American Academy Of Pediatrics Guidelines Research Articles

Effectiveness of Intranasal Mometasone Furoate vs Saline for Sleep-Disordered Breathing in Children

Obstructive sleep-disordered breathing (SDB) in children is characterized by snoring and difficulty breathing during sleep. SDB affects at least 12% of otherwise healthy children and is associated with significant morbidity. Evidence from small clinical trials suggests that intranasal corticosteroids improve SDB as measured by polysomnography; however, the effect on symptoms and quality of life is unclear. To determine whether intranasal mometasone furoate is more effective than intranasal saline for improving symptoms and quality of life in children with SDB. The MIST trial was a multicenter, randomized, double-blind, placebo-controlled trial, recruiting participants from June 8, 2018, to February 13, 2020. Children aged 3 to 12 years who were referred to a specialist for significant SDB symptoms were included; exclusions were previous adenotonsillectomy, body mass index greater than the 97th percentile, and severe SDB. Randomization was stratified by site, and data were analyzed on an intention-to-treat basis from October 28, 2020, to September 25, 2022. Participants were randomly assigned to receive mometasone furoate, 50 μg, or sodium chloride (saline), 0.9%, 1 spray per nostril daily, dispensed in identical bottles. The primary outcome was resolution of significant SDB symptoms (ie, reduction to a level no longer requiring referral to a specialist as per the American Academy of Pediatrics guidelines) at 6 weeks, measured by parental report of symptoms using the SDB Score. A total of 276 participants (mean [SD] age, 6.1 [2.3] years; 146 male individuals [53%]) were recruited, 138 in each treatment arm. Resolution of significant SDB symptoms occurred in 56 of 127 participants (44%) in the mometasone group and 50 of 123 participants (41%) in the saline group (risk difference, 4%; 95% CI, -8% to 16%; P = .51) with 26 participants lost to follow-up and missing values managed by multiple imputation. The main adverse effects were epistaxis, affecting 12 of 124 participants (9.7%) in the mometasone group and 18 of 120 participants (15%) in the saline group, and nasal itch/irritation, affecting 12 of 124 participants (9.7%) in the mometasone group and 22 of 120 participants (18%) in the saline group. Results of this randomized clinical trial suggest that there was no difference in treatment effect between intranasal mometasone and saline for the management of SDB symptoms. The results suggest that almost one-half of children with SDB could be initially managed in the primary care setting and may not require referral to specialist services, as is currently recommended. Australian New Zealand Clinical Trials Registry: ANZCTRN12618000448246.

Interpretation of the 2022 American Academy of Pediatrics guidelines for the management of hyperbilirubinemia in newborn infants

The American Academy of Pediatrics updated the guidelines for the management of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks in September 2022. Based on the evidence over the past 18 years, the guidelines are updated from the aspects of the prevention, risk assessment, intervention, and follow-up of hyperbilirubinemia in the newborn infants with a gestational age of ≥35 weeks. This article gives an interpretation of the key points in the guidelines, so as to safely reduce the risk of bilirubin encephalopathy and unnecessary intervention.

Prevalence of Hypertension among Children Based on the New American Academy of Pediatrics Clinical Practice Guidelines.

In 2017, the American Academy of Pediatrics (AAP) updated clinical practice guidelines for the diagnosis and management of hypertension in children. The present study aimed to assess the prevalence of hypertension in Iranian children based on the latest guidelines. Data on 7301 student participants (3589 boys and 3712 girls) aged between 7-12 yr were assessed. The data were extracted from the fifth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable Disease (CASPIAN V) school-based study conducted in the 30 provinces of Iran in 2015. Blood pressure (BP) was classified as normal, elevated BP, and stage 1 and 2 hypertension using weighted analysis and the 2017 AAP guidelines. All analyses were performed in STATA 14.0 statistical software, with findings presented in terms of prevalence. The overall prevalence of high BP in Iranian children was 14.7%. In addition, 15.1% of boys had high BP, with 9.4% and 1.7% of them with stage 1 and 2 hypertension, respectively. Moreover, 14.3% of girls had high BP, of which 10% had stage 1 and 1.3% with stage 2 hypertension. For elevated hypertension, it was observed in 4% of boys and 3% of girls. Using the 2017 AAP guidelines demonstrated a higher prevalence of hypertension in children (14.7%) in Iran. The prevalence of hypertension in boys was slightly higher compared to girls.

Improving Prescribing for Otitis Media in a Pediatric Emergency Unit: A Quality Improvement Initiative.

We performed a quality improvement project to improve antibiotic prescribing in a tertiary pediatric EU over 16 months, focusing on shorter prescription durations and WSPs. We assessed AOM management via chart review, then implemented interventions, including clinician education, a guideline card, visual reminders, and updated emails. In addition, we contacted a percentage of families after their visit to assess their child's outcome and parental satisfaction. Our baseline data showed that only 39% of patients prescribed antibiotics were prescribed an appropriate duration based on age and estimated AOM severity, and only 3% were prescribed WSPs. Via 2 plan-do-study-act (PDSA) cycles, we increased the percentage of patients who received appropriate antibiotics to an average of 67%, sustained for >6 months. Follow-up phone calls suggested no difference in satisfaction or need for nonroutine follow-up care based on prescription length. We did not see a substantial increase in WSPs. AOM management in our children's hospital's EU was often inconsistent with AAP guidelines. Two PDSA cycles improved the rate of appropriate duration antibiotics, and follow-up phone calls suggested no difference in satisfaction or need for nonroutine follow-up care based on prescription length. The next steps involve developing an order set and implementing individualized feedback.

High blood pressure pattern amongst adolescents in Lagos, South West Nigeria.

high blood pressure (HBP), once considered rare in adolescents is now a growing health problem. Usually asymptomatic in adolescents, if uncontrolled, can track into adulthood leading to various end-organ complications. In 2017, the American Academy of Pediatrics (AAP) published a new Clinical Practice Guideline (CPG) for screening and management of high blood pressure in children and adolescents to update the 2004 Fourth report. The objective of this study was to determine the prevalence of high blood pressure among adolescents in Mushin Local Government Area (LGA) using the 2017 AAP guidelines. a descriptive cross-sectional study, conducted from August 2020 to December 2020. A two-stage sampling technique was used to select 1490 students aged 10 to 19 years, from 14 secondary schools. Socio-demographic information and relevant clinical data were obtained using a structured questionnaire. The anthropometry and blood pressure measurements were taken according to standard protocol (elevated blood pressure is systolic and/or diastolic blood pressure ≥ 90th percentile but ≤ 95th percentile for age, gender and height). Socio-demographic and anthropometric characteristics were described with descriptive statistics. Categorical variables were summarized using frequency and percentages, while numerical variables were summarized using mean and standard deviation. The predictors of hypertension were determined using logistic regression analysis. study participants were 1490, 49.9% (744) were male and 50.1% (746) females (male: female ratio was 1: 1). Subjects mean age was 14.39 ± 2.79 years. There were 8.9% overweight and 1.7% obese participants. Prevalence of high blood pressure, elevated blood pressure and hypertension were 26.7% (n = 398), 13.8% (n = 205), and 12.9% (n = 193). Middle and late adolescence, when compared to early adolescence, significantly predicted the likelihood of high blood pressure; aOR 1.78, 95%CI: 1.20 - 2.63, p=0.004 and 3.90 (2.69 - 5.67, p=0.001 respectively). Similarly, male sex had increased odds for raised blood pressure when compared to female sex aOR 1.49,95% CI: 1.1 - 2.0, p= 0.009. the prevalence of high blood pressure, elevated blood pressure and hypertension amongst adolescents was high. Early detection and treatment will forestall development of complications.

Newborn Weight Loss Tool and Readmission for Hyperbilirubinemia.

The aim of this study was to determine if the Newborn Weight Loss Tool (NEWT) can predict hospital readmission due to hyperbilirubinemia. This is a case-control study of 93 newborns and 186 controls ≥35 weeks' gestation. All were discharged from the Mother-Baby unit of an urban academic center and subsequently readmitted for hyperbilirubinemia. Controls were matched for date of birth, gestational age, and Bhutani risk zone. All infants were screened for hyperbilirubinemia prior to discharge and managed according to American Academy of Pediatrics guidelines in place at the time. Chi-square, Fisher's exact test, and multivariate analysis were utilized as appropriate. There was no significant difference between the groups for a NEWT < 50% at discharge. More cases than controls breastfed. A significantly greater percentage of cases had NEWT > 50% at readmission than discharge. NEWT > 90% was moderately associated with readmission for hyperbilirubinemia (p = 0.081). NEWT provides a more nuanced assessment of weight loss following birth and can aid in highlighting newborns at risk for readmission due to hyperbilirubinemia. · Weight loss is a risk factor for readmission after birth.. · NEWT is a more nuanced assessment of weight loss.. · NEWT > 90% is associated with readmission for jaundice..

563. Nationwide Trends in Antibiotic Selection for the Treatment of Pediatrics Acute Sinusitis, 2003-2020

Abstract Background Acute sinusitis is a common diagnosis associated with outpatient antibiotic prescribing for children. Infectious Diseases Society of America guidelines (published in 2012) and American Academy of Pediatrics guidelines (published in 2013) for the management of acute sinusitis recommend amoxicillin with or without clavulanate as empiric therapy. Nationwide trends in antibiotic treatment of sinusitis have not been described since guideline publication. Methods We evaluated trends in antibiotic prescriptions for new acute sinusitis diagnoses among commercially insured patients &amp;lt; 18 years old between January 1, 2003 and December 31, 2020 using the MarketScan Research Database. Subjects were identified via an outpatient encounter with an ICD code for acute sinusitis along with an oral antibiotic prescription dispensed on the day of the visit. New diagnoses were defined as having no sinusitis diagnosis in the preceding 180 days. Patients were excluded if they had a diagnosis code for chronic sinusitis or cystic fibrosis in the 6 months prior to the acute sinusitis diagnosis or had a same-day ICD code for another infection that would influence antibiotic selection (acute otitis media, cellulitis/abscess, community acquired pneumonia, Group A Streptococcal pharyngitis/tonsillitis, or urinary tract infection). Results 3.3 million patients met the inclusion and exclusion criteria (Table 1). From 2003-2012, about 50% of patients received amoxicillin with or without clavulanate (Figure 1). Since 2013, the proportion of patients receiving first line antibiotics increased by 13%. The proportion receiving two or more antibiotics was unchanged. Approximately 80% of patients were prescribed 10-13 days of antibiotics (Figure 2). The proportion of patients receiving 14 or more days decreased by 67% over the study period. Conclusion In a nationwide cohort of commercially insured children with acute sinusitis, prescriptions for amoxicillin with or without clavulanate increased after publication of society guidelines. About 40% of patients are prescribed a non-first line antibiotic or multiple antibiotics and nearly 90% of patients are prescribed 10 or more days of antibiotics, presenting important opportunities for antimicrobial stewardship interventions. Disclosures Timothy J. Savage, MD, MPH, MSc, UCB: Contract to Brigham and Women's Hospital.

Blood Pressure Classification Status in Children With CKD Following Adoption of the 2017 American Academy of Pediatrics Guideline

Accurate detection of hypertension is crucial for clinical management of pediatric chronic kidney disease (CKD). The 2017 American Academy of Pediatrics (AAP) clinical practice guideline for childhood hypertension included new normative blood pressure (BP) values and revised definitions of BP categories. In this study, we examined the effect of applying the AAP guideline's normative data and definitions to the Chronic Kidney Disease in Children (CKiD) cohort compared with use of normative data and definitions from the 2004 Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Observational cohort study. Children and adolescents in the CKiD cohort. Clinic BP measurements. BP percentiles and hypertension stages calculated using the 2017 AAP guideline and the Fourth Report from2004. Agreement analysis compared the estimated percentile and prevalence of high BP based on the 2017 guideline and 2004 report to clinic and combined ambulatory BP readings. The proportion of children classified as having normal clinic BP was similar using the 2017 and 2004 systems, but the use of the 2017 normative data classified more participants as having stages 1-2 hypertension (22% vs 11%), with marginal reproducibility (κ=0.569 [95% CI, 0.538-0.599]). Those identified as having stage 2 hypertension by the 2017 guideline had higher levels of proteinuria compared with those identified using the 2004 report. Comparing use of the 2017 guideline and the 2004 report in terms of ambulatory BP monitoring categories, there were substantially more participants with white coat (3.5% vs 1.5%) and ambulatory (15.5% vs 7.9%) hypertension, but the proportion with masked hypertension was lower (40.2% vs 47.8%, respectively), and the percentage of participants who were normotensive was similar (40.9% vs 42.9%, respectively). Overall, there was good reproducibility (κ=0.799 [95% CI, 0.778-0.819]) of classification by ambulatory BP monitoring. Relationship with long-term progression and target organ damage was not assessed. A greater percentage of children with CKD were identified as having hypertension based on both clinic and ambulatory BP when using the 2017 AAP guideline versus the Fourth Report from 2004, and the 2017 guideline better discriminated those with higher levels of proteinuria. The substantial differences in the classification of hypertension when using the 2017 guideline should inform clinical care.

Caregiver knowledge of obstructive sleep apnoea in Down syndrome.

Down syndrome (DS) population has a very high prevalence of obstructive sleep apnoea (OSA), but this remains underdiagnosed. Hence, we aimed to evaluate caregiver's knowledge of OSA and related sociodemographic factors that could contribute to OSA screening patterns in this population. An online survey though the LuMind IDSC Foundation focused on OSA diagnosis, treatments and the number of sleep studies performed. Data were compared between subjects born before and after the American Academy of Pediatrics (AAP) recommendations for OSA screening. Of the caregivers, 724 (parents 96.3%), responded to the survey. The median [interquartile (IQR)] age of the subjects with DS was 12 [20;7] years. The majority (84.3%) had sleep apnoea diagnosis, and half of them were initially referred for a sleep study due to disturbed sleep symptoms. Only 58.7% of the responders were aware of the AAP recommendations. This was linked to higher socioeconomic and/or educational level and to an earlier OSA diagnosis. The median (IQR) age of OSA diagnosis was lowered after the AAP guidelines publication compared with before its publication (3 [4;2] years vs. 10 [18;5] years, P<0.000). Adenotonsillectomy (81.9%) and continuous positive airway pressure (61.5%) were the most commonly prescribed treatments. Few had discussed other new therapies such as hypoglossal nerve stimulation (16.0%). Only 16.0% of the subjects repeated the sleep study to monitor OSA with ageing, and 30.2% had to wait more than 4years between studies. This study reinforces the need to improve OSA knowledge of caregivers and clinicians of individuals with DS to promote an earlier diagnosis and optimal treatment of OSA in this population.

Long-Awaited AAP Hyperbilirubinemia Guidelines Have Arrived.

Long-Awaited AAP Hyperbilirubinemia Guidelines Have Arrived.

Prevalence of and Factors Associated With High Blood Pressure Among Adolescents in India

High blood pressure (BP) in children and adolescents is becoming one of the most common health conditions worldwide and is much more widely prevalent than previously thought. To estimate the prevalence of high BP in adolescents in India and identify associated factors. This cross-sectional study is a secondary analysis of data from the Comprehensive National Nutrition Survey (CNNS, 2016-2018), which used a multistage, stratified, probability proportion to size cluster sampling design to enroll a nationally representative sample of households and individuals aged 10 to 19 years across all states and union territories of India. Adolescents with acute or chronic illness, physical deformity, mental illness, or cognitive disability were excluded from the survey. Because BP was measured only in children between 10 and 19 years of age, only data from children within this age group were included for secondary analyses. Data analysis was performed from March 2021 to April 2022. Anthropometry. On the basis of the 2017 American Academy of Pediatrics guidelines, high BP was defined as stage 1 and 2 hypertension, with BP above the 95th percentile in children younger than 13 years and greater than 130/80 mm Hg in children 13 years or older. The association of age, sex, region, socioeconomic status, body mass index, fasting blood glucose, hemoglobin A1c, and lipid profile with high BP were examined using log binomial regression. Among 16 182 eligible children aged 10 to 19 years (mean [SD] age, 14.2 [2.8] years; 7849 [48.5%] female and 8333 [51.5%] male), 11 718 had valid BP data with 3 repeated readings. the prevalence of high BP was 35.1% (95% CI, 31.5%-38.9%) in children aged 10 to 12 years and 25.1% (95% CI, 22.5%-28.0%) in children 13 years or older. Overweight and obesity were associated with a higher risk of high BP in both younger (prevalence ratio, 1.17; 95% CI, 1.04-1.34) and older children (prevalence ratio, 1.33; 95% CI, 1.18-1.49). The prevalence of high BP in younger children with stunting was high at 40.1% (95% CI, 31.9%-48.9%) and was 21.9% (95% CI, 18.2%-26.1%) among older children with stunting. In both age groups, high BP coexisted with other cardiovascular disease risk factors, such that adolescents with high fasting blood glucose, high hemoglobin A1c, high triglyceride, and high low-density lipoprotein cholesterol levels had a higher risk of high BP. In this cross-sectional study, the prevalence of high BP, along with cardiovascular risk factors, was substantial in Indian adolescents. There is a need to screen and identify adolescents who have high BP and initiate interventions to control the burden of hypertension and its consequences in India.

Health Surveillance in a Down Syndrome Specialty Clinic: Implementation of Electronic Health Record Integrations During the Coronavirus Disease 2019 Pandemic

To address gaps in routine recommended care for children with Down syndrome, through quality improvement during the coronavirus disease 2019 (COVID-19) pandemic. A retrospective chart review of patients with Down syndrome was conducted. Records of visits to the Massachusetts General Hospital Down Syndrome Program were assessed for adherence to 5 components of the 2011 American Academy of Pediatrics (AAP) Clinical Report, "Health Supervision for Children with Down Syndrome." The impact of 2 major changes was analyzed using statistical process control charts: a planned intervention of integrations to the electronic health record for routine health maintenance with age-based logic based on a diagnosis of Down syndrome, created and implemented in July 2020; and a natural disruption in care due to the COVID-19 pandemic, starting in March2020. From December 2018 to March 2022, 433 patients with Down syndrome had 940 visits. During the COVID-19 pandemic, adherence to the audiology component decreased (from 58% to 45%, P<.001); composite adherence decreased but later improved. Ophthalmology evaluation remained stable. Improvement in adherence to 3 components (thyroid-stimulating hormone, hemoglobin, sleep study ever) in July 2020 coincided with electronic health record integrations. Total adherence to the 5 AAP guideline components was greater for follow-up visits compared with new patient visits (69% and 61%, respectively; P<.01). The COVID-19 pandemic influenced adherence to components of the AAP Health supervision for children with Down syndrome, but improvements in adherence coincided with implementation of our intervention and reopening after the COVID-19 pandemic.

Frequency of Potentially Avoidable Surgical Referrals for Asymptomatic Umbilical Hernias in Children.

The American Association of Pediatrics released guidelines in 2019 recommending delay of surgical referral in children with asymptomatic umbilical hernias until 4-5y of age. The purpose of this study was to assess contemporary rates of potentially avoidable referrals in this cohort of children, and to assess whether rates have decreased following guideline release. Retrospective analysis of umbilical hernias referrals evaluated at a single pediatric surgery clinic from October 2014 to August 2021. Potentially avoidable referrals (PAR) were defined as asymptomatic, non-enlarging umbilical hernia referrals in a child 3y of age or younger without a history of incarceration. Referral indication, disposition following clinic visit, and rates of PAR were compared before and after guideline release. A total of 803 umbilical hernia referrals were evaluated, of which 48% were in children 3y of age or younger at time of evaluation ("early" referrals). 33% of all referrals and 68% of early referrals were categorized as a PAR, and rates were similar before and after guideline release (all referrals: 32% versus 33%, P=0.94; early referrals: 68% versus 67%, P=0.94). Of the 333 early referrals who were managed expectantly per guideline recommendations, 2 (0.6%) developed incarceration which was managed with successful reduction and interval repair. One-third of all referrals for umbilical hernia evaluation are potentially avoidable, and this rate did not change following release of American Academy of Pediatrics guidelines. Aligning expectations between surgeons and referring providers through improved education and guideline dissemination may reduce avoidable visits, lost caregiver productivity, and exposure to potentially avoidable surgery.

Adherence to Screen Time and Physical Activity Guidelines is Associated with Executive Function in US Toddlers Participating in the STRONG Kids 2 Birth Cohort Study

To test the hypothesis that healthy weight status and adherence to American Academy of Pediatrics (AAP) guidelines for diet and physical activity would extend to greater executive function (EF) at age 24months. Parents of 24-month-old children from the STRONG Kids 2 cohort study (n=352) completed the Behavioral Rating Inventory of Executive Function for Preschoolers (BRIEF-P) and reported physical activities, diet, and screen time. Toddlers met AAP guidelines if they consumed at least 5 servings of fruits and vegetables, were physically active, refrained from sugar-sweetened beverages, and limited daily screen time to <60minutes. Relationships between EF, 24-month weight status, and meeting AAP guidelines were tested independent of child sex, ethnicity, socioeconomic status, weight status at birth, and maternal pregnancy weight status. Weight-for-length z-score had no effect on EF. Toddlers meeting the screen time guideline had greater EF (β, -0.125; 95% CI, 0.234 to -0.008), inhibitory self-control (β, -0.142; 95% CI, -0.248 to -0.029), and emergent metacognition (β, -0.111; 95% CI, -0.221 to 0.002), indicated by lower BRIEF-P scores. Those with more minutes of screen time had poorer overall EF (β, 0.257; 95% CI, 0.118-0.384), inhibitory self-control (β, 0.231; 95% CI, 0.099-0.354), cognitive flexibility (β, 0.217; 95% CI, 0.082-0.342), and emergent metacognition (β, 0.257; 95% CI, 0.120-0.381). Daily physical activity was associated with greater emergent metacognition (β, -0.116; 95% CI, -0.225 to -0.005). Meeting AAP guidelines for physical activity and screen time was related to greater EF in a demographically homogenous sample of toddlers. Future randomized control trials and more diverse samples are needed to confirm the directionality of this relationship. ClinicalTrials.gov, NCT03341858.

Revised American Academy of Pediatrics Guidelines for Breastfeeding: The Benefits and Challenges

Revised American Academy of Pediatrics Guidelines for Breastfeeding: The Benefits and Challenges

Brief Resolved Unexplained Events (BRUEs): New Name, Similar Challenges

Brief Resolved Unexplained Events (BRUEs): New Name, Similar Challenges

Association of Newborn Telomere Length With Blood Pressure in Childhood

Adult telomere length (TL) is a biological marker of aging associated with vascular health. TL at birth is associated with later life TL and may contain early biological information of later life cardiovascular health and disease. To evaluate whether newborn TL is associated with early life blood pressure differences in childhood. This cohort study was part of the ENVIRONAGE (Environmental Influence on Aging in Early Life) study, a birth cohort of Belgian mother-child pairs with recruitment at birth and a median follow-up of 4.5 years conducted between October 2014 and July 2021. Participants included for analysis provided full data for evaluation at follow-up visit. Data analysis was conducted between August and September 2021. Cord blood and placental average relative TL were measured at birth using quantitative polymerase chain reaction (qPCR). Systolic, diastolic, and mean arterial pressure (MAP) were evaluated at follow-up. High childhood blood pressure (standardized for child age, sex, and height) was defined following the 2017 American Academy of Pediatrics guidelines. Multivariable adjusted linear and logistic regression models were used to associate newborn TL and blood pressure indicators in childhood. This study included 485 newborn children (52.8% girls) with a mean (SD) age of 4.6 (0.4) years at the follow-up visit. Newborn TL was associated with lower blood pressure in childhood. A 1-IQR increase in cord blood TL was associated with a -1.54 mm Hg (95% CI, -2.36 to -0.72 mm Hg) lower diastolic blood pressure and -1.18 mm Hg (95% CI, -1.89 to -0.46 mm Hg) lower MAP. No association was observed with systolic blood pressure. Furthermore, a 1-IQR increase in cord blood TL was associated with lower odds of having high blood pressure at the age of 4 to 6 years (adjusted OR, 0.72; 95% CI, 0.53 to 0.98). In placenta, a 1-IQR increase in TL was associated with a -0.96 mm Hg (95% CI, -1.72 to -0.21 mm Hg) lower diastolic, -0.88 mm Hg (95% CI, -1.54 to -0.22 mm Hg) lower MAP, and a lower adjusted OR of 0.69 (95% CI, 0.52 to 0.92) for having a high blood pressure in childhood. In this prospective birth cohort study, variation in early life blood pressure at school-age was associated with TL at birth. Cardiovascular health may to some extent be programmed at birth, and these results suggest that TL entails a biological mechanism in this programming.

Predicting the Need for Phototherapy After Discharge: Update for 2022 Phototherapy Guidelines.

In 2021, Kuzniewicz et al1 reported that the difference (Δ-total serum bilirubin [TSB]) between last TSB before discharge and the 2004 American Academy of Pediatrics (AAP) phototherapy threshold was an excellent predictor of a postdischarge TSB above the 2004 AAP phototherapy threshold (area under the receiver operating characteristic curve = 0.93). The 2004 AAP hyperbilirubinemia guidelines have since been updated with thresholds for phototherapy that now increase with each week of gestation and are about 1 to 3 mg/dL higher than those from 2004. We sought to quantify how well the predischarge Δ-TSB predicts a postdischarge TSB exceeding the new 2022 AAP phototherapy thresholds.2This retrospective cohort study used the same cohort as our 2021 publication: 163 930 infants born at ≥35 weeks’ gestation July 1, 2012, to December 31, 2017, at 11 Kaiser Permanente Northern California hospitals employing universal TSB screening with at least 1 predischarge TSB. We excluded 9800 for prolonged hospitalization, 4 for direct hyperbilirubinemia, 476 with a predischarge TSB before 12 hours of age, and 2425 who received phototherapy or had a TSB above the 2022 AAP threshold before discharge from all analyses.For all analyses except those used to calculate inverse-probability of censoring weights, we also excluded 4546 infants who, after discharge, received phototherapy before having a TSB above the 2022 AAP threshold. Thus, the final cohort included 146 679 infants. The Kaiser Permanente Northern California institutional review board approved the study (CN-17-3051 01).Our primary predictor was Δ-TSB, defined as the difference between the 2022 AAP phototherapy threshold (for infants of the same age, gestational age and direct antiglobulin test result) and the last inpatient TSB level. (Note in our previous article, our definition was the negative of the above: the TSB minus the threshold.) We created a 5-category Δ-TSB variable to match the AAP 2022 follow-up guideline, as well as an 8-category Δ-TSB variable. We did not have data on transcutaneous bilirubin levels.Our outcomes were a TSB level above the 2022 AAP phototherapy threshold at <24 hours, <48 hours or <30 days from the predischarge TSB. We used linear interpolation to estimate the time that the TSB crossed the phototherapy thresholds.To avoid bias from censoring those who received phototherapy before exceeding the threshold (“subthreshold phototherapy”), we used inverse probability of (non)censoring weights.3 We created models for the probability P of receiving subthreshold phototherapy, based on data available at the time of discharge. We then excluded those infants who had received subthreshold phototherapy and weighted the remaining observations by 1/(1-P) after replacing weights above the 99th percentile with 99th percentile weights.Results by either in 1-mg/dL categories of Δ-TSB or in the 5 categories used in the 2022 guideline (0–<2; 2–<3.5; 3.5–<7; or ≥7 mg/dL) were consistent with those previously reported,1 showing excellent prediction and discrimination (Table 1). Eighty-four percent of the infants had Δ-TSB ≥5.5 mg/dL, with a risk of crossing the phototherapy threshold ≤0.3% (Table 1).We have documented that a single number available at the time of hospital discharge, the Δ-TSB, was a strong predictor of the probability of exceeding the AAP's 2022 phototherapy threshold. The maintenance of discrimination with the higher thresholds is not surprising: Although the slightly raised phototherapy thresholds reduced the risk of the outcome, for an infant with the same TSB level, the Δ-TSB would also be slightly increased, thereby reflecting that lower risk.The excellent discrimination we observed (area under the receiver operating characteristic curve ≥0.93) is largely a result of 84% of the infants having a Δ-TSB that correctly identified them as being at very low risk.Strengths of this study include the large sample size and population with near universal TSB screening. As previously described,1 prediction could be improved by including additional variables, including the most recent rate of rise, formula feeding, age, and gestational age. Nonetheless, our results suggest that a single number, the Δ-TSB divided into 5 categories, provides considerable prognostic information. This supports its use in the 2022 AAP guideline, which provides explicit follow-up recommendations based upon the Δ-TSB in 5 categories.

Perinatal Program Manager

In our NICU, neonates born to women with intraamniotic infection (IAI) received antibiotic treatment, per the Centers for Disease Control and Prevention and the American Academy of Pediatrics guidelines, for early-onset bacterial sepsis evaluation. We conducted a quality improvement project to decrease antibiotic use and NICU admission in neonates born to women with IAI. This project supports the mission of the Association of Women’s Health, Obstetric and Neonatal Nurses by providing education and research to nurses caring for newborns.

Predictors of sleep disordered breathing in children with Down syndrome: a systematic review and meta-analysis.

Children with Down syndrome are at increased risk of sleep disordered breathing (SDB). SDB is associated with significant morbidity including neurocognitive impairment, cardiometabolic disease and systemic inflammation. The identification of clinical markers that may predict SDB is critical in facilitating early diagnosis and treatment, and ultimately, preventing morbidity. The objective of this systematic review was to identify predictors of SDB in patients with Down syndrome. A search was conducted using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and the Cumulative Index to Nursing and Allied Health Literature. A meta-analysis was performed according to the Meta-analyses of Observational Studies in Epidemiology checklist. Our review of the literature identified inconsistent associations between a variety of variables and SDB in children with Down syndrome, although the quality of evidence was poor. Meta-analysis of age and sex identified that children with OSA were older than those without OSA, and there was a similar risk of OSA in males and females, although risk favoured males. Currently, the American Academy of Pediatrics guidelines recommend that children with Down syndrome undergo polysomnography by the age of 4 years. Our review supports the recommendation for routine screening of children with Down syndrome. However, results from our meta-analysis suggest a need for longitudinal screening to diagnose children who may develop SDB as they get older.