Predicting Survival Without Disability Among Preterm Infants

A recent article (J Bourke et al. .J Pediatr 2019; 215: 90-7) made me wonder if my outlook on disability-free survival of preterm infants has been skewed by the population that I encounter.  That is, the outcomes from this large Australia study were better than I would have guessed.

This retrospective cohort study identified 720.091 live births from 1983-2010; in this group, 12,083 were diagnosed with a disability and 5,662 died. The authors sought to determine rates of intellectual disability or autism as identified by the IDEA (Intellectual Disability Exploring Answers) database.  Because this is a retrospective study, it did not capture milder and more common neurodevelopmental disorders like attention deficit hyperactivity disorder.

Key findings:

The probability of disability-free survival to 25 years was the following:

  • 4.1% for those born at 22 weeks gestation
  • 19.7% for those born at 23 weeks gestation
  • 42.4% for those born at 24 weeks gestation
  • 53.0% for those born at 25 weeks gestation
  • 78.3% for those born at 28 weeks gestation
  • 97.2% for those born full term (39-41 weeks)

Risk factors for lower rates of disability-free survival:

  • Aboriginal population (instead of Caucasian), low Apgar score, male sex, low socioeconomic status, and remote region of residence

My take: This data shows the marked improvement in outcomes with longer gestation age.

No Show (“Unattended Appointment”) Data

A recent study (JC Bohnhoff et al. Pediatrics ) provided data on “unattended appointments.” Thanks to John Pohl for this reference from his twitter feed. Link to Full Abstract: Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral (article behind paywall).

Key points:

  • Of 20 466 referrals, 13 261 (65%) resulted in an appointment scheduled within 90 days and 10 514 (51%) resulted in a visit attended within 90 days.
  • Compared with appointments scheduled within 7 days, appointments with intervals from referral to scheduled appointment exceeding 7 days were associated with decreasing likelihood of visit attendance (adjusted odds ratio 8–14 days 0.48; 95% confidence interval 0.37–0.61).
  • Patient factors associated with decreased likelihood of both appointment scheduling and visit attendance included African American race, public insurance, and lower zip code median income.

My take: To reduce no show rates, shorter wait times and frequent reminders are important.

Lullwater Park. Atlanta

The High Toll of Sudden Infant Death

Sudden unexpected infant death (SUID) is not frequently an issue that is addressed by pediatric gastroenterology.  However, it is very common and needs to  be considered as we see infants with reflux, irritability, diarrhea, and dyschezia.

A recent report (DR Roehler et al. J Pediatr 2019; 212: 224-7) puts the magnitude of this problem into perspective.

Key points:

  • From 2013-2015, there was an average of 3523 US infants each year who died from SUID, peaking at 1-2 months of life.
  • The average annual risk of SUID during the first year of life was more than 5 times the peak risk of mortality from firearms homicide, motor vehichle-traffic, drugs/opioid overdose, and suicide.
  • More black infants died of SUID in the first year than black children who died from firearm homicides in all of childhood through age 19 years.
  • SUID deaths from 2013-2015 (10,568) was similar to the total number of motor vehicle-traffic deaths in all of childhood (10,714) and greater than the total number of any of the other causes.
  • Rates of SUID deaths were much higher for non-hispanic blacks than non-hispanic whites or hispanics.  Peak rates reached 481 per 100,000 per month compared with 215 per 100,000 per month and 130 per 100,000 per month respectively in these three groups (Figure 1).

Related study: AB Erck Lambert et al. Pediatrics 2019; 13.pii.e20183408.  In a SUID database analysis, 14% (250) of SUID cases from 2011-2014 were due to suffocation, most commonly due to soft bedding (69%), overlay (19%), and wedging (12%).

My take: The first year of life, particularly the first 3 months, is a very dangerous time for infants.  More attention to SUID could prevent a great amount of tragedy.

Related blog posts:

Useful website: Charlieskids.org This website has a book called “Sleep Baby Safe and Snug” which incorporates updated recommendations on safe sleep practices.

Children should sleep in the same room but on a separate surface from their parents for at least the first six months of their lives, and ideally the first year. They say that this can halve the risk of SIDS…You can read the AAP’s full guidance here. These are a few more of the pediatricians’ recommendations:

  • Infants under a year old should always sleep lying on their backs. Side sleeping “is not safe and is not advised,” the AAP says.
  • Infants should always sleep on a firm surface covered by only a flat sheet. That’s because soft mattresses “could create a pocket … and increase the chance of rebreathing or suffocation if the infant is placed in or rolls over to the prone position.”
  • Any other bedding or soft objects, like pillows or stuffed animals, could obstruct a child’s airway and increase the risk of SIDS and suffocation, according to the AAP.
  • The pediatricians say breastfeeding reduces the risk of SIDS.
  • The same goes for pacifiers at nap time and bedtime, although the doctors say the “mechanism is yet unclear.” They add that “the protective effect is observed even if the pacifier falls out of the infant’s mouth.”
  • Smoking – both during pregnancy and around the infant after birth – can increase the risk of SIDS. Alcohol and illicit drugs during pregnancy can also contribute to SIDS, and “parental alcohol and/or illicit drug use in combination with bed-sharing places the infant at particularly high risk of SIDS,” the pediatricians say.

Pittock Mansion, Portland, OR

 

Blaming Reflux for BRUEs -Not Changing Despite Guideline Recommendations

Briefly noted: DR Duncan et al. J Pediatr 2019; 211: 112-9.

In this retrospective cohort study of infants with brief resolved unexplained events (BRUEs) at Boston Children’s Hospital, the authors examined guideline implementation among 359 subjects in the year before and the year after AAP guidelines.

Key findings:

  • There were no significant changes in practice after guideline publication
  • Only 13% had videofluoroscopic swallow study performed; 72% of these showed aspiration/penetration
  • No subject had reflux testing, “yet reflux was implicated as the cause” for BRUE in 40%. Children continued to be “discharged on acid suppression despite lack of efficacy”

My take: The pendulum is (slowly) starting to swing back from blaming everything (including BRUEs) on reflux but this change is not evident in this study.

Related blog posts:

Vaccine Injury Claims Are Rare

NY Times: Vaccine Injury Claims Are Few and Far Between

An excerpt:

The data comes from the National Vaccine Injury Compensation Program, a no-fault system begun in 1988 after federal law established it as the place where claims of harm from vaccines must be filed and evaluated. It currently covers claims related to 15 childhood vaccines and the seasonal flu shot.

Over the past three decades, when billions of doses of vaccines have been given to hundreds of millions of Americans, the program has compensated about 6,600 people for harm they claimed was caused by vaccines. About 70 percent of the awards have been settlements in cases in which program officials did not find sufficient evidence that vaccines were at fault…

The Centers for Disease Control and Prevention has estimated that vaccines prevented more than 21 million hospitalizations and 732,000 deaths among children over a 20-year period….

There were about two claims of injury for every one million doses of all vaccines distributed in the United States from 2006 through 2017, the period for which the injury compensation program has dosage data. It says more than 3.4 billion vaccine doses were distributed during that time.

The rarity of claims is especially notable because the program aims to make it easy to file a petition…

A growing proportion of recent claims, about half of all petitions since 2017, do not involve the content of vaccines themselves. Instead, they refer to shoulder injuries, usually in adults, that occurred because a health provider injected a vaccine too high on the shoulder, or into the joint space instead of into muscle tissue. That may cause an inflammatory response leading to shoulder pain and limited motion.

My take (from Paul Offit, MD): “The most dangerous aspect of giving your child vaccines is driving to the office to get them.”

Related blog posts:

Early Psychosocial Environment and Cardiometabolic Risk

“It is easier to build strong children that to repair broken men”

-Frederick Douglass

This quote comes from a previous lecture on adverse childhood experiences (ACEs) and comes to mind after reading a recent study: JR Doom et al. J Pediatr 2019; 209; 85-91.

This study examined 588 adolescents (16-18 yrs) from a longitudinal cohort that began in infancy (in Chile).

Methods: Psychosocial environmental factors including depressive symptoms, stressful life events, poor support for child development, father absence, and socioeconomic status was reported by mothers at 6-12 months of age.  These factors were analyzed to determine association with adolescent cardiometabolic parameters including BMI, higher blood pressure, anthropometric risk factors for cardiovascular disease, biomarkers for cardiovascular disease (e.g. triglycerides, HOMA, cholesterol) and metabolic syndrome

Key findings:

  • Infants with poor psychosocial environments had higher BMIs at 10 years and in adolescence, higher blood pressures, greater anthropometric risk, worsened cardiovascular biomarkers, and higher likelihood of metabolic syndrome (aOR 1.5)
  • The Figure in the article shows sequential worsening by quartiles -those with the highest risk based on psychosocial stress composite were worse on these outcomes compared to the 2nd highest risk factor quartile group. And in turn, the 2nd highest risk group >3rd highest risk group >lowest quartile.
  • “It is unknown whether these associations may be reversible.”

My take: While these results show a clear association of early life factors and worsened cardiovascular/metabolic outcomes, the mechanism for this is unclear.  Is this related to diet, less physical activity, stress hormones, a combination or other factors?

Related blog post:

How Often is Arthritis a Presenting Feature of Pediatric IBD & How to Make the Right Diagnosis

A recent retrospective study (R Levy et al. J Pediatr 2019; 209: 233-5) analyzed the musculoskeletal presenting manifestations of pediatric inflammatory bowel disease (IBD).

In their cohort of 715 patients with IBD, 137 had arthritis and/or arthralgia.  28 of these 137 patients (3.9% of total cohort) had arthritis preceding the diagnosis of IBD and were eligible for this study.  Only 23 had complete data and were compared with 46 children with arthritis due to JIA (n=21), FMF (n=7), and postinfectious arthritis (n=18).

Key findings:

  • Patients with subsequent IBD diagnosis were more likely to have sacroiliac involvement (34.8% vs. 2.2%), more likely to have anemia (mean hgb 10.5 vs 12), more likely to have low albumin (mean 3.5 vs 4.3) and to have higher inflammatory markers (ESR 81 vs 46; CRP 6.6 vs 4.5 mg/dL)
  • In patients with calprotectin levels, 5 of 6 were >300 mg/kg and one was borderline
  • On direct questioning at time of IBD diagnosis, prolonged gastrointestinal symptoms (e.g. abdominal pain, diarrhea, weight loss, aphthous ulcers) were evident in 78%.
  • 4 of the 23 (17.3%) were diagnosed with IBD during the primary investigation. Ultimately, Crohn’s diagnosis was established in 87% of the IBD group.

My take: This study is important for pediatricians and rheumatologists. ~4% of children presenting with arthritis have IBD.  Careful interrogation for GI symptoms (and perianal exam) will avoid diagnostic delay in most patients as would a stool calprotectin. Features like sacroileitis, and abnormal labs should also increase the suspicion for IBD.

Briefly noted: In a study discussing pediatrician beliefs about JIA (MR Pavo, J de Inocencio, J Pediatr 2019; 209: 236-9) there is an important caveat for GI doctors:

“It is clear that booster vaccinations against measles, mumps, rubella, or varicella zoster virus, can be considered in patients receiving < 15 mg/m-squared/week of MTX [methotrexate]”  (Pediatr Rheumatol Online J 2018; 16: 46).

Related blog post:

  • IBD Update Feb 2019 -last entry shows study indicating that patients with IBD and arthritis were more likely to require biologics.

Calprotectin:

El Retiro Park, Madrid