Effect of split posterior tibialis tendon transfer on foot progression angle in children with cerebral palsy.

OBJECTIVES: A common orthopedic issue for patients with spastic cerebral palsy (CP) is hindfoot varus deformity. One method of treatment is the split posterior tibialis tendon transfer (SPOTT). There is limited literature on the effect of SPOTT on foot progression angle (FPA) in children with CP who have equinovarus deformities. The objective of our study was to evaluate the change in FPA after SPOTT to determine if this procedure can improve FPA. RESEARCH QUESTION: This study aims to determine what axial changes are generated from a split posterior tibial tendon transfer in children with CP. METHODS: We performed a retrospective analysis of all ambulatory children with a diagnosis of CP who underwent SPOTT at our institution. Patients with bony rotational procedures were excluded. Descriptive statistics including mean and standard deviation (SD) were used to characterize continuous variables. Paired t-tests were used to evaluate outcomes, in which a target outcome was defined as a post-operative FPA between 0-10° of external rotation. RESULTS: 44 limbs were included. Demographics were as follows: 26/13 female/male; mean age[SD] (years): 9.8[3.5]; 30 hemiplegic, 9 diplegic, and 1 triplegic. Of the 44 limbs, 18 limbs had a target outcome, 4 had no change, and 22 had a non-target outcome. Of the 22 with an outcome outside of the target, 4 limbs trended away from a target outcome. The overall change in FPA measured was - 10.9 ± 14.7° (p < 0.0001) Age at time of surgery, CP involvement, pre-operative FPA, and GMFCS level were not predictors of outcome (p > 0.05). CONCLUSIONS: SPOTT produced a change of 10.9° external rotation in FPA post-operatively and its effects should be considered when planning a SEMLS.

Mixed Methods Evaluation of the Impact of the COVID-19 Pandemic on Immigrant Families.

Introduction: Little is known about the experiences of immigrant families with COVID-19 illness. This mixed methods study compared child and household experiences at the time of a child's COVID-19 diagnosis between immigrant and US-born parents and explored immigrant Latino perspectives on underlying causes of COVID-19 disparities between immigrant and US-born families. Methods: Study data includes surveys of parents of a child with a positive SARS-CoV2 test resulting at Children's Hospital Colorado and focus groups with Latino immigrant adults. We compared household COVID-19 experiences, use of mitigation measures, vaccine intention and sociodemographic information between survey participants stratified by nativity and completed thematic qualitative data analysis. Results: Findings from quantitative data were reinforced by qualitative data including: lower socio-economic status and higher employment in essential services increased infections and spread in immigrant families and higher risk of limited information access related to language barriers and prevalent misinformation. Survey results showed no difference in COVID-19 vaccine intention by nativity. Focus group participants reported limited access to non-English language culturally-tailored vaccine information and competing work demands decreased uptake. Conclusion: Avoiding exacerbating disparities in the face of another public health emergency requires focused investments in policies and approaches specifically directed at immigrant communities.

Changes in estimated glomerular filtration rate over the first year following repeat heart transplant in children and young adults.

BACKGROUND: Renal function is reduced in patients undergoing heart transplant due to hemodynamic compromise, cardiorenal syndrome, and nephrotoxin exposure. No current studies evaluate renal function in retransplants. METHODS: We reviewed all heart transplants at our center from 1995 to 2021 and matched first-time heart transplants with retransplants, based on age at transplant, sex, and race. Estimated glomerular filtration rate (eGFR) was derived from CKiD-U25 calculator using creatinine and measured prior to transplant, 1-week post-transplant, 1-3, 6, and 12 months post-transplant, and recent follow-up. Changes in eGFR were measured within and between patients using a piecewise linear mixed effect model with matching. Exploratory univariate analysis was performed to evaluate pre-transplant risk factors for decreased eGFR. RESULTS: The unmatched cohort included 393 heart transplant recipients, with 47 being retransplants. Thirty-eight patients in both groups with at least 1 year of follow-up underwent matching. Both retransplants and first-time transplants had an initial decline in eGFR. eGFR rebounded to baseline or above baseline at 1-3 months post-transplant, but eGFR in retransplants remained significantly lower. At 1-year post-transplant, the average eGFR was 67.8 ± 4.3 mL/min/1.73 m2 versus 104.7 ± 4.3 mL/min/1.73 m2 (p < .001) in the retransplants and first-time transplants group, respectively. CONCLUSION: This study provides data on anticipated renal trajectory following retransplantation.

Modern antiretroviral regimens in pregnant women: virologic outcomes and durability.

OBJECTIVES: Data are lacking on the virologic efficacy and durability of modern antiretroviral treatment (ART) regimens during pregnancy. We compared virologic outcomes at delivery among women receiving dolutegravir versus other ART and the rate of change of the initial pregnancy regimen. DESIGN: Single-site retrospective cohort between 2009 and 2019. METHODS: We used univariable and multivariable generalized estimating equations to model the relationship between the maternal ART anchor and the proportion of women with a detectable viral load (greater than or equal to 20 HIV RNA copies/mL of plasma) closest to delivery (suboptimal virologic control) and with a detectable viral load at any time in the third trimester. We also compared changes in ART during pregnancy. RESULTS: We evaluated 230 pregnancies in 173 mothers. Rates of optimal virologic control at delivery did not significantly differ in mothers who received dolutegravir (93.1%), rilpivirine (92.1%), boosted darunavir (82.6%), or efavirenz (76.9%) but were significantly lower among mothers receiving atazanavir (49.0%) or lopinavir (40.9%). The odds of having a detectable viral load at any time in the third trimester was also higher for atazanavir and lopinavir. Raltegravir, elvitegravir, or bictegravir were used in less than 10 mothers at delivery, which precluded statistical analyses. The frequency of change in ART was significantly higher in mothers who initially received elvitegravir (68%) or efavirenz (47%) than dolutegravir (18%). CONCLUSION: Dolutegravir-containing, rilpivirine-containing, and boosted darunavir-containing regimens conferred excellent virologic control in pregnancy. Atazanavir and lopinavir, elvitegravir, and efavirenz were associated with either high rates of virologic failure or regimen change during pregnancy.

Variation over Time in Child and Neighborhood Characteristics Associated with COVID-19.

Introduction: To examine the associations between child and neighborhood characteristics and incidence of COVID-19 infection during the first 19 months of the pandemic. Study Design: We utilized individual electronic health record data and corresponding census tract characteristics for pediatric SARS-CoV-2 cases (age <18 years) from March 23, 2020 to September 30, 2021 with molecular tests resulted at a children's health system in Colorado. We compared associations between individual SARS-CoV-2 cases and census tract SARS-CoV-2 positivity rates over three time periods (TP1: March-September 2020; TP2: October 2020-March 2021; TP3: April-September 2021) using multinomial logistic regression for individual associations and negative binomial regression for census tract associations. Results: We included 7498 pediatric SARS-CoV-2 cases and data from 711 corresponding census tracts. Spanish preferred health care language was associated with SARS-CoV-2 positivity for TP1 (odds ratio [OR] 4.9, 95% confidence interval [CI] 3.7-6.5) and TP2 (OR 2.01, 95% CI 1.6-2.6) compared with TP3. Other non-English preferred health care language was associated with SARS-CoV-2 positivity in TP1 (OR 2.4, 95% CI 1.4-4.2). Increasing percentage internationally born in a census tract was associated with SARS-CoV-2 positivity for TP1 (multivariable incident rate ratio [IRR]=1.040, p<0.0001), TP2 (multivariable IRR=1.028, p<0.0001), and in all TP combined (multivariable IRR=1.024, p<0.0001). Discussion: Our study is notable for the identification of COVID-19 disparities among children in immigrant families and communities, particularly early in the pandemic. Addressing disparities for immigrant communities requires targeted investments in public health infrastructure.

Outbreak of Invasive Group A Streptococcus in Children-Colorado, October 2022-April 2023.

BACKGROUND: In the fall of 2022, we observed a sharp rise in pediatric Invasive Group A Streptococcus (iGAS) hospitalizations in Colorado. We compared the epidemiology, clinical features, and patient outcomes in this outbreak to prior years. METHODS: Between October 2022 and April 2023, we prospectively identified and reviewed iGAS cases in hospitalized pediatric patients at Children's Hospital Colorado. Using laboratory specimen records, we also retrospectively compared the number of patients with sterile site GAS-positive cultures across three time periods: pre-COVID-19 (January 2015-March 2020), height of COVID-19 pandemic (April 2020-September 2022), and outbreak (October 2022-April 2023). RESULTS: Among 96 prospectively identified iGAS cases, median age was 5.7 years old; 66% were male, 70% previously healthy, 39% required critical care, and four patients died. Almost 60% had associated respiratory viral symptoms, 10% had toxic shock syndrome, and 4% had necrotizing fasciitis. Leukopenia, bandemia, and higher C-reactive protein values were laboratory findings associated with need for critical care. There were significantly more cases during the outbreak (9.9/month outbreak vs 3.9/month pre-pandemic vs 1.3/month pandemic), including more cases with pneumonia (28% outbreak vs 15% pre-pandemic vs 0% pandemic) and multifocal disease (17% outbreak vs 3% pre-pandemic vs 0% pandemic), P < .001 for all. CONCLUSIONS: Outbreak case numbers were almost triple the pre-pandemic baseline. The high percentage of cases with associated viral symptoms suggests a link to coinciding surges in respiratory viruses during this time. Invasive GAS can be severe and evolve rapidly; clinical and laboratory features may help in earlier identification of critically ill children.

Top caregiver concerns in Rett syndrome and related disorders: data from the US natural history study.

OBJECTIVE: Recent advances in the understanding of neurodevelopmental disorders such as Rett syndrome (RTT) have enabled the discovery of novel therapeutic approaches that require formal clinical evaluation of efficacy. Clinical trial success depends on outcome measures that assess clinical features that are most impactful for affected individuals. To determine the top concerns in RTT and RTT-related disorders we asked caregivers to list the top caregiver concerns to guide the development and selection of appropriate clinical trial outcome measures for these disorders. METHODS: Caregivers of participants enrolled in the US Natural History Study of RTT and RTT-related disorders (n = 925) were asked to identify the top 3 concerning problems impacting the affected participant. We generated a weighted list of top caregiver concerns for each of the diagnostic categories and compared results between the disorders. Further, for classic RTT, caregiver concerns were analyzed by age, clinical severity, and common RTT-causing mutations in MECP2. RESULTS: The top caregiver concerns for classic RTT were effective communication, seizures, walking/balance issues, lack of hand use, and constipation. The frequency of the top caregiver concerns for classic RTT varied by age, clinical severity, and specific mutations, consistent with known variation in the frequency of clinical features across these domains. Caregivers of participants with increased seizure severity often ranked seizures as the first concern, whereas caregivers of participants without active seizures often ranked hand use or communication as the top concern. Comparison across disorders found commonalities in the top caregiver concerns between classic RTT, atypical RTT, MECP2 duplication syndrome, CDKL5 deficiency disorder, and FOXG1 syndrome; however, distinct differences in caregiver concerns between these disorders are consistent with the relative prevalence and impact of specific clinical features. CONCLUSION: The top caregiver concerns for individuals with RTT and RTT-related disorders reflect the impact of the primary clinical symptoms of these disorders. This work is critical in the development of meaningful therapies, as optimal therapy should address these concerns. Further, outcome measures to be utilized in clinical trials should assess these clinical issues identified as most concerning by caregivers.

The Association Between Age at Diagnosis and Disease Characteristics and Damage in Patients With ANCA-Associated Vasculitis.

OBJECTIVE: This study examined the relationship between age at diagnosis and disease characteristics and damage in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHODS: Analysis of a prospective longitudinal cohort of patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA) in the Vasculitis Clinical Research Consortium (2013-2021). Disease cohorts were divided by age at diagnosis (years): children (<18), young adults (18-40), middle-aged adults (41-65), and older adults (>65). Data included demographics, ANCA type, clinical characteristics, Vasculitis Damage Index (VDI) scores, ANCA Vasculitis Index of Damage (AVID) scores, and novel disease-specific and non-disease-specific damage scores built from VDI and AVID items. RESULTS: Analysis included data from 1020 patients with GPA/MPA and 357 with EGPA. Female predominance in GPA/MPA decreased with age at diagnosis. AAV in childhood was more often GPA and proteinase 3-ANCA positive. Children with GPA/MPA experienced more subglottic stenosis and alveolar hemorrhage; children and young adults with EGPA experienced more alveolar hemorrhage, need for intubation, and gastrointestinal involvement. Older adults (GPA/MPA) had more neurologic manifestations. After adjusting for disease duration, medications, tobacco, and ANCA, all damage scores increased with age at diagnosis for GPA/MPA (P < 0.001) except the disease-specific damage score, which did not differ (P = 0.44). For EGPA, VDI scores increased with age at diagnosis (P < 0.009), whereas all other scores were not significantly different. CONCLUSION: Age at diagnosis is associated with clinical characteristics in AAV. Although VDI and AVID scores increase with age at diagnosis, this is driven by non-disease-specific damage items.

Measurement of Physical Activity by Actigraphy in Infants and Young Children with Pulmonary Arterial Hypertension.

OBJECTIVE: To evaluate the feasibility, tolerability, and adherence with wearable actigraphy devices among infants and children with pulmonary arterial hypertension (PAH). STUDY DESIGN: This multicenter, prospective, observational study included children ages 0-6 years with and without PAH. Participants wore the ActiGraph wGT3X-BT on the hip and FitBit Inspire on the wrist during waking hours for 14 days. Steps, vector magnitude counts per minute, activity intensity, heart rate, and heart rate variability were compared between groups. RESULTS: Forty-seven participants (18 PAH, 29 control) were enrolled from 10 North American sites. PAH patients were mostly functional class II (n = 16, 89%) and treated with oral medications at the time of enrollment. The number of wear days was not significantly different between the groups (ActiGraph: 10 [95% CI: 5.5, 12.2] in PAH vs 8 [4, 12] in control, P = .20; FitBit 13 [10, 13.8] in PAH vs 12 [8, 14] in control, P = .87). Complete data were obtained in 81% of eligible ActiGraph participants and 72% of FitBit participants. PAH participants demonstrated fewer steps, lower vector magnitude counts per minute, more sedentary activity, and less intense physical activity at all levels compared with control participants. No statistically significant differences in heart rate variability were demonstrated between the 2 groups. CONCLUSIONS: Measurement of physical activity and other end points using wearable actigraphy devices was feasible in young children with PAH. Larger studies should determine associations between physical activity and disease severity in young patients with PAH to identify relevant end points for pediatric clinical trials.

Efficacy of IV Valproic Acid and Oral Valproic Acid Tapers for the Treatment of Pediatric Headaches in the Emergency Department.

Background and Objectives: Pediatric headaches, including migraine, are a common reason for emergency department (ED) presentation. IV valproic acid (VPA) followed by oral VPA tapers are often used to abort pediatric headache and reduce recurrence, though limited data exist regarding this approach. This study evaluated the effectiveness of IV VPA and oral VPA tapers for the treatment of acute pediatric headaches in the ED in preventing return encounters. Methods: This is a retrospective cohort study of patients aged 5-21 years presenting to a tertiary-care pediatric ED from 2010 to 2016 who received IV VPA for headache or migraine. Primary outcomes were ED disposition, percent pain reduction (initial vs 2-hour patient-reported pain score [10-point scale]), and return for acute headache treatment within 1 month. Results: A total of 486 ED encounters were included with a median patient age of 15 years; most of them were females (76%, 369/486). Of available pain scores within 2 hours of IV VPA administration, 41% (173/425) had ≥50% pain reduction. Fifty-two percent (254/486) were discharged without additional treatment, 14% (69/486) were discharged after additional treatment, and 33% (163/486) were admitted to the hospital. Initial pain score, number of preceding home treatments, and number of preceding ED treatments were not associated with ED disposition. Oral VPA tapers were prescribed in 39% (94/253) of encounters when the patient was discharged after IV VPA. Oral VPA tapers produced a transient decrease in recurrence at 72 hours, which was no longer present at 1 week nor 1 month. There was no difference in the time to recurrence or total number of return visits within 1 month. Discussion: IV VPA was efficacious in treating pediatric headaches evaluated in the ED, with nearly two-thirds of patients discharged home after administration. Oral VPA tapers did not reduce total headache recurrence nor time to recurrence. Given the limited benefit of oral VPA tapers, this practice should be re-examined. Classification of Evidence: This study provides Class IV evidence that for children with headache seen in the ED, IV VPA reduces head pain and Class III evidence that following this with an oral VPA taper is of no benefit.

Development and Evaluation of a Child Neurology Resident Curriculum for Communication Around Serious Illness.

Background: Communication around serious illness is a core competency for all residencies. One-fifth of neurology residencies have no curriculum. Published curricula use didactics or role-play to assess confidence performing this skill without evaluation in clinical settings. The SPIKES mnemonic (Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary) outlines 6 evidence-based steps for communication around serious illness. It is unknown whether child neurology residents can incorporate SPIKES into communication around serious illness in clinical settings. Objective: To develop and evaluate a curriculum on communication around serious illness using SPIKES for child neurology residents that shows long-term skill retention in clinical settings at a single institution. Methods: In 2019, we created a pre-post survey and skills checklist based on SPIKES, with 20 total including 10 core skills. Faculty observed residents' (n = 7) communication with families and completed both preintervention and postintervention checklists for comparison. Residents underwent training in SPIKES during a 2-hour session using didactic and coached role-play. Results: All (n = 7) residents completed preintervention surveys, 4 of 6 completed postintervention. All (n = 6) participated in the training session. Following the training, 75% of residents reported improved confidence in use of SPIKES, though 50% were still unsure about appropriately responding to emotions. There was improvement in all SPIKES skills, with significant improvement in 6 of 20 skills up to 1 year following training. Conclusion: This is the first evaluation of the implementation of a communication around serious illness curriculum for child neurology residents. We identified improved comfort with SPIKES after training. Successful acquisition and utilization of this framework in our program suggests it could be incorporated into any residency program.

Submaximal Exercise Response is Associated with Future Hypertension in Patients with Coarctation of the Aorta.

Hypertension (HTN) is common in patients with a history of coarctation of the aorta (CoA) and remains underrecognized and undertreated. Studies in the non-coarctation otherwise healthy adult population have correlated an exaggerated blood pressure response during mild to moderate exercise with subsequent diagnosis of HTN. The goal of this study was to determine if blood pressure response to submaximal exercise in normotensive CoA patients correlated with development of HTN.Retrospective chart review was performed in individuals ≥ 13 years old with CoA and no diagnosis of HTN at time of cardiopulmonary exercise testing (CPET). Systolic blood pressure (SBP) during CPET at rest, submax 1 (stage 1 Bruce or minute 2 bicycle ramp), submax 2 (stage 2 Bruce or minute 4 bicycle ramp), and peak were recorded. The primary composite outcome was HTN diagnosis or initiation of anti-hypertensive medications at follow up.There were 177 patients (53% female, median age 18.5 years), of whom 38 patients (21%) met composite outcome during a median follow up of 46 months. Men were more likely to develop hypertension. Age at repair and age at CPET were not significant covariates. At each stage of CPET, SBP was significantly higher in those who met the composite outcome. Submax 2 SBP ≥ 145 mmHg was 75% sensitive, 71% specific in males and 67% sensitive, 76% specific in females for development of composite outcome.Our study shows an exaggerated SBP response to submaximal exercise may portend an increased risk of developing hypertension during short- to mid-term follow up.

Finger Puppets to Support Early Language Development: Effects of a Primary Care-Based Intervention in Infancy.

Verbally rich interactions beginning in early infancy are critical to future vocabulary development. We explored the effectiveness of introducing finger puppets in the primary care setting to support caregiver-infant interactions. The intervention cohort was given a puppet at 2 months, with high dosage defined as using the puppet daily in the first 2 weeks. At 6 months, a usual care cohort was enrolled, and outcome measures were collected for all participants. For the intervention, 92% (n = 70) of those eligible participated, and 80% (n = 56) completed the 6-month visit. For usual care, 78% (n = 60) of those eligible participated. In per-protocol analysis, overall cognitive stimulation (StimQ-I) (P = .04) and Parental Involvement in Developmental Advance subscale (P = .03) scores were higher for the high-dosage group (28.68, 5.16) than those for the low-dosage (24.81, 4.48) and usual care (24.15, 3.98) groups. Finger puppets may provide a low-cost and scalable way to support early language and child development.

Using the Ages & Stages Questionnaire to assess later effects of an infant intervention promoting language in primary care.

BACKGROUND: Positive relational experiences during infancy have a profound impact on child development and are critical for future health and school readiness. We have been evaluating a simple finger puppet intervention that takes one minute and costs $1USD to deliver in the primary care setting to promote caregiver-infant interactions. We explored using developmental trajectories to determine later outcomes of our early intervention program by comparing trajectories to age 36 months to assess optimal intervention timing when delivered in early versus late infancy. METHODS: Three cohorts were enrolled and given a puppet at 2 months (early intervention) and 6 or 12 months (late intervention). Child development was assessed using the Ages & Stages Questionnaires (ASQ-3), which were independently collected during well visits. Scanned ASQ-3 forms from 2 to 36 months were obtained retrospectively through the electronic medical record. To compare longitudinal scores at different ages, all raw scores were first converted to z-scores. Longitudinal mixed effects models examined the trajectories of participant ASQ-3 scores over time by comparing the average intercepts and slopes. RESULTS: Of 180 children enrolled, 172 (96%) completed 2 or more ASQ-3 questionnaires and were included in the analysis, with a mean of 4.9 and a total of 843 questionnaires. Most children (85%) were on government-sponsored insurance. There were no statistical differences comparing cohort intercepts, while early intervention had a significant difference in slope compared to late intervention for the Personal-Social domain (0.12, p=0.018), resulting in higher predicted scores at 36 months. Early compared to late intervention had a difference in slope approaching significance for Communication (0.14, p=0.056) and the combined non-motor score (0.33, p=0.052). There were no significant differences in slope for Problem Solving (0.05, p=0.48), Gross Motor (-0.009, p=0.84), Fine Motor (0.06, p=0.22), and total ASQ-3 (0.32, p=0.17) scores. CONCLUSIONS: Finger puppets may provide a simple and scalable way to encourage responsive caregiver-infant interactions promoting language and social-emotional development, especially when provided in early versus late infancy. Our trajectory analysis also demonstrates a useful and potentially cost-effective approach to evaluating long-term developmental outcomes of an early intervention.

Dots and spots: A retrospective review of T2-hyperintense white matter lesions in pediatric patients with and without headache.

OBJECTIVE: We aimed to determine if T2-weighted hyperintense white matter lesions (WMLs) on brain magnetic resonance imaging (MRI) occur more frequently in pediatric patients with migraine and other primary headache disorders compared to the general pediatric population. BACKGROUND: Small foci of T2 hyperintensity in the white matter are frequently identified on brain MRI during the workup of pediatric headache. Such lesions have been reported to be more common among adults with migraine versus adults without migraine; however, this association has not been well established in the pediatric population. METHODS: We performed a retrospective cross-sectional single-center study of electronic medical records and radiologic studies, examining pediatric patients from 3 to 18 years old who underwent brain MRI between 2016 and 2021. Patients with existing intracranial disease or abnormalities were excluded. Patients with reports of headache were categorized. Imaging was reviewed to determine the number and location of WMLs. Headache-associated disability scores (Pediatric Migraine Disability Assessment) were noted, when available. RESULTS: Brain MRI of 248 patients with a diagnosis of headache (144 with migraine, 42 with non-migraine primary headache, and 62 with headache that could not be further classified) and 490 controls were reviewed. WMLs were encountered commonly among all study participants, with a prevalence of 40.5% (17/42) to 54.1% (265/490). There was no statistically significant difference comparing the number of lesions between each of the headache groups and the control group: migraine group versus control group median [interquartile range (IQR)], 0 [0-3] versus 1 [0-4], incidence rate ratio [95% confidence interval (CI)], 0.99 [0.69-1.44], p = 0.989, non-migraine headache group versus control group median [IQR], 0 [0-3] versus 1 [0-4], 0.71 [0.46-1.31], p = 0.156, headache not otherwise specified group versus control group median [IQR], 0 [0-4] versus 1 [0-4], 0.77 [0.45-1.31], p = 0.291. There was no significant correlation between headache-associated disability and the number of WMLs (0.07 [-0.30 to 0.17], rho [95% CI]). CONCLUSION: T2 hyperintense WMLs are common within the pediatric population and are not encountered more frequently in pediatric patients with migraine or other primary headache disorders. Thus, such lesions are presumably incidental and unlikely related to headache history.

Changing Characteristics of Children With COVID-19 in Colorado Admitted During Different Variant Periods.

BACKGROUND: Data are lacking on the impact of different severe acute respiratory syndrome coronavirus 2 variants in children and on pediatric vaccine effectiveness. We examined differences among children requiring hospital admission associated with coronavirus disease 2019 (COVID-19) during wild type, Delta and Omicron variant periods and calculated vaccine effectiveness at preventing symptomatic hospitalization during the Delta and Omicron variant periods. METHODS: We conducted a retrospective review of children younger than 21 years of age hospitalized with symptomatic COVID-19. Characteristics were compared between variant periods using Kruskal-Wallis or generalized Fisher exact tests. We estimated vaccine effectiveness in preventing symptomatic hospitalization. RESULTS: We included 115 children admitted during the wild type period, 194 during Delta and 226 during the Omicron periods. Median age (years) decreased (12.2 wild type, 5.9 Delta, 1.3 Omicron periods, P < 0.0001) over time. Children were less likely to have a comorbid condition, including diabetes or obesity, and had shorter admissions during Omicron compared with the wild type and Delta periods. Intensive care unit admissions and respiratory support requirements were highest during the Delta period ( P = 0.05). Among children ≥12 years, adjusted vaccine effectiveness at preventing symptomatic hospitalization was 86% during Delta and 45% during Omicron periods. CONCLUSIONS: Children hospitalized with COVID-19 during later variant periods were younger and less likely to have comorbidities. Children admitted during the Delta variant period required more intensive care and respiratory support compared to other variant periods. Vaccination was less effective at preventing symptomatic hospital admission during the Omicron period compared to the Delta period.

Top Caregiver Concerns in Rett syndrome and related disorders: data from the US Natural History Study.

Objective: Recent advances in the understanding of neurodevelopmental disorders such as Rett syndrome (RTT) has enabled development of novel therapeutic approaches that are currently undergoing clinical evaluation or are proposed to move into clinical development. Clinical trial success depends on outcome measures that assess clinical features that are most impactful for affected individuals. To determine the top concerns in RTT and RTT-related disorders we asked caregivers to list the top clinical concerns in order to gain information to guide the development and selection of outcome measures for future clinical trials. Methods: Caregivers of participants enrolled in the US Natural History Study of RTT and related disorders were asked to identify the top 3 concerning problems impacting the affected participant. We generated a weighted list of top caregiver concerns for each of the diagnostic categories and compared results between the disorders. Further, for Classic RTT, caregiver concerns were analyzed by age, clinical severity, and common RTT-causing mutations in MECP2. Results: The top caregiver concerns for Classic RTT were effective communication, seizures, walking/balance issues, lack of hand use, and constipation. The rank order of the frequency of the top caregiver concerns for Classic RTT varied by age, clinical severity, and specific mutations, consistent with known variation in the frequency of clinical features across these domains. The frequency of caregiver concern for seizures, hand use, and spoken language increased in relation to clinician assessed severity in these clinical domains, showing consistency between clinician assessments and caregiver concerns. Comparison across disorders found commonalities in the top caregiver concerns between Classic RTT, Atypical RTT, MECP2 Duplication Syndrome, CDKL5 Deficiency Disorder, and FOXG1 Syndrome; however, distinct differences in caregiver concerns between these disorders are consistent with the relative prevalence and impact of specific clinical features. Conclusion: The top caregiver concerns for individuals with RTT and the RTT-related disorders reflect the impact of the primary clinical symptoms of these disorders. This work is critical in the development of meaningful therapies, as optimal therapy should address these concerns. Further, outcome measures to be utilized in clinical trials should assess these clinical issues identified as most concerning by caregivers.

Impact on Maternal Postpartum Depressive Symptoms of a Primary Care Intervention Promoting Early Language: A Pilot Study.

OBJECTIVES: Maternal depressive symptoms are an important risk factor for adverse child outcomes, especially in the perinatal period. We studied whether introducing finger puppets in the primary care setting to promote infant language improves maternal postpartum depressive symptoms. METHODS: An intervention cohort was enrolled and given a finger puppet at the 2-month infant well visit. Two usual care cohorts were enrolled at either the 6- or 12-month well visit as part of a larger study. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), which was administered by clinic providers as part of routine screening done at both the 2- and 4-month well visits. EPDS scores were obtained retrospectively through the electronic medical record. RESULTS: Included mothers (n = 127) completed the EPDS at 2 and 4 months postpartum. Most children (83%) were on government-sponsored insurance. Mean EPDS scores and scores classified as possible depression (≥ 10) did not differ between cohorts. However, the change in scores between visits was significantly different for intervention (n = 46) compared to usual care (n = 81) participants (-1.1 vs. +0.4, p = 0.001). More intervention scores improved (n = 17, 37%) compared to usual care (n = 14, 17%), while more usual care scores worsened (n = 28, 35%) compared to intervention (n = 6, 13%) (p = 0.008). CONCLUSION: Finger puppets introduced during infant primary care visits to support language-rich maternal-infant interactions may provide a simple, low-cost way to improve maternal postpartum depressive symptoms. Larger studies with more diverse populations are needed to determine if effects are replicable, generalizable, and translate into better clinical outcomes.

Postoperative Immobilization After Hip Reconstruction in Cerebral Palsy: No Difference Between Hip Spica and Abduction Pillow.

Purpose: This study aims to compare radiographic outcomes and complication rates of immobilization with an abduction pillow to spica casting for postoperative care after a hip reconstruction with varus derotational proximal femur osteotomy (VDRO) with or without pelvic osteotomy for children with cerebral palsy (CP). Methods: 233 children (1-18 years old) diagnosed with CP that underwent VDRO with or without pelvic osteotomy were identified, of which 188 patients were immobilized with a spica cast and 45 were immobilized with an abduction pillow, based on surgeon preference. 123 (65%) in the Spica group and 21 (47%) in the pillow group had pelvic osteotomies. Demographic data and complication rates were collected. Radiographic parameters, including anatomic medial proximal femoral angle (aMPFA), acetabular index (AI) and migration percentage (MP), were measured for each patient at the completion of surgery, six weeks post-operatively, and one year post-operatively. Results: There was not a statistically significant difference in BMI (p = 0.285), gender distribution (p = 0.984), or median follow-up time (p = 0.314) between groups. Rates of complications were consistent among groups with no differences in instances of delayed unions (p = 0.10), subluxations (p = 0.55), infection (p = 0.71), or non-unions (p = 0.10). There was no statistically significant difference in number of patients with an ideal aMPFA, AI, or MP (p = 0.44, p = 0.19, p = 1.00) at one year post-operatively. Conclusions: Immobilization with an abduction pillow is a safe and effective alternative to hip spica casting following hip reconstruction.

Congenital Co-infections Among HIV-Exposed Infants Born to Mothers on Antiretroviral Treatment in the United States.

Background: Many women living with HIV (WLHIV) are co-infected with cytomegalovirus (CMV), Toxoplasma gondii (T gondii), and/or hepatitis C virus (HCV). The rates of congenital or perinatal transmission of these co-infections are not well defined in the current era, when most WLHIV receive antiretroviral therapy (ART) during pregnancy. Methods: Retrospective review of infants of WLHIV born between 2009-2019. Mothers were screened for antibodies to CMV, T. gondii, and HCV; chronic HCV infection was confirmed using plasma RNA PCR. Infants whose mothers had positive/unknown serostatus were screened for CMV using urine or saliva DNA PCR or culture at ≤3 weeks of life; T. gondii using serology at ≤1 month; and HCV using plasma RNA PCR at ≤6 months and serology at ≥12 months. Results: The study included 264 infants from 255 pregnancies in 191 mothers. At delivery, the median (IQR) CD4 count was 569 (406-748) cells/mm3 and plasma HIV load was 0 (0-24) RNA copies/mL. Among 243 infants born to CMV-seropositive (209) or CMV-missed serostatus (25) mothers, 163 (67.1%) were tested for CMV. Four infants had CMV detected, resulting in a rate of congenital infection of 2.5%. Among 65 infants from 54 (21.2%) pregnancies in T. gondii-seropositive women and 8 in women with unknown T. gondii-serostatus, one acquired congenital toxoplasmosis in the setting of acute maternal T. gondii infection. There were no episodes of vertical transmission from mothers with latent toxoplasmosis. Among 18 infants from 13 (5.1%) pregnancies in HCV RNA PCR-positive women and 4 in women with unknown HCV serostatus, there were no congenital or perinatal HCV transmissions. Conclusions: In a US cohort of pregnant WLHIV on ART, we identified high maternal CMV seroprevalence and a high rate of congenital CMV infection. We did not identify any congenital or perinatal transmissions of T. gondii or HCV among mothers who had latent or chronic infections. Our data support screening pregnant WLHIV and their infants for CMV and suggest that the rates of congenital and perinatal T. gondii and HCV infections among infants born to WLHIV on ART may be lower in the era of effective ART.