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Three-Year Follow-up of 2-Dose Versus 3-Dose HPV Vaccine

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

Human papillomavirus (HPV) antibody responses to the 9-valent human papillomavirus (9vHPV) vaccine among girls and boys (aged 9–14 years) receiving 2-dose regimens (months 0, 6 or 0, 12) were noninferior to a 3-dose regimen (months 0, 2, 6) in young women (aged 16–26 years) 4 weeks after last vaccination in an international, randomized, open-label trial (NCT01984697). We assessed response durability through month 36.

METHODS:

Girls received 2 (months 0 and 6 [0, 6]: n = 301; months 0 and 12 [0, 12]: n = 151) or 3 doses (months 0,2, and 6 [0, 2, 6]: n = 301); boys received 2 doses ([0, 6]: n = 301; [0, 12]: n = 150); and young women received 3 doses ([0, 2, 6]: n = 314) of 9vHPV vaccine. Anti-HPV geometric mean titers (GMTs) were assessed by competitive Luminex immunoassay (cLIA) and immunoglobulin G-Luminex immunoassay (IgG-LIA) through month 36.

RESULTS:

Anti-HPV GMTs were highest 1 month after the last 9vHPV vaccine regimen dose, decreased sharply during the subsequent 12 months, and then decreased more slowly. GMTs 2 to 2.5 years after the last regimen dose in girls and boys given 2 doses were generally similar to or greater than GMTs in young women given 3 doses. Across HPV types, most boys and girls who received 2 doses (cLIA: 81%–100%; IgG-LIA: 91%–100%) and young women who received 3 doses (cLIA: 78%–98%; IgG-LIA: 91%–100%) remained seropositive 2 to 2.5 years after the last regimen dose.

CONCLUSIONS:

Antibody responses persisted through 2 to 2.5 years after the last dose of a 2-dose 9vHPV vaccine regimen in girls and boys. In girls and boys, antibody responses generated by 2 doses administered 6 to 12 months apart may be sufficient to induce high-level protective efficacy through at least 2 years after the second dose.

Pediatric Ambulatory Central Line-Associated Bloodstream Infections

Vie, 01/01/2021 - 10:01
BACKGROUND:

Inpatient pediatric central line–associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes.

METHODS:

Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors.

RESULTS:

Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4–5.5) and low albumin (OR 2.3; 95% CI: 1.2–4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12–0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16–0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5–13).

CONCLUSIONS:

Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

Provider Specialty and Receipt of Metabolic Monitoring for Children Taking Antipsychotics

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

Metabolic monitoring is important for children taking antipsychotic medication, given the risk for increased BMI, impaired glucose metabolism, and hyperlipidemia. The purpose was to examine the influence of provider specialty on the receipt of metabolic monitoring. Specifically, differences in the receipt of recommended care when a child receives outpatient care from a primary care provider (PCP), a mental health provider with prescribing privileges, or both was examined.

METHODS:

Medicaid enrollment and health care and pharmacy claims data from 2 states were used in the analyses. Providers were assigned to specialties by using a crosswalk of the National Provider Identifier numbers to specialty type. A total of 41 078 children were included.

RESULTS:

For both states, 61% of children saw ≥1 provider type and had adjusted odds ratios for receiving metabolic monitoring that were significantly higher than those of children seeing PCPs only. For example, children seeing a PCP and a mental health provider with prescribing privileges during the year had adjusted odds of receiving metabolic monitoring that were 42% higher than those seeing a PCP alone (P < .001).

CONCLUSIONS:

Shared care arrangements significantly increased the chances that metabolic monitoring would be done. For states, health plans, and clinicians to develop meaningful quality improvement strategies, identifying the multiple providers caring for the children and potentially responsible for ordering tests consistent with evidence-based care is essential. Provider attribution in the context of shared care arrangements plays a critical role in driving quality improvement efforts.

Rare Genetic Variants in Immune Genes and Neonatal Herpes Simplex Viral Infections

Vie, 01/01/2021 - 10:01

Neonatal herpes simplex virus (HSV) infection is a devastating disease with high mortality, particularly when disseminated. Studies in adults and children suggest that susceptibility to herpes simplex encephalitis (HSE) may represent phenotypes for inborn errors in toll-like receptor 3 (TLR3) signaling. However, the genetic basis of susceptibility to neonatal HSV including disseminated disease remains unknown. To test the hypothesis that variants in known HSE-susceptible genes as well as genes mediating HSV immunity will be identified in neonatal HSV, we performed an unbiased exome sequencing study in 10 newborns with disseminated, HSE, and skin, eyes, and mouth disease. Determination of potential impact on function was determined by following American College of Medical Genetics and Genomics guidelines. We identified deleterious and potentially deleterious, rare variants in known HSE-related genes including a stop IRF3 variant (disseminated), nonsynonymous variants in TLR3 and TRAF3 (HSE), STAT1 (skin, eyes, and mouth), and DBR1 (disseminated) in our cohort. Novel and rare variants in other immunodeficiency genes or HSV-related immune genes GRB2, RAG2, PRF1, C6, C7, and MSR1 were found in 4 infants. The variant in GRB2, essential for T-lymphocyte cell responses to HSV, is a novel stop variant not found in public databases. In this pilot study, we identified deleterious or potentially deleterious variants in TLR3 pathway and genes that regulate anti-HSV immunity in neonates with HSV including disseminated disease. Larger, definitive studies incorporating functional analysis of genetic variants are required to validate these data and determine the role of immune genetic variants in neonatal HSV susceptibility.

Effects of Probiotics in Preterm Infants: A Network Meta-analysis

Vie, 01/01/2021 - 10:01
CONTEXT:

Probiotics have proven to be effective in promoting premature infants’ health, but the optimal usage is unknown.

OBJECTIVE:

To compare probiotic supplements for premature infants.

DATA SOURCES:

We searched PubMed, Embase, Cochrane, and ProQuest from inception of these databases to June 1, 2020.

STUDY SELECTION:

Randomized trials of probiotic supplement intervention for preterm infants were screened by 2 reviewers independently. The primary outcomes were mortality and the morbidity of necrotizing enterocolitis (NEC). Secondary outcomes were morbidity of sepsis, time to achieve full enteral feeding, and length of hospital stay.

DATA EXTRACTION:

The data of primary and secondary outcomes were extracted by 2 reviewers and pooled with a random-effects model.

RESULTS:

The meta-analysis included 45 trials with 12 320 participants. Bifidobacterium plus Lactobacillus was associated with lower rates of mortality (risk ratio 0.56; 95% credible interval 0.34–0.84) and NEC morbidity (0.47; 0.27–0.79) in comparison to the placebo; Lactobacillus plus prebiotic was associated with lower rates of NEC morbidity (0.06; 0.01–0.41) in comparison to the placebo; Bifidobacterium plus prebiotic had the highest probability of having the lowest rate of mortality (surface under the cumulative ranking curve 83.94%); and Lactobacillus plus prebiotic had the highest probability of having the lowest rate of NEC (surface under the cumulative ranking curve 95.62%).

LIMITATIONS:

In few studies did authors report the data of infants with a lower birth weight or gestational age.

CONCLUSIONS:

The efficacy of single probiotic supplements is limited, compared to combined use of probiotics. To achieve optimal effect on premature infant health, combined use of prebiotic and probiotic, especially Lactobacillus or Bifidobacterium, is recommended.

A Survivor-Derived Approach to Addressing Trafficking in the Pediatric ED

Vie, 01/01/2021 - 10:01
OBJECTIVES:

Our objective was to elicit the perspectives of survivors of child trafficking on addressing trafficking in the pediatric emergency department (ED) and, secondarily, to provide a survivor-derived framework to help pediatric emergency medicine (PEM) providers discuss trafficking with their patients.

METHODS:

We conducted in-depth, semistructured interviews with young adults who experienced trafficking as children and/or as adolescents. In the interviews, we employed a novel video-elicitation method designed by the research team to elicit detailed participant feedback and recommendations on the pediatric ED through an interactive, immersive discussion with the interviewer. A grounded theory approach was employed.

RESULTS:

Seventeen interviews were conducted revealing the following themes, which we present in an integrated framework for PEM providers: (1) fear is a significant barrier; (2) participants do want PEM providers to ask about trafficking, and it is not harmful to do so; (3) PEM providers should address fear through emphasizing confidentiality and privacy and encouraging agency; (4) PEM providers should approach the patient in a direct, sensitive, and nonjudgmental manner; and (5) changes to the ED environment may facilitate the conversation. Suggested wordings and tips from survivors were compiled.

CONCLUSIONS:

Trafficking survivors feel that the pediatric ED can be a place where they can be asked about trafficking, and that when done in private, it is not harmful or retraumatizing. Fear is a major barrier to disclosure in the pediatric ED setting, and PEM providers can mitigate this by emphasizing privacy and confidentiality and increasing agency by providing choices. PEM providers should be direct, sensitive, and nonjudgmental in their approach to discussing trafficking.

Vitamin D for Growth and Rickets in Stunted Children: A Randomized Trial

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

Vitamin D is essential for healthy development of bones, but little is known about the effects of supplementation in young stunted children. Our objective was to assess the effect of vitamin D supplementation on risk of rickets and linear growth among Afghan children.

METHODS:

In this double-blind, placebo-controlled trial, 3046 children ages 1 to 11 months from inner-city Kabul were randomly assigned to receive oral vitamin D3 (100 000 IU) or placebo every 3 months for 18 months. Rickets Severity Score was calculated by using wrist and knee radiographs for 631 randomly selected infants at 18 months, and rickets was defined as a score >1.5. Weight and length were measured at baseline and 18 months by using standard techniques, and z scores were calculated.

RESULTS:

Mean (95% confidence interval [CI]) serum 25-hydroxyvitamin D (seasonally corrected) and dietary calcium intake were insufficient at 37 (35–39) nmol/L and 372 (327–418) mg/day, respectively. Prevalence of rickets was 5.5% (placebo) and 5.3% (vitamin D): odds ratio 0.96 (95% CI: 0.48 to 1.92); P = .9. The mean difference in height-for-age z score was 0.05 (95% CI: –0.05 to 0.15), P = .3, although the effect of vitamin D was greater for those consuming >300 mg/day of dietary calcium (0.14 [95% CI: 0 to 0.29]; P = .05). There were no between-group differences in weight-for-age or weight-for-height z scores.

CONCLUSIONS:

Except in those with higher calcium intake, vitamin D supplementation had no effect on rickets or growth.

Early Physical Abuse and Adult Outcomes

Vie, 01/01/2021 - 10:01
BACKGROUND:

Because most physical abuse goes unreported and researchers largely rely on retrospective reports of childhood abuse or prospective samples with substantiated maltreatment, long-term outcomes of physical abuse in US community samples are unknown. We hypothesized that early childhood physical abuse would prospectively predict adult outcomes in education and economic stability, physical health, mental health, substance use, and criminal behavior.

METHODS:

Researchers in two multisite studies recruited children at kindergarten entry and followed them into adulthood. Parents completed interviews about responses to the child’s problem behaviors during the kindergarten interview. Interviewers rated the probability that the child was physically abused in the first 5 years of life. Adult outcomes were measured by using 23 indicators of education and economic stability, physical health, mental health, substance use, and criminal convictions reported by participants and their peers and in school and court records.

RESULTS:

Controlling for potential confounds, relative to participants who were not physically abused, adults who had been abused were more likely to have received special education services, repeated a grade, be receiving government assistance, score in the clinical range on externalizing or internalizing disorders, and have been convicted of a crime in the past year (3.20, 2.14, 2.00, 2.42, 2.10, and 2.61 times more likely, respectively) and reported levels of physical health that were 0.10 SDs lower. No differences were found in substance use.

CONCLUSIONS:

Unreported physical abuse in community samples has long-term detrimental effects into adulthood. Pediatricians should talk with parents about using only nonviolent discipline and support early interventions to prevent child abuse.

Coronary Artery Aneurysms as a Feature of Granulomatosis With Polyangiitis

Vie, 01/01/2021 - 10:01

Granulomatosis with polyangiitis is an antineutrophil cytoplasmic antibody–associated vasculitis that primarily affects small vessels. The disease typically affects the respiratory tract and kidneys but has also been known to involve the gastrointestinal tract, genitourinary tract, thyroid, and liver. Cardiac involvement is rare. Coronary artery aneurysms (CAAs) are an extremely uncommon finding, with only 1 reported case in an adult patient and no pediatric cases reported to date. Here, we report the unique case of a child with granulomatosis with polyangiitis who initially presented with fever of unknown origin and pulmonary and renal symptoms with no cardiac complaints. An echocardiogram revealed severe bilateral fusiform CAAs. Because of the high risk of mortality posed by the severity of her renal and cardiac disease, the patient was managed with intensive induction immunosuppression with steroids, rituximab, and cyclophosphamide. She is maintained on steroids, rituximab, aspirin, and warfarin with improved renal function but no change in her CAAs.

Severe Benzodiazepine Use Disorder in a 16-Year-Old Adolescent: A Rapid and Safe Inpatient Taper

Vie, 01/01/2021 - 10:01

We describe the case of a 16-year-old boy with a 1-year history of severe benzodiazepine misuse. After being denied access to several treatment programs and hospital centers that felt unprepared to manage benzodiazepine use disorder and withdrawal in an adolescent, the patient was admitted to a tertiary pediatric unit for rapid inpatient tapering and detoxification. The patient was hospitalized for 13 days and received decreasing doses of diazepam under close monitoring of withdrawal symptoms. The taper was well tolerated, and the patient was transferred to a youth residential substance use treatment center, where he completed a successful 2-month placement. This case highlights the lack of adolescent-friendly facilities allowing safe tapering of rapid-acting benzodiazepines in North America. Given high rates of benzodiazepine misuse among youth and the risks associated with benzodiazepine misuse and withdrawal, there is a critical need for more research, provider training, and dedicated resources in this area.

Sensor-Based Electronic Monitoring for Asthma: A Randomized Controlled Trial

Vie, 01/01/2021 - 10:01
BACKGROUND:

Although sensor-based monitoring of daily inhaled corticosteroids (ICSs) and short-acting β-agonist medications may improve asthma outcomes, the effectiveness of these interventions in diverse pediatric populations remains unclear.

METHODS:

Caregiver and child dyads were randomly assigned to receive inhaler sensors that allowed for caregiver and clinician electronic monitoring of medications. End points included Asthma Control Test scores (≥19 indicated asthma control) and asthma health care use. Caregiver quality of life (QoL) and child ICS adherence were also assessed. Multilevel models were used to estimate adjusted changes from baseline.

RESULTS:

Dyads were assigned to the control (n = 127) or intervention (n = 125) arms. At the end line, the mean Asthma Control Test score increased from 19.1 (SE = 0.3) to 21.8 (SE = 0.4) among the intervention and from 19.4 (SE = 0.3) to 19.9 (SE = 0.4) among the control (intervention-control = 2.2; SE = 0.6; P < .01). Adjusted rates of emergency department visits and hospitalizations among the intervention were significantly greater (incidence rate ratioemergency department = 2.2; SE = 0.5; P < .01; incidence rate ratiohospital = 3.4; SE = 1.4; P < .01) at endline than the control. Caregiver QoL was greater among the intervention at the endline (intervention-control = 0.3; SE = 0.2; P = .1) than the control.

CONCLUSIONS:

Findings suggest that sensor-based inhaler monitoring with clinical feedback may improve asthma control and caregiver QoL within diverse populations. Higher health care use was observed among the intervention participants relative to the control, indicating further refinement is warranted.

Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes

Vie, 01/01/2021 - 10:01

Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children’s Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children’s hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media

Vie, 01/01/2021 - 10:01
OBJECTIVES:

To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).

METHODS:

We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.

RESULTS:

Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%–1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%–3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%–1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.

CONCLUSION:

Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Effects of Peer Victimization on Child and Adolescent Physical Health

Vie, 01/01/2021 - 10:01

Peer victimization is recognized as a pressing public health issue, affecting ~1 in 5 youth. Although extensive research demonstrates the negative effects of peer victimization on youth mental health, considerably less is known about if and how peer victimization adversely impacts physical health. Focusing on studies published in the past 5 years, this state-of-the-art review synthesizes recent research examining the relationship between peer victimization and physical health outcomes among children and adolescents. In addition to reviewing evidence for associations between peer victimization and global subjective health indices (eg, somatic symptoms), I highlight several biological sequelae of victimization (eg, cortisol dysregulation, inflammation) that may increase long-term risk for illness and disease. I conclude by considering strengths and limitations of existing work and suggesting several key directions for future research. I also discuss implications for practitioners and the role primary care providers can play in promoting health among peer victimized youth.

Under-5 Mortality in Central America: 1990-2016

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

We aimed to calculate the change in under-5 mortality rates (U5MRs) (1990–2016), to assess countries’ status regarding Sustainable Development Goal (SDG) 3.2.1 (reducing the U5MR to ≤25 deaths per 1000 live births by 2030), to list the most important causes of death (1990, 2016), and to examine the association between selected SDG indicators and U5MRs using a linear mixed-effects regression.

METHODS:

Ecological study in which we used estimates from the Global Burden of Disease Study 2016 for Central American countries. Results were expressed as U5MRs (deaths per 1000 live births), cause-specific mortality rates (deaths per 100 000 population <5 years of age), and regression coefficients with 95% confidence intervals.

RESULTS:

U5MRs decreased 65% (1990–2016), and in 2016, all countries but Guatemala had met SDG 3.2.1. The main causes of death were diarrheal diseases (1990; 311.1 per 100 000) and lower respiratory infections (LRIs) (2016; 78.1 per 100 000). When disaggregated by country (2016), congenital birth defects were the most important cause of death in all countries except for in Honduras (neonatal preterm birth) and Guatemala (LRIs). Nutritional status; availability of water, sanitation, and hygiene services; coverage of vaccines; and coverage of contraception were associated with a reduction in U5MRs.

CONCLUSIONS:

Central America has achieved a large reduction in U5MRs. Countries must address both the high mortality caused by LRIs and the rising mortality caused by noncommunicable causes of death through an improvement of SDG indicators that guarantees equitable progress in child survival in the region.

Suspected Nonfatal Drug-Related Overdoses Among Youth in the US: 2016-2019

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

During the current drug overdose crisis, the United States is experiencing a significant number of overdose deaths, hospitalizations, and emergency department visits. Given the vulnerability of young persons to substance use, it is important to assess how this crisis affects the nation’s youth. In this study, we investigate trends in suspected nonfatal drug-related overdoses (all-drugs, opioids, heroin, and stimulants) among youth using syndromic surveillance data from 2016 to 2019.

METHODS:

A retrospective analysis of emergency department syndromic surveillance data were used to detect quarterly trends in suspected drug overdoses from April 2016 through September 2019 among youth aged 0 to 10, 11 to 14, and 15 to 24 years. Syndrome definitions were developed using chief complaint free-text and discharge diagnosis codes to identify overdoses involving all-drugs, opioids, heroin, and stimulants. Pearson 2 tests detected quarter-to-quarter changes, and joinpoint regression analysis assessed trends over time.

RESULTS:

On average, there was a 2.0% increase for youth aged 0 to 10 years and a 2.3% increase for youth aged 11 to 14 years for suspected all-drug overdoses. Suspected heroin overdoses decreased by an average of 3.3% per quarter for youth aged 15 to 24 years. Among all age groups, suspected stimulant overdoses increased across the study period, 3.3% for 0 to 10-year-olds, 4.0% for 11- to 14-year-olds, and 2.3% for 15- to 24-year-olds.

CONCLUSIONS:

Suspected stimulant-involved drug overdoses appear to be rising among youth. These findings could inform targeted interventions, such as stimulant-focused prevention, and comprehensive approaches, including school-based prevention and other strategies to lower morbidity and mortality.

Prediction of In-Hospital Mortality After 24 Hours in Very Low Birth Weight Infants

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

The existing prediction formulas for in-hospital mortality of very low birth weight (VLBW) infants were mostly developed in the 1990s or 2000s and thus may not reflect the recently improved levels of neonatal care. We conducted this study to build a model for predicting the in-hospital mortality using perinatal factors available soon after birth.

METHODS:

We gathered data on VLBW infants from the Korean Neonatal Network, a nationwide, prospective, Web-based registry that enrolled patients from 2013 to 2017. Perinatal variables that were significantly associated with mortality in univariate logistic regression or those with apparent clinical importance were included in the multivariable logistic regression model. The final formula was constructed by considering the collinearity, parsimony, goodness of fit, and clinical interpretation.

RESULTS:

A total of 9248 VLBW infants were analyzed, including 1105 (11.9%) who died during hospitalization. The mean gestational age was 29.0 ± 2.9 weeks and the mean birth weight was 1096 ± 280 g. Significant variables used in the final equation included polyhydramnios, oligohydramnios, gestational age, Apgar score at 1 minute, intubation at birth, birth weight, and base excess. In internal validation, the area under the curve (AUC) for the prediction of in-hospital mortality was 0.870 and the optimism-corrected AUC was 0.867. The prediction equation revealed good discrimination and calibration in the external validation as well (AUC: 0.876).

CONCLUSIONS:

The newly developed Korean Neonatal Network prediction formula for in-hospital mortality could be a useful tool in counseling by providing a reliable prediction for the in-hospital mortality of VLBW infants.

Evaluating Definitions for Neonatal Abstinence Syndrome

Vie, 01/01/2021 - 10:01
BACKGROUND AND OBJECTIVES:

National estimates indicate that the incidence of neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased more than fivefold between 2004 and 2016. There is no gold standard definition for capturing NAS across clinical, research, and public health settings. Our objective was to evaluate how different definitions of NAS modify the calculated incidence when applied to a known population of opioid-exposed infants.

METHODS:

Data for this retrospective cohort study were obtained from opioid-exposed infants born at Vanderbilt University Medical Center in 2018. Six commonly used clinical and surveillance definitions of opioid exposure and NAS were applied to the study population and evaluated for accuracy in assessing clinical withdrawal.

RESULTS:

A total of 121 opioid-exposed infants met the criteria for inclusion in our study. The proportion of infants who met criteria for NAS varied by predefined definition, ranging from 17.4% for infants who received morphine to 52.8% for infants with the diagnostic code for opioid exposure. Twenty-eight infants (23.1%) received a clinical diagnosis of NAS by a medical provider, and 38 (34.1%) received the diagnostic code for NAS at discharge.

CONCLUSIONS:

We found significant variability in the incidence of opioid exposure and NAS among a single-center population using 6 common definitions. Our findings suggest a need to develop a gold standard definition to be used across clinical, research, and public health surveillance settings.

A Child Development Fund Program, Emotional Development, and Poverty Reduction

Vie, 01/01/2021 - 10:01
OBJECTIVES:

We aim to examine the effects of the Child Development Fund (CDF) program on the long-term psychological, health, social, and financial development of children in poverty.

METHODS:

The current study was a 4-year follow-up survey study (the follow-up study) of a nonrandomized controlled trial (the first study), conducted in 2019 and 2015, respectively, in Hong Kong. Subjects were 902 young adults who were from families living in poverty and receiving financial assistance from the government and who had completed the first study. Approximately 61% of the subjects (N = 546) completed the current follow-up study.

RESULTS:

Of the 546 subjects (46% male), 335 (61%; CDF participants) completed the CDF program between 2011 and 2015, and 211 (39%; CDF nonparticipants) were matched controls in the first study. The mean age was 20.64 years (SD = 2.72). After adjustments of covariates, the CDF participants reported fewer behavioral problems, higher levels of study motivation, higher levels of hope, and more positive attitudes toward their future education. The CDF participants also perceived greater social support from significant others and reported greater amounts of money saved every month. After further adjustments, CDF participants showed greater improvements in health-related quality of life related to emotional functioning. A considerable number of families of the CDF participants who were working for a living were no longer reliant on financial assistance from the government.

CONCLUSIONS:

The positive effects of the CDF program on children in poverty could be sustained throughout adolescence to young adulthood. Findings warrant the promotion of the program to reach more children.

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