The 50 most-cited articles in PEDIATRICS, 2019

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity…

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline’s recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with…

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient,…

OBJECTIVES: To study the national prevalence of 10 developmental disabilities in US children aged 3 to 17 years and explore changes over time by associated demographic and socioeconomic characteristics, using the National Health Interview Survey. METHODS: Data come from the 2009 to 2017 National Health Interview Survey, a nationally representative survey of the civilian noninstitutionalized population. Parents reported physician or other health care professional diagnoses of attention-deficit/hyperactivity disorder; autism spectrum disorder; blindness; cerebral palsy; moderate to profound hearing loss; learning disability; intellectual disability; seizures; stuttering or stammering; and other developmental delays. Weighted percentages for each of the selected developmental disabilities and any developmental disability were calculated and stratified by demographic and socioeconomic characteristics. RESULTS: From 2009 to 2011 and 2015 to 2017, there were overall significant increases in the prevalence of any developmental disability (16.2%–17.8%, P < .001),…

The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. By acknowledging the role of racism in child and adolescent health, pediatricians and other pediatric health professionals will be able to proactively engage in strategies to optimize clinical care, workforce development, professional education, systems engagement, and research in a manner designed to reduce the health…

Early identification and intervention for developmental disorders are critical to the well-being of children and are the responsibility of pediatric professionals as an integral function of the medical home. This report models a universal system of developmental surveillance and screening for the early identification of conditions that affect children's early and long-term development and achievement, followed by ongoing care. These conditions include autism, deafness/hard-of-hearing, intellectual and motor disabilities, behavioral conditions, and those seen in other medical conditions. Developmental surveillance is supported at every health supervision visit, as is as the administration of standardized screening tests at the 9-, 18-, and 30-month visits. Developmental concerns elicited on surveillance at any visit should be followed by standardized developmental screening testing or direct referral to intervention and specialty medical care. Special attention to surveillance is recommended at the 4- to 5-year well-child visit, prior to entry into elementary education, with…

OBJECTIVES: To determine if racial and ethnic subgroups of adolescents are at high risk for engagement in suicidal behaviors. METHODS: Using the nationally representative school-based Youth Risk Behavior Survey from the years 1991 to 2017, we conducted logistic regression analyses to examine trends by different racial and ethnic groups, with each suicide indicator serving as a dichotomous outcome. Participants included 198 540 high school students. RESULTS: Across all sex and race and ethnic groups, there were significant linear decreases in self-reported suicidal ideation and suicide plans from 1991 to 2017. Female adolescents (odds ratio [OR], 0.98; P < .001) had significant decreases in attempts over time. Black adolescents had positive linear trends for suicide attempts among both boys (OR, 1.04; P < .001) and girls (OR, 1.02; P = .003). Black adolescent boys (OR, 1.04; P = .048) had a significant linear increase in injury by attempt. CONCLUSIONS: The results suggest that, over time, black youth have experienced an increase in suicide attempts, which is troubling because…

This clinical report updates and replaces a 2008 clinical report from the American Academy of Pediatrics, which addressed the roles of maternal and early infant diet on the prevention of atopic disease, including atopic dermatitis, asthma, and food allergy. As with the previous report, the available data still limit the ability to draw firm conclusions about various aspects of atopy prevention through early dietary interventions. Current evidence does not support a role for maternal dietary restrictions during pregnancy or lactation. Although there is evidence that exclusive breastfeeding for 3 to 4 months decreases the incidence of eczema in the first 2 years of life, there are no short- or long-term advantages for exclusive breastfeeding beyond 3 to 4 months for prevention of atopic disease. The evidence now suggests that any duration of breastfeeding ≥3 to 4 months is protective against wheezing in the first 2 years of life, and some evidence suggests that longer duration of any breastfeeding protects against asthma even after 5 years of age. No conclusions can be made about the…

OBJECTIVES: To examine the impact of social media influencer marketing of foods (healthy and unhealthy) on children’s food intake. METHODS: In a between-subjects design, 176 children (9–11 years, mean 10.5 ± 0.7 years) were randomly assigned to view mock Instagram profiles of 2 popular YouTube video bloggers (influencers). Profiles featured images of the influencers with unhealthy snacks (participants: n = 58), healthy snacks (n = 59), or nonfood products (n = 59). Subsequently, participants’ ad libitum intake of unhealthy snacks, healthy snacks, and overall intake (combined intake of healthy and unhealthy snacks) were measured. RESULTS: Children who viewed influencers with unhealthy snacks had significantly increased overall intake (448.3 kilocalories [kcals]; P = .001), and significantly increased intake of unhealthy snacks specifically (388.8 kcals; P = .001), compared with children who viewed influencers with nonfood products (357.1 and 292.2 kcals, respectively). Viewing influencers with healthy snacks did not significantly affect intake. CONCLUSIONS: Popular social media…

OBJECTIVES: Food insecurity is an important public health problem facing children in the United States. Although a number of previous studies suggest that food insecurity has negative impacts on health, these studies have not dealt thoroughly with issues of selection bias. We use propensity scoring techniques to approximate the causal effects of food insecurity on children's health and health care use outcomes. METHODS: = 29 341). Using inverse probability of treatment weighting, a propensity scoring method, we examine a broad range of child health outcomes and account for a comprehensive set of controls, focusing on a sample of children 2 to 17 years old. RESULTS: Household food insecurity was related to significantly worse general health, some acute and chronic health problems, and worse health care access, including forgone care and heightened emergency department use, for children. Compared to rates had they not been food insecure, children in food-insecure household had rates of lifetime asthma diagnosis and depressive symptoms that were 19.1% and 27.9% higher, rates of…

Group B streptococcal (GBS) infection remains the most common cause of neonatal early-onset sepsis and a significant cause of late-onset sepsis among young infants. Administration of intrapartum antibiotic prophylaxis is the only currently available effective strategy for the prevention of perinatal GBS early-onset disease, and there is no effective approach for the prevention of late-onset disease. The American Academy of Pediatrics joins with the American College of Obstetricians and Gynecologists to reaffirm the use of universal antenatal microbiologic-based testing for the detection of maternal GBS colonization to facilitate appropriate administration of intrapartum antibiotic prophylaxis. The purpose of this clinical report is to provide neonatal clinicians with updated information regarding the epidemiology of GBS disease as well current recommendations for the evaluation of newborn infants at risk for GBS disease and for treatment of those with confirmed GBS infection. This clinical report is endorsed by the American College of Obstetricians and Gynecologists (ACOG), July…

Electronic cigarettes (e-cigarettes) and vape devices have rapidly become the most common tobacco products used by youth, driven in large part by marketing and advertising by e-cigarette companies. There is substantial evidence that adolescent e-cigarette use leads to use of combustible tobacco products. E-cigarette companies commonly advertise that e-cigarettes contain nicotine, flavoring chemicals, and humectants (propylene glycol and/or vegetable glycerin), but toxicants, ultrafine particles, and carcinogens have also been found in e-cigarette solutions and emissions, many of which are known to cause adverse health effects. Most major e-cigarette brands are owned by big tobacco companies that use similar marketing and advertising strategies to attract youth users as they did with traditional tobacco products. In this review, we provide an overview of e-cigarettes and vape devices with an emphasis on the impact for the pediatric population. We describe the vast array of e-cigarette devices and solutions, concern for nicotine addiction, and the scientific background on the known…

BACKGROUND: Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide. METHODS: and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates. RESULTS: Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6-11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit. CONCLUSIONS:…

OBJECTIVES: To investigate the temporal trend in the national incidence of bronchiolitis hospitalizations, their characteristics, inpatient resource use, and hospital cost from 2000 through 2016. METHODS: J21. Complex chronic conditions were defined by the pediatric complex chronic conditions classification by using inpatient data. The primary outcomes were the incidence of bronchiolitis hospitalizations, mechanical ventilation use, and hospital direct cost. We examined the trends accounting for sampling weights. RESULTS: < .001] adjusted for inflation) from 2003 to 2016. CONCLUSIONS: From 2000 through 2016, the incidence of bronchiolitis hospitalizations among US children declined. In contrast, mechanical ventilation use and nationwide hospital direct cost substantially increased.

CONTEXT: Screening children for social determinants of health (SDOHs) has gained attention in recent years, but there is a deficit in understanding the present state of the science. OBJECTIVE: To systematically review SDOH screening tools used with children, examine their psychometric properties, and evaluate how they detect early indicators of risk and inform care. DATA SOURCES: Comprehensive electronic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection. STUDY SELECTION: Studies in which a tool that screened children for multiple SDOHs (defined according to Healthy People 2020) was developed, tested, and/or employed. DATA EXTRACTION: Extraction domains included study characteristics, screening tool characteristics, SDOHs screened, and follow-up procedures. RESULTS: The search returned 6274 studies. We retained 17 studies encompassing 11 screeners. Study samples were diverse with respect to biological sex and race and/or ethnicity. Screening was primarily conducted in…

Severe obesity among youth is an "epidemic within an epidemic" and portends a shortened life expectancy for today's children compared with those of their parents' generation. Severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Emerging evidence has linked severe obesity to the development and progression of multiple comorbid states, including increased cardiometabolic risk resulting in end-organ damage in adulthood. Lifestyle modification treatment has achieved moderate short-term success among young children and those with less severe forms of obesity, but no studies to date demonstrate significant and durable weight loss among youth with severe obesity. Metabolic and bariatric surgery has emerged as an important treatment for adults with severe obesity and, more recently, has been shown to be a safe and effective strategy for groups of youth with severe obesity. However, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among…

CONTEXT: Early language development supports cognitive, academic, and behavioral success. Identifying modifiable predictors of child language may inform policies and practices aiming to promote language development. OBJECTIVE: To synthesize results of observational studies examining parenting behavior and early childhood language in typically developing samples. DATA SOURCES: Searches were conducted in Medline, Embase, PsycINFO, Web of Science, and Dissertation Abstracts (1967 to 2017). STUDY SELECTION: Studies had 1 of 2 observational measures of parenting behavior (i.e., sensitive responsiveness or warmth) and a measure of child language. DATA EXTRACTION: Data from 37 studies were extracted by independent coders. Estimates were examined by using random-effects meta-analysis. RESULTS: = 0.16; 95% confidence interval: 0.09 to 21). The pooled effect size for the association between sensitive responsiveness and child language was statistically higher than that of warmth and child language. The association between sensitive responsiveness and child language was moderated by family…

Interest and participation in organized sports for children, preadolescents, and adolescents continue to grow. Because of increased participation, and younger entry age, in organized sports, appropriate practice, game schedules, and content become more important, taking into account athlete developmental stage and skills. Parental support for organized sports in general, with focus on development and fun instead of winning, has emerged as a key factor in the athlete's enjoyment of sports. Schools and community sports organizations who support multiple levels of sport (eg, recreational, competitive, elite) can include more youth who want to play sports and combat sport dropout. This report reviews the benefits and risks of organized sports as well as the roles of schools, community organizations, parents, and coaches in organized sports. It is designed to complement the American Academy of Pediatrics clinical reports "Physical Activity Assessment and Counseling in Pediatric Clinical Settings" and "Sports Specialization and Intensive Training in Young Athletes" by reviewing relevant…

More than 6.5 million children in the United States, approximately 13% of all students, miss 15 or more days of school each year. The rates of chronic absenteeism vary between states, communities, and schools, with significant disparities based on income, race, and ethnicity. Chronic school absenteeism, starting as early as preschool and kindergarten, puts students at risk for poor school performance and school dropout, which in turn, put them at risk for unhealthy behaviors as adolescents and young adults as well as poor long-term health outcomes. Pediatricians and their colleagues caring for children in the medical setting have opportunities at the individual patient and/or family, practice, and population levels to promote school attendance and reduce chronic absenteeism and resulting health disparities. Although this policy statement is primarily focused on absenteeism related to students' physical and mental health, pediatricians may play a role in addressing absenteeism attributable to a wide range of factors through individual interactions with patients and their parents and…

BACKGROUND: Universal screening is recommended to reduce the age of diagnosis for autism spectrum disorder (ASD). However, there are insufficient data on children who screen negative and no study of outcomes from truly universal screening. With this study, we filled these gaps by examining the accuracy of universal screening with systematic follow-up through 4 to 8 years. METHODS: Universal, primary care-based screening was conducted using the Modified Checklist for Autism in Toddlers with Follow-Up (M-CHAT/F) and supported by electronic administration and integration into electronic health records. All children with a well-child visit (1) between 16 and 26 months, (2) at a Children’s Hospital of Philadelphia site after universal electronic screening was initiated, and (3) between January 2011 and July 2015 were included (N = 25 999). RESULTS: Nearly universal screening was achieved (91%), and ASD prevalence was 2.2%. Overall, the M-CHAT/F’s sensitivity was 38.8%, and its positive predictive value (PPV) was 14.6%. Sensitivity was higher in older toddlers and with repeated…

Neurofibromatosis type 1 (NF1) is a multisystem disorder that primarily involves the skin and peripheral nervous system. Its population prevalence is approximately 1 in 3000. The condition is usually recognized in early childhood, when pigmentary manifestations emerge. Although NF1 is associated with marked clinical variability, most children affected follow patterns of growth and development within the normal range. Some features of NF1 can be present at birth, but most manifestations emerge with age, necessitating periodic monitoring to address ongoing health and developmental needs and minimize the risk of serious medical complications. In this report, we provide a review of the clinical criteria needed to establish a diagnosis, the inheritance pattern of NF1, its major clinical and developmental manifestations, and guidelines for monitoring and providing intervention to maximize the health and quality of life of a child affected.

Pediatricians have unique opportunities and an increasing sense of responsibility to promote healthy social-emotional development of children and to prevent and address their mental health and substance use conditions. In this report, the American Academy of Pediatrics updates its 2009 policy statement, which proposed competencies for providing mental health care to children in primary care settings and recommended steps toward achieving them. This 2019 policy statement affirms the 2009 statement and expands competencies in response to science and policy that have emerged since: the impact of adverse childhood experiences and social determinants on mental health, trauma-informed practice, and team-based care. Importantly, it also recognizes ways in which the competencies are pertinent to pediatric subspecialty practice. Proposed mental health competencies include foundational communication skills, capacity to incorporate mental health content and tools into health promotion and primary and secondary preventive care, skills in the psychosocial assessment and care of children with…

BACKGROUND: Emergency departments (EDs) vary in their level of readiness to care for pediatric emergencies. We evaluated the effect of ED pediatric readiness on the mortality of critically ill children. METHODS: We conducted a retrospective cohort study in Florida, Iowa, Massachusetts, Nebraska, and New York, focusing on patients aged 0 to 18 years with critical illness, defined as requiring intensive care admission or experiencing death during the encounter. We used ED and inpatient administrative data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project linked to hospital-specific data from the 2013 National Pediatric Readiness Project. The relationship between hospital-specific pediatric readiness and encounter mortality in the entire cohort and in condition-specific subgroups was evaluated by using multivariable logistic regression and fractional polynomials. RESULTS: We studied 20 483 critically ill children presenting to 426 hospitals. The median weighted pediatric readiness score was 74.8 (interquartile range: 59.3–88.0; range:…

CONTEXT: Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. OBJECTIVE: To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. DATA SOURCES: Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care." STUDY SELECTION: English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. DATA EXTRACTION: Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. RESULTS: Initial…

BACKGROUND AND OBJECTIVES: Use of commercial direct-to-consumer (DTC) telemedicine outside of the pediatric medical home is increasing among children, and acute respiratory infections (ARIs) are the most commonly diagnosed condition at DTC telemedicine visits. Our objective was to compare the quality of antibiotic prescribing for ARIs among children across 3 settings: DTC telemedicine, urgent care, and the primary care provider (PCP) office. METHODS: In a retrospective cohort study using 2015–2016 claims data from a large national commercial health plan, we identified ARI visits by children (0–17 years old), excluding visits with comorbidities that could affect antibiotic decisions. Visits were matched on age, sex, chronic medical complexity, state, rurality, health plan type, and ARI diagnosis category. Within the matched sample, we compared the percentage of ARI visits with any antibiotic prescribing and the percentage of ARI visits with guideline-concordant antibiotic management. RESULTS: There were 4604 DTC telemedicine, 38 408 urgent care, and 485 201 PCP visits for ARIs in the…

OBJECTIVES: Newborn screening for severe combined immunodeficiency (SCID) was instituted in California in 2010. In the ensuing 6.5 years, 3 252 156 infants in the state had DNA from dried blood spots assayed for T-cell receptor excision circles (TRECs). Abnormal TREC results were followed-up with liquid blood testing for T-cell abnormalities. We report the performance of the SCID screening program and the outcomes of infants who were identified. METHODS: Data that were reviewed and analyzed included demographics, nursery summaries, TREC and lymphocyte flow-cytometry values, and available follow-up, including clinical and genetic diagnoses, treatments, and outcomes. RESULTS: Infants with clinically significant T-cell lymphopenia (TCL) were successfully identified at a rate of 1 in 15 300 births. Of these, 50 cases of SCID, or 1 in 65 000 births (95% confidence interval 1 in 51 000-1 in 90 000) were found. Prompt treatment led to 94% survival. Infants with non-SCID TCL were also identified, diagnosed and managed, including 4 with complete DiGeorge syndrome who received thymus…

CONTEXT: Survival of infants born at the limit of viability varies between high-income countries. OBJECTIVE: To summarize the prognosis of survival and risk of impairment for infants born at 22 + 0/7 weeks' to 27 + 6/7 weeks' gestational age (GA) in high-income countries. DATA SOURCES: We searched 9 databases for cohort studies published between 2000 and 2017 in which researchers reported on survival or neurodevelopmental outcomes. STUDY SELECTION: GA was based on ultrasound results, the last menstrual period, or a combination of both, and neurodevelopmental outcomes were measured by using the Bayley Scales of Infant Development II or III at 18 to 36 months of age. DATA EXTRACTION: Two reviewers independently extracted data and assessed the risk of bias and quality of evidence. RESULTS: Sixty-five studies were included. Mean survival rates increased from near 0% of all births, 7.3% of live births, and 24.1% of infants admitted to intensive care at 22 weeks' GA to 82.1%, 90.1%, and 90.2% at 27 weeks' GA, respectively. For the survivors, the rates of severe impairment decreased from…

Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.

BACKGROUND: Because little is known about long-term effects of adolescent protective factors across multiple health domains, we examined associations between adolescent connectedness and multiple health-related outcomes in adulthood. METHODS: = 14 800). Linear and logistic models were used to examine associations between family and school connectedness in adolescence and self-reported health risk behaviors and experiences in adulthood, including emotional distress, suicidal thoughts and attempts, physical violence victimization and perpetration, intimate partner physical and sexual violence victimization, multiple sex partners, condom use, sexually transmitted infection (STI) diagnosis, prescription drug misuse, and other illicit drug use. RESULTS: In multivariable analyses, school connectedness in adolescence had independent protective associations in adulthood, reducing emotional distress and odds of suicidal ideation, physical violence victimization and perpetration, multiple sex partners, STI diagnosis, prescription drug misuse, and other illicit drug use. Similarly, family…

BACKGROUND AND OBJECTIVES: Emerging evidence indicates transgender adolescents (TGAs) exhibit elevated rates of suicidal ideation and attempt compared with cisgender adolescents (CGAs). Less is known about risk among subgroups of TGAs because of limited measures of gender identity in previous studies. We examined disparities in suicidality across the full spectrum of suicidality between TGAs and CGAs and examined risk for suicidality within TGA subgroups. METHODS: = 2020, including 1148 TGAs). Participants reported gender assigned at birth and current gender identity (categorized as cisgender males, cisgender females, transgender males, transgender females, nonbinary adolescents assigned female at birth, nonbinary adolescents assigned male at birth, and questioning gender identity). Lifetime suicidality (passive death wish, suicidal ideation, suicide plan, suicide attempt, and attempt requiring medical care) and nonsuicidal self-injury were assessed. RESULTS: Aggregated into 1 group, TGAs had higher odds of all outcomes as compared with CGAs. Within TGA subgroups, transgender males…

BACKGROUND: Ongoing monitoring of concussion rates and distributions is important in assessing temporal patterns. Examinations of high school sport-related concussions need to be updated. This study describes the epidemiology of concussions in 20 high school sports during the 2013-2014 to 2017-2018 school years. METHODS: In this descriptive epidemiology study, a convenience sample of high school athletic trainers provided injury and athlete exposure (AE) data to the National High School Sports-Related Injury Surveillance Study (High School Reporting Information Online). Concussion rates per 10 000 AEs with 95% confidence intervals (CIs) and distributions were calculated. Injury rate ratios and injury proportion ratios examined sex differences in sex-comparable sports (soccer, basketball, baseball and softball, cross country, track, and swimming). We also assessed temporal trends across the study period. RESULTS: Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 AEs (95% CI: 4.09 to 4.26). Football had the highest concussion rate (10.40 per 10 000 AEs).…

CONTEXT: Advances in neuroimaging techniques have resulted in an exponential increase in the number of studies investigating the effects of physical activity on brain structure and function. Authors of studies have linked physical activity and fitness with brain regions and networks integral to cognitive function and scholastic performance in children and adolescents but findings have not been synthesized. OBJECTIVE: To conduct a systematic review of studies in which the impact of physical activity on brain structure and function in children and adolescents is examined. DATA SOURCES: Six electronic databases (PubMed, PsychINFO, Scopus, Ovid Medline, SportDiscus, and Embase) were systematically searched for experimental studies published between 2002 and March 1, 2019. STUDY SELECTION: Two reviewers independently screened studies for inclusion according to predetermined criteria. DATA EXTRACTION: Two reviewers independently extracted data for key variables and synthesized findings qualitatively. RESULTS: Nine studies were included (task-based functional MRI [n = 4], diffusion tensor…

This Policy Statement was revised. See https://doi.org/10.1542/peds.2026-077410. Drowning is a leading cause of injury-related death in children. In 2017, drowning claimed the lives of almost 1000 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning.

OBJECTIVES: Maternal smoking during pregnancy is an established risk factor for sudden unexpected infant death (SUID). Here, we aim to investigate the effects of maternal prepregnancy smoking, reduction during pregnancy, and smoking during pregnancy on SUID rates. METHODS: codes R95 (sudden infant death syndrome), R99 (ill-defined or unknown cause), or W75 (accidental suffocation or strangulation in bed). RESULTS: SUID risk more than doubled (adjusted odds ratio [aOR] = 2.44; 95% confidence interval [CI] 2.31-2.57) with any maternal smoking during pregnancy and increased twofold between no smoking and smoking 1 cigarette daily throughout pregnancy. For 1 to 20 cigarettes per day, the probability of SUID increased linearly, with each additional cigarette smoked per day increasing the odds by 0.07 from 1 to 20 cigarettes; beyond 20 cigarettes, the relationship plateaued. Mothers who quit or reduced their smoking decreased their odds compared with those who continued smoking (reduced: aOR = 0.88, 95% CI 0.79-0.98; quit: aOR = 0.77, 95% CI 0.67-0.87). If we assume causality, 22% of…

BACKGROUND: Lower weight has historically been equated with more severe illness in anorexia nervosa (AN). Reliance on admission weight to guide clinical concern is challenged by the rise in patients with atypical anorexia nervosa (AAN) requiring hospitalization at normal weight. METHODS: We examined weight history and illness severity in 12- to 24-year-olds with AN (n = 66) and AAN (n = 50) in a randomized clinical trial, the Study of Refeeding to Optimize Inpatient Gains (www.clinicaltrials.gov; NCT02488109). Amount of weight loss was the difference between the highest historical percentage median BMI and admission; rate was the amount divided by duration (months). Unpaired t tests compared AAN and AN; multiple variable regressions examined associations between weight history variables and markers of illness severity at admission. Stepwise regression examined the explanatory value of weight and menstrual history on selected markers. RESULTS: Participants were 16.5 ± 2.6 years old, and 91% were of female sex. Groups did not differ by weight history or admission heart rate (HR).…

School readiness includes the readiness of the individual child, the school's readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to meet the needs of all children at all levels of readiness. Children's readiness for kindergarten should become an outcome measure for a coordinated system of community-based programs and supports for the healthy development of young children. Our rapidly expanding insights into early brain and child development have revealed that modifiable factors in a child's early experience can greatly affect that child's health and learning trajectories. Many children in the United States enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification and attention to child and family needs. A strong correlation between social-emotional development and school and life success, combined with alarming rates of preschool expulsion, point toward the…

Neonatal opioid withdrawal syndrome (NOWS) has risen in prevalence from 1.2 per 1000 births in 2000 to 5.8 per 1000 births in 2012. Symptoms in neonates may include high-pitched cry, tremors, feeding difficulty, hypertonia, watery stools, and breathing problems. However, little is known about the neurodevelopmental consequences of prenatal opioid exposure in infancy, early childhood, and middle childhood. Even less is known about the cognitive, behavioral, and academic outcomes of children who develop NOWS. We review the state of the literature on the neurodevelopmental consequences of prenatal opioid exposure with a particular focus on studies in which NOWS outcomes were examined. Aiming to reduce the incidence of prenatal opioid exposure in the near future, we highlight the need for large studies with prospectively recruited participants and longitudinal designs, taking into account confounding factors such as socioeconomic status, institutional variations in care, and maternal use of other substances, to independently assess the full impact of NOWS. As a more immediate solution,…

OBJECTIVE: To provide an updated birth weight-for-gestational age (BW-for-GA) reference in the United States by using the most recent, nationally representative birth data with obstetric estimates of gestational age (GA). METHODS: We abstracted 3 285 552 singleton births between 22 and 42 weeks' gestation with nonmissing race and/or ethnicity, infant sex, parity, birth weight, and obstetric estimate of GA from the 2017 US natality files. We used 2 techniques (nonlinear, resistant smoothing [4253H] and lambda-mu-sigma) to derive smoothed BW-for-GA curves and compared resulting BW-for-GA cut-points at the third, 10th, 90th, and 97th percentiles with US references from 1999 to 2009. RESULTS: The smoothed BW-for-GA curves from both techniques overlapped considerably with each other, with strong agreements seen between the 2 techniques (>99% agreement; κ-statistic >0.9) for BW-for-GA cut-points at the third, 10th, 90th, and 97th percentiles across all GAs. Cut-points from 2017 using the lambda-mu-sigma method captured 9.8% to 10.2% of births <10th and >90th percentiles and 2.6% to 3.3%…

CONTEXT: Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models. OBJECTIVE: We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development. DATA SOURCES: A total of 14 600 records were identified, and 158 studies were included. STUDY SELECTION: Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials. Outcomes included positive mental health, depressive and anxious symptomatology, violence perpetration and bullying, and alcohol and other substance use. DATA EXTRACTION: Data were…

BACKGROUND: Overuse of antibiotics can facilitate antibiotic resistance and is associated with adverse neonatal outcomes. We studied the association between duration of antibiotic therapy and short-term outcomes of very low birth weight (VLBW) (<1500 g) infants without culture-proven sepsis. METHODS: We included VLBW infants admitted to NICUs in the Canadian Neonatal Network between 2010-2016 who were exposed to antibiotics but did not have culture-proven sepsis in the first week. Antibiotic exposure was calculated as the number of days an infant received antibiotics in the first week of life. Composite primary outcome was defined as mortality or any major morbidity (severe neurologic injury, retinopathy of prematurity, necrotizing enterocolitis, chronic lung disease, or hospital-acquired infection). RESULTS: = 5856) received 0, 1 to 3, and 4 to 7 days of antibiotics, respectively. Antibiotic exposure for 4 to 7 days was associated with higher odds of the composite outcome (adjusted odds ratio 1.24; 95% confidence interval [CI] 1.09-1.41). Each additional day of antibiotic use was…

CONTEXT: Young children have increasing access to interactive applications (apps) at home and at school. Existing research is clear on the potential dangers of overuse of screens, but there is less clarity around the extent to which interactive apps may be helpful in supporting early learning. OBJECTIVE: In this systematic review, we present a narrative synthesis of studies examining whether children <6 years can learn from interactive apps. DATA SOURCES: The PsycInfo, PubMed, ACM Digital Library, and ERIC databases were searched. STUDY SELECTION: Studies were included if the study design was randomized or nonrandomized controlled (quasi-experimental), the sample mean age was <6 years, the intervention involved children playing with an interactive app, and academic, cognitive, or social-emotional skill outcomes were measured. DATA EXTRACTION: Of 1447 studies, 35 were included. RESULTS: Evidence of a learning benefit of interactive app use for early academic skills was found across multiple studies, particularly for early mathematics learning in typically developing children.…

BACKGROUND: Historically, there has been a shortage of child psychiatrists in the United States, undermining access to care. This study updated trends in the growth and distribution of child psychiatrists over the past decade. METHODS: Data from the Area Health Resource Files were used to compare the number of child psychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county. We also examined sociodemographic characteristics associated with the density of child psychiatrists at the county level over this period using negative binomial multivariable models. RESULTS: From 2007 to 2016, the number of child psychiatrists in the United States increased from 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children also grew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth varied widely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC, and SD) and 6 states increasing by >50% (AK, AR, NH, NV, OK, and RI). Seventy percent of counties had no child psychiatrists in…

BACKGROUND: The intestinal microbiome in early infancy affects immunologic development and thus may affect vaccine memory, though few prospective studies have examined such associations. We examined the association of Bifidobacterium levels in early infancy with memory responses to early vaccination measured at 2 years of age. METHODS: In this prospective observational study, we examined the association of Bifidobacterium abundance in the stool of healthy infants at 6 to 15 weeks of age, near the time of vaccination, with T-cell and antibody responses measured at 6 weeks, 15 weeks, and 2 years of age. Infants were vaccinated with Bacillus Calmette-Guérin (BCG) (at birth), oral polio virus (at birth and at 6, 10, and 14 weeks), tetanus toxoid (TT) (at 6, 10, and 14 weeks), and hepatitis B virus (at 6, 10, and 14 weeks). Fecal Bifidobacterium was measured at 6, 11, and 15 weeks. Bifidobacterium species and subspecies were measured at 6 weeks. RESULTS: Mean Bifidobacterium abundance in early infancy was positively associated with the CD4 T-cell responses to BCG, TT, and hepatitis B…

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers,…

Pediatricians render care in an increasingly complex environment, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown since the National Academy of Medicine (formerly the Institute of Medicine) published its report "To Err Is Human: Building a Safer Health System" in 1999. Patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to reveal a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification and diagnostic error. Pediatric health care providers in all practice environments benefit from having a working knowledge of patient safety language. Pediatric providers should serve as advocates for best practices and policies with the goal of attending to risks that are unique to children, identifying and supporting a culture of safety, and…

BACKGROUND AND OBJECTIVES: Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are suggested to be overrepresented in unstable housing and foster care. In the current study, we assess whether LGBTQ youth are overrepresented in unstable housing and foster care and examine disparities in school functioning, substance use, and mental health for LGBTQ youth versus heterosexual youth in unstable housing and foster care. METHODS: A total of 895 218 students (10–18 years old) completed the cross-sectional California Healthy Kids Survey from 2013 to 2015. Surveys were administered in 2641 middle and high schools throughout California. Primary outcome measures included school functioning (eg, school climate, absenteeism), substance use, and mental health. RESULTS: More youth living in foster care (30.4%) and unstable housing (25.3%) self-identified as LGBTQ than youth in a nationally representative sample (11.2%). Compared with heterosexual youth and youth in stable housing, LGBTQ youth in unstable housing reported poorer school functioning (Bs = −0.10 to 0.40), higher…

BACKGROUND AND OBJECTIVES: Social robots (SRs) are increasingly present in medical and educational contexts, but their use in inpatient pediatric settings has not been demonstrated in studies. In this study, we aimed to (1) describe the introduction of SR technology into the pediatric inpatient setting through an innovative partnership among a pediatric teaching hospital, robotics development, and computational behavioral science laboratories and (2) present feasibility and acceptability data. METHODS: Fifty-four children ages 3 to 10 years were randomly exposed to 1 of 3 interventions: (1) interactive SR teddy bear; (2) tablet-based avatar version of the bear; or (3) plush teddy bear with human presence. We monitored intervention enrollment and completion patterns, obtained qualitative feedback on acceptability of SR use from child life-specialist stakeholders, and assessed children's positive and negative affect, anxiety, and pain intensity pre- and postintervention. RESULTS: The intervention was well received and appeared feasible, with 93% of those enrolled completing the study…

OBJECTIVES: To describe the epidemiology of foreign-body ingestions (FBIs) of children <6 years of age who were treated in US emergency departments from 1995 to 2015. METHODS: We performed a retrospective analysis using data from the National Electronic Injury Surveillance System for children <6 years of age who were treated because of concern of FBI from 1995 to 2015. National estimates were generated from the 29 893 actual cases reviewed. RESULTS: On the basis of those cases, 759 074 children <6 years of age were estimated to have been evaluated for FBIs in emergency departments over the study period. The annual rate of FBI per 10 000 children increased by 91.5% from 9.5 in 1995 to 18 in 2015 (R2 = 0.90; P < .001). Overall, boys more frequently ingested foreign bodies (52.9%), as did children 1 year of age (21.3%). Most children were able to be discharged after their suspected ingestion (89.7%). Among the types of objects ingested, coins were the most frequent (61.7%). Toys (10.3%), jewelry (7.0%), and batteries (6.8%) followed thereafter. The rates of ingestions of those products…

OBJECTIVES: Electronic cigarettes (e-cigarettes) are available in nontraditional flavors (eg, fruit and candy) that are banned in combustible cigarettes in the United States. Whether adolescent use of e-cigarettes in nontraditional flavors prospectively predicts continuation of vaping and progression to more frequent vaping is unknown. METHODS: = 478), e-cigarette flavor (or flavors) used was coded into 2 mutually exclusive categories at each wave (use of ≥1 nontraditional flavors [fruit, candy, sweet or dessert, buttery, blends or combinations, and other] versus exclusive use of tobacco, menthol or mint, or flavorless). Flavor used during waves 1 to 4 was modeled as a time-varying, time-lagged regressor of vaping status and frequency outcomes 6 months later at waves 2 to 5. RESULTS: Across waves 1 to 4, there were 739 (93.8%) observations of nontraditional-flavor use and 49 (6.2%) observations of exclusive use of tobacco, mint or menthol, or flavorless e-cigarettes. Use of e-cigarettes in nontraditional flavors (versus only tobacco, mint or menthol, or flavorless) was positively…

BACKGROUND AND OBJECTIVES: Food insecurity and pediatric obesity affect young children. We examine how food insecurity relates to obesity, underweight, stunting, health, and development among children <4 years of age. METHODS: Caregivers of young children participated in a cross-sectional survey at medical centers in 5 US cities. Inclusion criteria were age of <48 months. Exclusion criteria were severely ill or injured and private health insurance. The Household Food Security Survey Module defined 3 exposure groups: food secure, household food insecure and child food secure, and household food insecure and child food insecure. Dependent measures were obesity (weight-age >90th percentile), underweight (weight-age <5th percentile), stunting (height/length-age <5th percentile), and caregiver-reported child health and developmental risk. Multivariable logistic regression analyses, adjusted for demographic confounders, maternal BMI, and food assistance program participation examined relations between exposure groups and dependent variables, with age-stratification: 0 to 12, 13 to 24, 25…