Multisystem inflammatory syndrome in U.S. children and adolescents
Feldstein LR, Rose EB, Horwitz SM et al
N Engl J Med (2020) 383:334-346
Multisystem inflammatory syndrome in children (MIS-C) is a recently described complication of coronavirus disease 2019 (COVID-19). The authors of this paper discussed the epidemiology and clinical characteristics of 186 cases of MIS-C in children and adolescents from 26 states. The cases were gathered between March 15 and May 20, 2020, and reported to the United States Centers for Disease Control and Prevention. Six criteria were used to establish the diagnosis of MIS-C, including evidence of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), age younger than 21 years, serious illness resulting in hospitalization, fever for at least 24 h, multisystemic organ involvement, and laboratory evidence of inflammation. The median age of the children was 8.3 years, 70% were positive for SARS-CoV-2, 88% were hospitalized, 62% were male and 73% were previously healthy. Most patients (71%) had at least four organ systems involved, most commonly the gastrointestinal (92%), cardiovascular (80%), hematologic (76%), mucocutaneous (74%) and respiratory (70%) systems. Kawasaki-disease-like features occurred in 40%, with coronary artery aneurysms in 8%. Most patients had elevated inflammatory biomarkers, and most were treated with immunomodulating therapies. The median duration of hospitalization was 7 days, and 80% of patients received intensive care. Four children died, two of whom had pre-existent medical conditions. The authors concluded that multisystem inflammatory syndrome with SARS-CoV-2 in previously healthy children and adolescents resulted in severe life-threatening illness.
Association of media coverage of transgender and gender diverse issues with rates of referral of transgender children and adolescents to specialist gender clinics in the UK and Australia
Pang KC, de Graaf NM, Chew D et al
JAMA Netw Open (2020) 3:e2011161
There has been a worldwide surge in the number of referrals of transgender and gender-diverse (TGD) children and adolescents to gender identity clinics over the last decade. However, the underlying factors accounting for the increase have not been elucidated. The authors of this cross-sectional study investigated whether the increase might be associated with media coverage of TGD-related items. Participants included children and adolescents who were referred to two publicly funded specialist gender services, one located in the United Kingdom (UK) and the other in Australia. Data for 5,242 TGD children ranging in age from birth to 18 years were obtained over an 8-year period during which children and their families were exposed to media coverage of TGD topics. Patients included 4,684 from the UK, of whom 1,847 (39.4%) were designated as male at birth and 2,837 (60.6%) were designated as female; and 558 from Australia, of whom 250 (44.8%) were designated as male at birth and 308 (55.2%) were designated as female. A total of 2,614 news items were identified (UK, 2,194; Australia, 420). Referral rates to each gender service were compared with local TGD-related media coverage during the study period. The authors performed fractional polynomial regression analysis to determine the association between the total number of media items appearing in a given week and the number of referrals occurring either in that same week (week 1) or either of the 2 subsequent weeks (weeks 2 and 3), with separate regression analyses for weeks 1, 2 and 3. To examine the association between referrals and media more closely, the authors also performed nonlinear regression modeling on week-to-week data. The annual number of TGD individuals referred to both specialist gender clinics was positively correlated with the number of TGD-related local media stories appearing each year (Spearman r=1.0; P<0.001). Weekly referral rates in both the UK (week 1: β=0.16; 95% confidence interval [CI], 0.03–0.29; P=0.01) and Australia (week 2: β=0.23; 95% CI, 0.11–0.35; P<0.001) were also associated with the number of TGD-related items appearing within the local media. The authors concluded that media coverage of topics of direct relevance and interest to TGD children and their families may encourage them to seek out clinics specializing in gender identity services.
Early-onset neonatal sepsis 2015 to 2017, the rise of Escherichia coli, and the need for novel prevention strategies
Stoll BJ, Puopolo KM, Hansen NI et al
JAMA Pediatr (2020) 174:e200593
Neonatal early onset sepsis (EOS) is an important cause of morbidity and mortality. Optimal guidance regarding recommendations for intrapartum antibiotics to prevent EOS and for empirical antibiotic treatment of newborns at risk for EOS depends on ongoing longitudinal surveillance to characterize its epidemiology, microbiology and antibiotic susceptibilities. The authors conducted a prospective surveillance study of a cohort of 217,480 term and preterm infants from 18 centers in the United States between 2015 and 2017. The infants were born at a gestational age (GA) of at least 22 weeks with a birth weight of greater than 400 g. EOS was defined by isolation of pathogens from blood or cerebrospinal fluid within 72 h of birth and antibiotic treatment for at least 5 days or until death. There were 235 cases (54% male). The highest incidence occurred in infants with GA of 22–28 weeks (18.5 cases/1,000). No significant differences in incidence were observed by gender, race or ethnicity. Escherichia coli (E. coli [36.6%]) and group B streptococcus (GBS [30.2%]) were the most common pathogens. E. coli occurred mainly in preterm infants (51.9%), whereas GBS primarily affected the same percentage of term infants. Intrapartum antibiotics were administered to 162 mothers (68.9%), usually for suspected chorioamnionitis. Empirical neonatal antibiotic treatment most often included ampicillin and gentamicin. Neonates with EOS generally developed signs of illness within 72 h of birth. All affected term infants survived, whereas 29.0% of infants with a GA less than 37 weeks died. Compared with earlier surveillance from 2006 to 2009, the rate of E. coli infection increased among very-low-birth-weight (401–1,500 g) infants (8.7 vs. 5.1 per 1,000 live births). In most cases, ampicillin and gentamicin were effective. The authors concluded that the incidence and associated mortality of EOS disproportionately affected preterm infants. The increase in E. coli infections among very-low-birth-weight infants was of particular concern, warranting continued study.
Association of nonoperative management using antibiotic therapy vs. laparoscopic appendectomy with treatment success and disability days in children with uncomplicated appendicitis
Minneci PC, Hade EM, Lawrence AE et al
JAMA (2020) 324:581-593
Uncomplicated appendicitis in children can be treated nonoperatively with antibiotics and might lead to fewer days of disability than conventional surgical treatment. This multi-institutional nonrandomized controlled intervention study evaluated the success rate of nonoperative management. The investigators compared differences in treatment-related disability, patient satisfaction, health-related quality of life, and complications between nonoperative management and surgery in 1,068 children with uncomplicated appendicitis. Patients were treated between 2015 and 2018 at 10 tertiary-care children’s hospitals in 7 states in the United States. Primary outcomes assessed at 1 year were disability days (number of days the child was unable to participate in all normal activities because of appendicitis-related care) and success rate of nonoperative management (proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year). The threshold success rate for nonoperative management was set at 70%, and the threshold clinically important difference in mean disability days was 3 days, with the authors anticipating a 5-day difference. Three hundred seventy (35%) children and their families chose antibiotics and 698 (65%) chose urgent laparoscopic appendectomy. Characteristics of the nonoperative group compared with the surgical group were median age, 12.3 years vs. 12.5 years; caregivers with a bachelor’s degree, 29.8% vs. 23.5%; and a diagnostic US study, 79.7% vs. 74.5%. Eight hundred six children (75%) had complete follow-up, including 284 (77%) in the nonoperative group and 522 (75%) in the surgery group. At 1 year, the success rate of nonoperative management of uncomplicated appendicitis was 67.1%. Nonoperative management was associated with significantly fewer patient disability days at 1 year than surgery (6.6 vs. 10.9 days; mean difference −4.3 days). Of 16 other prespecified secondary end points, 10 showed no significant difference. Satisfaction with decision scores were significantly lower for the nonoperative group at 30 days and at 1 year. Quality-of-life scores were significantly higher in the nonoperative group at 30 days but not significantly different at 1 year. The major limitation of this study was the substantial loss to follow-up, such that comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.
Sex differences in surgically correctable congenital anomalies: a systematic review
Black AJ, Lu DY, Yefet LS et al
J Pediatr Surg (2020) 55:811-820
Although most surgically correctable congenital anomalies anecdotally occur in males, an accurate assessment of the magnitude of this observed difference has been lacking. This study compared the prevalence and outcomes of 14 surgically correctable congenital anomalies between genders based on a systematic review of published studies. The study was registered on PROSPERO, an international database of prospectively registered systematic reviews in health and social care, and a review was undertaken according to PRISMA guidelines. The authors identified 42,722 studies, of which they ultimately included 68 in the analysis. All included anomalies had more than 1,000 patients except for duodenal atresia (n=787) and intestinal duplication (n=148). Congenital anomalies were significantly more prevalent in males than females in 10/14 anomalies (i.e. Hirschsprung disease, omphalomesenteric duct, congenital diaphragmatic hernia, anorectal malformation, malrotation, esophageal atresia, congenital pulmonary airway malformation, intestinal atresia, omphalocele and gastroschisis; P<0.001). There was no gender difference in the prevalence of duodenal atresia or intestinal duplication (P=0.88 and P=0.65, respectively). Biliary anomalies (biliary atresia and choledochal cyst) were significantly more prevalent in females than males. This study showed that males have higher prevalence rates of most surgically correctable congenital anomalies. The authors opined that further investigation is required to elucidate the embryology underlying this gender distribution and to determine whether gender influences outcomes.
Abstracted by: Harriet J. Paltiel
E-mail: harriet.paltiel@childrens.harvard.edu