Pediatrics Current

10.1542/6376238924112Video AbstractPEDS-VA_2024-0681336376238924112BACKGROUND AND OBJECTIVESex chromosome trisomies (SCT), including XXY, XYY, and XXX syndromes, have been historically underdiagnosed. Noninvasive prenatal cell-free DNA screening has significantly increased identification, leading to a need for pediatric care for a growing population of newborns with SCT. Our goal was to analyze and compare perinatal, medical, and physical features in infants with prenatal identification of SCT through 12 months of age.METHODSThe eXtraordinarY Babies Study is a prospective natural history study of prenatally identified children with SCT. Participants enroll prior to 12 months of age and have medical histories and examinations at 2-, 6-, and 12-month visits. Descriptive statistics were followed by comparisons between SCT groups (t tests, analysis of variance, Fisher exact tests). Relative risks were calculated compared to general population rates.RESULTSA total of 309 infants are included (XXY = 182; XXX = 76; XYY = 51). Relative risk (RR) compared to general population is elevated for breastfeeding difficulties (51.1%; RR 2.7 [CI 2.1–3.4]), positional torticollis (29.4%; RR 7.5 [5.3–10.7]), eczema (47.6%; RR 3.5 [3.1–3.9]), food allergies (19.4%; RR 2.4 [1.9–3.1]), small cardiac septal defects (7.8%; RR 17.3 [11.8–25.3]), and structural renal abnormalities (4.5%; RR 10.1 [6.0–16.8]), all P < .001. Comparisons between groups show more similarities than differences; however, infants with an extra X chromosome are at higher risk for lower birth weight and length, infants with XXX have higher risk for renal and cardiac malformations, and the risk of eczema is higher in boys.DISCUSSIONResults inform care as pediatricians and families can be reassured that a prenatal diagnosis of SCT is not associated with complex medical or physical abnormalities within the first year of life, but proactive monitoring for select at-risk conditions is warranted.

We present a case of infectious endocarditis in the immediate post-transplant period in a 7-year-old child. On postoperative day 6, an elevation in inflammatory markers was detected, and the echocardiogram revealed a pedunculated mass on the mitral valve. The patient underwent surgical resection on postoperative day 14, followed by a 6-week course of antibiotics. The patient demonstrated complete resolution of endocarditis and, at 5-year follow-up, has excellent allograft function without recurrence of endocarditis.

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” William Osler

10.1542/6377236003112Video AbstractPEDS-VA_2025-0711346377236003112OBJECTIVETo examine the effects of acceptance and commitment therapy (ACT) on reducing psychological distress and promoting quality of life (QoL) in parents of children with cancer.METHODSA 2-arm paralleled randomized controlled trial was conducted with the intervention group receiving a 4-session weekly ACT-based intervention and the control group receiving the usual care. The primary outcomes were parental psychological distress and QoL. Secondary outcomes were parental experience of child’s illness, experiential avoidance, psychological flexibility, and child’s psychological adjustment to cancer. Data were collected at baseline (T0), after the intervention (T1), and 3 months after the intervention (T2).RESULTSA total of 142 children and their parents were recruited. Generalized estimating equation analyses showed that the intervention group reported significantly positive changes in parental psychological distress (β = −13.54, 95% CI: −20.04 to −7.03, P < .001 at T1; β = −11.86, 95% CI: −18.92 to −4.80, P = .001 at T2) and QoL (β = 8.61, 95% CI: 3.42 to 13.80, P = .001 at T1; β = 8.52, 95% CI: 2.79, 14.26, P = .004 at T2) compared with those in the control group. Parents who received ACT-based intervention also reported significantly less negative experience of child’s illness, less experiential avoidance, and more psychological flexibility. Meanwhile, parents in the intervention group reported significantly greater reductions in the difficulties of psychological adjustment in their children.CONCLUSIONSThe 4-session ACT-based intervention represents a promising approach for reducing psychological distress and improving QoL in the parents of children with cancer.

In this issue of Pediatrics, Holicky and colleagues describe findings from the 2016 to 2020 Illinois Pregnancy Risk Assessment Monitoring System (PRAMS), demonstrating important variations in maternal adherence to recommendations regarding infant sleep practices, breastfeeding, and smoking abstinence.1 Importantly, the report describes patterns of infant sleep and care practices instead of focusing on just 1 element.

OBJECTIVEThe American Academy of Pediatrics (AAP) publishes evidence-based infant sleep recommendations to prevent sudden unexpected infant death (SUID). We defined common patterns of infant sleep and care practices in Illinois and assessed variation in patterns across demographic characteristics.METHODSWe measured maternal report of AAP recommended practices in the 2016–2020 Illinois Pregnancy Risk Assessment Monitoring System, including breastfeeding greater than or equal to 8 weeks; no maternal smoking; and 4 aspects of the sleep environment for infant sleeping on back, on an approved surface, without items in sleep area, and without bed sharing. We applied nonhierarchical cluster analysis, coupled with knowledge of AAP recommendations, to define 6 mutually exclusive patterns of infant sleep and care practices. We produced weighted prevalence estimates for each individual practice and pattern and examined differences by maternal race and ethnicity, age, parity, education, and socioeconomic status using χ2 tests.RESULTSPrevalence estimates for individual practices ranged from 49.6% for infants sleeping without items in sleep area to 90.8% for not smoking. When examining patterns, only 19.3% of new mothers reported all 6 recommended practices; this pattern varied significantly across all demographics examined. The prevalence of the other 5 patterns were as follows: 8.1% following all 4 sleep environment practices, 28.1% bed sharing and breastfeeding, 11.7% bed sharing and no breastfeeding, 25.1% no bed sharing and back sleep positioning, and 7.8% no bed sharing and no back sleep positioning.CONCLUSIONExamining common patterns of infant sleep and care practices provides improved understanding of how infant sleep recommendations are followed and may inform intervention strategies.

10.1542/6376239004112Video AbstractPEDS-VA_2024-0698086376239004112BACKGROUND AND OBJECTIVESHIV preexposure prophylaxis (PrEP) is a safe and effective way to reduce HIV acquisition and was approved for adolescents in 2018. We assessed whether states with minor consent laws (MCLs) allowing younger adolescents to receive PrEP without parental/guardian consent were associated with increased prescription fills.METHODSA legal review classified whether states had MCLs. A negative binomial regression model using national all-payer pharmacy claims compared PrEP fills between minors (13–17 years) and majority-age adolescents (18–19 years) between states with and without MCLs from 2015 to 2021, among 15 states with the highest minor PrEP fills. Key informant interviews (n = 25 experts from 7 states) elicited context for interpreting statistical results.RESULTSOn average, minors had lower PrEP fills than majority-age adolescents (incident rate ratio [IRR], 0.21; 95% CI, 0.17–0.24). However, the interaction term between MCL and age group was insignificant (IRR, 1.11; 95% CI, 0.91–1.36), indicating that age group differences were similar between MCL and non-MCL states. Experts described numerous barriers faced by adolescents in accessing PrEP, including confidentiality concerns, clinic access, stigma, providers’ hesitancy to discuss sexual health with and prescribe PrEP to minors, limited information on PrEP in school-based sexual education, and health care literacy.CONCLUSIONSWe did not find evidence that the gap in PrEP prescription fills between minor and majority-age adolescents was smaller among states with PrEP-inclusive MCLs. Strategies to address the numerous barriers in PrEP access experienced by adolescents may be needed.

10.1542/6375930237112Video AbstractPEDS-VA_2025-0716056375930237112OBJECTIVESUnsafe sleep practices contribute to sleep-related infant mortality. Recent infant illness is a risk factor for sudden unexplained infant death. This study examined changes to safe sleep practices during and after infant illness.METHODSWe performed a prospective cohort survey study of caregivers of infants (aged 0–12 months) presenting to the pediatric emergency department (ED) for illness. Surveys assessed sleep practices before, during, and after illness (2-week and 1-month follow-ups). We assessed adherence to the American Academy of Pediatrics (AAP) safe sleep recommendations at each time point. Differences in adherence were evaluated using mixed-effects logistic regression, whereas Poisson regression was used to evaluate the change in number of safe sleep practices for selected participant characteristics.RESULTSOf 131 enrolled participants, 106 (81%) completed all follow-up surveys. Adherence to AAP recommendations was low (<10%) across all time points but decreased during illness without a significant change following illness. Bed-sharing increased from 57.3% pre-illness to 68.7% during illness (P = .032) and remained elevated at the 1-month follow-up (83.6%). Sleeping in a crib or pack n’ play decreased from 61.8% pre-illness to 48.1% during illness (P = .005) and remained low at follow-up. Caregiver motivations changed during illness, with fewer citing safety (46.6% vs 42.0%) and more being influenced by family recommendations (5.3% vs 15.3%).CONCLUSIONSCaregivers of infants presenting to the ED for low acuity illness report low adherence to safe sleep practices, which worsened during and after illness. Future studies should explore targeted, illness-specific anticipatory guidance to reinforce safe sleep practices during and after illness.

OBJECTIVEThe objective of this study was to increase dental varnish application rates across a large pediatric primary care network for all children, regardless of insurance type or race and ethnicity, using a quality improvement (QI) intervention.METHODSFrom July 2023 to October 2024, we implemented a multifaceted, iterative QI intervention that included electronic health record (EHR) prompts, practice-level education, maintenance of certification credit with monthly audit-and-feedback, and financial incentives. The primary outcome was the proportion of eligible preventive care visits (children aged 6 months to 5.99 years) at which dental varnish was applied. Balancing measures included application rates by insurance type and race and ethnicity. We evaluated implementation using Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework measures as follows: “Reach” (number of visits with varnish applied), “Effectiveness” (proportion of children receiving ≥1 varnish annually), “Adoption” (proportion of practices administering varnish), “Implementation” (visit-level application rate), and “Maintenance” (annual reimbursement, comparing July 2022 to June 2023 with July 2023 to June 2024).RESULTSDuring the intervention, 92 056 eligible preventive care visits occurred. Varnish application increased from 3.7% preintervention to 30.5%, exceeding our 20% target. RE-AIM findings included the following: Reach, application at more than 4000 visits per month (up from ∼400); Effectiveness, more than 50% of children received varnish annually (vs 25% at baseline); Adoption, increased from 6 to all 33 practices; Implementation, 30.5% application rate; and Maintenance, reimbursement increased from $155 000 to $416 000. Improvements were consistent across child insurance and race and ethnicity.CONCLUSIONSA system-wide, EHR-enabled QI intervention significantly improved dental varnish application for all children, regardless of insurance type or race and ethnicity. This approach may serve as a scalable model for integrating dental varnish into pediatric primary care.

In 1904, Abraham Jacobi envisioned a future where pediatricians used knowledge, privilege, and power for good, at the bedside and in society.1 His vision foreshadowed the Modern Hippocratic Oath, which acknowledges that we, as physicians, are members of a “society, with special obligations to [our] fellow human beings.”2–4 Every year, new physicians join our profession. New pediatricians conclude residencies, begin practice, or embark on further training. Our traditions ground and push us, new and seasoned, to act ethically and responsibly, to support children, and to advance and shape our field. Still, many of us are currently struggling to find our footing amid dizzying societal shifts affecting our patients, colleagues, science, and society.

10.1542/6376239505112Video AbstractPEDS-VA_2025-0718836376239505112OBJECTIVESTo assess the risk of concurrent emergency department use (Co-ED) among women with a preexisting disability and their infants.METHODSThis population-based cohort study was completed in Ontario, Canada. Included were all mother–infant pairs with a hospital delivery, 2008–2023. Those with a maternal physical (N = 152 171), sensory (N = 54 716), or intellectual/developmental (N = 2913) disability or multiple disabilities (N = 11 800) were compared with those with no disability (N = 1 548 178). Multinomial logistic regression–generated odds ratios (ORs) and 95% CI for Co-ED (ie, mother and infant both had emergency department (ED) visits within 90 days after hospital discharge), a maternal ED visit only, or an infant ED visit only were calculated, each vs no ED visit. Models were adjusted for maternal age, parity, income quintile, rurality, immigration status, and delivery year.RESULTSCo-ED was more likely among women with (5.4%) than without (3.4%) a disability (adjusted OR [aOR], 1.66; 95% CI, 1.62–1.71). The median number of days between the first maternal and first infant ED visit was 19 (IQR, 4–41) days, and 18.3% occurred within 24 hours of each other. The aOR for maternal ED visit alone was 1.38 (95% CI, 1.35–1.40) and 1.20 (95% CI, 1.19–1.22) for an infant ED visit alone.CONCLUSIONSCo-ED was an important outcome for all mother–infant pairs, particularly so for mothers with a disability, of whom about 1 in 20 experienced Co-ED. These dyads may benefit from careful postdischarge planning during the birth hospital stay and enhanced outpatient health care.

The following essay, by Dr Nadia Nikroo, is the winner of this year’s annual Section on Pediatric Trainees (SOPT) essay competition. The competition focused on the 2024-2025 SOPT advocacy campaign “HEADSS Up!” by inviting essays on adolescent mental health. The runner-up essay will appear in a future issue of Pediatrics.

OBJECTIVESResearch pertaining to disparities in access to health care transition preparation is limited. This study examined a broad set of individual, family, and health system characteristics to determine which are associated with disparities in receipt of health care transition preparation services among US youth.METHODSThis cross-sectional study used data from the 2018–2022 National Survey of Children’s Health, a nationally representative survey based on responses from parents or caregivers. We conducted bivariate analyses to examine receipt of health care transition preparation among youth aged 12 to 17 years (N = 77 280) and multivariable logistic regression models to estimate associations with covariates of interest.RESULTSOnly 18% of youth with and without special health care needs received health care transition preparation services from their health care professionals. In adjusted analyses, youth who were male, aged between 12 and 14 years, and who were Hispanic, non-Hispanic Black, and non-Hispanic Asian were significantly less likely to receive recommended health care transition services. Health care transition preparation was also less likely among youth without special health care needs, without care in a medical home, without insurance, and from households with a high school education only. There were also state-level variations in health care transition preparation (range: 11%-32%).CONCLUSIONSPrevalence of receipt of health care transition preparation services is low among all youth. Findings from this study draw attention to subgroups of youth least likely to receive guidance about health care transition preparation. Health care professionals should be supported to develop clinical and system-level interventions to improve health care transition preparation.

10.1542/6375931865112Video AbstractPEDS-VA_2025-0708866375931865112BACKGROUND AND OBJECTIVESSchools are an important setting for infectious disease transmission. Baseline rates of respiratory virus detections and acute respiratory illnesses (ARIs) in schools are lacking and needed to inform transmission risks and prevention strategies. This investigation sought to determine the incidence of respiratory virus detections and ARIs in pre-kindergarten (pre-K) to 12th-grade students and staff.METHODSKnowledge of Infectious Diseases in Schools (School KIDS) is a longitudinal prospective surveillance study conducted in a large (>20 000 students) Kansas City, Missouri public school district. Students and staff self-collected nasal swabs and reported respiratory symptoms from November 2022 to May 2023. Primary outcomes were respiratory virus detection by polymerase chain reaction and ARI rates by school level.RESULTSThe 816 participants were enrolled for a median of 24.5 weeks (IQR, 23.5–25.0) and submitted a median of 7 (6–8) specimens. Participants included 590 (72.3%) students and 226 (27.7%) staff, providing 5981 specimens and 5198 symptom surveys with 698 (85.5%) participants having at least 1 virus detected and 656 (80.4%) at least 1 ARI episode. Adjusted virus detection rates per 100 enrollment days were highest in pre-K (1.46) and elementary (1.51) followed by middle (1.19), high school (0.90), and staff (0.87). Adjusted ARI rates per 100 enrollment days were 1.66 (pre-K), 1.19 (elementary), 1.17 (middle), 0.76 (high), and 1.45 (staff).CONCLUSIONSPre-K and elementary students had the highest virus detection rates, and pre-K students and school staff had the highest ARI episode rates. These findings provide estimated rates of virus detections and ARIs in school populations and may provide useful data when determining effectiveness of prevention strategies in schools. Future studies are needed to determine the location of viral acquisition and correlation with ARI.

BACKGROUND AND OBJECTIVESHuman parechovirus (PeV) is an increasingly recognized cause of meningoencephalitis (ME) in infants. The US 2022 outbreak provided opportunity to analyze the clinical presentation and predictors of severe disease in affected infants.METHODSWe conducted a multicenter retrospective review of infants diagnosed with PeV ME during the outbreak. We examined demographics, clinical features, laboratory findings, and neuroimaging results. Logistic regression was used to identify predictors of complicated disease and abnormal brain magnetic resonance imaging (MRI). Complicated disease was defined as requiring intensive care or findings of an abnormal brain MRI or electroencephalogram.RESULTS139 infants had PeV ME. The median age was 19 days. Fever was the most common presenting symptom (89.2%) and was associated with uncomplicated disease and normal MRI. A total of 42 (30.2%) infants had complicated disease. Hypothermia (36.5% vs 5.1%), somnolence (38.1% vs 13.4%), poor feeding (76.1% vs 47.4%), hemodynamic instability (28.5% vs 3%), seizures (57.1% vs 4.1%), apnea (40.4% vs 0%), hypoglycemia (16.6% vs 1%), mechanical ventilation (23.8% vs 0%), and inotropic support (11.9% vs 0%) were associated with complicated disease. Younger age and seizures were predictors of abnormal MRI on multivariable analysis (adjusted odds ratio, 0.92 [0.48–0.99] and 40.1 [3.49–460.7], respectively). Laboratory findings, including cerebrospinal fluid indices, were rarely abnormal.CONCLUSIONDespite nonspecific symptoms on presentation and normal laboratory values, PeV can cause complicated disease, requiring clinicians to maintain high suspicion for this infection. We suggest PeV evaluation in workup of infant sepsis cases, neuroimaging in patients at high risk, and long-term developmental follow-up.

Anti-NMDA (N-methyl-D-aspartate) receptor encephalitis (NMDARE) is an autoimmune disease associated with a variety of neuropsychiatric signs and symptoms. Among the most common presentations is catatonia, a psychomotor syndrome associated with mutism, stupor, and abnormal or repetitive movements. Catatonia increases the morbidity associated with NMDARE and must be treated aggressively. Although immunotherapy is the mainstay of treatment for NMDARE, such treatment can take prolonged periods of time to take effect, and thus, alternative approaches to the management of catatonia must be considered. The gold standard treatment for catatonia in psychiatric populations is electroconvulsive therapy (ECT), although there is often hesitance to use this in pediatric populations due to limited evidence, concerns about cognitive impact, and, in some cases, state-level legal restrictions on its use. Here, we report the case of a 5-year-old girl with NMDARE who remained catatonic for 8 months despite treatment with numerous immunotherapeutic agents and high-dose lorazepam and whose catatonia responded robustly and ultimately resolved with the initiation of ECT. This response significantly preceded the introduction of additional immunotherapy, suggesting strongly that ECT had a causal impact. The patient approached premorbid levels of motor and cognitive function within 3 months of the initiation of ECT. This case suggests a benefit of ECT augmentation of immunotherapy as a symptomatic treatment for catatonia in NMDARE.

Surgical innovation spans a spectrum from minor modifications of existing procedures to the development of new procedures. Surgeons routinely innovate at the lower end of this spectrum to adapt standardized procedures to the unique needs of individual patients. These innovations can be made at the surgeon’s discretion without external oversight because they form part of clinical practice. In contrast, new procedures present challenges for oversight because they occur at the boundary between clinical practice and research.Partial heart transplantation is a new procedure designed to provide growing heart valve substitutes for children. Partial heart transplants differ from heart transplants because only the part of the heart containing the necessary valve is transplanted. The rationale for partial heart transplantation is that the valves contained in pediatric heart transplants grow. After partial heart transplant growth had been experimentally confirmed in a piglet model, the stage was set for first-in-human implementation. This Ethics Rounds article discusses potential mechanisms of oversight for first-in-human surgical procedures. Although all 3 commentators agree that relying solely on individual surgeon discretion is inadequate to protect patients, they differ on the most appropriate form of oversight. The perspectives presented advocate for oversight by local surgical departments, institutional review boards, and specially convened surgical innovation boards.

OBJECTIVEFeeling prepared for a child’s end of life (EOL) may help to alleviate parents’ psychological symptoms following their child’s death from cancer. However, most parents report feeling unprepared, and data on how parents define feeling prepared for their child’s EOL remain limited. In this study, we explored how parents define “preparing” for a child’s EOL and identified barriers and facilitators to feeling prepared.METHODSWe conducted a qualitative descriptive study using semistructured interviews with parents whose child died of cancer in the past 4 years. Interviews were audio-recorded, transcribed verbatim, and synthesized using thematic analysis.RESULTSAmong the 15 bereaved parents interviewed, 86% were non-Hispanic white mothers. Parents viewed preparing for their child’s EOL as a combination of internal and external actions and identified that external prompts, such as clinician communication about impending death, were often necessary triggers for preparatory work. Parents identified 3 key barriers to feeling prepared: clinicians’ difficulties discussing EOL and the impact on patient care, child death as antithetical to the natural life order, and isolation and limited support following a transition to EOL care. Parents also identified 3 facilitators: guidance in EOL decision-making and care, peer support, and engaging the dying child in decision-making and planning when appropriate.CONCLUSIONParental preparation for EOL is often prompted by external factors, resulting in both internal and external actions. Parents identified specific factors that contributed to becoming prepared. These data provide a foundation for the development of targeted interventions grounded in the reality of bereaved parents.

Over the last few decades, childhood mental health (MH) concerns and suicides in the United States have been steadily increasing at alarming rates.1,2 As a response, in 2021, the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly issued a statement declaring a national state of emergency in children’s MH.3 With this dramatic increase in MH crises, there has been a subsequent increase in emergency department (ED) primary psychiatric encounters, outpacing increases in ED encounters for other complaints.4,5 Although the AAP recommends against routine medical clearance testing for MH-related concerns among children who are admitted for psychiatric reasons,6,7 there is still no uniformly accepted definition of medical clearance of pediatric patients with a psychiatric health complaint nor consensus on how to achieve this clearance and what ancillary testing or procedures should be involved.8

10.1542/6373872903112Video AbstractPEDS-VA_2025-0710076373872903112BACKGROUND AND OBJECTIVESThere are recommendations against routine medical clearance testing for children evaluated in the emergency department (ED) for mental health concerns. Our objective was to determine variation, factors, and costs associated with medical clearance testing during ED encounters for mental health concerns.METHODSWe conducted a cross-sectional study of ED encounters among children aged 5 to 18 years who presented to 35 US children’s hospitals for mental health concerns (2016–2023). We determined the prevalence of medical clearance testing defined as any electrocardiogram, complete blood count, serum chemistry, urine or serum drug screening, urine pregnancy, urinalysis, COVID-19, or thyroid function testing. We used generalized estimating equations to identify patient and hospital factors associated with medical clearance testing. Costs for medical clearance evaluation were estimated from billed charges.RESULTSAmong 604 869 ED encounters, 56.9% had at least 1 medical clearance test conducted. Medical clearance testing varied substantially by hospital (range: 33.5% to 85.3% of ED encounters). Compared with encounters resulting in ED discharge, admission to a psychiatric unit at the same facility (aOR, 30.73; 95% CI, 21.73–43.47) and transfer to a psychiatric facility (aOR, 5.64; 95% CI, 4.01–7.92) were associated with greater odds of medical clearance testing. Medical clearance testing cost a total of $25 187 999 per year across the included hospitals.CONCLUSIONSMore than half of ED encounters for children with mental health concerns involved medical clearance testing and such practices varied across hospitals. Medical clearance testing in ED encounters for mental health–related concerns resulted in substantial and potentially unnecessary costs.

10.1542/6375979358112Video AbstractPEDS-VA_2024-0701316375979358112OBJECTIVETo describe the integration of routine diaper insecurity screening and diaper resource program within a safety net health system and to report diaper insecurity prevalence, demographic characteristics, co-existing social drivers of health (SDOH), and associated health outcomes.METHODSA retrospective cross-sectional study was conducted in 9 urban Federally Qualified Health Centers (FQHC). Pediatric patients, aged 0 to 36 months, were screened for diaper insecurity from June 2022 to July 2024. Data from 16 677 unique patients were extracted and analyzed from the electronic health record.RESULTSOf 16 677 pediatric patients potentially eligible for screening, 7700 (46%) were screened for diaper insecurity. Diaper insecurity prevalence was 41% (n = 3147). The highest diaper insecurity prevalence was reported by non-Hispanic Black 45% (n = 1462) and Hispanic 39.9% (n = 1352) patients, and those preferring to communicate in Haitian Creole (n = 748, 66%). Screening rates were equitable by race/ethnicity but inequitable for most preferred languages other than English.Diaper insecurity often co-occurs with other SDOH with 78% (n = 951) also reporting food insecurity; 65% (n = 963) transportation insecurity; 72% (n = 97) unhoused/homeless; 71% (n = 484) rent/mortgage payment insecurity; and 88% (n = 445) with financial insecurity; 48% (n = 1042) of households report receiving Supplemental Nutrition Assistance Program benefits.Maternal depression, low birth weight, fewer toilet training difficulties, and increased emergency department visits were all associated with diaper insecurity.CONCLUSIONIntegration of diaper insecurity screening within a health system reveals frequent reports of diaper insecurity with significant differences in prevalence among racial, ethnic, and language subgroups. Conducting this screening in the context of a health care visit provides opportunities to connect patients to essential resources.

10.1542/6376120802112Video AbstractPEDS-VA_2024-0697536376120802112OBJECTIVETo investigate the characteristics and trends of exposures to medications, dietary supplements, and psychoactive substances among children aged 6 to 12 years reported to US poison centers (PCs) with a focus on exposures associated with suspected self-harm or suicidal intent.STUDY DESIGNNational Poison Data System data from 2000 to 2023 were analyzed.RESULTSThere were 1 541 565 primary substance exposures among 6- to 12-year-old children reported to US PCs from 2000 to 2023. Most involved a single substance (90.1%), involved boys (58.2%), or occurred in a residence (95.8%). Although most exposures were associated with minimal medical consequences, 3.5% of children were medically admitted, 4.0% experienced moderate effects, and 0.3% had major effects; there were 95 reported deaths. Therapeutic errors accounted for 48.6% of exposures. Although exposures associated with suspected self-harm or suicidal intent represented 4.7% of exposures overall, they accounted for 25.8% of exposures among 12-year-old children. Exposures associated with suspected self-harm or suicidal intent were more likely to be medically admitted (risk ratio [RR], 14.32; 95% CI, 14.10–14.56) or experience a serious medical outcome (RR, 8.04; 95% CI, 7.91–8.17) than other reasons for exposure. The overall rate of exposure increased by 53.8% from 2000 to 2023, whereas the exposure rate associated with suspected self-harm or suicidal intent increased by 311.2%.CONCLUSIONSThe rate of exposure to medications, dietary supplements, and psychoactive substances among children aged 6 to 12 years increased from 2000 to 2023, especially exposures associated with suspected self-harm or suicidal intent. Additional targeted research and interventions are needed to prevent substance exposures among 6- to 12-year-old children, especially exposures associated with suspected self-harm or suicidal intent among 11- to 12-year-old children.

OBJECTIVEAmong extremely low-birth-weight (ELBW; <1000 g) or extremely preterm (EPT; <28 + 0 weeks) infants, we aimed to describe size indicators at 18 to 24 months of corrected age and growth from neonatal intensive care unit (NICU) discharge to follow-up and to examine infant and maternal determinants of those outcomes.METHODSWe studied 7301 ELBW/EPT children from 77 Vermont Oxford Network member hospitals. Continuous size indicators at 18 to 24 months were z scores of weight, length, head circumference, and body mass index based on World Health Organization standards. We represented growth by z score changes in weight and head circumference from NICU discharge to 18 to 24 months. We estimated associations of infant and maternal factors with indicators of size and growth in multivariate linear and logistic regression.RESULTSMedian gestational age was 26 weeks and birth weight was 800 g. From NICU discharge to 18 to 24 months, weight increased by median 0.74 z scores, but at 18 to 24 months, ELBW/EPT children remained lighter than the reference (median z score −0.26). In adjusted analyses, small-for-gestational-age (SGA) status, NICU weight faltering, and surgical necrotizing enterocolitis all predicted more rapid weight gain after NICU discharge, but infants with those conditions remained smaller at 18 to 24 months. For example, SGA infants gained 0.44 z scores more weight after NICU discharge than non-SGA infants (95% CI, 0.34–0.54) but were nonetheless 0.95 z scores lighter at 18 to 24 months (95% CI, −1.05 to −0.86).CONCLUSIONSOur findings suggest substantial, albeit incomplete, catch-up growth in ELBW/EPT infants after NICU discharge through 18 to 24 months.

OBJECTIVESThe 2-bag intravenous (IV) fluid system for diabetic ketoacidosis (DKA) has been associated with shorter duration of insulin and faster resolution of acidosis. Our aims were to increase the use of 2-bag IV fluids among children with medium- or high-risk DKA treated at 2 tertiary care pediatric hospitals and to increase the proportion of children who receive timely administration of fluid and insulin treatments.METHODSWe conducted a quality improvement initiative using data from January 1, 2014, to December 31, 2021, among patients 21 years or younger with medium- or high-risk DKA. The study spanned pre- and post-initiative periods and a stability period. Our interventions included development of a clinical practice guideline, education, and electronic medical record updates. Statistical process control methods were used to evaluate outcome changes.RESULTSWe identified 876 eligible encounters. Age, sex, and the proportion of children with medium- or high-risk DKA were similar across study periods. A higher proportion of non-Hispanic Black children was observed in the stability period (26.3%) than the pre- (17.7%) and post-initiative (18.2%) periods. We observed an increase in 2-bag IV fluid use from an average of 41.3% to 77.7%. We did not observe changes in time to isotonic fluid bolus, continuous insulin, or 2-bag IV fluids. There was no change in hypoglycemic events.CONCLUSIONWe increased the proportion of children with medium- or high-risk DKA treated with 2-bag IV fluids through a combination of interventions, including implementation and refinement of a clinical guideline, creation of a nurse algorithm, and nursing education.

In this issue of Pediatrics, Rolin et al present a timely examination of sexually transmitted infection (STI) testing practices among male adolescents, a group often overlooked in sexual health research.1 Using emergency department (ED) data, the authors found that a substantial proportion (>60%) of symptomatic youth were not tested for chlamydia or gonorrhea, while non-Hispanic Black male adolescents were significantly more likely than white male adolescents to be screened. These findings expose a dual problem: both missed clinical opportunities for adolescents and disproportionate screening of Black male adolescents. The authors highlight how, in the absence of universal guidance, racial and gendered biases may shape screening and testing practices.

BACKGROUNDRacial differences in Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) testing and screening are well documented among adolescent females; however, data on adolescent males are limited. We sought to compare racial and ethnic differences in CT/GC testing and screening among adolescent males presenting to a pediatric emergency department (ED).METHODSCross-sectional analysis of ED visits made by males aged 13 to 21 years at 2 urban pediatric hospital campuses between January 2021 to February 2023. The primary outcome was performance of CT/GC testing or screening. Multivariable logistic regression assessed racial and ethnic differences in CT/GC testing or screening, adjusting for age and ED site.RESULTSAmong 17 244 ED visits, 643 (3.7%) included CT/GC testing or screening. Of the 473 (2.7%) visits by symptomatic males, 187 (39.5%) included CT/GC testing. Testing rates were higher in visits by non-Hispanic Black males compared with non-Hispanic white males (50.0% vs 11.8%; adjusted odds ratio [aOR], 3.3 [95% CI, 1.3–8.3]). Of the 16 771 visits by males with non-STI–related chief complaints, 456 (2.7%) included CT/GC screening. Screening rates were higher among visits by non-Hispanic Black males compared with non-Hispanic white males (3.5% vs 0.8%; aOR 3.1 [95% CI, 1.6–5.9]).CONCLUSIONSThere were low rates of CT/GC testing overall; however, visits by non-Hispanic Black adolescent males were more likely to include both testing and screening compared with non-Hispanic white males. More research is needed to determine possible cause of this racial difference and to identify strategies to mitigate potential racial differences in CT/GC testing in the ED.

10.1542/6375930473112Video AbstractPEDS-VA_2024-0698376375930473112OBJECTIVEPreterm children exhibit a higher prevalence of autism spectrum disorder (ASD) than the general population. The unique neurodevelopmental characteristics of preterm children present challenges in screening for and diagnosing ASD. To date, a systematic review of screening tools for ASD in this population has not been completed. This systematic review and meta-analysis evaluates the diagnostic performance of currently used ASD screening tools in the preterm population.METHODSThe database search was conducted by using MEDLINE, PsycINFO, PubMed, Embase, and CINAHL in July 2024. Articles that quantified the diagnostic accuracy of ASD screening tools in the preterm population were included. Nine studies were included in this review, and only 4 studies in the meta-analyses. All studies were assessed for risk of bias, applicability, and certainty.RESULTSSensitivity of screening tools for ASD in preterm children ranged from 0% to 100%, whereas specificity ranged from 38% to 98%. Pooled data were available for the Modified Checklist for Autism in Toddlers (2 studies) and Social Communication Questionnaire. (2 studies), with pooled sensitivities of 55% and 53% and specificities 85% and 90%, respectively.CONCLUSIONSThere was significant study heterogeneity, limiting the number of studies from which to pool diagnostic accuracy data. Screening tools vary in their ability to identify ASD in the preterm population, underscoring how overlapping behavioral phenotypes may confound early identification. There is a critical need to refine and assess ASD screening tools in preterm children, facilitating timely interventions in this cohort.

Disseminated herpes simplex virus (HSV) can be life-threatening in neonates without treatment. We present a case involving twins diagnosed with disseminated HSV who experienced different clinical courses. Twin A was more severely affected, developing severe capillary leak syndrome (CLS) that led to cardiovascular compromise, acute kidney injury, and hepatic failure. However, with innovative immunologic treatment and expert hemodynamic management, the patient recovered despite high mortality in infants with this presentation. Twin B had a less severe initial presentation but experienced long-term neurologic sequelae, including keratitis of both eyes occurring at different times and recurrent HSV meningitis. This case report displays novel translational and clinical methods that may improve survival in neonates with severe disseminated HSV and CLS.