PEDIATRICS recent issues

Maternal Chronic Conditions and Risk of Cerebral Palsy in Offspring: A National Cohort Study

BACKGROUND AND OBJECTIVES:

Previous studies suggest that children of mothers with certain chronic conditions may be at increased risk of cerebral palsy (CP). We explored possible associations between 17 maternal chronic conditions and CP in offspring.

METHODS:

We conducted a prospective cohort study of Norwegian children born in 1990–2012 and surviving to 2 years of age. Information on maternal chronic conditions during pregnancy were extracted from the Medical Birth Registry of Norway (1990–2012). Information on chronic conditions in mothers and fathers recorded in the Norwegian Patient Registry (2008–2014) was available for a subset of children. CP diagnoses were extracted from the National Insurance Scheme (1990–2014) and the Norwegian Patient Registry (2008–2014). We estimated relative risks (RRs) and 95% confidence intervals (CIs) of CP in offspring of parents with chronic conditions compared with the general population using log binominal regression models.

RESULTS:

A total of 1 360 149 Norwegian children, including 3575 children with CP (2.6 per 1000 live births), fulfilled the inclusion criteria. The highest risk of CP was among offspring of mothers with type 2 diabetes (RR 3.2; 95% CI 1.8–5.4), lupus erythematosus (RR 2.7; 95% CI 0.9–8.3), type 1 diabetes (RR 2.2; 95% CI 1.4–3.4), and Crohn disease (RR 2.1; 95% CI 1.0–4.1) during pregnancy. No increased risks were seen for offspring of fathers with chronic conditions.

CONCLUSIONS:

Several maternal chronic conditions were associated with increased risk of CP in offspring. Maternal autoimmune disorders carried a particular risk.

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial

OBJECTIVES:

To assess the effectiveness and safety of delayed antibiotic prescription (DAP) compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with uncomplicated respiratory infections.

METHODS:

Randomized clinical trial comparing 3 antibiotic prescription strategies. The participants were children with acute uncomplicated respiratory infections attended to in 39 primary care centers. Children were randomly assigned into prescription arms as follows: (1) DAP, (2) IAP, or (3) NAP. Primary outcomes were symptom duration and severity. Secondary outcomes were antibiotic use, parental satisfaction, parental beliefs, additional primary care visits, and complications at 30 days.

RESULTS:

In total, 436 children were included in the analysis. The mean (SD) duration of severe symptoms was 10.1 (6.3) for IAP, 10.9 (8.5) for NAP, and 12.4 (8.4) for DAP (P = .539), although the differences were not statistically significant. The median (interquartile range) of the greatest severity for any symptom was similar for the 3 arms (median [interquartile range] score of 3 [2–4]; P = .619). Antibiotic use was significantly higher for IAP (n = 142 [96%]) compared to DAP (n = 37 [25.3%]) and NAP (n = 17 [12.0%]) (P < .001). Complications, additional visits to primary care, and satisfaction were similar for all strategies. Gastrointestinal adverse effects were higher for IAP.

CONCLUSIONS:

There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP strategies; however, DAP reduced antibiotic use and gastrointestinal adverse effects.

Improving Influenza Vaccination in Children With Comorbidities: A Systematic Review

CONTEXT:

Children with medical comorbidities are at greater risk for severe influenza and poorer clinical outcomes. Despite recommendations and funding, influenza vaccine coverage remains inadequate in these children.

OBJECTIVE:

We aimed to systematically review literature assessing interventions targeting influenza vaccine coverage in children with comorbidities and assess the impact on influenza vaccine coverage.

DATA SOURCES:

PubMed, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, and Web of Science databases were searched.

STUDY SELECTION:

Interventions targeting influenza vaccine coverage in children with medical comorbidities.

DATA EXTRACTION:

Two reviewers independently screened articles, extracting studies’ methods, interventions, settings, populations, and results. Four reviewers independently assessed risk of bias.

RESULTS:

From 961 screened articles, 35 met inclusion criteria. Published studies revealed that influenza vaccine coverage was significantly improved through vaccination reminders and education directed at either patients’ parents or providers, as well as by vaccination-related clinic process changes. Interventions improved influenza vaccine coverage by an average 60%, but no significant differences between intervention types were detected. Significant bias and study heterogeneity were also identified, limiting confidence in this effect estimate.

LIMITATIONS:

A high risk of bias and overall low quality of evidence limited our capacity to assess intervention types and methods.

CONCLUSIONS:

Interventions were shown to consistently improve influenza vaccine coverage; however, no significant differences in coverage between different intervention types were observed. Future well-designed studies evaluating the effectiveness of different intervention are required to inform future optimal interventions.

Improving Autism Screening and Referrals With Electronic Support and Evaluations in Primary Care

BACKGROUND:

Universal screening for autism promotes early evidence-based treatment. However, many children are not screened, and screened children are often not referred for autism evaluation.

METHODS:

We implemented process changes in 3 phases: phase 1, changing the screening instrument and adding decision support; phase 2, adding automatic reminders; and phase 3, adding a referral option for autism evaluations in primary care. We analyzed the proportion of visits with autism screening at 2 intervention clinics before and after implementation of process changes versus 27 community clinics (which received only automatic reminders in phase 2) with 2 test and interrupted time series. We evaluated changes in referral for autism evaluation by calculating the rate ratio for referral.

RESULTS:

In 12 233 visits over 2 years (baseline and phased improvements), autism screening increased by 52% in intervention clinics (58.6%–88.8%; P < .001) and 21% in community clinics (43.4%–52.4%; P < .001). In phase 1, interrupted time series trend for screening in intervention clinics increased by 2% per week (95% confidence interval [CI]: 1.1% to 2.9%) and did not increase in community clinics. In phase 2, screening in the community clinics increased by 0.46% per week (95% CI: 0.03% to 0.89%). In phase 3, the intervention clinic providers referred patients for diagnostic evaluation 3.4 times more frequently (95% CI: 2.0 to 5.8) than at baseline.

CONCLUSIONS:

We improved autism screening and referrals by changing the screening instrument, adding decision support, using automatic reminders, and offering autism evaluation in primary care in intervention clinics. Automatic reminders alone improved screening in community clinics.

Efficacy and Safety of Metformin for Obesity: A Systematic Review

CONTEXT:

The efficacy and safety of metformin for obesity in children and adolescents remains unclear.

OBJECTIVE:

To assess the efficacy and safety of metformin via systematic review.

DATA SOURCES:

Data sources included PubMed, Embase, the Cochrane Library, Scopus, and ClincalTrials.gov (inception to November 2019).

STUDY SELECTION:

We selected randomized controlled trials (RCTs) in which researchers assessed the efficacy and safety of metformin with lifestyle interventions, compared with a placebo with lifestyle interventions, in children and adolescents with obesity.

DATA EXTRACTION:

Two researchers independently extracted data and assessed quality. The primary outcomes were mean changes from baseline in BMI, BMI z score, homeostatic model assessment of insulin resistance, and gastrointestinal adverse effects.

RESULTS:

Twenty-four RCTs (1623 patients; range: 16 to 151) were included. Ages ranged from 4 to 19 years, and follow-up ranged from 2 months to 2 years. Metformin resulted in a modest decrease in BMI (range of mean values: –2.70 to 1.30 vs –1.12 to 1.90), BMI z score (range of mean values: –0.37 to –0.03 vs –0.22 to 0.15), and homeostatic model assessment of insulin resistance (range of mean values: –3.74 to 1.00 vs –1.40 to 2.66). Metformin resulted in a higher frequency of gastrointestinal adverse effects (range: 2% to 74% vs 0% to 42%).

LIMITATIONS:

The available evidence is of varying quality, with high heterogeneity between trials, suggesting some uncertainty in the benefits of metformin in this population.

CONCLUSIONS:

With this systematic review of RCTs, we suggest that metformin has modest but favorable effects on weight and insulin resistance and a tolerable safety profile among children and adolescents with obesity.

Validation of The Reading House and Association With Cortical Thickness

BACKGROUND AND OBJECTIVES:

The American Academy of Pediatrics recommends literacy and school readiness promotion during well visits. The Reading House (TRH) is a children’s book–based screener of emergent literacy skills in preschool-aged children. Vocabulary, rhyming, and rapid naming are core emergent skills, and reading abilities are associated with thicker cortex in the left hemisphere. Our objective was to expand validity of TRH relative to these skills and explore association with cortical thickness.

METHODS:

Healthy preschool-aged children completed MRI including a T1-weighted anatomic scan. Before MRI, TRH and assessments of rapid naming (Comprehensive Test of Phonological Processing, Second Edition), rhyming (Pre-Reading Inventory of Phonological Awareness), vocabulary (Expressive Vocabulary Test, Second Edition), and emergent literacy (Get Ready to Read!) were administered. Analyses included Spearman- correlations (r) accounting for age, sex, and socioeconomic status (SES). MRI analyses involved whole-brain measures of cortical thickness relative to TRH scores, accounting for covariates.

RESULTS:

Seventy children completed assessments (36–63 months old; 36 female) and 52 completed MRI (37–63 months; 29 female). TRH scores were positively correlated with Comprehensive Test of Phonological Processing, Second Edition (r = 0.61), Expressive Vocabulary Test, Second Edition (r = 0.54), Get Ready to Read! (r = 0.87), and Pre-Reading Inventory of Phonological Awareness scores (r = 0.64; all P < .001). These correlations remained statistically significant across age, sex, and SES groups. TRH scores were correlated with greater thickness in left-sided language and visual cortex (P–family-wise error <.05), which were similar for higher SES yet more bilateral and frontal for low SES, reflecting a less mature pattern (P–family-wise error <.10).

CONCLUSIONS:

These findings expand validation evidence for TRH as a screening tool for preschool-aged children, including associations with emergent skills and cortical thickness, and suggest important differences related to SES.

Improving Parent-Child Interactions in Pediatric Health Care: A Two-Site Randomized Controlled Trial

BACKGROUND AND OBJECTIVES:

Heterogeneity in risk among low-income families suggests the need for tiered interventions to prevent disparities in school readiness. Smart Beginnings (SB) integrates two interventions: Video Interaction Project (VIP) (birth to 3 years), delivered universally to low-income families in pediatric primary care, and Family Check-Up (6 months to 3 years), targeted home visiting for families with additional family risks. Our objective was to assess initial SB impacts on parent-child activities and interactions at 6 months, reflecting early VIP exposure.

METHODS:

Two-site randomized controlled trial in New York City (84% Latinx) and Pittsburgh (81% Black), with postpartum enrollment and random assignment to treatment (SB) or control. At 6 months, we assessed parent-child interactions through surveys (StimQ, Parenting Your Baby) and observation (video-recorded play, coded by using Parent-Child Interaction Rating Scales – Infant Adaptation).

RESULTS:

A total of 403 families were enrolled at child’s birth (201 treatment) with 362 (89.8%) assessed at 6 months. Treatment families had increased StimQ, including total score (Cohen’s d = 0.28; P < .001) and domains reflecting reading (d = 0.23; P = .02) and teaching (d = 0.25; P = .01), and Parent-Child Interaction Rating Scales – Infant Adaptation, including a cognitive stimulation factor (d = 0.40; P < .001) and domains reflecting support for cognitive development (d = 0.36; P < .001), and language quantity (0.40; P < .001) and quality (d = 0.37; P < .001). Thus, significant effects emerged across a broad sample by using varied methodologies.

CONCLUSIONS:

Findings replicate and extend previous VIP findings across samples and assessment methodologies. Examining subsequent assessments will determine impacts and feasibility of the full SB model, including potential additive impacts of Family Check-Up for families at elevated risk.

National Perinatal Hepatitis B Prevention Program: 2009-2017

OBJECTIVES:

To assess trends and programmatic outcomes among infants born to hepatitis B surface antigen (HBsAg)–positive women from 2009 to 2017 and case-managed by the Centers for Disease Control and Prevention’s national Perinatal Hepatitis B Prevention Program (PHBPP).

METHODS:

We analyzed 2009–2017 annual programmatic reports submitted by 56 US jurisdictions funded through the Centers for Disease Control and Prevention’s PHBPP to assess characteristics of maternal-infant pairs and achievement of objectives of infant hepatitis B postexposure prophylaxis, vaccine series completion, and postvaccination serologic testing (PVST). We compared the number of maternal-infant pairs identified by the program with the number estimated born to HBsAg-positive women from 2009 to 2014 and 2015 to 2017 by using a race and/or ethnicity and maternal country of birth methodology, respectively.

RESULTS:

The PHBPP identified 103 825 infants born to HBsAg-positive women from 2009 to 2017, with a range of 10 956 to 12 103 infants annually. Births estimated annually to HBsAg-positive women increased nonsignificantly from 24 804 in 2009 to 26 444 in 2014 (P = .0540) and 20 678 in 2015 to 20 832 in 2017 (P = .8509). The proportion of infants identified annually increased overall from 48.1% to 52.6% (P = .0983). The proportion of case-managed infants receiving postexposure prophylaxis, at least 3 vaccine doses, and PVST increased overall from 94.7% to 97.0% (P = .0952), 83.1% to 84.7% (P = .5377) and 58.8% to 66.8% (P = .0002), respectively.

CONCLUSIONS:

The PHBPP has achieved success in managing infants born to HBsAg-positive women and ensuring their immunity to hepatitis B. Nonetheless, strategies are needed to close gaps between the number of infants estimated and identified, increase vaccine series completion, and increase ordering of recommended PVST for all case-managed infants.

Exclusive Breastfeeding, Child Mortality, and Economic Cost in Sub-Saharan Africa

BACKGROUND:

Sub-Saharan Africa remains the region with the highest under-5 mortality (U5M) rates globally. Emerging evidence revealed that exclusive breastfeeding (EBF) rates are significantly associated with a decreased risk for child mortality. Our aim with this study is to fill the gap of knowledge regarding the economic impact of EBF practices in relation to U5M in sub-Saharan African countries.

METHODS:

Data were gathered from the World Bank’s database during the period 2000–2018. A meta-analytical approach was used to evaluate heterogeneity of country estimates and to perform an estimate of the prevalence of EBF and economic cost by country. The association between estimates of U5M and EBF prevalence was estimated and used to perform the total cumulative nonhealth gross domestic product loss (TCNHGDPL) attributable to U5M in 2018 and 2030.

RESULTS:

The prevalence of EBF increased by 1%, and U5M reduced significantly by 3.4 per 1000 children each year during 2000–2018. A U5M reduction of 5.6 per 1000 children could be expected if EBF prevalence improved by 10%. The TCNHGDPL in sub-Saharan Africa had a total value higher than $29 billion in 2018. The cost of U5M is estimated to increase to ~$42 billion in 2030.

CONCLUSIONS:

If EBF prevalence improve by 10%, the related TCNHGDPL was estimated to be $27 billion in 2018 and $41 billion in 2030, therefore saving ~$1 billion. Sub-Saharan Africa should imperatively prioritize and invest in essential approaches toward EBF implementation.

Childhood and Adolescent Bullying Perpetration and Later Substance Use: A Meta-analysis

CONTEXT:

Previous meta-analyses substantially contributed to our understanding of increased drug use risk in bullies but only included research up to 2014 and did not report on other types of substances.

OBJECTIVE:

To review and meta-analyze existing evidence regarding the prospective association between peer bullying perpetration in childhood and adolescence and later substance use.

DATA SOURCES:

Electronic databases were searched on March 14, 2019.

STUDY SELECTION:

We selected peer-reviewed articles and dissertations in English reporting original empirical studies on associations between bullying perpetration in childhood or adolescence and later use of drugs, alcohol, or tobacco. Records were assessed for eligibility independently by 2 authors.

DATA EXTRACTION:

Data extraction and quality assessment was performed by one author and checked by another author.

RESULTS:

In total, 215 effects were included from 28 publications, reporting on 22 samples, comprising 28 477 participants. Bullying perpetration was associated positively with all types of substance use (drugs, alcohol, tobacco, and general). The results for combined bullying-victimization were more mixed, with generally weaker effects.

LIMITATIONS:

Effects were based on a large variability in operationalizations and measures of bullying and substance use, impeding the interpretation of the pooled effect sizes. Although bullying appears to be a risk factor for substance use, no inferences can be made about so-called causal risk factors that can provide the basis for preventive interventions.

CONCLUSIONS:

There is evidence that adolescents and particularly children who bully their peers have a higher risk of substance use later in life than their nonbullying peers.

Enrolling Minors in COVID-19 Vaccine Trials

It is widely agreed that an effective response to the coronavirus disease 2019 pandemic needs to include a vaccine that is safe and effective for minors. However, many current vaccine trials have no plans for when to enroll minors. Others have recently proposed enrolling minors as young as 12 years old. This lack of a systematic approach raises 2 concerns. Waiting too long to enroll minors could unjustly deny minors and their families the benefits of a vaccine and has the potential to delay an effective response to the pandemic by a year or longer. At the same time, enrolling minors too soon runs the risk of exposing them to excessive risks. With these concerns in mind, in the present article, we propose recommendations for when and how to enroll minors in vaccine trials for the coronavirus disease 2019.

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