PEDIATRICS recent issues

Acute ANCA Vasculitis and Asymptomatic COVID-19

We describe the presentation and diagnosis of a child with newly diagnosed antineutrophil cytoplasmic antibody–associated vasculitis and associated diffuse alveolar hemorrhage who was positive for coronavirus disease 2019 immunoglobulin G antibodies, indicative of a previous asymptomatic infection. Results of multiple polymerase chain reaction tests coinciding with the start of symptoms were negative, indicating that acute infection was not the cause of the patient’s symptoms. Coronavirus disease 2019–induced autoimmune diseases have been described in adults, but this case report represents the first case described in a pediatric patient.

Exposure to Suicidal Behavior and Social Support Among Sexual- and Gender-Minority Youth

OBJECTIVES:

In this study, we examine reports of exposure to suicidal behavior by youth sexual and gender identity. We explore how exposure is related to depressed mood in the context of high social support while accounting for cumulative adversity.

METHODS:

Data from a large national sample of youth aged 14 to 15 years in the United States (N = 3979) were collected online in 2018–2019.

RESULTS:

Sexual- and gender-minority youth were more likely to know someone close to them who attempted suicide, relative to cisgender heterosexual youth. Cisgender heterosexual youth were buffered from recent depressed mood when they endorsed having high social support in the context of exposure to suicidal behavior; less social support did not provide such a buffer. For cisgender sexual-minority male and female youth, exposure to suicidal behavior was related to recent depressed mood regardless of the level of social support. For gender-minority youth assigned female at birth, the combination of exposure and high social support was significantly associated with elevated depressed mood. Cumulative adversity accounted for some but not all of these relationships, indicating the influential role of exposure to suicidal behavior on depressed mood for some youth.

CONCLUSIONS:

These findings illustrate the complexities of social support and raise questions about its potential to magnify stress rather than serve as a buffer for some youth. Although findings need to be replicated, suicide prevention efforts should carefully consider how to promote resilience among these suicide-exposed sexual- and gender-minority youth who may themselves be at risk for suicidal ideation and behavior.

Machine Learning for Accurate Intraoperative Pediatric Middle Ear Effusion Diagnosis

OBJECTIVES:

Misdiagnosis of acute and chronic otitis media in children can result in significant consequences from either undertreatment or overtreatment. Our objective was to develop and train an artificial intelligence algorithm to accurately predict the presence of middle ear effusion in pediatric patients presenting to the operating room for myringotomy and tube placement.

METHODS:

We trained a neural network to classify images as " normal" (no effusion) or "abnormal" (effusion present) using tympanic membrane images from children taken to the operating room with the intent of performing myringotomy and possible tube placement for recurrent acute otitis media or otitis media with effusion. Model performance was tested on held-out cases and fivefold cross-validation.

RESULTS:

The mean training time for the neural network model was 76.0 (SD ± 0.01) seconds. Our model approach achieved a mean image classification accuracy of 83.8% (95% confidence interval [CI]: 82.7–84.8). In support of this classification accuracy, the model produced an area under the receiver operating characteristic curve performance of 0.93 (95% CI: 0.91–0.94) and F1-score of 0.80 (95% CI: 0.77–0.82).

CONCLUSIONS:

Artificial intelligence–assisted diagnosis of acute or chronic otitis media in children may generate value for patients, families, and the health care system by improving point-of-care diagnostic accuracy. With a small training data set composed of intraoperative images obtained at time of tympanostomy tube insertion, our neural network was accurate in predicting the presence of a middle ear effusion in pediatric ear cases. This diagnostic accuracy performance is considerably higher than human-expert otoscopy-based diagnostic performance reported in previous studies.

Higher-Calorie Refeeding in Anorexia Nervosa: 1-Year Outcomes From a Randomized Controlled Trial

BACKGROUND AND OBJECTIVES:

We recently reported the short-term results of this trial revealing that higher-calorie refeeding (HCR) restored medical stability earlier, with no increase in safety events and significant savings associated with shorter length of stay, in comparison with lower-calorie refeeding (LCR) in hospitalized adolescents with anorexia nervosa. Here, we report the 1-year outcomes, including rates of clinical remission and rehospitalizations.

METHODS:

In this multicenter, randomized controlled trial, eligible patients admitted for medical instability to 2 tertiary care eating disorder programs were randomly assigned to HCR (2000 kcals per day, increasing by 200 kcals per day) or LCR (1400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and 12 months post discharge. Clinical remission at 12 months post discharge was defined as weight restoration (≥95% median BMI) plus psychological recovery. With generalized linear mixed effect models, we examined differences in clinical remission over time.

RESULTS:

Of 120 enrollees, 111 were included in modified intent-to-treat analyses, 60 received HCR, and 51 received LCR. Clinical remission rates changed over time in both groups, with no evidence of significant group differences (P = .42). Medical rehospitalization rates within 1-year post discharge (32.8% [19 of 58] vs 35.4% [17 of 48], P = .84), number of rehospitalizations (2.4 [SD: 2.2] vs 2.0 [SD: 1.6]; P = .52), and total number of days rehospitalized (6.0 [SD: 14.8] vs 5.1 [SD: 10.3] days; P = .81) did not differ by HCR versus LCR.

CONCLUSIONS:

The finding that clinical remission and medical rehospitalization did not differ over 1-year, in conjunction with the end-of-treatment outcomes, support the superior efficacy of HCR as compared with LCR.

Pediatric Emergency Department Visits at US Childrens Hospitals During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES:

The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic.

METHODS:

We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children’s hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017–2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low–resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed.

RESULTS:

ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017–2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low–resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period.

CONCLUSIONS:

The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.

Grief and Bereavement in Fathers After the Death of a Child: A Systematic Review

CONTEXT:

The death of a child is devastating, and complicated grief adversely impacts parental physical and psychosocial well-being. Most research currently is centered on bereaved mothers, and the experiences of fathers remains underexplored.

OBJECTIVE:

We systematically reviewed the literature to characterize the grief and bereavement experiences of fathers after the death of a child.

DATA SOURCES:

We searched Medline, PsycInfo, Embase, and Cumulative Index to Nursing and Allied Health Literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

STUDY SELECTION:

Inclusion criteria encompassed English language articles published between 2007 and 2019 that evaluated the grief and bereavement experiences of fathers after the death of their child. We excluded studies describing paternal bereavement after the death of a child aged older than 21 years, stillbirth, miscarriage, or studies that did not specify age of death.

DATA EXTRACTION:

Extracted domains included study design, demographics, findings, and quality assessment.

RESULTS:

We screened 1848 deduplicated titles and abstracts and 139 full articles, yielding 21 articles for inclusion in this analysis. Fathers often avoided discussing their grief with others, returned to work earlier, and used goal-oriented tasks as coping strategies. Intense grief reactions and posttraumatic psychological sequelae diminished over time in mothers yet persisted in fathers.

LIMITATIONS:

Included studies were primarily descriptive in nature, without ability to ascertain causality. Limited paternal data exists in the literature compared with maternal data.

CONCLUSIONS:

Despite evolving gender roles, many fathers navigate loss through stoicism, self-isolation, and hard work. For some fathers, these coping mechanisms may be inadequate for navigating grief.

Simulation-Based Neonatal Resuscitation Team Training: A Systematic Review

CONTEXT:

Several neonatal simulation-training programs have been deployed during the last decade, and in a growing number of studies, researchers have investigated the effects of simulation-based team training. This body of evidence remains to be compiled.

OBJECTIVE:

We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome.

DATA SOURCES:

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library.

STUDY SELECTION:

Two authors included studies of team training in critical neonatal situations with reported outcomes on clinical performance and patient outcome.

DATA EXTRACTION:

Two authors extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool 2.0 and the Newcastle-Ottawa quality assessment scale.

RESULTS:

We screened 1434 titles and abstracts, evaluated 173 full texts for eligibility, and included 24 studies. We identified only 2 studies with neonatal mortality outcomes, and no conclusion could be reached regarding the effects of simulation training in developed countries. Considering clinical performance, randomized studies revealed improved team performance in simulated re-evaluations 3 to 6 months after the intervention.

LIMITATIONS:

Meta-analysis was impossible because of heterogenous interventions and outcomes. Kirkpatrick’s model for evaluating training programs provided the framework for a narrative synthesis. Most included studies had significant methodologic limitations.

CONCLUSIONS:

Simulation-based team training in neonatal resuscitation improves team performance and technical performance in simulation-based evaluations 3 to 6 months later. The current evidence was insufficient to conclude on neonatal mortality after simulation-based team training because no studies were available from developed countries. In future work, researchers should include patient outcomes or clinical proxies of treatment quality whenever possible.

Symptomatic SARS-CoV-2 Transmission in Youth and Staff Attending Day Camps

BACKGROUND AND OBJECTIVES:

As schools reopen nationwide, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in youth settings remains a concern. Here, we describe transmission of SARS-CoV-2 among >6800 youth and staff at YMCA of the Triangle day camps in North Carolina (March to August 2020).

METHODS:

We performed a retrospective analysis of deidentified SARS-CoV-2 cases reported by YMCA day camps in 6 counties (Chatham, Durham, Johnston, Lee, Orange, Wake) over 147 days. Inclusion criteria were youth and staff who enrolled or worked in camps during the study period. Individual-level youth and staff demographics (age, sex, race and ethnicity) were self-reported and linked to SARS-CoV-2 case data by using unique identifiers.

RESULTS:

Youth (n = 5344; 66% white, 54% male, mean age 8.5 years) had a mean camp attendance rate of 88%; staff (n = 1486) were 64% white and 60% female (mean age 22 years). Seventeen primary SARS-CoV-2 infections occurred during the study period among 9 youth (mean age 9.7 years) and 8 staff (mean age 27 years) who were linked to 3030 contacts present in-person during the week before positive cases. Only 2 secondary infections (1 youth and 1 staff) were linked to primary cases. SARS-CoV-2 primary case attack rate was 0.6% (17/3030), and secondary case transmission rate was 0.07% (2/3011).

CONCLUSIONS:

Extremely low youth and staff symptomatic SARS-CoV-2 attack and transmission rates were observed over a 147-day period across 54 YMCA camps from March to August 2020, when local coronavirus disease 2019 prevalence peaked. These findings suggest that the benefit of in-person programming in recreation settings with appropriate mitigation may outweigh the risk of viral transmission.

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