Childhood mental health, emotional, and behavioral problems are common and have reached crisis proportions, yet they often go undetected and untreated despite being responsible for significant morbidity and mortality. Approximately 16% of children under 6 years of age have clinically significant mental health difficulties, which require attention in early life1 Early intervention in infant mental health can have a profound impact on a child's future development and well-being. While pediatric primary care is an ideal setting for early detection of mental, emotional, and behavioral symptoms and social determinants of health, until recently, mental health training for pediatric residents was limited to elective experiences that were not standardized nor mandatory. With the recent ACGME addition of a required mental health rotation in pediatric residency curricula, our service assembled a panel of experts in infant mental health to identify the most important curricular elements to include as part of the Pediatrics Mental Health rotation in our safety net hospital. In the Pediatric Mental Health rotation at our institution, one of the four pediatric mental health rotation weeks was dedicated to Infant/Preschool Mental Health (0-6 years old). This manuscript provides background information and resources that can be used by pediatricians, and which can assist in the process of designing curricula for pediatric residents.
Traumatic experiences in early childhood trauma are increasingly recognized as a major public health concern, with infants and toddlers particularly vulnerable because of their rapidly developing brains. Repeated or prolonged exposure to trauma is shown to disrupt neurodevelopment, particularly in brain regions responsible for emotion regulation, executive functioning, stress-response processing, and memory. While it is well established that early childhood trauma negatively impacts social, emotional, and cognitive development, growing evidence demonstrates that early trauma also contributes to long term physical health challenges. In young children, trauma frequently manifests through physiological and bodily symptoms due to their limited capacity to communicate psychological distress. As a result, trauma may present as heightened arousal, somatic issues, sleep disturbances, and feeding difficulties. These concerns are commonly encountered in pediatric healthcare settings, though they may be overlooked or misattributed because of their overlap with other medical conditions. Early childhood represents a critical time for identification and intervention. Pediatric providers are uniquely positioned to identify these early physiological signs of trauma in young children because of their frequent touch points with families. A greater understanding of the manifestations of early trauma in health is needed to improve diagnostic accuracy and promote early intervention. In this paper, we review the effects of early trauma on the physical health of infants and toddlers, highlighting the critical role of pediatric providers in early identification and the integration of trauma-informed care within pediatric settings.
Preterm birth (PTB) is a leading worldwide cause of morbidity and mortality among children less than five years old. In 2006, Puerto Rico reported a PTB rate of 19.9%, the highest in the United States that year. Health care factors did not explain the high rate, leading to environmental exposures as potential risk factors. The PROTECT Center studied the role of diverse chemicals in the risk of PTB and other pregnancy outcomes by recruiting and following up a cohort of pregnant persons in northwest Puerto Rico. Study participants had high levels of phthalates, pesticides, metals, and most chemicals tested, and most were associated with PTB and other adverse pregnancy outcomes. Drinking water, personal care, and household products were major sources of exposure. PROTECT also delved into the biological mechanisms underlying PTB. Inflammation and oxidative stress emerged as key mechanisms leading to adverse pregnancy outcomes through endocrine disruption of several hormones. Reporting results back to PROTECT participants was integral to the PROTECT center, which developed diverse approaches to share results. PTB rates in Puerto Rico declined to 12.2% by 2024. Further studies are needed to examine the role that common chemicals used in consumer products may play in adverse pregnancy outcomes. Reducing the impact of environmental chemicals on pregnancy outcomes must be a priority. Efforts to reduce levels of chemicals among persons of reproductive age should start before conception to further reduce the PTB rate in Puerto Rico and the United States.
Vitamin D deficiency represents a global public health concern as studies indicate that half of the world's population may be deficient in vitamin D, particularly during the winter months. Vitamin D is the primary hormone for bone mineralization in humans. It is essential for the development of the skeleton in the fetus, and further bone development in the extra-uterine environment. There is no current consensus on the recommendations for screening for vitamin D deficiency because of disagreements on the cut-off values by various medical societies, variability in testing methodologies, and a lack of clarity on the cut-off points for skeletal and extra-skeletal functions of vitamin D. As a result, confusion remains among physicians and other healthcare providers regarding when and how to screen for vitamin D, and the therapeutic serum level targets for 25-hydroxyvitamin D. This review examines the current evidence on vitamin D deficiency across the lifespan, approaches to therapy, and the ongoing lack of consensus regarding diagnosis and management of vitamin D deficiency among medical societies.
After several decades of failed vitamin D trials, recent successes in vitamin D studies published since 2024 have demonstrated that high-dose vitamin D therapy and elevated serum 25-hydroxyvitamin D are necessary to demonstrate vitamin D's non-skeletal outcomes in clinical trials. In this review article, we focus on recent randomized controlled trials (RCTs) and large population studies to demonstrate the non-skeletal functions of vitamin D. Diseases and pathologic states covered in this review include prediabetes, type 1 diabetes, type 2 diabetes, multiple sclerosis, atherosclerotic vascular disease, longevity and telomere length preservation. These well-designed randomized controlled trials, large population studies, and long-term studies conclusively demonstrate the strong efficacy and safety of high-dose vitamin D supplementation for non-skeletal health. This review article analyzes these recent studies in light of the 2024 Endocrine Society Guidelines on Vitamin D, which were based on earlier studies. This is particularly important, as these studies indicate that the non-skeletal functions of vitamin D are elicited at a much higher serum concentration of 25-hydroxyvitamin D of 40-60 mg/dL, in contrast to the lower threshold of 20 ng/mL concentration advocated by the Endocrine Society.
Many pediatric patients face barriers to accessing dermatologic care. A non-profit electronic specialty consultation (eConsult) organization worked with a medical technology company to launch an innovative dermatology eConsult program at 5 School-Based Health Center locations which are part of a statewide Federally-Qualified Health Center. We present a patient case study that highlights the immediate impact these platforms can have on the lives of young patients with skin disease.
Plastic pollution is a growing global health threat, with healthcare an underrecognized contributor. Hospitals generate large volumes of single-use plastics from clinical care, pharmaceuticals, and sterile supply chains, accounting for nearly one-quarter of hospital waste. These materials, largely derived from fossil fuels, introduce more than 13,000 chemicals into the environment and frequently degrade into microplastics and nanoplastics that contaminate air, water, soil, and human biological systems. Children are uniquely vulnerable to plastic pollution due to developmental physiology and higher per-kilogram exposures. Pediatric health impacts may occur through micro- and nano-plastics and toxic plastic additives such as phthalates, bisphenols and per- and polyfluoroalkyl substances. Reducing healthcare plastic use and waste offers direct and immediate opportunities to reduce children’s exposures. Frontline clinical strategies to address healthcare plastic pollution include sustainability-oriented quality improvement efforts aimed at eliminating unnecessary single-use plastics, transitioning to safer material alternatives, optimizing clinical practice patterns, expanding reuse and reprocessing systems, and advancing regulatory policies that restrict harmful additives. Addressing healthcare plastic pollution is not only an environmental imperative but a critical pediatric health intervention.
Fetal Alcohol Spectrum Disorders (FASD) comprise a continuum of neurodevelopmental and physical disabilities resulting from the teratogenic effects of prenatal alcohol exposure. FASD is recognized as the leading cause of preventable developmental disabilities worldwide. Recent U.S. school-based studies estimate its prevalence at 11.3-50.0 per 1000 children (approximately 1-5 %), with rates in certain high-risk populations reaching up to 169 per 1000 (approximately 17 %). Although early diagnosis is associated with improved long-term outcomes, FASD remains frequently underrecognized or misdiagnosed. Multiple factors contribute to this gap, including a shortage of specialized multidisciplinary diagnostic teams and the absence of a universally accepted diagnostic framework. This narrative review examines recent advances in the clinical diagnosis of FASD and highlights areas for future research aimed at improving diagnostic precision. The evidence presented underscores a clear public health message: abstaining from alcohol consumption during pregnancy is the safest and most effective strategy to prevent FASD.
The evaluation and management of children with prenatal alcohol exposure and suspected fetal alcohol spectrum disorders (FASD) requires a multidisciplinary approach, grounded in the pediatric medical home. This process begins with the primary care provider who is often the initial point of contact for children presenting with developmental and behavioral concerns. An evaluation for a FASD requires the primary care provider to consider the effects of biological risk factors (e.g. genetic and mental health risks, maternal pregnancy risks, and history or prenatal substance exposures), and the role of co-occurring complex trauma, for which a trauma-informed, family-centered approach is necessary to mitigate secondary morbidities, and optimize future outcomes. In this article, we will present a holistic approach to evaluating a child with a suspected alcohol-related diagnosis, beginning with the diagnostic interview which centers on building a therapeutic alliance with the child and family grounded in a framework of trauma-informed care. We will consider the role of equifinality and multifinality in the evaluation of children with developmental and behavioral concerns and suspected prenatal alcohol exposure. We will briefly review the Collaboration on FASD Prevalence (CoFASP) Clinical Diagnostic Guidelines for FASD, and review the neurobehavioral deficits associated with prenatal alcohol exposure and their developmental emergence across the childhood spectrum, with suggestions for monitoring and intervention in primary care. We will also highlight neurobehavioral similarities between FASDs and other neurodevelopmental disorders, and we will discuss the importance of trauma-informed care to foster resilience and optimize future outcomes across the developmental lifespan in children and families with FASDs.
The last two decades have witnessed a remarkable transformation in the integration of artificial intelligence in healthcare. Similarly, our understanding of fetal alcohol spectrum disorders (FASD) has expanded and the data points now being considered are far more granular. In this article, we will review how investigators have attempted to apply technological innovations to enhance our knowledge of FASD and to fill some of the gaps that exist regarding access to experienced diagnosticians. We will summarize the salient studies to date and highlight future directions in terms of how the technology can move from research to healthcare delivery.
Resistance training in the pediatric population is often surrounded by myths and misconceptions, making it challenging to provide clear recommendations. However, evidence supports that resistance training, when appropriately designed and supervised, is both safe and effective for children and adolescents aged 7 to 18 years. Programs may incorporate bodyweight exercises, free weights, resistance bands, machines, and suspension systems such as TRX. When developmentally appropriate, resistance training not only promotes muscular strength and endurance but also supports healthy growth, motor coordination, bone health, and overall physical development.
Pediatric obesity, the most common chronic childhood disease in the United States is associated with significant comorbidities that persist into adulthood and increase the risk of early mortality. Metabolic and bariatric surgery (MBS) is the most effective intervention for severe obesity with durable reductions in BMI and obesity-related comorbidities as compared with medical therapy. MBS utilization remains strikingly low. Nearly three million children currently meet eligibility criteria for MBS, yet only about 2500 procedures are performed annually. There are many barriers to accessing MBS, including subspecialty surgeon availability, cost and geographic concentration of multidisciplinary programs, and the substantial burden of perioperative outpatient visits. Primary care physicians remain hesitant to refer adolescents for MBS due to outdated concerns about surgical risks, growth disruption, and adherence to the ineffective strategy of "watchful waiting." Insurance denials likewise remain a persistent challenge with approval of only 40 % of initial requests for pediatric MBS, leading to delays, program attrition, and widening disparities. These barriers are compounded by persistent socioeconomic and racial inequities. Minority and socioeconomically disadvantaged youth are disproportionately affected by obesity, yet less likely to receive early referral or access to specialized obesity care. At the time of surgery, these patients have higher BMI and more advanced comorbidities, reflecting systemic failures. Despite these challenges, MBS offers transformative, and often lifesaving, benefits. Addressing persistent disparities in access to care by improving physician education, expanding program access and capacity, and reforming insurance policies are essential steps toward equitable access to effective obesity treatment for all children.
Congenital muscular torticollis (CMT) typically is due to unilateral shortening of fibrosis of sternocleidomastoid muscle. Timely diagnosis and management are essential for improving outcomes in children. Within CMT, there are several classifications with variable prognosis: postural, muscular, and sternomastoid tumor group. The diagnosis of CMT involves comprehensive physical assessment. Treatment of CMT typically involves conservative treatment that includes physical therapy, but can involve pharmacologic treatment with botulinum toxin injections, and at worst case, surgical treatment. Caregiver education is the key to successful treatment.
Pediatric stroke, though less common than adult stroke, is a significant cause of morbidity and mortality in children, affecting neonates, infants, and adolescents. Strokes in children could be due to ischemic, hemorrhagic, or venous-thrombotic events. Timely recognition and intervention to optimize neurologic outcomes and minimize long-term disability is most critical. Clinical symptoms are dependent on location of the stroke, but pediatric-specific challenges include higher prevalence of stroke mimics and more frequent seizures. Rapid diagnosis hinges on detailed history, neurologic examination, and emergent imaging, with MRI and angiography preferred for evaluating ischemia and vascular anomalies. Hyperacute treatments include intravenous thrombolysis and mechanical thrombectomy. Risk factors are often multifactorial, including congenital heart disease, sickle cell disease, and thrombophilia. Acute complications may involve cerebral edema, hemorrhagic conversion, and post-stroke epilepsy. Rehabilitation is essential and begins early in the intensive care unit. A multidisciplinary team-including physical, occupational, and speech therapists alongside physiatrists-supports recovery. Rehabilitation intervention includes uses of orthoses to improve function, prevent complications, impairment specific treatment including constraint-induced movement therapy (CIMT) and goal-oriented hypertonia management. Cognitive and communication impairments also require tailored therapies and school reintegration planning. Although neural plasticity offers potential for recovery, many children experience persistent motor, cognitive, and psychosocial deficits. Early, aggressive rehabilitation and coordinated outpatient care are key to maximizing functional outcomes and improving long-term quality of life.
