Clinical diagnoses of autism spectrum disorder mostly consistent with, without Autism Diagnostic Observation Schedule

Clinical diagnoses of autism spectrum disorder (ASD) with and without the reference standard Autism Diagnostic Observation Schedule (ADOS) are consistent in 90.0 percent of cases, according to a study published online Oct. 17 in JAMA Pediatrics.

William Barbaresi, M.D., from Boston Children’s Hospital, and colleagues examined consistency between clinical diagnosis and diagnosis incorporating the ADOS in a prospective study conducted between May 2019 and February 2020. Developmental-behavioral pediatricians (DBPs) made a diagnosis based on clinical assessment; the ADOS was administered and then a DBP made a second diagnosis (index diagnosis and reference standard diagnosis). A total of 349 children completed the study.

The researchers found that index diagnoses and reference standard diagnoses were consistent for 314 children (90 percent) and changed for 35 children. The most sensitive and specific predictor of diagnostic consistency was clinician diagnostic certainty (area under curve, 0.860). No child or clinician factors improved prediction of diagnostic consistency based solely on clinician diagnostic certainty at the time of index diagnosis in a multilevel logistic regression.

“ASD diagnostic assessments that do not include the ADOS are less time consuming and costly, potentially leading to more streamlined assessments that could improve access to timely diagnosis by more children,” the authors write. “Additionally, this study suggests that results from the ADOS should not be required by insurers, early intervention programs, or schools for children to access intervention and treatment for ASD.”

 

Reduced initiation and duration of breastfeeding in SARS-CoV-2-positive mothers

A recent study published in the journal Academic Pediatrics evaluated the associations between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and early breastfeeding.

Study: Association of SARS-CoV-2 Infection with Early Breastfeeding. Image Credit: HTeam / Shutterstock

Breastfeeding offers profound benefits to children and mothers. However, some demographic characteristics are linked to lower breastfeeding rates. Besides, shorter postpartum stays in the hospital have been associated with early termination of breastfeeding.

The coronavirus disease 2019 (COVID-19) pandemic has created challenges for patients and healthcare providers. The American Academy of Pediatrics initially suggested that SARS-CoV-2-infected individuals should not probably breastfeed directly. However, subsequent guidance suggested continuing breastfeeding with precautions. There is no information on the association between maternal COVID-19 and breastfeeding. Patients have been discharged early postpartum due to the caution about SARS-CoV-2 transmission during the COVID-19 pandemic.

Shorter hospital stays prevent mothers from receiving adequate support on lactation and result in unreadiness at postpartum discharge. Telehealth has been a critical tool during the pandemic, allowing timely and safe clinical care. Its rapid implementation has been pivotal in ensuring prenatal and postpartum care among vulnerable populations.

About the study

In the present study, researchers compared breastfeeding initiation, duration, and exclusivity between SARS-CoV-2-positive and -negative mothers in the first two months of neonatal life. Mother-infant dyads presenting for ambulatory postpartum visits between April 7, and June 30, 2020, were screened for eligibility.

Mothers were encouraged to continue breastfeeding during this period by wearing face masks. The study included mothers without medical conditions that could impact breastfeeding and full-term singleton neonates with one week or less postpartum hospital stays. The authors reviewed every documented pediatric contract (in-person visit, phone call, and telehealth visit) within 90 days of life.

Days 1 – 45 were defined as month one, and the remaining days as month two. Maternal demographics, delivery characteristics, and feeding status were obtained. The researchers described breastfeeding initiation as breastfeeding in the first week of life. Exclusivity was defined as breastfeeding alone, without supplemental formula, during subsequent pediatric contacts.

Breastfeeding duration was the continuance of breastmilk beyond the first week of life. Differences between SARS-CoV-2-positive- and -negative mothers were assessed using Wilcoxon tests for continuous variables and chi-squared tests for categorical variables.

Associations of breastfeeding initiation, duration, and exclusivity with maternal COVID-19 status were evaluated using Wald tests. Multivariable logistic regression was performed to examine the contributions of maternal COVID-19 status to breastfeeding outcomes, controlling for pediatric contacts, maternal demographics, and delivery characteristics.

Findings

The researchers included 285 mother-infant dyads in the study. Fifty-four mothers (19%) were SARS-CoV-2-positive; their infants were SARS-CoV-2-negative at/before discharge. Maternal/infant characteristics, delivery characteristics, and maternal demographics between SARS-CoV-2-positive and -negative mothers were not significantly different.

Overall, there were no differences in the total number of pediatric contacts between the two cohorts, but SARS-CoV-2-positive mothers had significantly more virtual contacts and fewer in-person visits than SARS-CoV-2-negative mothers. Fewer infected mothers (78%) started breastfeeding in the first week of life than non-infected mothers (87%).

The proportion of breastfeeding mothers during month 1 was similar in the two cohorts. However, twice as many mothers in the SARS-CoV-2-negative group (29%) reported breastfeeding exclusivity compared to 15% of SARS-CoV-2-positive mothers. The authors noted that race and ethnicity were significant predictors of breastfeeding initiation during the first week. Mothers who underwent a Cesarean (C) section had 53% lower odds of breastfeeding by month two than those with vaginal delivery.

Besides, postpartum length of stay was related to exclusivity. Each additional 12 hours in the hospital decreased the breastfeeding odds by 24% during month 1. In-person visits were associated with more significant breastfeeding initiation, whereas virtual contacts were not. Multivariable analyses similarly maintained the associations of breastfeeding outcomes with SARS-CoV-2 infectivity.

Conclusions

The findings suggest that maternal SARS-CoV-2 infection at delivery is associated with adverse outcomes in breastfeeding initiation and duration in the first two months of neonatal life. Multivariable analyses, controlling for pediatric contacts, maternal demographics, and maternal/infant characteristics, revealed that breastfeeding initiation in the first week of life was significantly reduced in infected mothers.

Notably, subjects with C-section deliveries were less likely to breastfeed during month 2. Moreover, there were disparities in breastfeeding initiation between multiracial/Black and White individuals. In summary, maternal SARS-CoV-2 positive status at the time of delivery was significantly and independently associated with decreased breastfeeding initiation and duration. Therefore, pediatricians should continue to encourage breastfeeding, emphasizing the neurodevelopmental benefits.  

 

MONDAY, Aug. 29, 2022 (HealthDay News) — Recent years have seen several high-profile cases of doctors sexually abusing young patients. Now the American Academy of Pediatrics (AAP) is issuing new recommendations aimed at prevention.

Medical visits are usually a safe place for children and teenagers, but when abuse does happen, it is an egregious violation.

One reason, the AAP says, is because parents and kids trust that health care providers are looking out for their welfare.

Experts who were not involved in the recommendations pointed to another central issue: the imbalance of power and knowledge. In a medical setting, young patients and parents may not even know when abuse has occurred.

“This is not a high-risk setting, but it is a complicated setting,” said David Finkelhor, director of the Crimes Against Children Research Center at the University of New Hampshire. “Health care providers have tremendous authority. They’re expected to do physical exams, they’re expected to do things that other people cannot.”

Perhaps the most infamous cases is that of Larry Nassar, a former team physician for USA Gymnastics who was accused of assaulting at least 265 girls under his care between 1992 and 2014. Many victims were sexually abused at every visit, under the guise of medical care — often with their parents in the room.

“The health care provider is someone you trust, and in the moment, you’re so vulnerable,” said Melissa Merrick, president and CEO of the nonprofit Prevent Child Abuse America.

When a violation occurs, she added, the victim may only realize it at some point later on.

Merrick said she was glad to see the AAP issuing its recommendations.

“Child abuse prevention is an adult responsibility,” she said. “It’s everybody’s business — everybody who comes into the life of a child.”

As a basic step, the AAP says medical facilities should do background checks on all staff and volunteers who will have contact with children, looking for any past allegations of abuse. That, however, is not adequate on its own, the group adds, since less than 1% of people who molest children have a criminal record.

The recommendations also advise having explicit policies around “sensitive” exams (involving the genital area or breasts), as well as training on staff-patient boundaries and how to report possible abuse by colleagues. That’s in part because those policies send a message to potential perpetrators that patient abuse will not be tolerated, the AAP says.

“Chaperones” are one specific safeguard. Any time a doctor is performing a sensitive exam, another medical professional, such as a nurse, should be present, the AAP says. Parents are not considered adequate chaperones, because they do not know whether proper procedures are being followed.

Finkelhor said chaperones are helpful, though “not foolproof.” He encouraged parents and kids to speak up and ask questions if they are ever uncomfortable with something a health care provider is doing.

Ideally, doctors should be proactive in that regard. The AAP stresses that they should explain why a sensitive exam is being done, as well as each step in the exam.

That’s a critical recommendation, Merrick said. But whether it happens in real life — or whether patients and parents feel a doctor’s explanation was clear — is a different matter.

Merrick agreed that in those cases, parents and kids should trust their instincts and speak up if they have questions.

Child sexual abuse is, unfortunately, common: Studies estimate that in the United States, up to 25% of girls and 10% of boys have been victimized. There are no good statistics on the prevalence of child sexual abuse in health care, specifically, according to the AAP.

Finkelhor pointed to what he thinks is likely a much more common problem: poorly done sensitive exams. That is, exams where a doctor has no intention of abuse, but does not explain or conduct the procedure properly.

“There are certainly children who have been harmed by an incompetently done sensitive exam,” Finkelhor said.

Among its recommendations, the AAP says pediatricians need specific training in how to conduct those exams. That same standard should go for any doctor who treats children, Finkelhor said, noting that many kids see family physicians or other primary care doctors.

Merrick agreed that such training is key.

“Health care providers should recognize that this is probably an uncomfortable experience for a child,” she said. “It needs to be done properly and sensitively.”

The recommendations were published online Aug. 29 in the AAP journal Pediatrics.

SOURCES: David Finkelhor, PhD, professor, sociology, and director, Crimes against Children Research Center, University of New Hampshire, Durham; Melissa Merrick, PhD, president and CEO, Prevent Child Abuse America, Chicago; Pediatrics, Aug. 29, 2022, online

 International Conference on Pediatrics, Perinatology and Child Health

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Pediatric Influenza Patients and Treatment With Oseltamivir

In an interview with HCPLive, Patrick S. Walsh, MD, discussed his team’s research into the use of oseltamivir—a neuraminidase inhibitor—for pediatric patients with influenza.

Walsh works as an assistant professor of Pediatrics at the Medical College of Wisconsin. He and David Schnadower, MD, MPH, with the Division of Emergency Medicine at Cincinnati Children’s Hospital Medical Center, led their team in a study in which they identified evidence of oseltamivir’s use as an antiviral drug treatment specifically for younger influenza patients.

The team’s research had determined that among their sample size, influenza patients treated early with oseltamivir were found to have lower hospital readmission rates, lower rates of in-hospital mortality, and hospital quicker lengths-of-stay (LOS).

“We developed interest in the project early on in my fellowship because we were, honestly, somewhat skeptical of the evidence behind the drug oseltamivir,” Walsh said. “We thought, given the lack of evidence, we could potentially look into it a little bit further and a few years later, here we are.”

Prior to Walsh’s research, there had not been a significant amount of data regarding the specific use of oseltamivir in pediatric patients, although it had become accepted as the primary antiviral drug treatment for influenza patients since its approval by the US Food and Drug Administration (FDA) in 1999.

“I think there’s a few different reasons,” Walsh explained. “One, there are randomized clinical trials from back when it was first becoming FDA-approved, kind of in the pre-H1N1 time. It’s not that the data doesn’t exist, but there’s maybe some debate on how strong the evidence is for treatment with the drug.”

Walsh went on to describe his beliefs on the reason for the study’s use of a larger database, as well as the lack of significant background information on pediatric patient oseltamivir-use.

“I do think there’s a lack of evidence in the pediatric, and really any inpatient population, and I think the reason is probably because it’s difficult to get enough patients with the outcomes of interest to truly compare, which is part of why we designed the study the way we did, with such a large database,” he said.

The results of Walsh and colleagues’ research aligned with longstanding recommendations for the antiviral treatment’s use by healthcare providers.

 International Conference on Pediatrics, Perinatology and Child Health

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Formula may be right for infants, but experts warn that toddlers don’t need it

Formulas for toddlers are a burgeoning business in the United States: Sales of the drinks more than doubled in recent years as companies convinced parents that their little ones needed the liquid boost. But many experts warn that these products, designed for children ages 1 to 3, fill no nutritional needs beyond what is available in a typical toddler diet, are subject to less regulation than infant formula, and are expensive.

In addition, some parents feed the toddler versions to infants even though they do not meet federal standards for infant formula and may not provide babies with adequate nutrients to sustain their growth.

Pediatricians and federal health officials say that when most children turn 1, they can begin drinking cow milk or an unsweetened plant-based milk substitute. In a 2019 “consensus” statement, the American Academy of Pediatrics and other health and nutrition organizations recommended against using toddler formulas, saying “they offer no unique nutritional value beyond what could be obtained with healthy foods; furthermore, they may contribute added sugars to the diet.” The toddler formulas often contain sweeteners and fats that add calories.

Some of the same companies that produce infant formula—including Enfamil, Gerber, and Similac—also make toddler formulas, as do some smaller, boutique brands that advertise that they have organic or other special qualities. Toddler formulas are available nearly everywhere infant formulas are sold and are marketed as providing extra nutrients to help children’s brain, immune system, and eye development, among other benefits. They are different from medical formulas prescribed for children with specific needs.

A 2020 study found that sales of toddler formula in the U.S. rose to $92 million in 2015 from $39 million in 2006.

Parents are often confused by the marketing for the formulas, according to a study led by Jennifer Harris, a marketing and public health researcher at the University of Connecticut. She found that 60% of caregivers falsely believed toddler formulas have nutrients that toddlers can’t get from other foods.

Dr. Anthony Porto, a pediatric gastroenterologist and Pediatrics professor at Yale University, said he is concerned these products could be giving toddlers more nutrients and calories than they need. Unlike what’s designed for infants, toddler formula has no nutritional regulations: Experts say standardizing a supplement to toddlers’ diets is impossible because no two children are alike.

In focus groups, Harris said, parents report feeding their children toddler formula to fill nutritional gaps when a child isn’t eating enough, a common concern among parents.

“Infants are often voracious eaters,” said Dr. Stephen Daniels, chair of Pediatrics at Children’s Hospital Colorado. But at around a year of age, children’s growth plateaus, he said, and “they’re suddenly not hungry in the way they used to be anymore.” That can worry parents, he added, but “it’s a completely normal phenomenon.”

If parents have concerns about their children’s diet, Daniels said, they should consult a pediatrician or family doctor.

Blanche Lincoln, president of the Infant Nutrition Council of America, which represents the makers of Enfamil, Gerber, Similac, and store brands, said in an email that the toddler formulas can be helpful because they can fill “nutritional gaps during this period of transition to table foods.” Lincoln, a former U.S. senator from Arkansas, said the drinks “help contribute to the specific nutritional needs of toddlers by providing energy and important nutrients, as well as essential vitamins and minerals during this important period of growth and development.”

But toddler formula isn’t being ingested by toddlers alone—it’s also being fed to infants. In a recent study, Porto and colleagues found that 5% of infants’ parents reported giving their babies drinks marketed for the older age group. And Harris’ research indicated that 22% of parents of infants older than 6 months had fed their babies toddler formula in the previous month. Both studies were conducted before the recent infant formula shortage, which may have exacerbated the problem.

“Infant formulas and toddler formulas tend to be next to each other in the supermarket,” Harris said. “They look similar, but the toddler formulas are cheaper than the infant formulas. So people confuse them, and they grab the wrong one. Or they think, ‘Oh, this one is less expensive. I’ll get this one instead.'”

According to an email from FDA spokesperson Lindsay Haake, toddler drinks do not meet the definition of infant formula, so they are not subject to the same requirements. That means they do not have to undergo the clinical trials and pathogen safety testing that the infant versions do. “Unlike infant formulas, toddler formulas are not necessary to meet the nutritional needs of their intended consumers,” Haake said.

In a statement to KHN, the Infant Nutrition Council of America said, “Toddler drinks have a distinctive use and nutritional makeup from infant formula; the two are not interchangeable. The labeling of toddler nutritional drinks explicitly identifies the product as a toddler drink intended for children 12 months and older on the front of the package label.”

However, several expensive toddler formula brands made by smaller companies—often advertised as being made from goat milk, A2 whole milk (which lacks one common milk protein), or vegan ingredients that aren’t soy—do meet nutritional requirements for infants, and some advertise that.

Harris argued that this confuses parents, too, and shouldn’t be allowed. Just because a toddler formula has the nutritional ingredients required by the FDA for infant formula doesn’t mean it has met the other tests required of infant formula, she said.

Federal regulators have not forced any of the companies to withdraw those products. In an email, FDA spokesperson Marianna Naum said, “The FDA does not comment on potential compliance actions.”

One company, Nature’s One, whose toddler formulas are named “Baby’s Only,” received warning letters a decade ago from the FDA about marketing them for infants. That case was closed in 2016. The company’s website says that Baby’s Only formula “meets nutrient requirements for infant” and that “Baby’s Only Organic can be served up to 3-years of age.” Critics say that language implies the formula is fine for babies younger than 1. The company’s website and its Instagram account feature customer testimonials from parents who report feeding the formula to their infants, as well as pictures of infants drinking it.

Jay Highman, CEO and president of Nature’s One, said that Baby’s Only is clearly labeled as a toddler formula and that the back of the can states that “Baby’s Only is intended for a toddler 1-year of age or older OR when directed by a healthcare professional.” He also said that since the company launched in 1999, its formulas have met all the nutritional, manufacturing, and safety standards required of infant formula even though they don’t have to. “We behaved like we are an infant formula, but we were selling it as a toddler formula,” Highman said.

He said that the clinical trials required by the FDA are a huge barrier to bringing a new infant formula to market and that many other countries don’t require a clinical trial. Baby’s Only recently completed a clinical trial, he said, and the company expects to be able to sell it as an infant formula soon.

Yet pediatricians and nutritional experts continue to caution parents about using the toddler drinks. “There’s no question that infant formula is very important in the first year of life,” Daniels said. But he doesn’t recommend the toddler version “because it’s not that useful, because it’s confusing, because it’s expensive.”