Bedside use of artificial intelligence (AI) platforms is increasingly common. Busy clinicians may welcome these generative AI (Gen AI) tools, which have the potential to streamline many time-consuming tasks and aid in patient care. Trainees may find them useful to quickly evaluate complex medical information. Acceptance of bedside Gen AI tools by patients and their families, however, is less clear, and a definitive standard surrounding informed consent has yet to be established. Omission of certain types of information by Gen AI tools, including "small talk," which comprises an essential element of many pediatric clinical interactions, demands attention alongside the tendency of Gen AI tools to fabricate content. Medical students and resident physicians may be early adopters of Gen AI tools and may accept AI-generated statements at face value before having fully developed adequate knowledge and critical skills to independently evaluate their veracity. Despite these challenges, Gen AI tools in the clinical space are here to stay. Safe and effective incorporation of these tools in patient care and medical education must balance a wide range of considerations. In the following Ethics Rounds, stemming from a 2024 Pediatric Academic Society Bioethics Club Meeting session on the use of AI, the commentators draw on their diverse background as pediatric clinicians, bioethicists, and educators to explore these issues.
Catatonia is often underrecognized and underdiagnosed, particularly in young children. Catatonia occurs secondary to a medical and/or psychiatric etiology. The diagnosis can be supported by validated rating scales, including the Pediatric Catatonia Rating Scale and/or response to a dose of a benzodiazepine, often lorazepam. We present the case of a 6-year-old boy with acute behavioral changes in speech, affect, awareness, and new odd behaviors, admitted to a quaternary care pediatric hospital for further assessment and work-up of symptoms consistent with catatonia. Laboratory testing was notable for previously undiagnosed Becker muscular dystrophy (BMD), although otherwise unremarkable. He received many medication treatments for catatonia, including escalating doses of lorazepam and augmentation with memantine, zolpidem, quetiapine, and ultimately clozapine, without adequate symptom improvement and with side effects including significant weight gain. Neither behavioral interventions nor empirical treatment of presumed seronegative autoimmune encephalitis with intravenous immunoglobulin and methylprednisolone conferred benefit. He ultimately received electroconvulsive therapy, with significant and relatively rapid improvement occurring over 2 weeks after a 4-month hospitalization. This case highlights the importance of the identification of catatonia to guide evidence-based treatment and the value of timely access to electroconvulsive therapy for pediatric patients. While the etiology of his catatonia remains undetermined, his diagnosis of BMD could play a role and further supports the importance of a comprehensive medical work-up.
OBJECTIVES:Experiences in early life impact childhood, lifelong flourishing, and overall well-being. Yet a framework to guide promoting and measuring flourishing in early childhood has not emerged. The objective of this study was to identify frameworks and measures related to promoting and assessing early-childhood flourishing (0-5 years) to build on a preexisting, community-informed framework. METHODS:A systematic search was conducted across electronic databases and the gray literature for articles published between 2014-2026. Of 13 902 total references, 8592 were eligible for screening. A machine learning-assisted tool (Research Screener) was used to streamline screening of the abstracts against the inclusion criteria. A deductive approach guided by a preexisting community-informed framework was used to interpret the data. RESULTS:From 32 studies, we identified 6 frameworks and 9 measures that related to early-childhood flourishing. Frameworks typically identified preconditions of flourishing and indicators of child flourishing. Child flourishing measures commonly included items assessing healthy attachment, resilience, engagement and curiosity, and emotional openness and well-being. The National Survey of Children's Health Child Flourishing Index was the most cited measure. A new "curiosity" domain was added to the preexisting framework. Findings will guide the development of a new assessment tool. CONCLUSIONS:Studies from Western, high-income countries were largely represented. Optimizing early-childhood flourishing requires a positive health promotion approach that both fosters preconditions for and monitors flourishing as an outcome. This paper presents a unified, operational framework for measuring flourishing across key domains.
OBJECTIVES:To assess the effects of immersive virtual reality (IVR) for alleviating anxiety, anticipatory nausea and vomiting, and chemotherapy-induced nausea and vomiting (CINV) in patients with pediatric cancer receiving their first chemotherapy. METHODS:An assessor-blinded parallel-group randomized controlled trial was conducted in a local children's hospital among pediatric patients (aged 6-12 years) undergoing their first chemotherapy. Outcome measures included (1) anxiety; (2) anticipatory nausea and vomiting; and (3) CINV. Outcome assessments were conducted at baseline (T0), before (T1) and after first (T2) chemotherapy, and before (T3) and after (T4) second chemotherapy. RESULTS:A total of 128 patients (mean age = 9.02 years) were recruited. Generalized estimating equations analyses indicated that the intervention group had significantly greater reduction in anxiety than the control group before and after the first and second chemotherapy (time-by-group interaction, T1: β = -1.76, d = -0.67; T2: β = -3.71, d = -0.87; T3: β = -3.71, d = -0.91; T4: β = -6.30, d = -1.48; all P < 0.001), demonstrating that the IVR intervention effect progressively increased from medium to large over time. The Mann-Whitney U test showed that compared with the control group, the IVR group reported significantly fewer episodes of anticipatory nausea at T3 (P < 0.001), CINV (P = 0.03) at T4, and chemotherapy-induced vomiting (P = 0.003) at T2 and T4. CONCLUSIONS:IVR was beneficial in reducing anxiety, anticipatory nausea, and CINV among patients with pediatric cancer undergoing their first chemotherapy. The findings suggest a convenient and easily applied intervention for pediatric chemotherapy patients to enhance clinical care.
BACKGROUND AND OBJECTIVES:Clinical practice guidelines for pediatric obesity management allow for consideration of glucagon-like peptide-1 receptor agonists (GLP-1RA) in children ages 8-11. No study has documented secular trends in GLP-1RA prescribing in this group. We hypothesized that there would be a significant increase over time, particularly for children with more severe obesity, greater comorbidity burden, and less socioeconomic vulnerability. METHODS:This retrospective cross-sectional study of repeated annual cohorts from Epic Cosmos examined GLP-1RA prescriptions (Saxenda, Wegovy, Zepbound) for children (aged 8-11) without diabetes and with obesity from January 1, 2019 to June 17, 2026. A binomial logistic regression model for grouped data was performed to determine whether changes in the proportion of patients prescribed GLP-1RA over time were statistically significant. RESULTS:Among 3 520 531 children with obesity but without diabetes, 0.6% received a GLP-1RA prescription. Older children (11 years: 79.5/10 000 vs 8 years: 41.5/10 000), female children (75.9/10 000 vs 42.8/10 000), and children with less social vulnerability (low: 76.1/10 000 vs high: 49.2/10 000) were more likely to be prescribed GLP-1RAs. Children with obesity-related comorbidities were substantially more likely to be prescribed GLP-1RAs (188.9/10 000). Prevalent prescribing increased from 0.03% in 2019 to 9.3% in 2026, a 310-fold increase (P < .001). CONCLUSIONS:In this cohort of >3.5 million children aged 8 to 11 with obesity and without diabetes, GLP-1RA prescribing increased sharply from 2019 to 2026 yet remained uncommon, reaching 0.6% of children. Clinicians appear to be reserving GLP-1RAs for those at greatest cardiometabolic risk. Prescriptions are more likely to go to those with less socioeconomic vulnerability.
BACKGROUND AND OBJECTIVE:Neonatal organ donation could significantly expand the deceased donor pool, but referral pathways and acceptance criteria remain highly variable worldwide and determination of neurological death in neonatal patients has traditionally been considered challenging. Our national study aimed to determine the potential proportion of neonates eligible for donation after neurological and circulatory determination of death in Australia and to identify reasons for ineligibility. METHODS:We analyzed the Australian and New Zealand Neonatal Network data for neonates who died in one of 23 tertiary neonatal intensive care units between 2012 and 2022. Donation eligibility via neurological or circulatory death pathways were determined using International Classification of Diseases, Tenth Revision codes and Australia and New Zealand Neonatal Network morbidity data. RESULTS:Of 1760 infants, 750 (43%) met the inclusion criteria. Neurological causes accounted for 307 deaths; 65 (21%) were potentially eligible for donation via the neurological death pathway and 242 (79%) for donation after circulatory death. Among 443 infants with non-neurological causes of death, 257 (58%) were eligible for donation after circulatory death. Reasons for ineligibility included multiorgan failure, active infection at time of death, underlying chromosomal or genetic disorders, birth with multiple or complex congenital anomalies, intra-abdominal pathologies inclusive of necrotizing enterocolitis, and underlying disorders of metabolic, hematological, or lymphatic origin. CONCLUSION:Neonates represent a potentially underused donor population, with more than half of those dying of non-neurological causes meeting criteria for donation after circulatory determination of death. Consistent referral criteria and streamlined clinical pathways are needed to maximize donation opportunities.
This technical report accompanies the American Academy of Pediatrics (AAP) policy statement (https://doi.org/10.1542/peds.2026-079047) and recommendations for respiratory syncytial virus (RSV) immunization during the 2026-2027 RSV season. The rationale is presented for recommending immunization of all infants younger than 8 months born during or entering their first RSV season, unless the infant has documented protection from vaccination of the pregnant parent; and infants and children 8 through 19 months of age who are at high risk of severe RSV disease and entering their second RSV season. The report synthesizes current evidence on RSV epidemiology, disease burden, immunization effectiveness, safety, and cost-effectiveness in pediatric populations; including evidence supporting expansion of high-risk groups for second season administration. Additionally, the report provides an overview of available RSV immunization products, formulations, and coadministration with other immunizations.
This technical report accompanies the American Academy of Pediatrics policy statement recommendations for COVID-19 vaccination during the 2026-2027 respiratory virus season. The rationale is presented for recommending vaccination in all infants and children 6 through 23 months of age, children 6 months through 18 years of age who are moderately or severely immunocompromised, and children 2 through 18 years of age in certain additional risk groups, including those at high risk of severe COVID-19, residents of long-term care facilities or other congregate settings, children who have never been vaccinated against COVID-19, and children whose household contacts are at high risk for severe COVID-19. The report synthesizes currently available evidence on SARS-CoV-2 epidemiology, disease burden, COVID-19 vaccine effectiveness, vaccine safety, and vaccine cost-effectiveness in pediatric populations. Additionally, the report provides an overview of available COVID-19 vaccine products, formulations, storage and handling considerations, and coadministration with other immunizations.
This policy statement updates the recommendations of the American Academy of Pediatrics (AAP) for the use of COVID-19 vaccines in the prevention of severe COVID-19 in children. A review of evidence supporting these recommendations is in the accompanying technical report (https://doi.org/10.1542/peds.2026-079046). These COVID-19 vaccine recommendations may change in future seasons or as additional variants emerge. The AAP recommends all infants and children 6 through 23 months of age who do not have contraindications receive 2026-2027 COVID-19 vaccine. The AAP also recommends a single dose of age-appropriate 2026-2027 COVID-19 vaccine for all children and adolescents 2 through 18 years of age at increased risk of severe COVID-19, regardless of prior COVID-19 vaccination status. Children 2 through 18 years of age not considered at increased risk of severe COVID-19 whose parent or guardian desires their protection from COVID-19 should be offered a single dose of age-appropriate 2026-2027 COVID-19 vaccine. Any available COVID-19 vaccine appropriate by age and health status can be administered and the most updated version of the COVID-19 vaccine that is available should be used.
This policy statement updates recommendations of the American Academy of Pediatrics (AAP) for the use of respiratory syncytial virus (RSV) immunization for the prevention of lower respiratory tract infection (LRTI) caused by RSV in infants and children. The AAP recommends RSV immunization for all infants under 8 months of age born during or entering their first RSV season, unless the infant has documented protection from vaccination of their pregnant parent; and for infants and children 8 through 19 months of age who are at high risk of severe RSV disease and entering their second RSV season. A review of evidence supports expanding the high-risk criteria for administration of RSV immunization in infants and children 8 through 19 months of age entering their second RSV season. A discussion of the evidence supporting the AAP recommendations and additional details on infants and children included in the expanded recommendations are in the accompanying technical report (https://doi.org/10.1542/peds.2026-079049).
To report the successful use of continuous renal replacement therapy (CRRT) in a child with type 1 diabetes mellitus (T1DM) and intravenous immunoglobulin (IVIG)-refractory Kawasaki disease shock syndrome (KDSS). A 3-year, 10-month-old boy with poorly controlled T1DM and autoimmune thyroiditis presented with KDSS and diabetic ketoacidosis. Despite IVIG and high-dose aspirin, he developed refractory shock and metabolic acidosis. Continuous venovenous hemodiafiltration was initiated, leading to rapid hemodynamic stabilization, resolution of hyperinflammation, and metabolic normalization. CRRT may serve as a rescue therapy in critically ill children with concurrent cytokine storm and metabolic crisis, particularly when standard immunomodulatory therapies fail.
CONTEXT:Delirium is common in pediatric intensive care units. Reliable tools are needed, but evidence on measurement properties remains fragmented. OBJECTIVES:To identify pediatric delirium tools and evaluate their measurement properties and certainty of evidence. DATA SOURCES:MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Web of Science were searched without language or date restrictions. STUDY SELECTION:Original observational, cross-sectional, and validation studies evaluating at least 1 measurement property of a pediatric delirium tool in acute care were eligible. DATA EXTRACTION:Two reviewers independently screened studies, extracted data, and assessed risk of bias using the adapted COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methods and Quality Assessment of Diagnostic Accuracy Studies-2 for diagnostic accuracy. Evidence was rated using COSMIN-adapted Grading of Recommendations Assessment, Development and Evaluation. RESULTS:From 8378 records, 41 studies were included, covering 15 language versions of 6 tools: Cornell Assessment of Pediatric Delirium (CAPD), preschool-Confusion Assessment Method for Intensive Care Unit, pediatric-Confusion Assessment Method for Intensive Care Unit, Sophia Observation withdrawal Symptoms scale - Pediatric Delirium (SOS-PD), PEdiatric Delirium Scale (PEDS), and Child Delirium Assessment Scale (CDAS). CAPD had the largest evidence base. High-certainty evidence supported criterion validity of CAPD and Confusion Assessment Method tools, with moderate-certainty evidence for reliability. SOS-PD showed moderate-certainty evidence for criterion validity and high-certainty evidence for convergent validity and reliability but was evaluated in fewer studies. Evidence for CDAS and PEDS was limited to single studies. LIMITATIONS:Evidence was uneven across tools and mainly addressed criterion validity and interrater reliability. Measurement error, cross-cultural validity, and subgroup performance were rarely assessed. Criterion validity is difficult because no perfect gold standard exists for diagnosis. CONCLUSIONS:SOS-PD showed the most favorable certainty profile across evaluated measurement properties but was evaluated in fewer studies than CAPD. Further studies should address measurement error, cross-cultural validity, subgroup performance, and implementation.
BACKGROUND:Residency graduates must be "practice ready" by the time they leave training. This study explored how pediatric residency program directors view their role and responsibility in determining practice readiness and examined how characterizations of practice readiness differ based upon residents' intended career trajectories. METHODS:The authors conducted a constructivist grounded theory study, purposively and theoretically sampling 15 pediatric program directors to explore their experiences determining resident practice readiness. Iterative data collection and analysis continued until sufficient information power was achieved. RESULTS:Program director participants described an immense moral responsibility for determining practice readiness and positioned themselves as the central decision makers in these determinations. Participants emphasized their longitudinal knowledge of residents and sense of accountability as shaping their moral responsibility. Participants reported variability in what readiness means. Some believed all graduates should be ready to practice as general pediatricians regardless of future career plans, emphasizing the importance of a strong generalist foundation and the possibility of changing career trajectories. Others defined readiness relative to the specific context residents would enter after graduation, either readiness for the specific general pediatrics context they would be in or readiness for fellowship training. CONCLUSIONS:Despite the profound moral responsibility that program directors report in determining practice readiness, there is variation in how they conceptualize "readiness for what?" As the ABP certification process transitions toward Entrustable Professional Activity-based attestations of practice readiness in 2028, clarifying and aligning expectations for practice readiness is critical to ensuring consistent and defensible graduation and certification eligibility decisions.
Evidence of net benefit and feasibility of implementation is necessary for a health condition to become part of routine newborn screening. But acquiring data to support informed decision-making is difficult without a nimble and coordinated research capacity grounded in public health practice, a problem exacerbated in the case of rare disorders. To address this concern, we built and implemented Early Check to test the feasibility of a research resource that could adapt to changing needs for data. During the first 5 years, we (1) built a partnership among an independent scientific research institute, 2 universities, and the North Carolina State Laboratory of Public Health; (2) developed and evaluated low-touch statewide recruitment approaches and an online consent that met all institutional review board requirements; (3) selected 3 prototypic health conditions to test the system; (4) enrolled and screened nearly 27 000 newborns; and (5) identified 105 screen-positive participants for whom we provided counseling, diagnostic testing, and referral to specialized long-term clinical care for infants with confirmed diagnoses. After this initial phase, we used the same infrastructure to offer whole-genome sequencing at birth for more than 200 disorders. Lessons learned from Early Check and other similar projects will hopefully inform future efforts to build national capacity for newborn screening research.
Decision analytic models that project the outcomes of population-based newborn screening compared with clinical identification can inform newborn screening policymaking. A flexible decision analytic model that could be adapted for the many and growing number of conditions being considered for newborn screening would help expedite decision making while reducing the time and resources required to develop new condition-specific models. To address this need, we developed Decision Analysis to Inform Screening of the Young (DAISY), an interactive and adaptable generic newborn screening model that incorporates user-supplied inputs. To illustrate the use of this tool, we present a model of newborn screening for metachromatic leukodystrophy (MLD). DAISY projects that newborn screening would identify a greater number of MLD cases and improve survival outcomes over a 5-year time horizon compared with clinical identification. In a US birth cohort of 3.6 million newborns, we project that 36 infants with early-onset MLD cases would be identified per year through newborn screening, each of whom would be treatment eligible. In contrast, in the absence of screening, only 11.5 infants with early-onset MLD cases would be identified, 10 of whom would be treatment eligible. The number of children surviving without motor impairment approximately 5 years after symptom onset is projected to be 32.8 with newborn screening and 9.1 in the absence of screening. DAISY can be used to evaluate other newborn screening candidate conditions through specification of input parameters such as population size, clinical validity of the screening algorithm, and treatment effectiveness.
