Pediatrics Current

10.1542/6374766509112Video AbstractPEDS-VA_2024-0701436374766509112OBJECTIVEInfants with chronic critical illness (CCI) are increasingly surviving to neonatal intensive care unit (NICU) discharge. Following discharge, parents of infants with CCI must navigate complex decision-making, provide direct intensive care, “including managing supportive technologies”, and coordinate complex medical care, yielding high rates of distress. However, this vulnerable population’s specific support needs remain poorly understood.METHODSIn this longitudinal qualitative study, we conducted semi-structured interviews with parents of infants with CCI in 2 care settings: (1) NICU toward the end of the infant’s admission, and (2) home within 3 months of discharge. Rapid qualitative analysis identified emergent themes. Matrix analysis enabled comparison of content across individuals, care settings, and domains.RESULTSA total of 17 parents of 15 infants with CCI completed an interview while in the NICU, and 13 completed a second interview after discharge. Most parents were mothers (88%) and married (53%), and over one-quarter were Black (29%) or Latinx (24%). The most common infant diagnosis was prematurity (40%), and all infants were supported by medical technologies at discharge. Parents reported supports, gaps in support, and recommendations for improving supports across care settings. Their narratives depicted the contrast between feeling highly supported during the NICU stay and strikingly under-supported after discharge, illuminating the need for additional hospital- and community-based supports to bridge this transition.CONCLUSIONSParents of infants with CCI report a steep decline in supports on NICU discharge. Further studies must partner with parents to identify and test interventions to accompany them through the critical transition from NICU to home.

Gastrointestinal stromal tumors (GISTs) account for approximately 3% of gastrointestinal tumors and are the most prevalent mesenchymal tumors, primarily affecting the stomach and small intestine. In pediatrics, they are considered rare tumors and differ from GISTs that are found in adults because they often lack mutations in the KIT or platelet-derived growth factor α (PDGFRA) genes and are thereby classified as “wild-type.” Currently, there are few specific guidelines for treating this type of tumor in the pediatric population. More data are needed to better understand GISTs and develop more effective targeted therapies. The present report describes the case of a patient, now an adult, who was diagnosed with a GIST during childhood and experienced several relapses. A therapeutic regimen was devised and implemented, resulting in a favorable outcome.

10.1542/6373950435112Video AbstractPEDS-VA_2025-0716666373950435112OBJECTIVETo derive and internally validate a clinical prediction rule to identify febrile infants aged 61–90 days at low risk of invasive bacterial infections (IBIs).METHODSUsing data from 17 Pediatric Emergency Care Applied Research Network Registry (PECARN) emergency departments, we included noncritically ill, previously healthy infants aged 61–90 days with temperatures greater than or equal to 38°C and urinalyses and blood cultures obtained between January 1, 2012, and April 30, 2024. Our outcome was IBI, defined as growth of pathogenic bacteria from blood or cerebrospinal fluid culture. Using recursive partitioning with 10-fold cross-validation, we derived and internally validated a prediction rule using age, temperature, urinalysis (negative/positive), and absolute neutrophil count (ANC) as candidate predictors. Limiting the analysis to infants with procalcitonin (PCT) and ANC results, we evaluated PCT as an additional predictor.RESULTSOf 4952 infants included, 100 (2.0%) had IBIs, including 95 (1.9%) with bacteremia without meningitis and 5 (0.1%) with bacterial meningitis. The optimal prediction rule identified low-risk infants as those with negative urinalyses and highest temperatures less than or equal to 38.9°C, yielding a sensitivity of 86.0% (95% CI, 77.6–92.1) and specificity of 58.9% (95% CI, 57.5–60.3). In the subset of 1207 infants with PCT and ANC measurements, including 27 (2.2%) with IBIs (2 [0.2%] with bacterial meningitis), we identified PCT of 0.24 ng/mL or less and ANC of 10 710 cells/mm3 or less as low-risk predictors. This PCT-based rule demonstrated sensitivity of 100.0% (95% CI, 87.2–100.0) and specificity of 65.8% (95% CI, 63.0–68.5).CONCLUSIONSWe derived 2 accurate clinical prediction rules to identify febrile infants aged 61–90 days at low risk of IBIs when urine and blood testing are obtained. Prospective validation is needed.

The participation of advanced practice registered nurses (APRNs) in neonatal care continues to be supported by the American Academy of Pediatrics. Traditionally, neonatal nurse practitioners and neonatal clinical nurse specialists were the two roles well established within the Neonatal Intensive Care Unit (NICU). With ongoing shortages of these roles, some institutions have turned toward pediatric nurse practitioners (acute and primary care) and family nurse practitioners to meet patient care needs. This clinical report aims to review the roles, scope of practice, collaboration, and credentialling of these categories of APRNs with recommendations for the safe and effective utilization of these providers in neonatal care. This clinical report will not address other roles in the NICU, including hospitalists or physician assistants in the NICU, nor speak to the potential shortages and solutions these professions are experiencing, as those topics are well covered in the Standards for Levels of Neonatal Care: II, III, IV and Neonatal Provider Workforce Technical Report.

The majority of children, adolescents, and young adults with complex medical needs, especially those who use life-sustaining equipment, are cared for at home by their families and community. Home health care is an essential service that supports families to be able to safely care for their children outside of the hospital, and the medical home serves as the hub to help coordinate and communicate between providers and families. It is essential that pediatric health care providers develop and implement an interdisciplinary and coordinated plan of care that addresses the child’s ongoing health care needs. The goal is to ensure that each child remains healthy, thrives, and obtains optimal medical home and developmental supports that promote ongoing care at home. Discharge planning from long-term hospitalizations and rehabilitation for this population can be a complicated process that requires a deliberate, multistep approach. This clinical report presents an approach to addressing the needs of children with complex medical needs and their families in the home environment and supporting the transitions between hospital and home.

Rates of mental health, emotional, and behavioral (MEB) problems in the United States continue to rise, with current estimates of 13% to 20% of children having an MEB disorder and an additional 19% with problems causing impairment or distress that do not meet diagnostic criteria for a specific disorder. This clinical report incorporates and expands on recommendations from the 2019 American Academy of Pediatrics policy statement “Mental Health Competencies for Pediatric Practice” as well as “Recommendations for Preventive Pediatric Health Care.” It addresses the rising MEB needs of youth since the previous clinical report, “Promoting Optimal Development: Screening for Behavioral and Emotional Problems,” was published in 2015. This report outlines specific guidance for MEB screening, identification, and care of children in pediatric primary care. Screening, as part of regular health supervision visits and surveillance, begins within the first month of life to identify postpartum depression in caregivers. Child-focused screening for MEB problems begins at 6 months of age and continues at 12-, 24-, and 36-month health supervision visits, alternating with recommended developmental and autism spectrum disorder screenings at every visit in the Bright Futures Periodicity schedule and additionally when clinically indicated. After age 3, MEB screening continues annually. This report also 1) reviews updated information on prevalence of MEB problems; 2) articulates the current state of detection of these problems in pediatric primary care; 3) addresses how to manage a positive screen; 4) describes barriers to screening, including special population needs, and potential models to address those barriers; and 5) discusses potential changes at a practice and systems level that facilitate successful MEB screening.

10.1542/6373916301112Video AbstractPEDS-VA_2024-0663666373916301112BACKROUND AND OBJECTIVESWhether variables specific to children’s neighborhood-level social determinants of health are associated with neighborhood incidence of pediatric firearm-related injury hospital encounters has not been assessed in any entire state. This study sought to determine the relationship between home zip code Childhood Opportunity Index (COI) and zip code incidence of pediatric firearm-related injury hospital encounters in 4 geographically representative states.METHODSThis retrospective observational cohort study combined 2016–2021 discharge data from Florida, Maryland, New York, and Wisconsin with COI 3.0 zip code data. The primary exposure was zip code COI quintile. The primary outcome was zip code incidence of pediatric (ages 0–17 years) firearm-related injury hospital encounters. Hot spots of pediatric firearm-related injury hospital encounters were identified. Incidence rate ratios of pediatric firearm-related injury hospital encounters were compared by child home zip code COI quintile.RESULTSThere were 6896 pediatric firearm-related injury hospital encounters. A larger proportion of hot spots were among very low compared with very high COI zip codes (28.4% vs 5.5%, P < .001). The zip code incidence rate ratio of pediatric firearm-related injury hospital encounters incrementally decreased with each rising quintile of zip code COI in all 4 states. Unintentional injury accounted for the largest proportion of firearm-related injury for both very low COI zip codes (n = 2044/3600, 56.8%) and very high COI zip codes (n = 142/253, 56.1%).CONCLUSIONSIncidence of pediatric firearm-related injury hospital encounters increased as child opportunity decreased. Unintentional injury accounted for the largest proportion of pediatric firearm-related injury hospital encounters across all COI quintiles.

10.1542/6374900136112Video AbstractPEDS-VA_2025-0716706374900136112OBJECTIVEIntentional self-poisoning is the most common method by which youth attempt suicide, is increasing in frequency, and carries a high risk of morbidity. The objective of this study was to describe pediatric emergency department (ED) encounters for intentional self-poisoning and to identify factors associated with self-poisoning recurrence.METHODSWe conducted a retrospective cross-sectional study of patients aged 6 to 17 who presented to a pediatric ED with intentional self-poisoning between March 2020 and March 2023. Encounters with a reason-for-visit or billing code related to an ingestion, overdose, or suicide attempt were included. We extracted demographic data, clinical features of the ingestion, and medical and psychiatric history from the electronic medical record. We calculated descriptive statistics and constructed a multivariable logistic regression model to identify factors associated with self-poisoning recurrence.RESULTSFive hundred and thirty-five encounters representing unique patients were included. 70.3% ingested a single toxicant, 58.3% presented within 4 hours of poisoning, 46% required medical intervention in the ED, and 23.7% required admission to an inpatient medical or critical care unit. 68 patients (12.7%) had prior visit(s) for self-poisoning. Existing psychiatric diagnosis (aOR 17.03, 3.92–74.04), history of sexual abuse (aOR 1.96, 1.12–3.42), and history of self-injurious behavior (aOR 3.00, 1.22–7.38) were associated with self-poisoning recurrence.CONCLUSIONIntentional self-poisoning was associated with morbidity, with nearly half of the patients requiring medical intervention and nearly one-quarter requiring medical admission. Recurrent visits for intentional self-poisoning were not uncommon, occurring in 1 in 8 patients. We identified risk factors for recurrent intentional self-poisoning. Further study is required to devise targeted approaches for prevention.

OBJECTIVESTo characterize temperature percentiles for infants at least 35 weeks’ gestation through the first 48 hours of their birth hospitalization in the newborn nursery.METHODSThis retrospective cross-sectional study used electronic health record data from mothers and newborns admitted to a university-affiliated newborn nursery between May 2015 and August 2021. Axillary temperature values measured during the nursery stay were analyzed in prespecified time intervals to generate first, fifth, 50th, 95th, and 99th temperature percentiles from birth through 48 hours after birth. Descriptive, stratified subanalyses by infant sex, gestational age, birth weight, mode of delivery, and exposure to maternal peripartum fever were also conducted.RESULTSWe analyzed 227 813 axillary temperature values from 23 352 infants. The median temperature ranged from 36.9 °C at birth to 37.0 °C at 48 hours following birth. The temperature range between the first and 99th percentile was widest at birth (36.1–38.4 °C, δ 2.3 °C) and narrowed thereafter to a range of 36.5 °C to 37.8 °C (δ 1.3 °C) at 48 hours following birth. Temperature percentiles did not differ by sex but did increase minimally with increases in gestational age and birth weight; however, 95% CIs often overlapped. Infants delivered via cesarean had lower temperatures at birth than infants born vaginally, and infants exposed to peripartum maternal fever had higher temperatures following birth than nonexposed infants.CONCLUSIONSThese hour-specific temperature percentiles in late preterm and term infants in the newborn nursery strengthen the foundation for interpreting newborn temperatures in clinical context and highlight the need for more nuanced, evidence-based approaches to hypothermia evaluation and management.

The following is an address given by the 2025 recipient of the Joseph W. St Geme, Jr Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies meeting on April 25, 2025:

BACKGROUND AND OBJECTIVESPrevious studies have reported early undernutrition and growth delay in children born with esophageal atresia (EA). Our goal was to assess their long-term nutritional status.METHODSWe longitudinally studied 204 children born with EA (91% with tracheoesophageal fistula) from birth to 16 years. Undernutrition (Z-score for body mass index [BMI] < −2 SD), and stunting (Z-score for height for age [HFA] < −2 SD) were evaluated. Risk factors were analyzed using regression models for interval-censored data.RESULTSThe mean Z-BMI and Z-HFA were lower in children with EA than the normal population from birth to age 16 years. At 12 years, the Z-BMI had increased closer to the normal range, but the Z-HFA still differed from the normal range. The cumulative incidence of wasting was 7% (95% CI, 5–12) among 1-year-olds with EA and 25% (95% CI, 19–31) of this population were undernourished at least once between ages 1 and 16 years. Undernutrition was significantly associated with congenital heart malformation (hazard ratio [HR] 2.7 [1.5–5.1]), prenatal EA diagnosis (HR 2.3 [1.2–4.3]), and use of proton pump inhibitors (PPIs) after 1 year of age (HR 3.6 [1.1–11.4]). Stunting was significantly associated with genetic anomalies (HR 6.0 [2.8–12.8]), multiple pregnancies (HR 2.4 [1.1–5.6]), gastrostomy (HR 2.3 [1.3–3.8]), and the use of PPI after 1 year (HR 7.8 [2.4–26.1]).CONCLUSIONSDespite advances in care, children with EA remain at high risk of undernutrition and stunting from birth to age 16 years. Intensification of nutritional follow-up and early intervention are needed in high-risk patients.

10.1542/6373916608112Video AbstractPEDS-VA_2024-0696356373916608112OBJECTIVEPediatric patients with epilepsy are at risk for sudden cardiac arrest (SCA), and sleep apnea (SA) may exacerbate this risk. This study investigates the incidence and risk of SCA and cardiac dysrhythmia in pediatric patients with epilepsy and SA.METHODSUsing the TriNetX global research network, we identified pediatric patients (aged younger than 18 years) who were diagnosed with epilepsy between January 2000 and March 2025. SA was identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and polysomnography records. Two cohorts, ie, patients with epilepsy with and without SA, were matched using propensity scores. SCA and cardiac dysrhythmia were assessed over 5- and 10-year follow-up periods.RESULTSThe incidence of SCA was highest in patients with both epilepsy and SA (50.5 per 10 000 person-years) compared with those with epilepsy alone (20.0 per 10 000) or SA alone (9.0 per 10 000). Patients with epilepsy and SA had an increased risk of SCA (5-year hazard ratio [HR]: 1.99; 10-year HR: 1.74; both P < .001) and cardiac dysrhythmia (10-year HR: 2.06; P < .001). Refractory epilepsy increased the risk of SCA (odds ratio [OR]: 1.74; 95% CI: 1.25–2.42). Additionally, long-term continuous positive airway pressure (CPAP) therapy was associated with increased SCA risk (OR: 3.41; 95% CI: 2.27–5.11), whereas adenotonsillectomy reduced it (OR: 0.40; 95% CI: 0.27–0.60).CONCLUSIONSPediatric patients with epilepsy and SA are at significantly increased risk for SCA and cardiac dysrhythmia. Adenotonsillectomy may mitigate this risk, whereas long-term CPAP use may increase it. These findings highlight the importance of individualized treatment strategies in pediatric patients with epilepsy and comorbid SA to reduce the risk of SCA.

Sickle cell disease (SCD) is a complex pathophysiology with a wide range of symptoms. More than one-third of pediatric SCD emergency department encounters are due to fever. Patients with SCD are immunocompromised because of hyposplenism. Therefore, infection is a serious concern in any febrile patient with SCD. Although bacteremia is seen in only 1.1% of febrile patients with SCD, it remains the leading cause of death globally. However, several noninfectious causes of fever can be seen in SCD, which should be considered in appropriate settings.We present a case of an adolescent female patient with SCD who had an unusually prolonged fever and a complicated disease course that was initially attributed to infection but failed to resolve by appropriate antibiotics. Further investigations identified noninfectious etiologies of fever in the patient.

Opioids are often prescribed to children for pain relief related to procedures, acute injuries, and chronic conditions. Around-the-clock dosing of opioids can produce physiologic opioid dependence within 5 days. According to a 2001 consensus paper from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, dependence is defined as “a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, or administration of an antagonist.” The experience of children undergoing iatrogenic withdrawal symptoms is variable and may be mild and go unreported or can be severe and even life threatening. Guidance on opioid withdrawal is available only for adults and primarily for adults with substance use disorders. This report will summarize existing literature and provide readers with information on how to screen for symptoms of iatrogenic opioid withdrawal as well as mechanisms for opioid withdrawal prevention.

Injury is the leading cause of death and a frequent cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state or region encompassing the entire continuum of care regardless of where children live or where traumatic events occur. This continuum includes injury prevention, prehospital care, emergency department care, interfacility transport, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality. In this case, it represents a sequential practice of evidence-based evaluation and management along the continuum of care. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the “right child, at the right place, at the right time” across this continuum.

10.1542/6374898186112Video AbstractPEDS-VA_2025-0706976374898186112BACKGROUND AND OBJECTIVESAt age 2 years, the Centers for Disease Control and Prevention (CDC) recommends switching from the World Health Organization (WHO) Growth Standards to the CDC 2000 Growth Reference. This abrupt switch may affect growth assessment, such as causing a clinically important change in growth z score in a child with a stable growth pattern. We sought to create growth charts that gradually transition between WHO and CDC and to evaluate their impact on growth assessment of young children using real-world data.METHODSWe iteratively developed methods to create new charts for body mass index (BMI)-, weight-, and length/height-for-age. We performed a retrospective cohort study comparing the mean change in z scores for these parameters between 1.5 and 2 years for the CDC-recommended vs the new, gradually transitioned (gradual) charts. We also compared the prevalence of a large change in z score: <−1 (drop) or >1 (rise).RESULTSWe transitioned between the charts using a weighted average from ages 2 to 5 years. In 7429 children, there was a large decrease in mean body mass index-for-age z score (BMIz) and weight-for-age z score (WTz) in the CDC-recommended charts (BMIz −0.59, WTz −0.35) that was not seen in the gradual charts (BMIz −0.09, WTz −0.01). Correspondingly, using the CDC-recommended charts, the proportion with a drop in BMIz or WTz was much higher for the CDC-recommended (BMIz 28.3%, WTz 6.0%) than the gradual charts (BMIz 11.6%, WTz 0.85%).CONCLUSIONSWe created growth charts that gradually transition between WHO and CDC and may reduce overidentification of slow weight gain. These charts may be useful in clinical care and research.

Injury is the leading cause of death and a cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state, regional, or national trauma system across the entire continuum of care regardless of where they live or where the traumatic event occurs. This continuum includes injury prevention, prehospital care, interfacility transport between hospitals providing different levels of care, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach, one that requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality, is essential. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the “right child, at the right place, at the right time” across this continuum.

10.1542/6374763738112Video AbstractPEDS-VA_2024-0692746374763738112OBJECTIVESTo identify trends in pediatric tuberculosis (TB) epidemiology in California and measure progress in reducing health disparitiesMETHODSDemographic, clinical, and neighborhood health support data in persons younger than 25 years with TB during 2000–2023 in California were analyzed across age groups.RESULTSA total of 8249 individuals younger than 25 years were identified with active TB. Half (45.8%) were US-born. Incidence rates were highest among Asians, residents of the San Diego region, and those living in the least-health-supportive neighborhoods. The highest TB rates occurred among 18- to 24-year-olds in 6 regions and among children younger than 5 years in 2 regions. TB rates declined across the period; 2 regions had rate increases during 2020–2023. During 2020–2023, compared with white persons, the rate of TB disease was 20.2 (95% CI, 13.2–29.4) times higher among Asian, 10.8 (95% CI, 7.1–15.4) among Hispanic, and 8.5 (95% CI, 5.1–13.4) among Black persons. Central nervous system (CNS) TB did not decrease; deaths among individuals with CNS TB were 9.5 times greater (95% CI, 5.6–16.2) than among those with other forms of TB. After controlling for age, the incidence rate of CNS TB in US-born individuals was 2.9 (95% CI, 1.9–4.7) times that for non–US-born individuals younger than 18 years.CONCLUSIONSDespite falling TB rates among persons younger than 25 years in California, disparities were found by age, race and ethnicity, region, and health-supportiveness of neighborhood type. The incidence of CNS TB has not declined. Increased partnership between public health and primary care providers is needed to identify children and young adults at risk for TB.

Ocrelizumab (OCR) is an IgG1 humanized monoclonal antibody directed against CD20. Due to its B-cell–depleting ability, it is used in the treatment of multiple sclerosis, a disease that affects women of childbearing age. Although OCR use is not recommended in pregnancy, in utero exposure has occurred and resulted in normal to absent B cells at birth. Although this has been reported, longitudinal follow-up to determine whether B-cell reconstitution and function remain intact is lacking. Here, we present longitudinal follow-up of a neonate in which in utero OCR exposure resulted in B-cell depletion at birth. B-cell reconstitution occurred at age 4 months, with normal production of immunoglobulins and responses to vaccines noted at age 1 year. Awareness among pediatricians and neurologists regarding the effects of anti-CD20 therapies on the developing fetus and neonate may be lacking. An absence of B cells at birth should raise concern and be followed closely, as humoral immunity is an essential mechanism of passive and active immunity against infection throughout the lifetime. Recognition of patients exposed to anti-CD20 therapies during pregnancy allows for early detection and referral to an immunologist.

The Advisory Committee on Immunization Practices (ACIP), a group of medical and public health experts that provides advice to the Centers for Disease Control and Prevention, normally meets 3 times per year to develop US vaccine recommendations for use. The ACIP Work Groups conduct an in-depth review of the available scientific information regarding specific US Food and Drug Administration (FDA)–licensed vaccines or important vaccines in advanced stages of clinical development that are under consideration for FDA licensure and then present the information and their recommendation to the ACIP for a vote. If a recommendation receives a majority vote, it moves to the Centers for Disease Control and Prevention (CDC) Director for approval and, if approved, it is published in the CDC Morbidity and Mortality Weekly Report. At that point, the ACIP recommendation represents the official CDC recommendation for US immunizations. The ACIP met April 16–17, 2025, to discuss influenza vaccines, chikungunya vaccines, COVID-19 vaccines, respiratory syncytial virus (RSV) immunizations, meningococcal vaccines, Human Papillomavirus (HPV) vaccines, Mpox vaccines, and cytomegalovirus vaccines. This update summarizes the proceedings of these meetings, with an emphasis on topics that are most relevant to the pediatric population. Major updates for pediatric clinicians include information regarding HPV and meningococcal vaccination considerations and updates regarding RSV immunization in infants, which will likely be voted on during upcoming ACIP meetings.

OBJECTIVEThis quality improvement effort aimed to increase the proportion of shorter-duration prescriptions for acute otitis media (AOM) in patients aged at least 2 years from a baseline of 30% to 50% without using an electronic health record (EHR) alert.METHODSThe project was conducted in a large pediatric primary care network and used 2 plan-do-study-act cycles. Cycle 1 included updates to the electronic prescription orders of commonly used antibiotics to include shorter-duration “speed button” options. Cycle 2 combined education with clinician-specific performance feedback and clinical decision support in the form of a “preference list” of easily searchable, preconfigured electronic prescription orders with shorter durations. Weekly proportions of prescriptions for AOM with a duration of 7 days or fewer in children aged at least 2 years (primary measure) and a duration of fewer than 10 days in children aged less than 2 years (balancing measure) were analyzed. Interrupted time series models tested the association of interventions with observed changes in primary and balancing measures.RESULTSThe first intervention was ineffective at improving the primary measure. A combination of education, targeted feedback, and preconfigured prescription orders increased shorter-duration treatment courses for AOM by a factor of 2-fold to approximately 60% with an undesired small but statistically significant increase in the balancing measure (+1.8%).CONCLUSIONA combination of education with feedback and in-line clinical decision support in the form of easily searchable, preconfigured prescription orders (EHR “preference list”) was successful in increasing shorter-duration prescriptions for AOM in a large primary care network without an EHR alert.

10.1542/6374762715112Video AbstractPEDS-VA_2025-0711936374762715112OBJECTIVEProfessional societies recommend antiviral treatment of all children at high risk for severe or complicated influenza disease, regardless of symptom duration. However, outpatient antiviral prescribing practices are inconsistent. We aimed to assess pediatric clinicians’ outpatient prescribing practices for oseltamivir in children with influenza.METHODSThis vignette-based study of pediatric clinicians was conducted from March to June 2024 at 7 US children’s hospitals and their affiliated clinics. The survey included 4 clinical influenza vignettes, 3 of which represented scenarios warranting treatment per national recommendations. One vignette was randomized to explore the impact of symptom duration on treatment preferences. Our primary outcome was the proportion of vignettes for which respondents were likely, somewhat or extremely, to recommend oseltamivir.RESULTSOf 1124 eligible participants, 452 (40.2%) responded to the survey. Successive wave analysis revealed no evidence of response bias. Participants were likely to recommend oseltamivir in 36.2% of cases, with variation among specialties (29.6% for emergency medicine, 37.2% for general pediatrics, and 48.6% for infectious diseases; P < .001) and among study sites from 28.6% to 50.7% (P = .018), adjusted for clustering. Longer symptom duration (2 vs 4 days) significantly decreased respondents’ likelihood to recommend oseltamivir from 30.9% to 1.8% (P < .001).CONCLUSIONSWe demonstrate considerable nonadherence to national influenza treatment recommendations and variability regarding the outpatient use of oseltamivir to treat children with influenza. This indicates uncertainty of the perceived benefit of oseltamivir in a relatively healthy pediatric population with non-severe disease. Treatment standardization in accordance with national guidelines and rigorous monitoring of subsequent outcomes is needed.

BACKGROUND AND OBJECTIVESIdentifying neonates at risk for neonatal opioid withdrawal syndrome (NOWS) is important to ensure adequate monitoring and treatment. We sought to evaluate 3 screening modalities—maternal history and physical (H&P), maternal urine drug screening (MUDS), and neonatal urine drug screening (NUDS)—in the identification of neonates at risk for NOWS.METHODSRetrospective chart review was conducted for neonates with documented neonatal Finnegan scores at the University of Maryland Medical Center in Baltimore, Maryland, from January 1, 2017, through January 1, 2022. Maternal H&P was reviewed in addition to MUDS and NUDS. The institution’s criterion for pharmacologic intervention is 2 or more consecutive Finnegan scores of 9 or greater. Treatment receipt was defined as documentation of morphine administration for treatment of withdrawal.RESULTSOf the 460 neonates included, most (452 (98.3%) were identified by maternal screening, which included a documented maternal history of opioid use or a positive MUDS result. No neonates received monitoring for NOWS based solely on NUDS. Maternal history of opioid use also had the highest sensitivity for identifying neonates who received treatment for NOWS (96.1%).CONCLUSIONMaternal screening modalities including history and urine toxicology identify almost all neonates who require monitoring for NOWS. NUDS did not identify additional at-risk neonates. Prospective studies are warranted to assess a balanced approach to NUDS that prioritizes newborn safety while reducing maternal stigmatization and minimizing separation.

OBJECTIVETo describe changes in Michigan’s childhood immunization rates by county sociodemographic characteristics during 2017–2023.METHODSWe analyzed county-level data from Michigan’s immunization registry. For each quarter from quarter 1 2017 through quarter 1 2023, we calculated the mean completion rate of a childhood immunization composite, an adolescent immunization composite, the male human papillomavirus (HPV) vaccination series, and the female HPV vaccination series. We assessed changes in these rates among all Michigan counties and among county subgroups defined by median household income, rurality, and uninsurance rate.RESULTSDuring the study period, the mean completion rate of the childhood and adolescent immunization composite declined from 75.7% to 66.8% and from 80.7% to 74.7%, respectively. The mean completion rate of the male and female HPV vaccination series increased from 35.1% to 42.3% and from 43.4% to 45.2%, respectively. These increases were smaller than the increase predicted by prepandemic trends. In counties with lower income and higher uninsurance, declines in the mean completion rate of both composite measures were greater compared with counties with higher income and lower uninsurance, whereas increases in the mean completion rate of the male HPV vaccination series were smaller. Changes according to rurality were inconsistent.CONCLUSIONSRoutine childhood and adolescent immunizations are declining in Michigan, and increases in HPV vaccination are slowing, particularly in counties with lower income and higher uninsurance rates. Findings suggest progress toward increasing childhood immunizations is stalling. Targeted efforts to increase immunizations in counties with lower income and higher uninsurance rates may be warranted.

BACKGROUND AND OBJECTIVESRecent changes in European diagnostic criteria allow for serologic diagnosis of celiac disease in children. Those guidelines have not been adopted in North America; hence, we aim to assess the positive predictive value (PPV) of tissue transglutaminase (tTG) immunoglobulin A (IgA) assays used in North America in identifying histologic findings of celiac disease.METHODSMulticenter retrospective cohort study of children (<18 years) with an elevated tTG IgA within 6 months of an esophagogastroduodenoscopy between January 2016 and December 2021. Biopsy-confirmed celiac disease was determined by the presence of intraepithelial lymphocytosis and villous atrophy. The primary outcomes were the PPV of an elevated tTG IgA and tTG IgA greater than or equal to 10 times the upper limit of normal (10× ULN).RESULTSOverall, 4019 children (63.3% female; 9% type 1 diabetes, 2% Down syndrome) were included. Histologic findings were consistent with celiac disease for 3321 children (PPV = 82.6% [95% CI, 81.4–83.8]). Among the 1739/4019 (43.2%) children with tTG IgA greater than or equal to 10× ULN, 1651 had biopsy-confirmed celiac disease (PPV10× = 94.9% [95% CI, 93.8–95.9]). Five percent (88/1739) of children did not have histologic findings of celiac disease, including 41/1739 (2%) with normal histology. Diagnostic accuracy of tTG IgA varied widely among assays used in North America (PPV range: 71.5%–88.8%; PPV10× range: 89.3%–97.3%). Assays performed worse in children with type 1 diabetes (PPV10× 89% [95% CI, 83.5–92.8]).CONCLUSIONSElevated tTG IgA in isolation is insufficient to confidently diagnose celiac disease. As tTG assay performance varied widely, diagnostic confirmation by a specialist prior to dietary changes is essential.

BACKGROUNDYoung people undergoing cancer treatment are at increased risk of severe COVID-19 outcomes. Vaccination is recommended; however, data regarding vaccine response are limited.METHODSA prospective cohort study was conducted of children and adolescents (aged 5–19 years) with current solid or hematological cancer and life expectancy of at least 1 year, eligible for COVID-19 vaccination. Participants received 2 or 3 doses of BNT162b2. Blood was taken at baseline, after dose 1, and then 1 and 3 months after subsequent doses. Safety outcomes and patient-reported adverse events were collected. The proportion with neutralizing antibody (NAb) response after 2 vaccine doses was the primary outcome. Vaccine response was measured by NAb titer (positive ≥1:20), T-cell response (interferon-γ, positive ≥10 pg/mL), and binding antibody titer.RESULTSOf 113 patients enrolled, 108 (96%) currently or previously received cytotoxic chemotherapy, and most were on current or recent therapy, with 18 (16%) having completed treatment more than 6 months prior to vaccination. Positive NAb response occurred in 52/79 (66%) with samples available after 2 doses and 33/41 (80%) after 3 doses. Interferon-γ response occurred in 44/64 (59%) after 2 doses and 25/34 (74%) after 3 doses. Adverse events were generally mild to moderate, were transient if serious (fever, mucositis, headache), and did not delay cancer treatment. Fever was reported by 12% after doses 1 and 2 and 15% after dose 3.CONCLUSIONSMost children with cancer respond to BNT162b2 COVID-19 vaccination despite anticancer treatment. Vaccination should not be deferred until treatment completion. These data may have implications for other childhood vaccinations during cancer treatment.