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Parents as Advocates for Pediatric Palliative Care

Pediatrics - Lun, 01/11/2021 - 09:01

Caring for a child with a serious or life-limiting illness presents many challenges for families and health care providers. Through that experience (and, many times, as it ends), parents are compelled to find and make meaning from their ultimate loss and the many losses along the way. In this Advocacy Case Study, we describe the experiences that led a bereaved mother to seek to harness the insights from her own family’s loss to help support other families facing the challenges and complexities of a child’s serious illness. Her family initially established a family foundation to advocate for palliative care. She later partnered with her family’s general pediatrician and the American Academy of Pediatrics to educate providers and bring parent voices to health care provider discussions. This work eventually led to the development of the Courageous Parents Network, a nonprofit focused on making these parent and provider voices widely available to families and providers through a Web-based collection of videos, blogs, podcasts, and printable guides. Through these insights, the organization addresses feelings of isolation, anxiety, and grief. In addition, these voices illustrate the power and benefits of the growing acceptance of pediatric palliative care practices. Important lessons learned through these efforts include: (1) the power of stories for validation, healing, and understanding; (2) opportunity to extend the reach of pediatric palliative care through provider education and skill-building; (3) critical importance of the parent–provider advocacy collaboration; and (4) necessity of market testing and continuous improvement.

Deaths in Children and Adolescents Associated With COVID-19 and MIS-C in the United States

Pediatrics - Lun, 01/11/2021 - 09:01
OBJECTIVES

To describe the demographics, clinical characteristics, and hospital course among persons <21 years of age with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–associated death.

METHODS

We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons <21 years of age during February 12 to July 31, 2020. All states and territories were invited to participate. We abstracted demographic and clinical data, including laboratory and treatment details, from medical records.

RESULTS

We included 112 SARS-CoV-2-associated deaths from 25 participating jurisdictions. The median age was 17 years (IQR 8.5–19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least 1 underlying condition; obesity (42%), asthma (29%), and developmental disorders (22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (75%) and acute respiratory failure (82%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, sex, and race and/or ethnicity to decedents without MIS-C; 11 of 16 (69%) had at least 1 underlying condition.

CONCLUSIONS

SARS-CoV-2-associated deaths among persons <21 years of age occurred predominantly among Black (non-Hispanic) and Hispanic persons, male patients, and older adolescents. The most commonly reported underlying conditions were obesity, asthma, and developmental disorders. Decedents with coronavirus disease 2019 were more likely than those with MIS-C to have underlying medical conditions.

SARS-CoV-2 Antibodies in Breast Milk After Vaccination

Pediatrics - Lun, 01/11/2021 - 09:01
AbstractoBACKGROUND AND OBJECTIVES

Passive and active immunity transfer through human milk (HM) constitutes a key element in the infant’s developing immunity. Certain infectious diseases and vaccines have been described to induce changes in the immune components of HM.

METHODS

We conducted a prospective cohort single-institution study from February 2 to April 4, 2021. Women who reported to be breastfeeding at the time of their coronavirus disease 2019 (COVID-19) vaccination were invited to participate. Blood and milk samples were collected on day 14 after their second dose of the vaccine. Immunoglobulin G (IgG) antibodies against nucleocapsid protein as well as IgG, immunoglobulin M and immunoglobulin A (IgA) antibodies against the spike 1 protein receptor-binding domain against severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2 RBD-S1) were analyzed in both serum and HM samples.

RESULTS

Most of the participants (ie, 94%) received the BNT162b2 messenger RNA COVID-19 vaccine. The mean serum concentration of anti-SARS-CoV-2 RBD-S-IgG antibodies in vaccinated individuals was 3379.6 ± 1639.5 binding antibody units per mL. All vaccinated study participants had anti-SARS-CoV-2 RBD-S1-IgG, and 89% of them had anti-SARS-CoV-2 RBD-S-IgA in their milk. The antibody concentrations in the milk of mothers who were breastfeeding 24 months were significantly higher than in mothers with breastfeeding periods <24 months (P < .001).

CONCLUSIONS

We found a clear association between COVID-19 vaccination and specific immunoglobulin concentrations in HM. This effect was more pronounced when lactation periods exceeded 23 months. The influence of the lactation period on immunoglobulins was specific and independent of other variables.

Surfactant Nebulization to Prevent Intubation in Preterm Infants: A Systematic Review and Meta-analysis

Pediatrics - Lun, 01/11/2021 - 09:01
CONTEXT

Surfactant nebulization (SN) may offer a safe alternative for surfactant administration in respiratory distress syndrome of preterm infants.

OBJECTIVE

To evaluate the efficacy of SN for the prevention of early intubation.

DATA SOURCES

Medline, Embase, The Cochrane Library, clinicaltrials.gov, published abstracts, and references of relevant articles were searched through March 23, 2021.

STUDY SELECTION

Randomized clinical trials of preterm infants <37 weeks’ gestation comparing SN with noninvasive respiratory support or intratracheal surfactant application.

DATA EXTRACTION

Two reviewers extracted data and assessed risk of bias from included studies separately and blinded. Data were pooled by using a fixed-effects model. Subgroups (gestational age, type of nebulizer, surfactant type, and dosage) were evaluated. Primary outcome was intubation rate at 72 hours after birth.

RESULTS

Nine studies recruiting 1095 infants met inclusion criteria. SN compared with standard care significantly reduced intubation rate at 72 hours after birth (226 of 565 infants [40.0%] vs 231 of 434 infants [53.2%]; risk ratio [RR]: 0.73, 95% confidence interval [CI]: 0.63–0.84; number needed to treat: 8; 95% CI: 5–14]). Prespecified subgroup analysis identified important heterogeneity: SN was most effective in infants ≥28 weeks' gestation (RR: 0.70, 95% CI: 0.60–0.82), with a pneumatically driven nebulizer (RR: 0.52, 95% CI: 0.40–0.68) and in infants receiving ≥200 mg/kg and animal-derived surfactant (RR: 0.63, 95% CI: 0.52–0.75). No differences in neonatal morbidities or mortality were identified.

LIMITATIONS

Quality of evidence was low owing to risk of bias and imprecision.

CONCLUSIONS

SN reduced the intubation rate in preterm infants with a higher efficacy for specific subgroups. There was no difference in relevant neonatal morbidities or mortality.

Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event

Pediatrics - Lun, 01/11/2021 - 09:01
BACKGROUND AND OBJECTIVES

Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE.

METHODS

This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis.

RESULTS

Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients.

CONCLUSIONS

Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.

Exercise Intervention for Academic Achievement Among Children: A Randomized Controlled Trial

Pediatrics - Lun, 01/11/2021 - 09:01
OBJECTIVES

Physical inactivity is an important health concern worldwide. In this study, we examined the effects of an exercise intervention on children’s academic achievement, cognitive function, physical fitness, and other health-related outcomes.

METHODS

We conducted a population-based cluster randomized controlled trial among 2301 fourth-grade students from 10 of 11 public primary schools in 1 district of Ulaanbaatar between February and December 2018. Schools were allocated to an intervention or control group with 5 schools each by using urban and mixed residential area stratified block randomization. The intervention group received a 3-minute high-intensity interval exercise program that included jumps, squats, and various steps implemented twice weekly over 10 weeks for 10 to 25 minutes per session. The control group received the usual physical education class. The primary outcome was academic achievement assessed by scores on the national examination. A linear mixed-effects model was applied. The difference between preintervention and post intervention was compared by least-squares means, estimated on the basis of the interaction of group, measurement time point, and school location. Only 1 statistician, responsible for the analysis, was blinded.

RESULTS

Of 2301 students, 2101 (1069 intervention; 1032 control) were included in the analysis. Intervention group members in an urban area showed an 8.36-point improvement (95% confidence interval: 6.06 to 10.66) in academic scores when compared with the control group, whereas those in a mixed residential area showed a 9.55-point improvement (95% confidence interval: 6.58 to 12.51). No intervention-associated injuries were observed.

CONCLUSIONS

The exercise program significantly improved children’s academic achievement.

Variation of Patent Ductus Arteriosus Treatment in Very Low Birth Weight Infants

Pediatrics - Lun, 01/11/2021 - 09:01
BACKGROUND

Patent ductus arteriosus (PDA) treatment is common among very low birth weight (VLBW) infants. Given limitations in evidence, controversy exists regarding treatment risks and benefits. In this study, we describe PDA treatment trends and variation in a large, US, multicenter VLBW infant cohort.

METHODS

Data were collected through Vermont Oxford Network on 291 292 VLBW infants born 2012–2019 at 806 US NICUs. PDA diagnosis and treatment rates, further categorized as pharmacologic, invasive, or combined, were determined. NICUs were classified as capable versus noncapable of invasive PDA treatment. Infant and hospital characteristics were examined by NICU type and treatment quartile. Geographic NICU distribution and treatment rates were described in 9 US census divisions.

RESULTS

Of all infants, 24.6% were diagnosed with and 20.5% were treated for PDA. Diagnosis and treatment rates decreased over the study period. Treatment was predominantly pharmacologic. Treatment rates varied widely among NICUs (0% to 67%) despite similar infant characteristics. The median treatment rate was higher at NICUs capable of pharmacologic and invasive treatment (20.3%, interquartile range 13.3–28.6) than at NICUs capable of only pharmacologic treatment (8.9%, interquartile range 2.9–14.8). Treatment rates were highest in the northeast and lowest in the west. Invasive treatment was more common in the west.

CONCLUSIONS

PDA diagnosis and treatment rates are trending downward. Wide variation exists in PDA treatment despite a largely uniform VLBW infant population. This variation correlates with differences in hospital treatment capabilities and geography. Further understanding of the effects of treatment disparity could aid in guiding clinical management.

A Dating Violence Prevention Program for Middle School Youth: A Cluster Randomized Trial

Pediatrics - Lun, 01/11/2021 - 09:01
OBJECTIVES

We conducted a cluster randomized controlled trial to test the a priori hypothesis that students attending an intervention middle school would be less likely to report physical adolescent relationship abuse (ARA) 1 year later compared with students attending a control school. Secondary objectives were to determine if the intervention reduced substance misuse, bullying, and fighting.

METHODS

Twenty-four Texas public middle schools were matched by the size of student enrollment, number of economically disadvantaged students, and race and ethnicity of the student body and randomly assigned to the intervention (n = 12; 1237 participants) or the control (n = 12; 1531participants) group. The intervention, Fourth R, is a classroom-based curriculum delivered by existing teachers and consists of 21 lessons on injury prevention, substance use, and growth and development.

RESULTS

Participants (50% female) self-reported ethnicity as Hispanic or Latinx (35%), Black or African American (24%), Asian American (17%), White (8%), and multiethnicity or other (16%). Among those who have dated, students in the intervention schools were less likely to report perpetrating physical ARA (intervention = 14.9% versus control = 18.3%) relative to students in the control schools (adjusted odds ratio, 0.66; 95% confidence interval, 0.43–1.00; P = .05). In the overall sample, no significant differences emerged between control and intervention groups with respect to substance misuse, fighting, and bullying.

CONCLUSIONS

The middle school version of Fourth R is effective in reducing physical ARA perpetration over at least 1 year. The intervention did not have an effect on bullying perpetration, physical fighting with peers, and substance misuse. Long-term assessment, especially follow-up that covers the transition to high school, is needed to examine the program benefit on key outcomes.

The Health Impact of Evictions

Pediatrics - Lun, 01/11/2021 - 09:01

Child Development in Low- and Middle-Income Countries

Pediatrics - Lun, 01/11/2021 - 09:01
BACKGROUND

The United Nations (UN) created the Multiple Indicator Cluster Surveys (MICS) to monitor progress toward achieving goals of the World Declaration on the Survival, Protection, and Development of Children and its plan of action. The MICS is nationally representative and internationally comparable.

METHODS

In this study, we use MICS data from 51 low- and middle-income countries on 159 959 children between 36 and 59 months of age. To index national development, we used the 2013 UN Human Development Index (HDI), which provides data on country-level life expectancy, education, and income. To index child development, we used the Early Childhood Development Index (ECDI), which assesses literacy and numeracy, socioemotional development, physical health, and approaches to learning.

RESULTS

Children’s literacy and numeracy, socioemotional development, and approaches to learning all increase linearly as national development on the HDI (especially education) increases. Overall, the HDI revealed a positive association (r = 0.40) with the ECDI: the HDI explained 16% of variance in children’s ECDI scores and was the most influential predictor of ECDI scores examined. HDI-ECDI relations are robust, even when we control for multiple demographic aspects of children (age, sex), mothers (age, education), and households (size variables) as covariates. No family demographic variable was a stronger predictor of child development than national development.

CONCLUSIONS

To promote child development, low- and middle-income countries need to develop and implement policies that ensure national health and wealth and, particularly, the educational achievements of children’s caregivers. These findings are faithful to the World Summit for Children and inform the UN Sustainable Development Goals, which drive the international development agenda through 2030.

COVID-19 Vaccination-Associated Myocarditis in Adolescents

Pediatrics - Lun, 01/11/2021 - 09:01
OBJECTIVES

In this study, we aimed to characterize the clinical presentation, short-term prognosis, and myocardial tissue changes as noted on cardiovascular magnetic resonance (CMR) or cardiac MRI in pediatric patients with coronavirus disease 2019 vaccination-associated myocarditis (C-VAM).

METHODS

In this retrospective multicenter study across 16 US hospitals, patients <21 years of age with a diagnosis of C-VAM were included and compared with a cohort with multisystem inflammatory syndrome in children. Younger children with C-VAM were compared with older adolescents.

RESULTS

Sixty-three patients with a mean age of 15.6 years were included; 92% were male. All had received a messenger RNA vaccine and, except for one, presented after the second dose. Four patients had significant dysrhythmia; 14% had mild left ventricular dysfunction on echocardiography, which resolved on discharge; 88% met the diagnostic CMR Lake Louise criteria for myocarditis. Myocardial injury as evidenced by late gadolinium enhancement on CMR was more prevalent in comparison with multisystem inflammatory syndrome in children. None of the patients required inotropic, mechanical, or circulatory support. There were no deaths. Follow-up data obtained in 86% of patients at a mean of 35 days revealed resolution of symptoms, arrhythmias, and ventricular dysfunction.

CONCLUSIONS

Clinical characteristics and early outcomes are similar between the different pediatric age groups in C-VAM. The hospital course is mild, with quick clinical recovery and excellent short-term outcomes. Myocardial injury and edema are noted on CMR. Close follow-up and further studies are needed to understand the long-term implications and mechanism of these myocardial tissue changes.

COVID-19 Vaccine Uptake Among US Child Care Providers

Pediatrics - Lun, 01/11/2021 - 09:01
OBJECTIVES

Ensuring high coronavirus disease-2019 (COVID-19) vaccine uptake among US child care providers is crucial to mitigating the public health implications of child-staff and staff-child transmission of severe acute respiratory syndrome coronavirus 2; however, the vaccination rate among this group was previously unknown.

METHODS

To characterize vaccine uptake among US child care providers, we conducted a multistate cross-sectional survey of the child care workforce. Providers were identified through various national databases and state registries. A link to the survey was sent via e-mail between May 26 and June 23, 2021. A 37.8% response yielded 21 663 respondents, with 20 013 satisfying inclusion criteria.

RESULTS

Overall COVID-19 vaccine uptake among US child care providers (78.2%, 90% confidence interval: 77.5% to 78.9%) was higher than the US general adult population (65%). Vaccination rates varied between states from 53.5% to 89.4%. Vaccine uptake among respondents differed significantly (P < .01) based on respondent age (70.0% for ages 25–34, 91.6% for ages 75–84), race (70.0% for Black or African Americans, 92.5% for Asian Americans), annual household income (70.8% for <$35 000, 85.1% for >$75 000), and child care setting (73.0% for home-based, 79.7% for center-based).

CONCLUSIONS

COVID-19 vaccine uptake among US child care providers was higher than the general US adult population. Those who were younger, lower income, Black or African American, resided in states either in the Mountain West or the South, and/or worked in home-based child care programs reported the lowest rates of vaccination. State public health leaders and lawmakers should prioritize these subgroups to realize the largest gains in vaccine uptake among providers.

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