison sites within a large public hospital system. Regression models were used to analyze use, expenditure, enrollment, and quality outcomes between groups.RESULTSThere were 6045 children at the treatment sites and 4832 matched children from the comparison sites. IMPACT was associated with a significant increase in 6 or more well-child visits and a decrease in emergency department visit rates. There was also a significant increase in 6 more well-child visits specifically for Black and Hispanic children seeking care at IMPACT sites compared with comparison sites. There were no significant differences in expenditures, other use types, or Medicaid enrollment across groups.CONCLUSIONAn early childhood advanced primary care model that incorporates multiple evidence-based programs can show short-term, positive effects on preventative and acute care use and quality within Medicaid. These results highlight short-term strategies for sustainability while awaiting the long-term, cross-sector benefits expected from models like IMPACT. Future studies addressing additive model component effects and longer-term outcomes across mother-child dyadic and social-emotional outcomes are warranted.

In this issue of Pediatrics, Boolchandani et al describe HIV screening rates in 40 US pediatric emergency departments (EDs) and identify patient and hospital factors associated with HIV screening.1 In their analysis of 2 134 563 adolescents without a known HIV infection who were discharged from an ED visit between 2019 and 2023, only 1.3% (n = 28 052) received HIV screening during the visit. Despite International Classification of Diseases, Tenth Revision (ICD-10) codes suggesting elevated HIV risk (eg, signs or symptoms of HIV infection, concurrent symptoms, or diagnosis of another sexually transmitted infection [STI]) and/or a current pregnancy among most of the adolescents tested for HIV (n = 20 972, 75%), more than 90% of adolescents with those symptoms, findings, and/or diagnoses were not tested. Importantly, only 7080 adolescents without readily identifiable symptoms of STI or pregnancy underwent screening. This is a notable gap given that early HIV infection, as with bacterial STIs, is most often asymptomatic.

10.1542/6378936297112Video AbstractPEDS-VA_2025-0721086378936297112BACKGROUND AND OBJECTIVESAdolescents account for one-fifth of new HIV infections in the United States. Despite Centers for Disease Control and Prevention (CDC) recommendations for universal opt-out HIV screening for individuals aged 13 years or older in all health care settings, many adolescents remain undiagnosed due to limited access to testing. This study aimed to describe HIV testing rates in US pediatric emergency departments (EDs) and identify patient and hospital factors associated with testing.METHODSWe conducted a cross-sectional study of pediatric ED encounters for patients aged 13 to 18 years at 40 US children’s hospitals (January 2019-December 2023). Patient and hospital characteristics were analyzed using multivariable logistic regression analysis to assess associations with HIV testing.RESULTSOf 2 134 464 ED encounters, 28 052 (1.3%) included HIV testing. Of these, 75% (n = 20 972) were targeted tests based on ED diagnoses, whereas 25% (n = 7080) were screening tests. Factors associated with HIV testing were female sex (adjusted odds ratio [aOR], 1.46; 95% CI, 1.42–1.51), Black/African American race (aOR, 1.71; 95% CI, 1.65–1.77), 2 or more races documented (aOR, 1.52; 95% CI, 1.38–1.66), public insurance (aOR, 1.69; 95% CI, 1.63–1.75), and living in very low Childhood Opportunity Index neighborhoods (aOR, 1.67; 95% CI, 1.59–1.75). Hispanic/Latino (aOR, 0.84; 95% CI, 0.80–0.87), Asian (aOR, 0.73; 95% CI, 0.64–0.83), and adolescents with complex chronic conditions (aOR, 0.53; 95% CI, 0.49–0.57) were less likely to have HIV testing.CONCLUSIONSHIV testing during pediatric ED encounters was rare, demonstrating an opportunity to enhance pediatric HIV screening practices in accordance with recommendations from the CDC.

Streptococcus pyogenes (GAS) is responsible for many pediatric infections. Although outcomes are generally favorable with prompt diagnosis and treatment, it is necessary for pediatricians to remain vigilant for complications. We discuss a rare GAS complication: post-streptococcal myositis. An 8-year-old female patient recently hospitalized for cervical lymphadenitis presented with extremity pain and difficulty walking. Initial work-up revealed marked nonspecific inflammation, normal creatine kinase (CK), and superficial thrombophlebitis. Her symptoms progressed rapidly to high fevers, erythematous nodules, severe pain and edema, and superficial thrombophlebitis extension despite antibiotics and nonsteroidal anti-inflammatory pharmacotherapy. This was associated with rising inflammatory markers, extensive myositis of the extremities and mild fasciitis of the calves on imaging, and a muscle biopsy with normal architecture and no evidence of vasculitis or necrosis. A markedly elevated anti-streptolysin O (ASO) and anti-DNase B led to the diagnosis of post-streptococcal myositis. Symptoms responded rapidly to systemic steroids, with complete recovery within 5 months. Limited case reports of post-streptococcal myositis exist, which similarly describe severe myalgia and fevers, inflammation, elevated ASO, and typically normal CK. Most describe a self-limited disease course. This case describes a unique manifestation and sequelae of streptococcal infection in a child with an impressive degree of systemic inflammation and thrombotic complications. This report also describes pediatric muscle biopsy results in association with this diagnosis. Post-streptococcal myositis should be considered for patients with severe unexplained inflammation and myalgia.

10.1542/6378837665112Video AbstractPEDS-VA_2025-0711476378837665112OBJECTIVESIt is unclear how long youth with opioid use disorder (OUD) should continue taking buprenorphine, and what adherence they should achieve. We identified patterns of duration/adherence and assessed associations with subsequent overdose, emergency department (ED) use, and hospitalization.METHODSThis retrospective cohort analysis used 2014–2022 data from the Massachusetts Public Health Data Warehouse. We identified youth aged 13 to 26 years initiating buprenorphine and used group-based trajectory modeling to categorize youth into duration/adherence trajectories over 12 months. Using multivariable Cox regression, we examined associations between trajectories and time to fatal/nonfatal opioid overdose, all-cause ED use, and all-cause hospitalization during the subsequent 12-month period.RESULTSAmong 11 649 Massachusetts youth initiating buprenorphine, most were aged 21 years or older (89.0%), male (60.3%), white non-Hispanic (85.9%), and enrolled in Medicaid (55.4%). We identified 4 patterns of medication use: (1) high adherence for 12 months (23.7%); (2) low adherence for 12 months (27.5%); (3) discontinuation in 3 to 9 months (16.4%); and (4) discontinuation in less than 3 months (32.5%). Trajectories included 580 (5.0%) and 774 (6.6%) youth switching to methadone and naltrexone, respectively. Compared with high adherence for 12 months, overdose risk was higher with low adherence for 12 months (adjusted hazard ratio [aHR], 1.46; 95% CI, 1.24–1.73), discontinuation in 3 to 9 months (aHR, 1.82; 95% CI, 1.52–2.17), and discontinuation in less than 3 months (aHR, 1.76; 95% CI 1.50–2.06). Compared with high adherence, low adherence and discontinuation in less than 3 months had higher risk of ED use, and all other trajectories had higher risk of hospitalization.CONCLUSIONSMedication adherence may prevent overdose, ED use, and hospitalization. Strategies to increase treatment duration/adherence likely avert harm.

Home health care is essential for children with chronic conditions and disabilities and children recovering from acute illness, injury, or surgery to ensure their daily health, function, and community participation. The American Academy of Pediatrics advocates for accessible, high-quality pediatric home health care by calling for development of pediatric-specific home health care regulations, eligibility guidance, and pediatric-focused metrics to facilitate high quality and access.

10.1542/6380058313112Video AbstractPEDS-VA_2025-0730236380058313112OBJECTIVEDyadic care of the mother and infant simultaneously may improve postpartum morbidity and mortality. The aim of this scoping review was to synthesize the spectrum of dyadic care models that have been implemented globally, summarize the outcomes measured, and identify research and practice opportunities of maternal-infant dyadic care.METHODSWe conducted a comprehensive literature search through December 24, 2024, in 8 databases. The inclusion criteria were original research on interventions that provided care for both the mother and infant within 1 year of delivery, with outcomes reported for at least 1 member of the dyad. Studies were excluded if the evaluated practices are now considered standard of care or were educational only.RESULTSA total of 117 studies from 28 countries met the inclusion criteria. Ten dyadic care models were identified: shared medical visits, provision of maternal care at pediatric appointments, group dyadic care, mother-baby psychiatric units, care for mothers in the neonatal intensive care unit, couplet care, home visits by medical professionals, home visits by community health workers, mobile device interventions, and nutritional supplementation during pregnancy. Home visits by medically trained personnel were most frequently studied. Common outcomes assessed were maternal mental health, infant rehospitalization, breastfeeding rates, and implementation outcomes of acceptability and feasibility. Efficacy varied, with some interventions showing positive impacts, particularly those involving trained health professionals over longer periods.CONCLUSIONDyadic care interventions offer a compelling opportunity to streamline services, build trust between families and providers, and improve outcomes across the life course.

10.1542/6380056655112Video AbstractPEDS-VA_2024-0692836380056655112OBJECTIVEAchievable benchmarks of care (ABCs) use performance data to derive objective and attainable targets for improvement initiatives. We applied the Pediatric Health Information System (PHIS) low-value care (LVC) Calculator to describe variation in LVC across hospitals and identify measures with the greatest potential for improvement.METHODSWe applied the 16 LVC Calculator measures applicable to hospitalized patients younger than 18 years old to PHIS hospitalizations from July 1, 2022, to June 30, 2024. We used hospital-level data to assess LVC variation using IQRs and calculate ABCs, defined as the average performance attained by top-performing hospitals. We then compared median hospital-level performance to ABCs to derive measure-level performance gaps, signifying objective improvement potential. Finally, we performed a quartile analysis identifying hospitals with consistently high or low LVC delivery across measures.RESULTSA total of 401 683 hospitalizations at 43 children’s hospitals were eligible for included measures. LVC delivery varied widely across hospitals for many measures. Ten measures demonstrated performance gaps of greater than 10%; the greatest performance gaps were observed for C-reactive protein and/or erythrocyte sedimentation rate for community-acquired pneumonia (39%), electrolyte testing in patients with febrile seizure (38%), and blood cultures in community-acquired pneumonia (35%). Five measures demonstrated ABCs of less than 5%. Quartile analyses demonstrated small cohorts of hospitals with consistently high or low performance across all measures.CONCLUSIONSThis analysis suggests measurable improvement potential for several low-value services and offers measure-specific deimplementation targets. Further study of high- and low-performing hospitals may identify hospital-level drivers of LVC trends.

Papillary thyroid carcinoma (PTC) is one of the most common cancers in adolescents. The management of patients with advanced, metastatic PTC includes surgery and radioactive iodine (RAI); however, less than 20% of children with pulmonary metastases achieve a complete response to RAI. The discovery of targetable molecular alterations in pediatric PTC, including BRAF V600E mutations as well as RET and NTRK fusions, has broadened our therapeutic approach in pediatric patients with advanced and/or refractory disease. Targeted therapy in advanced thyroid cancer has been shown to resensitize tumors to RAI in adults. We describe 2 adolescents with RET-fusion and noniodine avid metastatic PTC who both achieved increased iodine avidity after treatment with selpercatinib, a selective inhibitor of RET, allowing for the successful use of RAI. These cases highlight the potential to include targeted therapy to optimize the treatment with RAI in pediatric patients with noniodine avid advanced PTC.

OBJECTIVEPediatric surgical conditions are a significant source of morbidity and mortality in low- and middle-income countries (LMICs), where children with surgically treatable conditions lack access to care owing to an insufficient number of pediatric surgeons, poor and limited training, and financial barriers. There is a growing shift from charitable missions to capacity-strengthening projects, which strengthen the skills and resources of communities. The objective of this study was to synthesize the literature to identify capacity-strengthening projects, their methods and outcomes, and their limitations and barriers.METHODSMEDLINE, EMBASE, Cochrane, and Web of Science were searched until May 5, 2023. Eligibility criteria were as follows: (1) inclusion of pediatric surgery patients; (2) designation as capacity-strengthening interventions; (3) outcomes of improved access defined through Lancet Commission on Global Surgery Indicators; and (4) designation as an LMIC defined by the World Bank. Two independent reviewers conducted screening and extraction.RESULTSA total of 80 studies met inclusion criteria. Interventions were implemented in 69 LMICs and used 19 different methods of capacity strengthening. Common capacity-strengthening methods included the following: international surgical visits, training programs, partnerships, mobile clinics and camps, infrastructure enhancements, and telemedicine. Common methods used included the following: training of local providers, continuous contact between both countries after the visit was completed, improved access for rural families, and economic support for low-income families. A total of 1 357 077 pediatric surgeries were performed through these interventions. Limitations included the fact that only peer-reviewed studies were included. Included studies were mainly case series or small observational studies with qualitative data.CONCLUSIONSThis review identifies methods to implement capacity-strengthening interventions in LMICs, including their successes and barriers. Future research should report ethical concerns and quantitative outcomes to determine effectiveness.

Despite decades of global progress, millions of children still die each year from preventable and treatable conditions.1–3 Deaths in children younger than age 5 years persist largely because of inequities in access to quality primary care, especially in low-resource settings.4,5 Under age 5 years mortality (U5M) remains highest in countries where health systems face structural challenges and where poverty and weaker health system infrastructure continue to restrict access to essential services, reflecting a stark equity divide between poor and rich regions.6–8 Without urgent action, it is projected that nearly one-third of countries will fail to meet the 2030 target for the United Nations Sustainable Development Goal (SDG) 3.2, which is focused on the reduction of U5M.9 As pediatricians and child health advocates, we are uniquely positioned to champion models that are grounded in evidence and designed to be scalable, cost-efficient, and sustainable.10 In this issue of Pediatrics, Fiori and colleagues present the effectiveness of the implementation of an integrated primary care program (IPCP) across 4 districts in Togo, demonstrating how strategic investments in integrated, community-based primary care can accelerate progress in reducing child deaths.11

10.1542/6379021775112Video AbstractPEDS-VA_2025-0713456379021775112OBJECTIVEThe objective of this study was to evaluate the effectiveness and implementation of the Integrated Primary Care Program (IPCP) in reducing under-five mortality rate (U5M) in Togo when implemented at scale.METHODSUsing a stepped-wedge cluster randomized trial design (identifier NCT03694366), the IPCP was sequentially implemented across 4 districts (ie, Bassar, Binah, Dankpen, and Kéran) in Togo between 2018 and 2021. This pragmatic type II hybrid effectiveness-implementation study collected data from the following: (1) household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Survey; (2) health center surveys using the Service Availability and Readiness Assessment; (3) key informant interviews using the Consolidated Framework for Implementation Research; and (4) costing data using the Community Health Planning and Costing Tool. Effectiveness was assessed through longitudinal measurements in U5M and quality of care. Implementation strategies were evaluated through secondary measures including reach, adoption, implementation, and maintenance.RESULTSA total of 50 404 household surveys were completed from 2018 to 2023 across the 4 districts. The hazard of U5M was 29% lower (95% CI: 4%-48%; P = .02675) in the intervention (45.5 deaths per 1000 live births) compared with the control periods (64.5 deaths per 1000 live births), adjusting for sociodemographic confounders. Health center assessments of service readiness and availability increased in all districts from baseline. Key informant interviews identified caregiver trust and engagement as critical success factors. The estimated annual average program cost was $10.28 per person.CONCLUSIONSOur findings suggest that successful implementation of the IPCP, a package of evidence-based interventions with integrated implementation strategies, reduces U5M, improves care quality, and can be delivered at scale.

This Ethics Rounds article brings together perspectives from a clinical ethicist, 2 resident physicians in pediatrics, and a social worker on a case involving a terminally ill, intubated, and sedated young adult patient whose health care proxy, extended family, and health care team disagree on the course of her care. Although the proxy, the patient’s adult sister, seems to agree in principle with the health care team’s recommendation to withdraw life-sustaining treatment, she is unwilling to consent to withdrawal due to perceived pressure from her extended family. From an ethics perspective, we discuss the concept of the “marginalized decision-maker” and how to blend the “best interests” approach from pediatric medicine with the “substituted judgment” standard applied in adult medicine when making decisions for incapacitated young adult patients. From a clinical perspective, we explore features of this case that may contribute to feelings of moral distress within the medical team, identify best practices for leading team and family meetings to avoid values imposition and promote shared decision-making, and argue for the importance of training physicians in clinical ethics and reflective skills to improve the quality of patient care and reduce experiences of moral distress in the workplace. Finally, we explore the role that family dynamics, families’ culture and values, and past experiences in the health care system can play in shared decision-making conversations.

BACKGROUNDEmergency medical services (EMS) system characteristics that promote quality pediatric care are uncertain. We evaluated agency and patient demographic factors associated with improved performance.METHODSWe evaluated care for children (aged <18 years) with a ground scene–level response using the 2020–2023 National EMS Information System (NEMSIS) datasets. We identified outcomes based on the NEMSIS Prehospital Pediatric Quality Measures Dashboard, including beta agonist for asthma/wheezing; glucagon/glucose for hypoglycemia; epinephrine for anaphylaxis; intravenous fluids for hypotension; pain improvement in trauma; pain assessment in trauma; and vital sign documentation in trauma. We evaluated the association of agency- and patient-level factors with high performance on each performance measure using mixed-effects logistic models.RESULTSWe identified 2 739 756 encounters. The proportion of cases achieving the performance measure ranged from 22.5% (improvement in pain for children with trauma reporting pain) to 85.2% (documentation of vital signs for children with trauma). Older age was associated with higher performance for most measures. Black and Hispanic and Latino children with trauma were less likely to have an improvement in pain compared with white children (adjusted odds ratio [aOR], 0.84 and 0.89, respectively) but were more likely to receive epinephrine for anaphylaxis (aOR, 1.50 and 1.32, respectively). There was improved performance over time for 4 measures. Most agency-level factors were not consistently associated with quality of care.CONCLUSIONEMS pediatric care quality is associated with multiple patient factors, including age. Further research is needed to determine whether these associations impact patient outcomes and to develop strategies to reduce unwarranted variability in prehospital pediatric care.

BACKGROUND AND OBJECTIVESAlthough tall stature is commonly associated with 47,XXY/Klinefelter syndrome (KS), detailed childhood growth patterns are not well-defined. This study aimed to develop KS-specific growth charts for stature-for-age, weight-for-age, weight-for-length (0–24 months), and body mass index (BMI)-for-age (2–18 years).METHODSWe conducted a population-based secondary analysis using clinical data from 6 US pediatric centers. The cohort included 1279 males aged younger than 20 years with a diagnosis of KS and at least 1 outpatient measurement of height and/or weight. Nonparametric quantile regression was used to model age-related growth trajectories.RESULTSA median of 6 longitudinal growth data points per individual contributed to the creation of KS-specific curves. Key differences from standard reference growth charts included the following: (1) approximately 20% of boys with KS aged younger than 4 years were below the 5th percentile for height, whereas approximately 25% exceeded the 95th percentile by late childhood; (2) height velocity increased in midchildhood (after age 6 years), but without a distinct pubertal growth spurt; and (3) BMI distribution was broader, with approximately 10% of individuals below the 5th percentile and approximately 25% above the 95th percentile.CONCLUSIONSBoys with KS demonstrate distinct and variable growth trajectories compared with the general population. These KS-specific growth charts offer a valuable clinical tool for monitoring growth, guiding anticipatory counseling, and identifying atypical development patterns.

This month’s issue of Pediatrics includes 2 articles detailing quality improvement (QI) efforts to improve outcomes in very preterm infants. In the article by Gentle, et al, the authors report an initiative to decrease the percentage of extremely preterm infants requiring mechanical ventilation of more than 7 days in a large level III neonatal intensive care unit (NICU).1 Using a range of interventions including consensus-based management, bedside tools to support decision-making, and empowerment of all care team members, they achieved their project aim and, notably, also observed a reduction in the rate of bronchopulmonary dysplasia (BPD) or death. In the article by Morris et al, the authors report improvement in a series of in-hospital growth parameters in very low birth weight infants (VLBW) across a group of NICUs in the California Perinatal Quality Collaborative (CPQCC).2 These authors used a collaborative model for improvement centered around broad-based guidelines for care that allowed units to adapt to their local culture. NICUs participating in the collaborative improved growth restriction at discharge and sustained that improvement for an additional 2 years, as compared with nonparticipating CPQCC NICUs that did not demonstrate improvement over the same period.

INTRODUCTIONVery low birth weight (VLBW) infants experience inadequate postnatal growth, which may be associated with poor neurodevelopmental outcomes. This statewide quality improvement collaborative aimed to improve VLBW infant growth.METHODSThe collaborative was conducted from October 2018 to March 2020. The aim was to reduce the primary outcome measure of proportion of weight <10th percentile at discharge among VLBW infants by 20% in 1 year. The secondary outcome measure was a z-score deficit ≥0.8 from birth. Process measures were early fortification, nutrition rounds, and feeding guideline compliance. Balancing measures were necrotizing enterocolitis and human milk feeding at discharge. Measures were analyzed with statistical process control charts. Outcome measures were compared among participant and nonparticipant neonatal intensive care units (NICUs) for a total of 6 years including 2 years after the collaborative.RESULTS22 NICUs participated in the collaborative. The 78-month analysis included 7856 VLBW infants. The participant group reduced growth restriction at discharge (45% to 37.6%) and z-score deficit ≥0.8 (44.4% to 33.3%). Postcollaborative improvement was sustained for 24 months. The 114 nonparticipant NICUs did not reduce rates of growth outcome measures. Several process measures showed sustained improvement. Balancing measures were unchanged during the collaborative period. However, post hoc analysis showed a higher necrotizing enterocolitis rate when 2 years after the collaborative were included.CONCLUSIONQuality improvement collaborative NICUs improved nutrition processes and VLBW growth. Improvement was sustained for 24 months after the collaborative. Nonparticipant NICUs did not show similar improvement. Implementing NICU nutrition processes may lead to sustained improvements in VLBW infant growth.

BACKGROUND AND OBJECTIVESProvider variability in mechanical ventilation weaning practices may result in prolonged invasive ventilation exposure that may contribute to the development of bronchopulmonary dysplasia (BPD) in extremely preterm infants. Our SMART aim was to reduce the proportion of infants born between 24 and 28 6/7 weeks’ gestation exposed to invasive ventilation for more than 7 days by 25% within 12 months.METHODSThis was a single-center quality improvement initiative at The University of Alabama at Birmingham conducted between January 2021 and March 2023. Interventions to reduce mechanical ventilation exposure included the following: (1) establishing a consensus for invasive ventilation exposure including intubation, extubation, and reintubation, (2) development of a bedside weaning readiness tool to facilitate permissive hypercapnia, (3) empowerment of respiratory therapist facilitated weaning, and (4) the creation of a ventilation dashboard. All measures were analyzed using statistical process control charts.RESULTSThe initiative included 340 infants with a median gestational age of 26 6/7 weeks (IQR, 25–28) and birth weight of 842 g (IQR, 686–1011). The baseline proportion of infants invasively ventilated for more than 7 days at baseline was 44%, which decreased to 25% following implementation of the bedside weaning readiness and communication tool. Special cause variation was also observed for rates of BPD or death, which decreased from a baseline of 55% to 40%.CONCLUSIONSIn infants between 24 and 28 6/7 weeks’ gestation, systematic ventilator weaning was associated with a decrease in infants invasively ventilated for more than 7 days and a decrease in BPD or death.

10.1542/6378835952112Video AbstractPEDS-VA_2025-0708306378835952112To address the growing youth suicide public health crisis in the United States, the American Academy of Pediatrics (AAP) partnered with the American Foundation for Suicide Prevention (AFSP) to create a comprehensive response through the Blueprint for Youth Suicide Prevention. The collaboration between AAP and AFSP also resulted in the Community Youth Suicide Prevention program. This program leveraged each organization’s network of state-level chapters and brought together subject-matter experts in pediatric health, suicide prevention, and community engagement to develop the Community Youth Suicide Prevention program. Subject-matter experts were named statewide Suicide Prevention ambassadors. Ambassadors participated in an 8-month Extension for Community Healthcare Outcomes (ECHO) educational series, which featured expert faculty in suicide prevention. Supported by a grant from the AAP, ambassadors developed an action plan of goals and activities centered around 5 domains based on the Blueprint. Domains focused on community suicide prevention strategies and included health equity, policy and advocacy, community partnerships, communications and media, and sustainability. Outcomes from the ECHO and chapter-based activities included increased knowledge of suicide prevention strategies along with increased commitment and confidence when applying suicide prevention education to community partnerships. Additionally, a special overview of the projects of 2 chapters, Maryland AAP and Mississippi AFSP, are presented.

People who use languages other than English (LOE)1 comprise around 8% of the US population2 and experience health inequities.3 In pediatrics, language-related inequities include lower health care quality and less access to care,4 increased adverse medical events,5 and higher readmission rates.6 Federal policies, including the Culturally and Linguistically Appropriate Services (CLAS) Standards and Section 1557 of the Affordable Care Act outline, as a civil right, the provision of language services, including interpreting, translation, and access to qualified bilingual or multilingual (hereafter described as multilingual) practitioners.7 Despite these long-standing policies, people who use LOE have inconsistent access to interpreting during health care visits, particularly during interactions with non–practitioner-allied health care staff (eg, pharmacist, registration).8 Additionally, the emergence of telemedicine and patient portals has led to increased opportunity for written communication. Although helpful to some, these innovations have created new barriers when hospital and research systems lack resources to provide access to written documents.9,10 Although research is a fundamental component of pediatric academic health care and often interwoven with clinical care, people who use LOE are largely excluded from pediatric research11,12; when included, they may have a suboptimal experience.13

Acrodermatitis continua of Hallopeau (ACH) is a sterile pustular psoriasis variant that is refractory to conventional therapies. The eruption typically develops following local trauma or infection, with other potential etiological factors including neural, inflammatory, and genetic origins. Notably, ACH is exceptionally rare in pediatric populations and presents significant therapeutic challenges owing to the safety limitations of conventional systemic therapies. A 7-year-old male patient with no personal or family history of psoriasis presented with recurrent episodes of erythema, edema, and pustule formation localized to the nail beds of 3 digits. Repeated microbiological analyses of pustular secretions, including mycological examinations, bacterial and/or atypical mycobacterial cultures, and viral tests, yielded negative results. Histopathology revealed parakeratosis, epidermal neutrophilic infiltrates, and ectatic dermal papillary vessels. Consequently, a diagnosis of ACH was established. After initial laboratory evaluations revealed no significant abnormalities, the patient received spesolimab at a dose of 450 mg (15 mg/kg) intravenously at weeks 0 and 1, with informed consent from the patient and his parents. Periungual inflammation resolved completely by week 8, accompanied by initiation of fingernail regrowth. No treatment-related adverse events occurred during therapy or follow-up. Our case report presents the successful application of spesolimab in a 7-year-old child with ACH, thus further supporting the potential of this targeted biologic agent in pediatric ACH treatment.

10.1542/6377133537112Video AbstractPEDS-VA_2025-0723496377133537112Bereaved caregivers are at risk of poor mental and physical health outcomes following the death of their child. However, their voices are often excluded from the very end-of-life and bereavement research aimed at improving outcomes during this vulnerable time. In this article, we highlight the importance of involving bereaved caregivers in research by sharing personal insights as well as data on bereavement outcomes and caregivers’ experiences with research participation. We then present strategies for effectively engaging bereaved caregivers throughout the research process, including evidence-based recommendations and practical approaches. Patient-engaged research helps (1) tailor interventions to the population of interest and (2) facilitate recruitment and retention (3) with results interpretation and (4) dissemination, among other benefits; all of which could benefit bereaved caregivers. Despite concerns that bereaved caregivers participating in research is overly burdensome, research shows that bereaved caregivers often find benefit in research participation and appreciate the opportunity to be involved, even when participation is emotionally challenging. Although distress during research participation is occasionally reported, it rarely reaches a level requiring professional assistance. Conducting high-quality bereaved caregiver research requires a thoughtful approach, ideally with bereaved-caregiver partners guiding the efforts. We describe best practices and considerations for identifying bereaved-caregiver research participants, timing of approach, recruitment, renumeration and appreciation, distress monitoring, and providing psychosocial support, as well as data collection, analysis, interpretation, and dissemination for studies. We must ensure that bereaved caregivers are meaningfully and appropriately engaged in bereaved caregiver research, which is an essential step in improving bereaved-caregiver outcomes.

This clinical report updates and replaces a 2010 clinical report from the American Academy of Pediatrics that addressed food allergy management in schools. Food allergy affects up to 10% of children, and anaphylaxis is estimated to occur in 1 in 15 schools per year. School food allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric primary care clinician may include diagnosing and documenting a potentially life-threatening food allergy; prescribing self-administered epinephrine to individual patients or for general use in a school (stock/unassigned epinephrine); educating children, parents, and school personnel on prevention, recognition, and management of allergic reactions to food; and working with schools in developing plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and primary care clinician in managing students with food allergies.

This statement updates the recommendations of the American Academy of Pediatrics (AAP) for the use of influenza vaccines and antiviral medications in the prevention and treatment of influenza in children during the 2025–2026 influenza season. A review of the evidence supporting these recommendations is in the accompanying technical report (https://doi.org/10.1542/peds.2025-073622).The AAP recommends annual influenza vaccination of all children without medical contraindications starting at 6 months of age. Influenza vaccination is an important strategy for protecting children and the broader community as well as reducing the overall burden of respiratory illnesses when other viruses are cocirculating. Any licensed influenza vaccine appropriate for age and health status can be administered, as soon as possible in the season, without preference for one product or formulation.Antiviral treatment of influenza is recommended for children with suspected or confirmed influenza who are hospitalized or have severe or progressive disease or have underlying conditions that increase their risk of complications of influenza. In this situation, antiviral treatment should be started as soon as possible regardless of duration of illness. Antiviral treatment is an option in the outpatient setting for other children with suspected or confirmed influenza in some circumstances.Antiviral chemoprophylaxis is an option in certain individuals, especially exposed children who are asymptomatic and are at high risk for influenza complications but have not yet been immunized or those who are not expected to mount an effective immune response.

This technical report accompanies the recommendations of the American Academy of Pediatrics for the routine use of influenza vaccine and antiviral medications in the prevention and treatment of influenza in children during the 2025–2026 influenza season. The rationale for the American Academy of Pediatrics recommendation for annual influenza vaccination of all children without medical contraindications starting at 6 months of age is provided. Influenza vaccination is an important strategy for protecting children and the broader community against influenza. This technical report summarizes recent influenza seasons, morbidity and mortality in children, vaccine effectiveness, and vaccination coverage and provides detailed guidance on vaccine storage, administration, and implementation. The report also provides a brief background on inactivated (non-live) and live attenuated influenza vaccines, available vaccines for the 2025–2026 influenza season, vaccination during pregnancy and breastfeeding, diagnostic testing for influenza, and antiviral medications for treatment and chemoprophylaxis. Strategies to promote vaccine uptake are emphasized.