PEDIATRICS recent issues

Ranitidine-Induced Delirium in a 7-Year-Old Girl: A Case Report

Ranitidine is a histamine-2 blocker commonly prescribed in PICUs for the prophylaxis of gastrointestinal bleeding and stress ulcers. However, it can be associated to central nervous system side effects, such as delirium, in adults. We present the first case of a child presenting delirium possibly caused by anticholinergic toxidrome secondary to the use of ranitidine, resolving after drug discontinuation. With this case report, we reinforce that a wide variety of clinical conditions can trigger delirium and that the best therapeutic approach is to minimize risk factors.

Effects of Feedback on Chest Compression Quality: A Randomized Simulation Study


Our aim for this study was to test whether visual and verbal feedback compared with instructor-led feedback improve the quality of pediatric cardiopulmonary resuscitation (CPR).


There were 653 third-year medical students randomly assigned to practice pediatric CPR on 1 of 2 manikins (infant and adolescent; n = 344 and n = 309, respectively). They were further randomly assigned to 1 of 3 feedback groups: The instructor feedback (IF) group (n = 225) received traditional, instructor-led feedback without any additional feedback device. The device feedback (DF) group (n = 223) received real-time visual feedback from a feedback device. The instructor and device feedback (IDF) group (n = 205) received verbal feedback from an instructor who continuously reviewed the trainees’ performance using the feedback device. After the training, participants’ CPR performance was assessed on the same manikin while no feedback was being provided.


For the primary outcome of total compression score, participants in the DF and IDF groups performed similarly, with both groups showing scores significantly (P < .001) better than those of the IF group. The same findings held for correct hand position and the proportion of complete release. For compression rate, the DF group was at the higher end of the guideline for 100 to 120 chest compressions per minute compared with the IF and IDF groups (both P < .001). No effect of feedback on compression depth was found.


Chest compression performance significantly improved with both visual and verbal feedback compared with instructor-led feedback. Feedback devices should be implemented during pediatric resuscitation training to improve resuscitation performance.

Contraceptive Initiation Among Women in the United States: Timing, Methods Used, and Pregnancy Outcomes


Timely contraceptive initiation is increasingly common, yet population trends by method and among subgroups with increased risk of unintended pregnancy are not well described. The impact of timing and type of contraceptive initiation on risk of unwanted pregnancy is unknown.


We used nationally representative cross-sectional data from 4 cycles of the National Survey of Family Growth, 2002–2015. We calculated outcomes from self-reported dates of sexual debut, contraceptive initiation, and unwanted pregnancy. We compared trends in timely contraceptive initiation (within 1 month of sexual debut) by method and by race and/or ethnicity and income. Using multivariable regression, we identified predictors of delayed contraceptive initiation. We compared the risk of unwanted pregnancy for delayed versus timely contraceptive initiation.


We analyzed responses from 26 359 women with sexual debuts in 1970–2014. One in 5 overall and 1 in 4 African American, Hispanic, or low-income respondents reported delayed contraceptive initiation, which was associated with unwanted pregnancy within 3 months of sexual debut (adjusted risk ratio 3.7 versus timely contraceptive initiation; 99.9% confidence interval: 2.3–5.9; P < .001). Timely contraceptive initiation with less effective versus effective methods was not associated with unwanted pregnancy within 3 months.


Delayed contraceptive initiation is more common among African American, Hispanic, and low-income women and is strongly associated with short-term risk of unwanted pregnancy. Pediatricians play a key role in making timely contraception available to adolescents at or before sexual debut. More research is needed to understand the importance of early contraceptive methods on pregnancy risk.

Youth and the Opioid Epidemic

The current epidemic of opioid addiction has arguably been the most recalcitrant in the nation’s history and the first to involve substantial numbers of adolescents. The country has embarked on a public health response, including increasing access to addiction treatment. However, the treatment infrastructure, which was initially created in the 1970s, is ill equipped for meeting the needs of adolescents and young adults, who are often cared for in pediatric primary care. In this article, I review the development of the current treatment system, examine shortfalls in regard to youth-specific needs, and propose suggestions for addressing the current crisis while simultaneously preparing to address future epidemics of addiction by enabling pediatricians to better manage substance use disorders in primary care.

Survival and Health Care Use After Feeding Tube Placement in Children With Neurologic Impairment


Children with neurologic impairment (NI) often undergo feeding tube placement for undernutrition or aspiration. We evaluated survival and acute health care use after tube placement in this population.


This is a population-based exposure-crossover study for which we use linked administrative data from Ontario, Canada. We identified children aged 13 months to 17 years with a diagnosis of NI undergoing primary gastrostomy or gastrojejunostomy tube placement between 1993 and 2015. We determined survival time from procedure until date of death or last clinical encounter and calculated mean weekly rates of unplanned hospital days overall and for reflux-related diagnoses, emergency department visits, and outpatient visits. Rate ratios were estimated from negative binomial generalized estimating equation models adjusting for time and age.


Two-year survival after feeding tube placement was 87.4% (95% confidence interval [CI]: 85.2%–89.4%) and 5-year survival was 75.8% (95% CI: 72.8%–78.4%). The adjusted rate ratio comparing weekly rates of unplanned hospital days during the 2 years after versus before tube placement was 0.92 (95% CI: 0.57–1.48). Similarly, rates of reflux-related hospital days, emergency department visits, and outpatient visits were unchanged. Unplanned hospital days were stable within subgroups, although rates across subgroups varied.


Mortality is high among children with NI after feeding tube placement. However, the stability of health care use before and after the procedure suggests that the high mortality may reflect underlying fragility rather than increased risk from nonoral feeding. Further research to inform risk stratification and prognostic accuracy is needed.

The 2018 Joseph W. St. Geme, Jr. Leadership Award Address: Reflections on Mentorship

The following is an address given by the author in receipt of the Joseph W. St. Geme, Jr. Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies Meeting in Toronto, Canada, on May 5, 2018. Gary R. Fleisher, MD, Chairman of the Department of (Pediatric) Medicine and Physician-in-Chief at Boston Children’s Hospital, and the Egan Professor of Pediatrics at Harvard Medical School, introduced the author.