Pediatric dermatofibromas: Truncal predominance in younger children.

Pediatric dermatofibromas are considered rare in young children and have not been well characterized, often misdiagnosed clinically. We performed a retrospective case series of children younger than 18 years with histopathologically diagnosed dermatofibromas at our institutions and evaluated age at onset and diagnosis, sex, lesion location, and size, associated symptoms, change over time, and pre-biopsy diagnosis. Overall, dermatofibromas were most common on the back and chest (20/53; 38%), followed by the legs (15/53; 28%) and arms (12/53; 23%) with the most common pre-biopsy diagnosis of "cyst" (23/53; 43%), followed by dermatofibroma (16/53; 30%), and pilomatricoma (12/53; 23%). Our study reinforces previous findings of truncal predominance of pediatric dermatofibromas, different from adults.

Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study.

OBJECTIVES: This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. METHODS: A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. RESULTS: Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). CONCLUSIONS: Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Moonless night sky increases Isistius species (cookiecutter shark) and live human contact.

The nocturnal feeding behavior and zoogeographical habitat of cookiecutter sharks Isistius brasiliensis and Isistius plutodus (Isistius spp.) greatly reduces interaction of this species with live humans. Attacks on live humans are exceedingly rare with 7 cases reported worldwide, 6 of them in Hawai'i, and 5 of these occuring among channel swimmers. Published research suggests that periods of bright moonlight may increase Isistius spp. contact with live humans and does not otherwise identify significant trends or risk factors. Yet 5 of the 6 Isistius spp. bites on live humans in Hawai'ian waters occurred with the moon set and after nautical twilight end and before nautical twilight start. From 1961-2023 in Hawai'i, 129 successful solo channel crosses and 5 Isistius spp. related injuries in the habitat of cookiecutter sharks were analyzed across two groups: one where both the moon and sun were set (dark group) and one where the moon and/or sun was in the sky (light group). There was a significant difference for swimmers bitten by Isistius spp. in the dark 4 (12%) versus light groups 1 (1%), p = 0.012, RR 12.6 (95% confidence interval: 1.5-108.9). Swim start time and year was also significant (Pearson correlation 0.566, p <0.001). Swimmer gender and use of shark deterrent devices and artificial illumination were not significant. The growing popularity of channel swimming in Hawai'i and swim start times have contributed to an increasing likelihood of live human and Isistius spp. contact and a moonless night sky is a significant risk factor for this interaction.

Profibrotic COVID-19 subphenotype exhibits enhanced localized ER-dependent HSP47+ expression in cardiac myofibroblasts in situ.

We recently described a subgroup of autopsied COVID-19 subjects (∼40%), termed 'profibrotic phenotype,' who exhibited clusters of myofibroblasts (Mfbs), which were positive for the collagen-specific chaperone heat shock protein 47 (HSP47+) in situ. This report identifies increased, localized (hot spot restricted) expression of αSMA, COLα1, POSTN and FAP supporting the identity of HSP47+ cells as myofibroblasts and characterizing a profibrotic extracellular matrix (ECM) phenotype. Coupled with increased GRP78 in COVID-19 subjects, these data could reflect induction of the unfolded protein response for mitigation of proteostasis (i.e., protein homeostasis) dysfunction in discrete clusters of cells. ECM shifts in selected COVID-19 subjects occur without significant increases in either global trichrome positive staining or myocardial injury based quantitively on standard H&E scoring. Our findings also suggest distinct mechanism(s) for ECM remodeling in the setting of SARS-CoV-2 infection. The ratio of CD163+/CD68+ cells is increased in hot spots of profibrotic hearts compared with either controls or outside of hot spots in COVID-19 subjects. In sum, matrix remodeling of human COVID-19 hearts in situ is characterized by site-restricted profibrotic mediated (e.g., HSP47+ Mfbs, CD163+ Mφs) modifications in ECM (i.e., COLα1, POSTN, FAP), with a strong correlation between COLα1 and HSP47+cells within hot spots. Given the established associations of viral infection (e.g., human immunodeficiency virus; HIV), myocardial fibrosis and sudden cardiac death, early screening tools (e.g., plasma biomarkers, noninvasive cardiac magnetic resonance imaging) for diagnosis, monitoring and treatment of fibrotic ECM remodeling are warranted for COVID-19 high-risk populations.

Intralesional measles, mumps, and rubella vaccine after failure of intralesional Candida antigen for the treatment of recalcitrant pediatric warts.

Numerous studies have investigated the efficacy of intralesional immunotherapy for warts, but there are a lack of studies investigating the efficacy of alternative intralesional immunotherapies following failure of initial intralesional immunotherapy. In this retrospective study, we aimed to investigate the efficacy of intralesional measles, mumps, and rubella vaccine for the treatment of pediatric warts following failure of intralesional therapy with Candida antigen. Following intralesional measles, mumps, and rubella vaccine administration, 8/51 (15.5%) patients had complete resolution of their warts, 6/51 (12%) had near complete resolution, 19/51 (37%) had partial improvement, 12/51 (23.5%) had no change, and 6/51 (12%) had worsening. Although limited by retrospective nature and low sample size, our results demonstrate that intralesional immunotherapy with measles, mumps, and rubella vaccine provides an alternative therapeutic option for the treatment of recalcitrant pediatric warts in patients who fail to respond to intralesional Candida antigen.

Does High-Intensity Exercise Cause Acute Liver Injury in Patients with Fontan Circulation? A Prospective Pilot Study.

The Fontan procedure results in chronic hepatic congestion and Fontan-associated liver disease (FALD) characterized by progressive liver fibrosis and cirrhosis. Exercise is recommended in this population, but may accelerate the progression of FALD from abrupt elevations in central venous pressure. The aim of this study was to assess if acute liver injury occurs after high-intensity exercise in patients with Fontan physiology. Ten patients were enrolled. Nine had normal systolic ventricular function and one had an ejection fraction < 40%. During cardiopulmonary exercise testing, patients had near-infrared spectroscopy (NIRS) to measure oxygen saturation of multiple organs, including the liver, and underwent pre- and post-exercise testing with liver elastography, laboratory markers, and cytokines to assess liver injury. The hepatic and renal NIRS showed a statistically significant decrease in oxygenation during exercise, and the hepatic NIRS had the slowest recovery compared to renal, cerebral, and peripheral muscle NIRS. A clinically significant increase in shear wave velocity occurred after exercise testing only in the one patient with systolic dysfunction. There was a statistically significant, albeit trivial, increase in ALT and GGT after exercise. Fibrogenic cytokines traditionally associated with FALD did not increase significantly in our cohort; however, pro-inflammatory cytokines that predispose to fibrogenesis did significantly rise during exercise. Although patients with Fontan circulation demonstrated a significant reduction in hepatic tissue oxygenation based on NIRS saturations during exercise, there was no clinical evidence of acute increase in liver congestion or acute liver injury following high-intensity exercise.

Effect of Presenting Survival Information as Text or Pictograph During Periviable Birth Counseling: A Randomized, Controlled Trial.

OBJECTIVES: To examine whether presenting a 30% or a 60% chance of survival in different survival information formats would influence hypothetical periviable birth treatment choice and whether treatment choice would be associated with participants' recall or their intuitive beliefs about the chances of survival. STUDY DESIGN: An internet sample of women (n = 1052) were randomized to view a vignette with either a 30% or 60% chance of survival with intensive care during the periviable period. Participants were randomized to survival information presented as text-only, in a static pictograph, or in an iterative pictograph. Participants chose intensive care or palliative care and reported their recall of the chance of survival and their intuitive beliefs about their infant's chance of survival. RESULTS: There was no difference in treatment choice by presentation with a 30% vs 60% chance of survival (P = .48), by survival information format (P = .80), or their interaction (P = .18). However, participants' intuitive beliefs about chance of survival significantly predicted treatment choice (P < .001) and had the most explanatory power of any participant characteristic. Intuitive beliefs were optimistic and did not differ by presentation of a 30% or 60% chance of survival (P = .65), even among those with accurate recall of the chance of survival (P = .09). CONCLUSIONS: Physicians should recognize that parents may use more than outcome data to make treatment choices and in forming their own, often-optimistic, intuitive beliefs about their infant's chance of survival. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04859114.

Pediatric Orbital Cellulitis/Abscess: Microbiology and Pattern of Antibiotic Prescribing.

INTRODUCTION: The treatment for pediatric orbital cellulitis/abscess is trending towards intravenous antibiotic management alone in appropriate cases. Without cultures to guide therapy, knowing the local microbiology is of utmost importance in managing these patients. METHODS: We conducted a retrospective case series for patients age 2 months to 17 years, who were hospitalized between January 1, 2013, and December 31, 2019, to evaluate the local microbiology and pattern of antibiotic prescribing in pediatric orbital cellulitis. RESULTS AND DISCUSSION: Of 95 total patients, 69 (73%) received intravenous antibiotics only and 26 (27%) received intravenous antibiotics plus surgery. The most common organism cultured was Streptococcus anginosus, followed by Staphylococcus aureus, and group A streptococcus. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence was 9%. MRSA-active antibiotics remain the most frequently used antibiotics.

Adolescent Drug Ingestions Requiring ICU Stay: Single-Center Retrospective Cohort Study.

OBJECTIVES: Ingestions are a prevalent form of self-harm in teenagers and are unfortunately an increasingly common reason for admission to both acute care and critical care services. The goal of this study was to identify characteristics associated with requiring PICU stay among adolescents hospitalized for ingestions. DESIGN: Retrospective cohort study comparing patients admitted to hospital medicine service and critical care service from January 2019 to December 2019. SETTING: Freestanding children's hospital in the midwestern United States. PATIENTS: Adolescents 12-18 years old hospitalized for ingestion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 209 patients included in the study cohort, 95 required PICU admission. High-risk behaviors (having had sex or usage of alcohol, drugs, tobacco, or vaping) were endorsed by 190 of 209 patients (91%). We compared patient characteristics, ingestion history, workup, and pharmacological and PICU-specific interventions between patients hospitalized on the hospital medicine service and the PICU. We failed to identify an association between reason for ingestion, substance ingested, and previously identified suicide risk factors including previous suicide attempt, previous self-harm, and psychiatric comorbidity and admission to PICU, as opposed to non-PICU admission. PICU stay was associated with longer peak corrected QT interval value, receiving a pharmacological intervention, and longer duration of hospital stay. Fifteen of 95 patients (16% [95% CI, 9-25%]) in the PICU received a PICU-specific intervention. CONCLUSIONS: We failed to identify specific patient demographics or mental behavioral health characteristics associated with PICU stay after ingestion. Therefore, we believe that all adolescents hospitalized due to ingestion-irrespective of disposition-should receive standardized high-risk behavior screening due to the pervasive nature of these behaviors among this patient population. PICU-specific care, beyond observation, could be needed in as high as one-in-four PICU admissions. Further research is needed to inform optimal disposition and resource allocation for this patient population.

After "The Talk": Adolescents' Perspectives Reveal Need for Improvement in Hospital Sexual Health Care Delivery.

OBJECTIVES: To fill access gaps for adolescents, addressing sexual and reproductive health (SRH) is recommended in nontraditional settings. In previous improvement work, we increased documentation of sexual history to >80% of adolescents hospitalized on our pediatric hospital medicine (PHM) service. This study assessed adolescents' perception of SRH conversations with hospital providers and the extent to which they were helpful. METHODS: Postdischarge survey of patients 13 to 17 years discharged from the PHM service at an academic children's hospital between August 2019 and March 2020. Survey items included demographics; whether confidential discussion of sexual health topics such as contraception, sexually transmitted infection (STI), and sexual orientation occurred; perceptions of these discussions, and sexual history. RESULTS: Eighty-three patients enrolled and 44 (53%) completed the survey after discharge. A total of 68% of respondents were female and median age was 15 years (interquartile range 14-16). A total of 77% reported discussing SRH privately with a PHM provider. A total of 18% recalled discussing condoms, and 63% rated the discussion helpful. A total of 27% of females reported discussing birth control, and 40% rated it helpful. A total of 57% recalled discussing sexual orientation, and 40% rated it helpful. None reported discussions of STI testing with PHM. Of the 23% who were sexually active, none reported being given condoms. CONCLUSIONS: Analysis of adolescent patient experiences identified opportunities for continued improvement in the content and quality of SRH discussions, specifically regarding offering STI testing, condom distribution, and sexual orientation conversations. Our work highlights the importance of incorporating patient-reported data into improvement work to ensure providers are addressing targeted gaps in adolescent care.

Retrospective Comparison of Cefdinir, Cephalexin, and Sulfamethoxazole-Trimethoprim in the Treatment of Outpatient Pediatric Urinary Tract Infections.

This retrospective single-center study included children aged 2 months to 18 years who were prescribed an oral antibiotic for microbiologically confirmed urinary tract infection (UTI). The primary outcomes were re-encounter to the hospital, emergency department, or urgent care within 30 days and modification of the antibiotic regimen within 14 days. Development of Clostridioides difficile (C difficile) infection or new allergic reaction to the antibiotic prescribed was the secondary outcome. The sample included 2685 children. Rates of re-encounter were similar regardless of the initial antibiotic prescribed (P = .88), and patients who received cefdinir had a lower rate of medication changes (5%) compared with both cephalexin (14%) and sulfamethoxazole-trimethoprim (15%) (P ≤ .001). The most common reason for medication change was susceptibility interpretation. Given its low side-effect profile and narrow spectrum compared with the alternatives, cephalexin appears to be a reasonable choice as first-line therapy for the treatment of uncomplicated pediatric UTI.

Safety and Efficacy of Direct Oral Anticoagulants for Treatment of Venous Thromboembolism in Pediatric Oncology Patients.

BACKGROUND/OBJECTIVES: Children with cancer have an increased risk for developing a venous thromboembolism (VTE) during their treatment course. Direct oral anticoagulants (DOACs) represent a relatively new class of oral medications to treat VTE; however, data are limited to support use in this patient group. Given the safety and efficacy data from numerous perspective adult studies, providers now consider off-label use in select children. METHODS: We performed a single-center, retrospective review of children 0 to 20 years of age from 2012 to 2020 with malignancy and confirmed VTE, with the objective to evaluate the hypothesis that the safety and the efficacy of DOACs are noninferior to enoxaparin in this population. The primary composite efficacy outcome comprises symptomatic recurrent VTE, death due to VTE, and thrombus progression. The principal safety outcome is a combination of major and clinically relevant nonmajor bleeding. RESULTS: The safety and efficacy outcomes collected revealed that DOAC use was equivalent when compared with the enoxaparin group for treatment of VTE. One patient in the DOAC group had clinically relevant, nonmajor bleeding compared with 2 patients in the enoxaparin group. No treatment failures were observed. CONCLUSIONS: This single-center study suggests that DOACs are both safe and efficacious for the treatment of VTE in children with cancer. It also highlights the need for larger studies to address this clinical question.

Pediatric COVID-19 Hospitalizations During the Omicron Surge.

BACKGROUND: Treatment recommendations for children hospitalized with COVID-19 during the winter 2021-2022 omicron variant surge included remdesivir and dexamethasone for hypoxia and remdesivir for patients at risk of severe illness, including those with comorbidities. The omicron variant caused many otherwise-healthy children without hypoxia to be hospitalized for common viral syndromes like croup. This study aimed to characterize children hospitalized with COVID-19 during the omicron surge and describe their management and clinical trajectory. METHODS: This single-center retrospective study included patients under 19 years old with a COVID-19 discharge diagnosis on the Pediatric Hospital Medicine service in January and February 2022. Hypoxia was defined by sustained oxygen saturation greater than 90%. Primary outcome was return to emergency department or readmission within 14 days. Secondary outcomes were length of stay, multisystem inflammatory syndrome within 6 weeks, and death. RESULTS: During the study time frame, 111 children were hospitalized with COVID-19, including 35 who had an incidental COVID-19 result. In the remaining 76 patients, the median length of stay was 1.9 days (1.0 - 3.3). Eight patients (11%) returned to the emergency department or were readmitted within 14 days of discharge; 3 of the emergency department visits were related to ongoing COVID-19 infection. Of the 10 patients with croup, 1 received remdesivir due to prolonged illness, and none returned to the emergency department or were readmitted. DISCUSSION: Most children hospitalized with COVID-19 were young, previously healthy and unvaccinated for COVID-19 due to age-based ineligibility. Hypoxia was the most common indication for use of remdesivir/corticosteroids (25%). Return to the emergency department for ongoing COVID-19 symptoms was uncommon (4%). Patients with croup, a presentation seen more commonly with the omicron variant than previously, appeared to do well without remdesivir.

A Trying Time: Problematic Internet Use (PIU) and its association with depression and anxiety during the COVID-19 Pandemic.

BACKGROUND: The prevalence of problematic Internet use (PIU) among adolescents and young adults (AYA) was approximately 9-11% before the COVID-19 pandemic. The purpose of this study was to determine the prevalence of PIU among AYAs (especially younger adolescents) during the COVID-19 pandemic using the Problematic and Risky Internet Use Screening Scale (PRIUSS). Additionally, we examined the relationship between PIU, depression and anxiety among AYAs during the same period. METHODS: A descriptive-analysis survey study was completed over a 6-month period from January 4, 2021, to June 30, 2021. It was conducted at a tertiary care Adolescent Medicine Clinic with AYAs age 12-21. The PRIUSS screened for PIU, the PHQ-9A [Patient Health Questionnaire-9A] screened for depression, and the GAD-7 [General Anxiety Disorder-7] screened for generalized anxiety. Fisher's exact test, the Mann-Whitney test and Spearman correlations were performed. RESULTS: A positive PRIUSS score was observed in 18% of the 447 participants. Of these participants, 44% had a pre-existing diagnosis of depression, 39% had a pre-existing diagnosis of anxiety and 29% had a pre-existing diagnosis of depression and anxiety. There was a positive correlation between PRIUSS, PHQ-9A and GAD-7 total scores. A higher PRIUSS score was associated with a higher PHQ-9A and GAD-7 score (p < 0.001). There was also a positive correlation between a positive PRIUSS score and a pre-existing diagnosis of depression (p < 0.001). CONCLUSIONS: This study showed a higher prevalence of PIU during the COVID-19 pandemic using the PRIUSS. In addition, a positive correlation between PRIUSS scores and pre-existing diagnosis of depression, positive GAD-7 and PHQ-9A scores was noted. In conclusion, medical providers should consider screening for PIU in AYAs with positive mental health screens.

Caregiver Reports of Infant Distress and Injury in Abused Infants.

OBJECTIVES: To determine whether in infants evaluated for physical abuse, medical encounters for infant distress are correlated with physical abuse or a history of sentinel injuries. STUDY DESIGN: This retrospective, case-control analysis of infants aged <12 months evaluated for physical abuse identified demographic characteristics, prior injuries, and medical encounters for infant distress. Variables were compared between abused infants and nonabused infants with and without sentinel injuries. A nonparametric recursive classification tree analysis assessed interactions between variables. RESULTS: Infant distress was associated with abuse (67.9% vs 44.7%; P = .008; OR, 2.6; 95% CI, 1.3-5.2). Infants with sentinel injuries had higher rates of infant distress (74.1% vs 42.4%; P ≤ .001) and crying (81.5% vs 62.7%; P = .012). Previous falls (32.6% vs 18.1%; P = .03) and nonsentinel injuries (18.2% vs 5.4%; P = .002) also were associated with abuse, although sentinel injuries were the most important predictor of abuse, followed by infant distress. CONCLUSIONS: Infants with medical encounters for distress and injury may be at higher risk for abuse and may benefit from intensive educational and support services for their caregivers. Additional research evaluating the most effective interventions for caregivers of fussy infants is needed.

Feasibility and Acceptability of a mHealth Self-Management Intervention for Pediatric Transplant Families.

Families of pediatric solid organ transplant recipients need ongoing education and support in the first 30 days following hospital discharge for the transplantation. The purpose of this report is to describe the feasibility, acceptability, and preliminary efficacy of a mHealth family-self management intervention, (myFAMI), designed to improve post-discharge outcomes of coping, family quality of life, self-efficacy, family self-management, and utilization of health care resources. We enrolled 46 primary family members. myFAMI was feasible and acceptable; 81% (n=17/21) of family members completed the app at least 24/30 days (goal 80% completion rate). Family members generated 134 trigger alerts and received a nurse response within the goal timeframe of < 2 h 99% of the time. Although there were no significant differences between groups, primary outcomes were in the expected direction. The intervention was well received and is feasible for future post-discharge interventions for families of children who receive an organ transplant.

Information Order for Periviable Counseling: Does It Make a Difference?

OBJECTIVES: To examine whether the order of presenting survival vs disability information, with or without the description of infant neonatal intensive care unit (NICU) experiences would influence treatment choice during hypothetical periviable birth counseling. STUDY DESIGN: An internet sample of childbearing-aged women (n = 839) viewed a pictograph displaying the chances of survival and a pictograph on the chances of disability for a baby resuscitated during the periviable period. The sample was randomized to the order of pictographs and level of description of infant NICU experiences. Participants selected between intensive care or comfort care and reported their personal values. RESULTS: The order of the information influenced treatment choices (P = .02); participants were more likely to choose intensive care if they saw the survival pictograph first (70%) than the disability pictograph first (62%). Level of description of premature infant NICU experiences did not influence treatment choice (P = .92). Participants who valued sanctity of life, autonomy in making decisions, who were more religious, and had adequate health literacy were more likely to choose intensive care. Such participant characteristics had greater explanatory power than the experimental manipulations. CONCLUSIONS: Subtle differences in how information is presented may influence critical decisions. However, even among women with the same values, diversity in treatment choice remains.

Gastric emptying in healthy children using the Spirulina breath test: The impact of gender, body size, and pubertal development.

BACKGROUND: There are no pediatric norms for gastric emptying (GE) measured by nuclear scintigraphy. The 13 C-labeled, stable isotope GE breath test (GEBT) is a non-radioactive alternative. We aimed to determine normative GEBT ranges in a cohort of healthy children and examine the influence of age, gender, puberty, and body surface area (BSA). METHODS: Healthy children ages 8-18 years completed the [13 C]-Spirulina platensis GEBT after an overnight fast. Breath samples were collected at baseline, every 15 min × 1 h, then every 30 min for 4 h total. The 13 CO2 excretion rate was determined by the change in 13 CO2 /12 CO2 over time in each breath sample, expressed as kPCD (Percent 13 C Dose excreted/min). A mixed model with random time was used for multivariable analysis and outcome fit into a quadratic model. KEY RESULTS: The 100 subjects completed the test meal within allotted time. Median (IQR) age was 13.5 (11.3-15.5) years; 51% were female. Females had lower 13 CO2 excretion rates (slower GE) than males across time (p < 0.001) while decreased excretion rates correlated with higher BSA (p = 0.015). Gender differences were also noted within pubertal stages with females showing slower GE. Multivariable analysis suggested that pre-pubertal children have faster GE than both peri- and post-pubertal groups (p < 0.0001). CONCLUSIONS & INFERENCES: Gender, puberty, and BSA influence GE rates in healthy children more than age. Although further data are needed, pubertal stage and hormonal influences may be unique factors to consider when assessing GE in children.