PEDIATRICS recent issues

Guillain-Barre Syndrome in a Child With COVID-19 Infection

Guillain-Barré syndrome (GBS) is characterized by a monophasic, ascending, and symmetrical paralysis with areflexia that progresses over days to weeks. It is typically a postinfectious autoimmune process that leads to destruction of myelin. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), originated in Wuhan, China, in late 2019 and rapidly spread around the world, causing a pandemic of novel coronavirus disease 2019 (COVID-19). There have been scattered reports of adults with possible GBS and concurrent evidence of COVID-19, but no previous reports in children. The patient is an 8-year-old boy who presented to the emergency department with progressive, ascending weakness with areflexia. He was intubated for airway protection because of poor secretion control. MRI of the spine revealed abnormal enhancement of posterior nerve roots. A lumbar puncture revealed albuminocytologic dissociation with 1 nucleated cell per mm3 and a protein level of 620 mg/dL. Electrodiagnostic findings were compatible with sensorimotor demyelinating polyneuropathy. The lumbar puncture, MRI, and electrodiagnostics were all consistent with GBS. Results of SARS-CoV-2 nucleic acid amplification and SARS-CoV-2 immunoglobulin G antibody tests were positive. Treatment was initiated with intravenous immunoglobulin; he received a total of 2 g/kg. His neurologic examination revealed improvement in the subsequent days. He was extubated after 4 days of intubation. This case is the first reported case of a child with GBS in the setting of an acute COVID-19 infection. This case reveals the wide scope of presentations of COVID-19 and postinfectious processes. Clinicians should constantly have a high level of suspicion for COVID-19.

Perceived Access to Handguns Among Colorado High School Students

OBJECTIVES:

Access to firearms among youth can increase the risk of suicide or other injury. In this study, we sought to estimate the population prevalence of adolescent perception of firearm access by demographic, geographic, and other individual health characteristics.

METHODS:

The 2019 Healthy Kids Colorado Survey was an anonymous survey administered to a representative sample of high school students in Colorado. The survey was used to assess health behaviors and risk and protective factors. Analysis was conducted with weights to the state population of public high school students.

RESULTS:

In total, 46 537 high school students responded (71% student response rate; 83% school response rate). One in 5 students said it was "sort of easy" (11.1%) or "very easy" (8.8%) to access a handgun, with higher prevalence among male and older-aged youth and differences in racial and/or ethnicity groups. There were geographic differences such that students in schools in more rural areas were more likely to report perceived easy access. Students who had felt sad or hopeless, attempted suicide, or been in a fight were more likely to say they had access to a handgun.

CONCLUSIONS:

A relatively high proportion of youth have easy access to a firearm, with differences across age, sex, race and/or ethnicity, and geography. This highlights the need for efforts to address ways to reduce firearm access for youth, including secure storage at home, for the prevention of youth firearm suicide and other firearm injuries.

Changes in Family Poverty Status and Child Health

OBJECTIVES:

In this study, we aim to assess the associations over time between poverty and child weight status, asthma, and health-related quality of life (HRQoL).

METHODS:

We analyzed data for 3968 children from the Generation R Study, a population-based cohort study in the Netherlands. Net household income and the number of adults and children living from this income were measured at 4 time-points (during pregnancy and at ages 2, 3, and 6). Poverty was defined on the basis of the equivalized household income being <60% of the median national income. Child health outcomes were measured at age 6 years. The association was explored by using logistic and linear regression models.

RESULTS:

In this cohort, 9.8% of children were born into poverty and 6.0% had experienced 3 to 4 episodes of poverty. Independent of current poverty status, children born into poverty had an odds ratio (OR) of 1.68 for having overweight/obesity and a lower physical HRQoL (OR = –1.32) than those not born into poverty. Children having experienced 3 to 4 episodes of poverty had an OR of 1.94 for having asthma and a lower physical HRQoL (OR = –3.32) compared with children from never-poor families. Transition out of poverty before age 2 was associated with lower risk of asthma and a higher physical HRQoL compared with children who remained in poverty.

CONCLUSIONS:

Being born into poverty or experiencing multiple episodes of poverty is associated with negative child health outcomes, such as having overweight, asthma, or a lower HRQoL. Support for children and families with a low household income is warranted.

Adolescent Risk Behavior Screening and Interventions in Hospital Settings: A Scoping Review

CONTEXT:

Risky behaviors are the main threats to adolescents’ health; consequently, evidence-based guidelines recommend annual comprehensive risk behavior screening.

OBJECTIVE:

To review studies of adolescent risk behavior screening and interventions in urgent care, emergency department (ED), and hospital settings.

DATA SOURCES:

Our data sources included PubMed (1965–2019) and Embase (1947–2019).

STUDY SELECTION:

Studies were included on the basis of population (adolescents aged 10–25 years), topic (risk behavior screening or intervention), and setting (urgent care, ED, or hospital). Studies were excluded if they involved younger children or adults or only included previously identified high-risk adolescents.

DATA EXTRACTION:

Data extracted were risk behavior screening rates, screening and intervention tools, and attitudes toward screening and intervention.

RESULTS:

Forty-six studies were included; most (38 of 46) took place in the ED, and a single risk behavior domain was examined (sexual health [19 of 46], mood and suicidal ideation [12 of 46], substance use [7 of 46], and violence [2 of 46]). In 6 studies, authors examined comprehensive risk behavior screening, demonstrating low rates at baseline (~10%) but significant increases with clinician reminder implementation. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. Reported barriers were time constraints and limited resources.

LIMITATIONS:

Only 1 included study was a randomized controlled trial, and there was large heterogeneity of included studies, potentially limiting generalizability.

CONCLUSIONS:

Rates of adolescent risk behavior screening are low in urgent care, ED, and hospital settings. Our findings outline promising tools for improving screening and intervention, highlighting the critical need for continued development and testing of interventions in these settings to improve adolescent care.

Thrombosis Risk in Transgender Adolescents Receiving Gender-Affirming Hormone Therapy

BACKGROUND AND OBJECTIVES:

Many transgender youth experience gender dysphoria, a risk factor for suicide. Gender-affirming hormone therapy (GAHT) ameliorates this risk but may increase the risk for thrombosis, as seen from studies in adults. The aim with this study was to examine thrombosis and thrombosis risk factors among an exclusively adolescent and young adult transgender population.

METHODS:

This retrospective chart review was conducted at a pediatric hospital-associated transgender health clinic. The primary outcome was incidence of arterial or venous thrombosis during GAHT. Secondary measures included the prevalence of thrombosis risk factors.

RESULTS:

Among 611 participants, 28.8% were transgender women and 68.1% were transgender men. Median age was 17 years at GAHT initiation. Median follow-up time was 554 and 577 days for estrogen and testosterone users, respectively. Individuals starting GAHT had estradiol and testosterone levels titrated to physiologic normal. Multiple thrombotic risk factors were noted among the cohort, including obesity, tobacco use, and personal and family history of thrombosis. Seventeen youth with risk factors for thrombosis were referred for hematologic evaluation. Five individuals were treated with anticoagulation during GAHT: 2 with a previous thrombosis and 3 for thromboprophylaxis. No participant developed thrombosis while on GAHT.

CONCLUSIONS:

In this study, we examined thrombosis and thrombosis risk factors in an exclusively adolescent and young adult population of transgender people receiving GAHT. These data suggest that GAHT in youth, titrated within physiologic range, does not carry a significant risk of thrombosis in the short-term, even with the presence of preexisting thrombosis risk factors.

Equivalence Curves for Healthy Lifestyle Choices

BACKGROUND:

Understanding equivalence of time-use trade-offs may inform tailored lifestyle choices. We explored which time reallocations were associated with equivalent changes in children’s health outcomes.

METHODS:

Participants were from the cross-sectional Child Health CheckPoint Study (N = 1179; 11–12 years; 50% boys) nested within the population-based Longitudinal Study of Australian Children. Outcomes were adiposity (bioelectrical impedance analysis, BMI and waist girth), self-reported health-related quality of life (HRQoL; Pediatric Quality of Life Inventory), and academic achievement (standardized national tests). Participants’ 24-hour time use (sleep, sedentary behavior, light physical activity, and moderate-to-vigorous physical activity [MVPA]) from 8-day 24-hour accelerometry was regressed against outcomes by using compositional log-ratio linear regression models.

RESULTS:

Children with lower adiposity and higher HRQoL had more MVPA (both P ≤ .001) and sleep (P = .001; P < .02), and less sedentary time (both P < .001) and light physical activity (adiposity only; P = .03), each relative to remaining activities. Children with better academic achievement had less light physical activity, relative to remaining activities (P = .003). A 0.1 standardized decrease in adiposity was associated with either 52 minutes more sleep, 56 minutes less sedentary time, 65 minutes less light physical activity, or 17 minutes more MVPA. A 0.1 standardized increase in HRQoL was associated with either 68 minutes more sleep, 54 minutes less sedentary time, or 35 minutes more MVPA.

CONCLUSIONS:

Equivalent differences in outcomes were associated with several time reallocations. On a minute-for-minute basis, MVPA was 2 to 6 times as potent as sleep or sedentary time.

Factors Associated With Age of Presentation to Gender-Affirming Medical Care

BACKGROUND:

Gender-incongruent youth may present to gender-affirming medical care (GAMC) later in adolescence and puberty when hormone blockers provide less benefit. Factors influencing age of presentation to GAMC have not been described.

METHODS:

A sequential mixed methods study. Participants were categorized on the basis of age at presentation to GAMC. Youth presenting at ≥15 years comprised the older-presenting youth, whereas those presenting at <15 years comprised the younger-presenting youth. Caregivers were categorized on the basis of the youth’s age of presentation. Twenty-four individuals were interviewed, 6 youth and 6 caregivers from each age category. Thematic analysis identified themes related to timing of presentation to GAMC. Themes differentially endorsed between older and younger youth or between caregivers of older and younger youth were used to design a questionnaire distributed to 193 youths and 187 caregivers. Responses were compared between age groups for youths and caregivers.

RESULTS:

Five themes differed between age groups: validity of gender identity, gender journey barriers, influential networks, perceptions of medical therapy, and health care system interactions. Questionnaires were completed by 121 youths and 121 caregivers. Compared with younger-presenting youth, older-presenting youth recognized gender incongruence at older ages, were less likely to have caregivers who helped them access care or LGBTQ+ (lesbian, gay, bisexual, transgender, queer) family members, more often endorsed familial religious affiliations, and experienced greater youth-caregiver disagreement around importance of GAMC.

CONCLUSIONS:

Family environment appears to be a key determinant of when youth present to GAMC. Whether this association occurs through affecting transgender identity formation and recognition requires further study.

Societal Costs of a Measles Outbreak

BACKGROUND AND OBJECTIVES:

Between December 31, 2018, and April 26, 2019, 72 confirmed cases of measles were identified in Clark County. Our objective was to estimate the economic burden of the measles outbreak from a societal perspective, including public health response costs as well as direct medical costs and productivity losses of affected individuals.

METHODS:

To estimate costs related to this outbreak from the societal perspective, 3 types of costs were collected or estimated: public health response (labor, material, and contractor costs used to contain the outbreak), direct medical (third party or patient out-of-pocket treatment costs of infected individuals), and productivity losses (costs of lost productivity due to illness, home isolation, quarantine, or informal caregiving).

RESULTS:

The overall societal cost of the 2019 Clark County measles outbreak was ~$3.4 million ($47 479 per case or $814 per contact). The majority of the costs (~$2.3 million) were incurred by the public health response to the outbreak, followed by productivity losses (~$1.0 million) and direct medical costs (~$76 000).

CONCLUSIONS:

Recent increases in incident measles cases in the United States and across the globe underscore the need to more fully understand the societal cost of measles cases and outbreaks and economic consequences of undervaccination. Our estimates can provide valuable inputs for policy makers and public health stakeholders as they consider budget determinations and the substantial value associated with increasing vaccine coverage and outbreak preparedness as well as the protection of society against vaccine-preventable diseases, such as measles, which are readily preventable with high vaccination coverage.

Fine Particles in Wildfire Smoke and Pediatric Respiratory Health in California

BACKGROUND AND OBJECTIVES:

Exposure to airborne fine particles with diameters ≤2.5 μm (PM2.5) pollution is a well-established cause of respiratory diseases in children; whether wildfire-specific PM2.5 causes more damage, however, remains uncertain. We examine the associations between wildfire-specific PM2.5 and pediatric respiratory health during the period 2011–2017 in San Diego County, California, and compare these results with other sources of PM2.5.

METHODS:

Visits to emergency and urgent care facilities of Rady’s Children Hospital network in San Diego County, California, by individuals (aged ≤19 years) with ≥1 of the following respiratory conditions: difficulty breathing, respiratory distress, wheezing, asthma, or cough were regressed on daily, community-level exposure to wildfire-specific PM2.5 and PM2.5 from ambient sources (eg, traffic emissions).

RESULTS:

A 10-unit increase in PM2.5 (from nonsmoke sources) was estimated to increase the number of admissions by 3.7% (95% confidence interval: 1.2% to 6.1%). In contrast, the effect of PM2.5 attributable to wildfire was estimated to be a 30.0% (95% confidence interval: 26.6% to 33.4%) increase in visits.

CONCLUSIONS:

Wildfire-specific PM2.5 was found to be ~10 times more harmful on children’s respiratory health than PM2.5 from other sources, particularly for children aged 0 to 5 years. Even relatively modest wildfires and associated PM2.5 resolved on our record produced major health impacts, particularly for younger children, in comparison with ambient PM2.5.

Inflammatory Bowel Disease Presenting With Concurrent COVID-19 Multisystem Inflammatory Syndrome

Coronavirus disease 2019 is associated with a postinfectious multisystem inflammatory syndrome in children (MIS-C). This syndrome is marked by cytokine storm and multiorgan dysfunction, often affecting the gastrointestinal tract, the heart, and the hematopoietic system. We describe the case of a 16-year-old boy with an initial presentation of severe inflammatory bowel disease and concurrent MIS-C. He presented with abdominal pain, diarrhea, and hematochezia and met criteria for the systemic inflammatory response syndrome. Laboratory inflammatory profiling revealed markedly elevated ferritin, D-dimer, C-reactive protein, soluble interleukin 2, and interleukin 6 levels. Endoscopy and colonoscopy revealed severe active gastroduodenitis, patchy colitis, and a normal-appearing terminal ileum. The patient was treated with a combination of steroids, intravenous immunoglobulin, and infliximab, and his symptoms slowly resolved over a 3-week period. In this case, we describe coincident MIS-C with a remarkably severe and difficult-to-treat initial presentation of inflammatory bowel disease and highlight the need to investigate the effect of coronavirus disease 2019 and MIS-C on inflammatory disorders.

Differences in Lifetime Earning Potential for Pediatric Subspecialists

OBJECTIVES:

Our 2011 report, reflecting data from 2007–2008, demonstrated that, for many pediatric subspecialties, pursuing fellowship training was a negative financial decision when compared with practicing as a general pediatrician. We provide an updated analysis on the financial impact of pediatric fellowship training and model interventions that can influence the results.

METHODS:

We estimated the financial returns a graduating pediatric resident might anticipate from fellowship training followed by a career as a pediatric subspecialist and compared them with the returns expected from starting a career as a general pediatrician immediately after residency. We evaluated the potential effects of eliminating medical school debt, shortening the length of fellowship training, and implementing a federal loan repayment program for pediatric subspecialists. We compared the financial returns of subspecialty training in 2018–2019 to those from our previous report.

RESULTS:

Pursuing fellowship training generated widely variable financial returns when compared with general pediatrics that ranged from +$852 129 for cardiology to –$1 594 366 for adolescent medicine. Twelve of 15 subspecialties analyzed yielded negative financial returns. The differences have become more pronounced over time: the spread between the highest and lowest earning subspecialties widened from >$1.4 million in 2007–2008 to >$2.3 million in 2018–2019. The negative financial impact of fellowship training could be partially ameliorated by shortening the length of training or by implementing pediatric subspecialist specific loan repayment programs.

CONCLUSIONS:

This report can be used to help guide trainees, educators, and policy makers. The interventions discussed could help maintain an adequate and balanced pediatric workforce.

Pleuropulmonary Blastoma in Pediatric Lung Lesions

BACKGROUND:

Pediatric lung lesions are a group of mostly benign pulmonary anomalies with a broad spectrum of clinical disease and histopathology. Our objective was to evaluate the characteristics of children undergoing resection of a primary lung lesion and to identify preoperative risk factors for malignancy.

METHODS:

A retrospective cohort study was conducted by using an operative database of 521 primary lung lesions managed at 11 children’s hospitals in the United States. Multivariable logistic regression was used to examine the relationship between preoperative characteristics and risk of malignancy, including pleuropulmonary blastoma (PPB).

RESULTS:

None of the 344 prenatally diagnosed lesions had malignant pathology (P < .0001). Among 177 children without a history of prenatal detection, 15 (8.7%) were classified as having a malignant tumor (type 1 PPB, n = 11; other PPB, n = 3; adenocarcinoma, n = 1) at a median age of 20.7 months (interquartile range, 7.9–58.1). Malignancy was associated with the DICER1 mutation in 8 (57%) PPB cases. No malignant lesion had a systemic feeding vessel (P = .0427). The sensitivity of preoperative chest computed tomography (CT) for detecting malignant pathology was 33.3% (95% confidence interval [CI]: 15.2–58.3). Multivariable logistic regression revealed that increased suspicion of malignancy by CT and bilateral disease were significant predictors of malignant pathology (odds ratios of 42.15 [95% CI, 7.43–340.3; P < .0001] and 42.03 [95% CI, 3.51–995.6; P = .0041], respectively).

CONCLUSIONS:

In pediatric lung masses initially diagnosed after birth, the risk of PPB approached 10%. These results strongly caution against routine nonoperative management in this patient population. DICER1 testing may be helpful given the poor sensitivity of CT for identifying malignant pathology.

Family and Child Risk Factors for Early-Life RSV Illness

BACKGROUND AND OBJECTIVES:

Most infants hospitalized with respiratory syncytial virus (RSV) do not meet common "high-risk" criteria and are otherwise healthy. The objective of this study was to quantify the risks and relative importance of socioeconomic factors for severe, early-life RSV-related illness. We hypothesized several of these factors, particularly those indicating severe social vulnerability, would have statistically significant associations with increased RSV hospitalization rates and may offer impactful targets for population-based RSV prevention strategies, such as prophylaxis programs.

METHODS:

We used linked health, laboratory, and sociodemographic administrative data for all children born in Ontario (2012–2018) to identify all RSV-related hospitalizations occurring before the third birthday or end of follow-up (March 31, 2019). We estimated rate ratios and population attributable fractions using a fully adjusted model.

RESULTS:

A total of 11 782 RSV-related hospitalizations were identified among 789 484 children. Multiple socioeconomic factors were independently associated with increased RSV-related admissions, including young maternal age, maternal criminal involvement, and maternal history of serious mental health and/or addiction concerns. For example, an estimated 4.1% (95% confidence interval: 2.2 to 5.9) of RSV-related admissions could be prevented by eliminating the increased admissions risks among children whose mothers used welfare-based drug insurance. Notably, 41.6% (95% confidence interval: 39.6 to 43.5) of admissions may be prevented by targeting older siblings (eg, through vaccination).

CONCLUSIONS:

Many social factors were independently associated with early-life RSV-related hospitalization. Existing RSV prophylaxis and emerging vaccination programs should consider the importance of both clinical and social risk factors when determining eligibility and promoting compliance.

Lung Ultrasound Score Progress in Neonatal Respiratory Distress Syndrome

BACKGROUND AND OBJECTIVES:

The utility of a lung ultrasound score (LUS) has been described in the early phases of neonatal respiratory distress syndrome (RDS). We investigated lung ultrasound as a tool to monitor respiratory status in preterm neonates throughout the course of RDS.

METHODS:

Preterm neonates, stratified in 3 gestational age cohorts (25–27, 28–30, and 31–33 weeks), underwent lung ultrasound at weekly intervals from birth. Clinical data, respiratory support variables, and major complications (sepsis, patent ductus arteriosus, pneumothorax, and persistent pulmonary hypertension of the neonate) were also recorded.

RESULTS:

We enrolled 240 infants in total. The 3 gestational age intervals had significantly different LUS patterns. There was a significant correlation between LUS and the ratio of oxygen saturation to inspired oxygen throughout the admission, increasing with gestational age (b = –0.002 [P < .001] at 25–27 weeks; b = –0.006 [P < .001] at 28–30 weeks; b = –0.012 [P < .001] at 31–33 weeks). Infants with complications had a higher LUS already at birth (12 interquartile range 13–8 vs 8 interquartile range 12–4 control group; P = .001). In infants 25 to 30 weeks’ gestation, the LUS at 7 days of life predicted bronchopulmonary dysplasia with an area under the curve of 0.82 (95% confidence interval 0.71 to 93).

CONCLUSIONS:

In preterm neonates affected by RDS, the LUS trajectory is gestational age dependent, significantly correlates with the oxygenation status, and predicts bronchopulmonary dysplasia. In this population, LUS is a useful, bedside, noninvasive tool to monitor the respiratory status.

Current Prescription Opioid Misuse and Suicide Risk Behaviors Among High School Students

BACKGROUND AND OBJECTIVES:

In previous studies, researchers have reported that youth with a lifetime history of prescription opioid misuse (POM) are at an increased risk for suicidal ideation, planning, and attempts. In this study, we investigate whether the association between youth POM and suicide outcomes differs by recency of POM (ie, none, past, or current misuse).

METHODS:

In this report, we use data from the 2019 Youth Risk Behavior Survey to examine associations between recency of POM (current POM, past POM, and no POM) and suicide risk behaviors among US high school students.

RESULTS:

After controlling for demographics, alcohol, and other drug use, both current POM and past POM were significantly associated with all suicide risk behaviors compared with no POM. Students who reported current POM had the highest adjusted prevalence ratios (aPRs) for suicidal ideation (aPR: 2.30; 95% confidence interval [CI] 1.97–2.69), planning (aPR: 2.33; 95% CI 1.99–2.79), attempts (aPR: 3.21; 95% CI 2.56–4.02), and feeling sad or hopeless (aPR: 1.59; 95% CI 1.37–1.84). Students who reported current POM also were significantly more likely than youth who reported past POM to report that they had seriously considered attempting suicide, made a suicide plan, and attempted suicide.

CONCLUSIONS:

Although POM, particularly current POM, is associated with increases in the risk for suicide-related behaviors and experiences of youth, comprehensive prevention approaches that address the intersections between suicide and POM provide a promising path forward for addressing these public health challenges among youth.

Mortality in South African Children and Adolescents Routinely Treated for Tuberculosis

BACKGROUND:

In South Africa, tuberculosis (TB) is a leading cause of death among those <20 years of age. We describe changes in TB mortality among children and adolescents in South Africa over a 13-year period, identify risk factors for mortality, and estimate excess TB-related mortality.

METHODS:

Retrospective analysis of all patients <20 years of age routinely recorded in the national electronic drug-susceptible TB treatment register (2004–2016). We developed a multivariable Cox regression model for predictors of mortality and used estimates of mortality among the general population to calculate standardized mortality ratios (SMRs).

RESULTS:

Between 2004 and 2016, 729 463 children and adolescents were recorded on TB treatment; 84.0% had treatment outcomes and 2.5% (18 539) died during TB treatment. The case fatality ratio decreased from 3.3% in 2007 to 1.9% in 2016. In the multivariable Cox regression model, ages 0 to 4, 10 to 14, and 15 to 19 years (compared with ages 5 to 9 years) were associated with increased risk of mortality, as was HIV infection, previous TB treatment, and extrapulmonary involvement. The SMR of 15 to 19-year-old female patients was more than double that of male patients the same age (55.3 vs 26.2). Among 10 to 14-year-olds and those who were HIV-positive, SMRs increased over time.

CONCLUSIONS:

Mortality in South African children and adolescents treated for TB is declining but remains considerable, with 2% dying during 2016. Adolescents (10 to 19 years) and those people living with HIV have the highest risk of mortality and the greatest SMRs. Interventions to reduce mortality during TB treatment, specifically targeting those at highest risk, are urgently needed.

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