PEDIATRICS recent issues

Neurodevelopment After Perinatal Arterial Ischemic Stroke

BACKGROUND AND OBJECTIVES:

Perinatal arterial ischemic stroke (PAIS) leads to cerebral palsy in ~30% of affected children and has other neurologic sequelae. Authors of most outcome studies focus on middle cerebral artery (MCA) stroke without differentiating between site and extent of affected tissue. Our aim with this study was to report outcomes after different PAIS subtypes.

METHODS:

Between 1990 and 2015, 188 term infants from 2 centers (London [n = 79] and Utrecht [n = 109]) had PAIS on their neonatal MRI. Scans were reevaluated to classify stroke territory and determine specific tissue involvement. At 18 to 93 (median 41.7) months, adverse neurodevelopmental outcomes were recorded as 1 or more of cerebral palsy, cognitive deficit, language delay, epilepsy, behavioral problems, or visual field defect.

RESULTS:

The MCA territory was most often involved (90%), with posterior or anterior cerebral artery territory strokes occurring in 9% and 1%, respectively. Three infants died, and 24 had scans unavailable for reevaluation or were lost to follow-up. Of 161 infants seen, 54% had an adverse outcome. Outcomes were the same between centers. Main branch MCA stroke resulted in 100% adverse outcome, whereas other stroke subtypes had adverse outcomes in only 29% to 57%. The most important outcome predictors were involvement of the corticospinal tracts and basal ganglia.

CONCLUSIONS:

Although neurodevelopmental outcome was adverse in at least 1 domain with main branch MCA stroke, in other PAIS subtypes outcome was favorable in 43% to 71% of children. Site and tissue involvement is most important in determining the outcome in PAIS.

Longitudinal BMI Growth Curves for Surviving Preterm NICU Infants Based on a Large US Sample

BACKGROUND:

Longitudinal growth curves, based on repeated measurements from the same group of infants, exist for preterm infant weight and length but not for BMI. Our existing BMI (weight divided by length squared) curves are based on cross-sectional birth data obtained from a different group of infants at each gestational age (GA).

METHODS:

We calculated BMI over time for 68 693 preterm infants between 24 and 36 weeks GA. Stratifying infants by sex, GA at birth, and quintiles based on birth BMI, we created longitudinal median curves using R and validated the resulting curves for empirical fit, proper classification, and normality of z scores.

RESULTS:

We created 2 sets of BMI growth charts. The first set displays fitted median curves for all 5 percentile groups in each GA group by sex. The second set displays fitted median curves with their corresponding third and 97th percentiles by percentile group, GA, and sex. In the validation analysis, percentage of daily observations below the median curve approximated the expected 50th percentile after the initial 3 days. Unlike the cross-sectional curves, the longitudinal curves reveal the pattern of change corresponding to nadir; postnadir, these curves remained consistently below the cross-sectional curves and varied by GA and sex as expected. The percentage of observations falling below the 50th percentile for cross-sectional curves (revealing optimal growth) was generally much higher than for longitudinal curves (revealing actual growth).

CONCLUSIONS:

These new longitudinal curves provide clinicians data on how premature infants’ body proportionality changes over time.

Meningococcal B Vaccine Immunogenicity in Children With Defects in Complement and Splenic Function

BACKGROUND:

The capsular group B meningococcal vaccine (4CMenB) is recommended for children with complement deficiencies, asplenia, and splenic dysfunction; however, data on the immunogenicity of 4CMenB in these "at-risk" children are missing.

METHODS:

Participants aged 2 to 17 years in Italy, Spain, Poland, the United Kingdom, and Russia with complement deficiencies, asplenia, or splenic dysfunction received 2 doses of 4CMenB 2 months apart, as did healthy children in the control group. Exogenous and endogenous human complement serum bactericidal activity (SBA) was determined at baseline and 1 month after the second immunization against 4 test strains: H44/76 (assessing vaccine antigen factor H binding protein), 5/99 (Neisserial adhesion A), NZ98/254 (Porin A), and M10713 (Neisserial heparin binding antigen).

RESULTS:

Of 239 participants (mean age 10.3 years, 45% female), 40 children were complement deficient (9 eculizumab therapy, 4 terminal-chain deficiencies, 27 "other"), 112 children had asplenia or splenic dysfunction (8 congenital asplenia, 8 functional asplenia, 96 splenectomy), and 87 children were in the control group. After immunization, the proportions of complement-deficient participants with exogenous complement SBA titers ≥1:5 were 87% (H44/76), 95% (5/99), 68% (NZ98/254), and 73% (M10713), compared with 97%, 100%, 86%, and 94%, respectively, for asplenic children and 98%, 99%, 83%, and 99% for children in the control group. When testing with endogenous complement, strain-specific bactericidal activity was evident in only 1 eculizumab-treated participant and 1 terminal chain complement-deficient participant.

CONCLUSIONS:

4CMenB administration is similarly immunogenic in healthy children and those with asplenia or splenic dysfunction. The significance of the trend to lower responses of SBA titers in complement-deficient children (especially those with terminal chain complement deficiency or those on eculizumab therapy) must be determined by ongoing surveillance for vaccine failures.

Predicting Escalated Care in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES:

Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care.

METHODS:

We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions.

RESULTS:

Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1–15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6–5.4]), apnea (OR: 3.0 [95% CI 1.9–4.8]), retractions (OR: 3.0 [95% CI 1.6–5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5–3.0]), dehydration (OR 2.1 [95% CI 1.4–3.3]), and poor feeding (OR: 1.9 [95% CI 1.3–2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%.

CONCLUSIONS:

We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.

Health Care Use and Health Behaviors Among Young Adults With History of Parental Incarceration

OBJECTIVES:

To determine if longitudinal associations exist between parental incarceration (PI) and health care use or health behaviors among a national sample of young adults.

METHODS:

We used the National Longitudinal Survey of Adolescent to Adult Health to examine associations between history of mother incarceration (MI) and father incarceration (FI), health care use, and 3 dimensions of health behaviors (eg, general health behaviors, substance use, and other risky behaviors) (N = 13 084). Multivariable logistic regression models accounted for individual, family, and geographic factors and generated adjusted odds ratios (aORs).

RESULTS:

Over 10% of the sample had a history of PI before the age of 18. History of MI and FI were both associated with forgone health care (aOR = 1.65 [95% confidence interval (CI), 1.20–2.27], aOR = 1.22 [95% CI, 1.02–1.47], respectively), prescription drug abuse (MI aOR = 1.61 [95% CI, 1.02–2.55], FI aOR = 1.46 [95% CI, 1.20–1.79]), and 10 or more lifetime sexual partners (MI aOR = 1.55 [95% CI, 1.08–2.22], FI aOR = 1.19 [95% CI, 1.01–1.41]). MI was associated with higher likelihood of emergency department use (aOR = 2.36 [95% CI, 1.51–3.68]), and FI was associated with illicit injection drug use (aOR = 2.54 [95% CI, 1.27–5.12]).

CONCLUSIONS:

The effects of incarceration extend beyond incarcerated individuals. PI histories are associated with lower health care use and unhealthy behaviors in young adulthood. By addressing barriers to health care and health-harming behaviors, health care providers and policy makers may reduce health disparities among this population.

Prenatal Diet and Child Growth at 18 Months

OBJECTIVE:

Our objective was to evaluate the effect of an antenatal dietary and lifestyle intervention in pregnant women who are overweight or obese on child outcomes at age 18 months.

METHODS:

We conducted a follow-up study of children at 18 months of age who were born to women who participated in the Limiting Weight Gain in Overweight and Obese Women during Pregnancy to Improve Health Outcomes randomized trial. The primary follow-up study outcome was prevalence of child BMI z scores >85th percentile. Secondary study outcomes included a range of anthropometric measures, neurodevelopment, general health, and child feeding. Intention to treat principles were used in analyses, according to the treatment group allocated at randomization.

RESULTS:

A total of 1602 children were assessed at age 18 months (lifestyle advice, n = 816; standard care, n = 786), representing 75.0% of the eligible sample (n = 2136). There were no statistically significant differences in the prevalence of child BMI z scores >85th percentile for children born to women in the lifestyle advice group, compared with the standard care group (lifestyle advice, 505 [47.11%] versus standard care, 483 [45.36%]; adjusted relative risk: 1.04; 95% confidence interval: 0.94 to 1.16; P = .45). There was no evidence of effects on child growth, adiposity, neurodevelopment, or dietary and physical activity patterns.

CONCLUSIONS:

There is no evidence that providing pregnant women who were overweight or obese with an antenatal dietary and lifestyle intervention altered 18-month child growth and adiposity.

Variations in Neonatal Antibiotic Use

OBJECTIVES:

We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens.

METHODS:

In a retrospective cohort study of >54 000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts.

RESULTS:

By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%–22.0%), reflecting 42 960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%–28.8%) compared with 16.2% (95% CI 16.1%–16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume ( = 0.53; P = .01), mortality rate ( = 0.57; P = .004), and average length of stay ( = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%–57%).

CONCLUSIONS:

Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

Prenatal Tetanus, Diphtheria, Acellular Pertussis Vaccination and Autism Spectrum Disorder

BACKGROUND:

Increasing vaccination of pregnant women makes it important to assess safety events potentially linked to prenatal vaccination. This study investigates the association between prenatal tetanus, diphtheria, acellular pertussis (Tdap) vaccination and autism spectrum disorder (ASD) risk in offspring.

METHODS:

This is a retrospective cohort study of mother-child pairs with deliveries January 1, 2011 to December 31, 2014 at Kaiser Permanente Southern California hospitals. Maternal Tdap vaccination from pregnancy start to delivery date was obtained from electronic medical records. A diagnosis of ASD was obtained by using International Classification of Diseases, Ninth and Tenth Revision codes. Children were managed from birth to first ASD diagnosis, end of membership, or end of follow-up (June 30, 2017). Cox proportional hazards models estimated the unadjusted and adjusted hazard ratios (HRs) for the association between maternal Tdap vaccination and ASD, with inverse probability of treatment weighting to adjust for confounding.

RESULTS:

Women vaccinated were more likely to be Asian American or Pacific Islander, be nulliparous, have a higher education, receive influenza vaccination prenatally, and give birth at term. ASD was diagnosed in 1341 (1.6%) children, and the incidence rate was 3.78 per 1000 person years in the Tdap exposed and 4.05 per 1000 person years in the unexposed group (HR: 0.98, 95% confidence interval: 0.88–1.09). The inverse probability of treatment weighting–adjusted analyses revealed that prenatal Tdap vaccination was not associated with an increased ASD risk (HR: 0.85, 95% confidence interval: 0.77–0.95).

CONCLUSIONS:

Prenatal Tdap vaccination was not associated with an increased ASD risk. We support recommendations to vaccinate pregnant women to protect infants, who are at highest risk of death after pertussis infection.

Prevalence of Autism Spectrum Disorder in Preterm Infants: A Meta-analysis

CONTEXT:

Evidence is emerging that preterm infants are at risk for autism spectrum disorder (ASD).

OBJECTIVES:

To conduct a systematic review and meta-analysis to estimate the prevalence of ASD in preterm infants.

DATA SOURCES:

Medline (via PubMed and Ovid), Embase, PsycINFO, and relevant conference proceedings were searched in May 2017.

STUDY SELECTION:

Original studies in which researchers report on the prevalence of ASD using diagnostic tests in children born preterm were included. Studies in which researchers used only ASD screening tools were excluded.

DATA EXTRACTION:

Relevant data were extracted independently by 3 authors.

RESULTS:

Researchers in a total of 18 studies (3366 preterm infants) used ASD diagnostic tools. The median gestation, birth weight, and age at assessment were 28.0 weeks (range: 25.1–31.3 weeks), 1055 g (range: 719–1565 g), and 5.7 years (range: 1.5–21 years), respectively. Meta-analysis revealed that the overall prevalence rate for ASD was 7% (95% confidence interval: 4% to 9%). The funnel plot and Egger’s test revealed that there was probably no evidence of publication bias.

LIMITATIONS:

The limitations were significant heterogeneity and a lack of studies from middle- and low-income countries.

CONCLUSIONS:

The prevalence of ASD is significantly high in the preterm population. Adequate resources are needed to improve the outcomes of these children.

Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis

Ammonium bifluoride is an inorganic, fluoride-containing compound found in glass and metal etching products, as well as wheel cleaners. Fluoride toxicity is a common cause of preventable poisoning and has been reported to cause life-threatening ventricular dysrhythmias. Here, we report a case of recurrent ventricular fibrillation secondary to ingestion of ammonium bifluoride. The patient presented with vomiting and coma. She was intubated for altered mental status and respiratory failure and subsequently had 5 episodes of ventricular fibrillation, each resolving with a single defibrillation. She developed metabolic acidosis and hypocalcemia, which were treated with sodium bicarbonate and calcium gluconate, respectively. During transfer to a tertiary care children’s hospital, ventricular fibrillation recurred despite electrolyte correction. Hemodialysis (HD) was initiated emergently. No further dysrhythmia occurred after initiation of HD. The result of a basic urine drug screen was negative, and a comprehensive drug screen (gas chromatography and mass spectroscopy) revealed only a nonsignificant peak for diphenhydramine. Subsequent laboratory evaluation revealed an elevated serum fluoride level. Diagnostic laryngoscopy and upper endoscopy did not reveal evidence of caustic injury. She was successfully extubated on hospital day 2 and discharged from the hospital on day 4 with no neurologic sequelae. With this example, we demonstrate a potential therapeutic approach to this potentially lethal poisoning. Fluoride toxicity is typically treated with calcium. However, dysrhythmia may result from calcium-independent direct myocardial toxicity. The kinetics of fluoride are amenable to HD, and renal clearance is slow. The potential use of HD in cases of fluoride poisoning refractory to other therapies warrants further study.

Lost Earnings and Nonmedical Expenses of Pediatric Hospitalizations

BACKGROUND AND OBJECTIVES:

Hospitalization-related nonmedical costs, including lost earnings and expenses such as transportation, meals, and child care, can lead to challenges in prioritizing postdischarge decisions. In this study, we quantify such costs and evaluate their relationship with sociodemographic factors, including family-reported financial and social hardships.

METHODS:

This was a cross-sectional analysis of data collected during the Hospital-to-Home Outcomes Study, a randomized trial designed to determine the effects of a nurse home visit after standard pediatric discharge. Parents completed an in-person survey during the child’s hospitalization. The survey included sociodemographic characteristics of the parent and child, measures of financial and social hardship, household income and also evaluated the family’s total nonmedical cost burden, which was defined as all lost earnings plus expenses. A daily cost burden (DCB) standardized it for a 24-hour period. The daily cost burden as a percentage of daily household income (DCBi) was also calculated.

RESULTS:

Median total cost burden for the 1372 households was $113, the median DCB was $51, and the median DCBi was 45%. DCB and DCBi varied across many sociodemographic characteristics. In particular, single-parent households (those with less work flexibility and more financial hardships experienced significantly higher DCB and DCBi. Those who reported ≥3 financial hardships lost or spent 6-times more of their daily income on nonmedical costs than those without hardships. Those with ≥1 social hardships lost or spent double their daily income compared with those without social hardships.

CONCLUSIONS:

Nonmedical costs place burdens on families of children who are hospitalized, disproportionately affecting those with competing socioeconomic challenges.

Down Syndrome and the Risk of Severe RSV Infection: A Meta-analysis

CONTEXT:

Down syndrome (DS) is the most common chromosomal condition in live-born infants worldwide, and lower respiratory infection caused by respiratory syncytial virus (RSV) is a leading cause of hospital admissions.

OBJECTIVE:

To evaluate RSV-associated morbidity among children with DS compared with a population without DS.

DATA SOURCES:

Four electronic databases were searched.

STUDY SELECTION:

All cohorts or case-control studies of DS with an assessment of RSV infection and the associated morbidity or mortality were included without language restriction.

DATA EXTRACTION:

Two reviewers independently reviewed all studies. The primary outcomes were hospital admission and mortality. Secondary outcomes included length of hospital stay, oxygen requirement, ICU admission, need for respiratory support, and additional medication use.

RESULTS:

Twelve studies (n = 1 149 171) from 10 different countries met the inclusion criteria; 10 studies were cohort studies, 1 study was retrospective, and 1 study had both designs. DS was associated with a higher risk of hospitalization (odds ratio [OR]: 8.69; 95% confidence interval [CI]: 7.33–10.30; I2 = 11%) and mortality (OR: 9.4; 95% CI: 2.26–39.15; I2 = 38%) compared with what was seen in controls. Children with DS had an increased length of hospital stay (mean difference: 4.73 days; 95% CI: 2.12–7.33; I2 = 0%), oxygen requirement (OR: 6.53; 95% CI: 2.22–19.19; I2 = 0%), ICU admission (OR: 2.56; 95% CI: 1.17–5.59; I2 = 0%), need for mechanical ventilation (OR: 2.56; 95% CI: 1.17–5.59; I2 = 0%), and additional medication use (OR: 2.65 [95% CI: 1.38–5.08; I2 = 0%] for systemic corticosteroids and OR: 5.82 [95% CI: 2.66–12.69; I2 = 0%] for antibiotics) than controls.

LIMITATIONS:

DS subgroups with and without other additional risk factors were not reported in all of the included studies.

CONCLUSIONS:

Children with DS had a significantly higher risk of severe RSV infection than children without DS.

Negative Chest Radiography and Risk of Pneumonia

BACKGROUND AND OBJECTIVES:

The ability of the chest radiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia.

METHODS:

Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit.

RESULTS:

There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4–5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%–99.6%).

CONCLUSIONS:

A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy.

The Healthy Neighborhood, Healthy Families Initiative

Extreme poverty and the associated effects, such as blight, housing insecurity, and crime, have debilitating consequences on child development. Health care institutions are largely ineffective in changing those outcomes 1 child at a time. We present a case study of a hospital treating the adjacent neighborhood as a "patient" to address social determinants. The community represents a largely impoverished and housing-unstable neighborhood that underwent an assessment by community partners and treatment with a multifaceted housing intervention. Marked improvement in vacancy rates occurred, although outcome assessments for children are still being gathered. Several case learnings are presented, but the involvement and investment of pediatric health care clinicians and institutions increased the speed and size of neighborhood development after 80 years of redlining and institutional racism.

Adolescent Tobacco Smoke Exposure, Respiratory Symptoms, and Emergency Department Use

OBJECTIVES:

Our objective was to examine the relationship between distinct tobacco smoke exposure (TSE) measures and TSE-related symptoms and emergency department (ED) and/or urgent care (UC) use among nonsmoking adolescents without asthma diagnoses.

METHODS:

We performed a secondary analysis of 7389 adolescents who completed the Population Assessment of Tobacco and Health Study wave 2. Logistic regression and Poisson regression models were built.

RESULTS:

Adolescents with TSE were at increased risk of reporting: shortness of breath, finding it hard to exercise, wheezing during or after exercise, and dry cough at night. Adolescents who lived with a smoker and had home TSE were at increased odds of reporting wheezing or whistling in the chest, and only adolescents with home TSE were at increased risk of reporting wheezing that disturbed sleep. Adolescents with TSE were less likely to report very good or excellent overall health and physical health but were more likely to report they sometimes, often, or very often missed school because of illness. Participants who lived with a smoker and had TSE ≥1 hour were more likely to have had an ED and/or UC visit. Participants with any TSE were at increased risk of having a higher number of ED and/or UC visits.

CONCLUSIONS:

Different TSE measures uniquely increased the risk of TSE-related symptoms, but any TSE increased the risk of having a higher number of ED and/or UC visits. The providers at these high-volume settings should offer interventions to adolescents who are exposed to tobacco smoke and their families to decrease these symptoms and related morbidity.

Sociodemographic Factors and Survival of Infants With Congenital Heart Defects

OBJECTIVES:

To examine the first-year survival of infants with congenital heart defects (CHDs) and investigate the potential role of socioeconomic and demographic factors on survival.

METHODS:

Subjects included 15 533 infants with CHDs born between 2004 and 2013 ascertained by the NC Birth Defects Monitoring Program. We classified CHDs into the following 3 groups: critical univentricular (n = 575), critical biventricular (n = 1494), and noncritical biventricular (n = 13 345). We determined vital status and age at death through linkage to state vital records and used geocoded maternal residence at birth to obtain census information for study subjects. We calculated Kaplan–Meier survival estimates by maternal and infant characteristics and derived hazard ratios from Cox proportional hazard models for selected exposures.

RESULTS:

Among all infants with CHDs, there were 1289 deaths (8.3%) in the first year. Among infants with univentricular defects, 61.6% (95% confidence interval [CI]: 57.7%–65.7%) survived. Survival among infants with univentricular defects was considerably better for those whose fathers were ≥35 years old (71.6%; 95% CI: 63.8%–80.3%) compared with those whose fathers were younger (59.7%; 95% CI: 54.6%–65.2%). Factors associated with survival among infants with any biventricular defect included maternal education, race and/or ethnicity, marital status, and delivery at a heart center. The hazard of infant mortality was greatest among non-Hispanic African American mothers.

CONCLUSIONS:

Survival among infants with critical univentricular CHDs was less variable across sociodemographic categories compared with survival among infants with biventricular CHDs. Sociodemographic differences in survival among infants with less severe CHDs reinforces the importance of ensuring culturally effective pediatric care for at-risk infants and their families.

D-lactic Acidosis: Successful Suppression of D-lactate-Producing Lactobacillus by Probiotics

Intestinal microbiota composition in children with short bowel syndrome (SBS) is an important factor influencing the clinical outcome. An increase of D-lactate–producing bacteria can lead to D-lactic acidosis, also referred to as D-lactate encephalopathy, with severe neurologic impairment. Antibiotic treatments for D-lactic acidosis in children with SBS offer often only short-term relief. Here, we present the case of a boy with SBS who developed recurrent episodes of D-lactic acidosis even under continuous cycling antibiotic treatment. Microbiological analyses were used to detect the presence of D-lactate–producing Lactobacillus species in the stool samples. A probiotic cocktail was introduced to alter the intestinal microbiota. During follow-up under treatment with probiotics, the patient remained stable, and there was no additional need for antibiotic therapy for more than a year. Stool composition of the patient was sequenced regularly over that period. His microbiota profile changed completely in species richness, and a clustering of species according to probiotic usage was seen. Importantly, D-lactate–producing Lactobacillus strains disappeared within a few weeks after probiotic introduction and were no longer detected in the subsequent follow-up specimens.

Adoption of Serogroup B Meningococcal Vaccine Recommendations

BACKGROUND AND OBJECTIVES:

In 2015, the Advisory Committee on Immunization Practices recommended that 16- to 23-year-olds may be vaccinated with the serogroup B meningococcal (MenB) vaccine on the basis of individual clinical decision-making (Category B). We assessed the following among US pediatricians and family physicians (FPs): (1) practices regarding MenB vaccine delivery, (2) factors influencing a decision to recommend the MenB vaccine, and (3) factors associated with discussing the MenB vaccine.

METHODS:

We surveyed a nationally representative sample of pediatricians and FPs via e-mail and Internet from October 2016 to December 2016.

RESULTS:

The response rate was 72% (660 of 916). During routine visits, 51% of pediatricians and 31% of FPs reported always or often discussing MenB vaccine. Among those who discussed often or always, 91% recommended vaccination; among those who never or rarely discussed, 11% recommended. We found that 73% of pediatricians and 41% of FPs currently administered the MenB vaccine. Although many providers reported not knowing about factors influencing recommendation decisions, MenB disease outbreaks (89%), disease incidence (62%), and effectiveness (52%), safety (48%), and duration of protection of MenB vaccine (39%) increased the likelihood of recommendation, whereas the Category B recommendation (45%) decreased likelihood. Those somewhat or not at all aware of the MenB vaccine (risk ratio 0.32 [95% confidence interval 0.25–0.41]) and those practicing in a health maintenance organization (0.39 [0.18–0.87]) were less likely, whereas those aware of disease outbreaks in their state (1.25 [1.08–1.45]) were more likely to discuss MenB vaccine.

CONCLUSIONS:

Primary care physicians have significant gaps in knowledge about MenB disease and the MenB vaccine, and this appears to be a major driver of the decision not to discuss the vaccines.

Repeat Head CT for Expectant Management of Traumatic Epidural Hematoma

BACKGROUND AND OBJECTIVES:

Guidelines regarding the role of repeated head computed tomography (CT) imaging in the nonoperative management of traumatic epidural hematomas (EDHs) do not exist. Consequently, some children may be exposed to unnecessary additional ionizing radiation. We describe the frequency, timing, and utility of reimaging of EDHs to identify patients who might avoid reimaging.

METHODS:

A retrospective cohort study of subjects aged 0 to 18 years with a traumatic EDH treated at a level I pediatric trauma center from 2003 to 2014. Radiographic and clinical findings, the frequency and timing of reimaging, and changes in neurologic status were compared between subjects whose management changed because of a meaningful CT scan and those whose did not.

RESULTS:

Of the 184 subjects who were analyzed, 19 (10%) had a meaningful CT. There was no difference in the frequency of CT scans between the meaningful CT scan and no meaningful CT groups (median 1 [interquartile range 1–2] in no meaningful CT and median 1 [interquartile range 1–2] in meaningful CT scans; P = .7). Only 7% of repeated CTs changed management. Neurologic status immediately before the repeat scan (odds ratio 45; 95% confidence interval 10–200) and mass effect on the initial CT (odds ratio 4; 95% confidence interval 1.5–13) were associated with a meaningful CT. Reimaging only subjects with concerning pre-CT neurologic findings or mass effect on initial CT would have decreased imaging by 54%.

CONCLUSIONS:

Reimaging is common, but rarely changes management. Limiting reimaging to patients with concerning neurologic findings or mass effect on initial evaluation could reduce imaging by >50%.

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