Otological conditions are known to be a contributing factor for delayed diagnosis of autism spectrum disorder (ASD). The co-occurrence of otological conditions and ASD, however, has not been adequately studied. This study aims to estimate the prevalence of ASD in children according to otological conditions and to assess the associations of otological conditions with ASD. A cross-sectional study of Medicaid beneficiaries aged 1 to 20 years using 2020 data on diagnoses and beneficiary demographics from the Transformed Medicaid Statistical Information System of the Medicaid and Children's Health Insurance Program was performed. Otological conditions examined included otitis media, sensorineural and conductive hearing loss, tinnitus, and hyperacusis. Prevalence and odds ratios of ASD adjusted for age group, sex, and race and ethnicity (aORs) were estimated according to otological conditions. Of 40,990,295 participants, 10.4

As more children with autism enter adulthood, updated data on co-occurring conditions throughout the lifespan are needed. We examined mental, neurodevelopmental and neurological (MNN) conditions among people with and without autism overall and by demographics. Using Medicaid claims data for beneficiaries aged ≥ 1 year enrolled during 2020, we identified autism and MNN diagnoses using ICD-10 codes. Adjusted prevalence ratios (aPRs) in beneficiaries with versus without autism were calculated using log-binomial models. Among 993,965 beneficiaries with autism, attention-deficit-hyperactivity and conduct disorders (ADHD/CD, 30.5

BACKGROUND:Sickle cell disease (SCD) is an inherited hemoglobinopathy affecting approximately 100 000 Americans, disproportionately affecting Black individuals. Sickling of hemoglobin S red blood cells due to conditions in the perioperative period including hypoxemia, hypothermia, surgical stress, and pain can reduce organ perfusion and lead to adverse outcomes including pain crisis, acute chest syndrome, and stroke. AIMS:This study evaluates perioperative outcomes and risk factors for sickle cell crisis in children with SCD undergoing common inpatient surgical procedures. METHODS:A retrospective cohort was created using the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) 2003-2019. Hospital admissions for children < 18 years of age undergoing a selected group of surgical procedures (cholecystectomy, appendectomy, congenital cardiac surgery, and posterior spinal fusions) commonly requiring inpatient stay were included. Diagnoses and procedures were identified using ICD-9/ICD-10 codes. Perioperative outcomes included post-operative length of stay (LOS), blood transfusions, hematologic, and infectious complications. Children with SCD were compared to those without SCD using multivariable Poisson regression to adjust for surgical procedure and sociodemographic, clinical, and hospital characteristics. RESULTS:Of 5 75 005 children studied, 2357 (0.4%) had SCD. Relative to children without SCD, those with SCD had a longer post-operative LOS (adjusted incidence rate ratio [aIRR]: 1.29; 95% CI [1.26-1.32], p < 0.001). Children with SCD hospitalized for a surgical procedure were also more likely to receive a blood transfusion (adjusted risk ratio [aRR]: 13.1; 95% CI [12.1-14.2], p < 0.001). Significantly increased associated risks of hematologic and infectious complications, however, were not observed. Of children with SCD, 17.5% experienced a sickle cell crisis during hospitalization. The odds of sickle cell crisis in non-elective admissions were more than three times as high as in elective admissions (aOR 3.36; 95% CI [2.46-4.60], p < 0.001). Children with sickle cell crisis had a longer post-operative hospital stay (aIRR: 1.58; 95% CI [1.49-1.67]) than those without a crisis. CONCLUSIONS:The perioperative course in children with SCD was associated with longer postoperative length of stay and higher blood transfusion rates relative to those without SCD undergoing similar surgical procedures. Perioperative sickle cell crisis was present in more than one out of six admissions, more common in non-elective admissions, and is associated with excess length of stay.

Background: Children with a respiratory disease requiring invasive mechanical ventilation (IMV) in the paediatric intensive care unit (PICU) have an elevated risk for subsequent neurodevelopmental and behavioural disorders (NDBD). This study evaluates NDBD in children receiving IMV during surgical admissions. Methods: Children enrolled in Texas Medicaid between 1999 and 2012 with a surgical admission were evaluated. Children in the PICU receiving IMV, in the PICU not receiving IMV, and in the intermediate medical care unit (IMCU) were identified and matched to children admitted to the general ward. The primary outcome was post-discharge NDBD. Secondary analyses evaluated NDBD risk by IMV duration and post-discharge psychotropic medication use. Results: Of 35 161 children with surgical admissions meeting eligibility criteria, 993 were in the PICU with IMV, 7670 in the PICU without IMV, and 1027 in the IMCU. Increased rates of NDBD were observed in children receiving IMV (hazard ratio [HR] 1.91, 95% confidence interval [CI] 1.27-2.89, P=0.002), but not in those in the PICU without IMV (HR 1.12, 95% CI 0.98-1.29, P=0.10) or IMCU (HR 0.88, 95% CI 0.61-1.26, P=0.48). Elevated rates of NDBD were detected primarily in children receiving IMV for 96 h or more. Increased psychotropic medication use was observed only in the IMV group. Conclusions: Children receiving invasive mechanical ventilation during a surgical admission are at increased risk of neurodevelopmental and behavioural disorders after hospital discharge. Further research is needed to clarify the mechanisms behind this association and to identify potentially modifiable risk factors.

BACKGROUND:Surgical procedure duration and anesthesia time are important variables, with applications including measurement of quality of care and quantity of anesthetic exposure. This study evaluates data from Medicaid anesthesia claims as a proxy for anesthesia time. METHODS:Fee-for-service anesthesia claims for appendectomies and cholecystectomies of beneficiaries under age 65 yr from the Medicaid Analytic eXtract (1999 to 2013) were identified. The quantity of service (QoS) variable in anesthesia claims was evaluated on three criteria: (1) reflection of expected anesthesia time, (2) correlation with Medicaid payment, and (3) state interpretation of QoS as anesthesia time by evaluating payments estimated using state-specific billing rules and correlation with actual payments. Spearman correlations were calculated with coefficients above 0.7 considered to be strong. RESULTS:A total of 902,492 fee-for-service anesthesia claims were identified from 48 states and Washington, D.C., with 14 states reporting QoS values in units, 19 reporting in minutes, and 16 reporting in both units and minutes. The median QoS values for appendectomy and cholecystectomy were 6 and 7 U in claims reporting time in units and 76 and 89 min in claims reporting time in minutes, respectively. The majority of unit states (9 of 14; 64%) and minute states (14 of 19; 74%) met all three criteria. For the 16 states reporting QoS values in both units and minutes, 8 of 16 (50%) reported unit claims and 9 of 16 (56%) reported minute claims that met the three criteria. CONCLUSIONS:The QoS variable reported on state Medicaid anesthesia claims had utility in approximating anesthesia time as minutes or 15-min units when evaluating anesthesia claims from two common surgical procedures. However, this variable does not accurately reflect anesthesia time in every state, and even in states where QoS was deemed to be usable, outliers and misclassified data need to be addressed.

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent challenges in communication and social interaction and, often accompanied by restricted and repetitive patterns of behavior and interests. The reported prevalence of ASD in the United States has tripled in the past two decades. Recent studies indicate that ASD is associated with increased self-injurious behaviors. The purpose of this study is to assess the excess risk of intentional self-harm associated with ASD. Using a repeated cross-sectional study design, we analyzed data from the 2016–2020 Nationwide Emergency Department Samples (NEDS), the largest all-payer emergency department (ED) database in the United States. ED visits for intentional self-harm were identified using the ICD–10–CM external cause-of-injury matrix. Adjusted odds ratios (aORs) and 95

( Anesthesiology . 2024;141(3):489–499. doi: 10.1097/ALN.0000000000005075) Exposure to anesthesia in children occurs every year due to required surgical procedures, however, there is suspicion that this exposure challenges the normal neurodevelopmental processes. Parents and professionals should be aware of potential anesthetic effects when considering treatment options. Although there is limited to no evidence of anesthetic effects in most neurodevelopmental areas, there are a few studies that suggest an effect on neurobehavioral outcomes in specific domains. In response, this study seeks to further understand the neurotoxicity of anesthesia and surgery by examining the incidence of neurobehavioral outcomes in children who underwent surgery for appendicitis, a nearly random childhood illness, as well as pediatric patients who required a hospitalization for medical illness without exposure to surgery or anesthesia.

( Anesthesiology . 2025 Oct 1;143(4):799–801. doi: 10.1097/ALN.0000000000005671) This editorial examines the issue, which has been debated for decades, of whether general anesthesia (GA) is neurotoxic for children. The problem is that this is confounded by other factors that often also contribute to worse neurodevelopmental outcomes in children. Sometimes these are somewhat obvious confounding variables; for example, children who need anesthesia for dental procedures usually have underlying behavioral problems. However, other times they are more subtle, like the fact that children who are already behind in meeting typical milestones for their ages, with symptoms of obstructive airways, are more likely to undergo a tonsillectomy.

The U.S. Food and Drug Administration has cautioned that prenatal exposure to anesthetic drugs during the third trimester may have neurotoxic effects; however, there is limited clinical evidence available to substantiate this recommendation. One major scientific question of interest is whether such neurotoxic effects might be due to surgery, anesthesia, or both. Isolating the effects of these two exposures is challenging because they are observationally equivalent, thereby inducing an extreme positivity violation. To address this, we adopt the separable effects framework of Robins and Richardson (2010) to identify the effect of anesthesia (alone) by blocking effects through variables that are assumed to completely mediate the causal pathway from surgery to the outcome. We apply this approach to data from the nationwide Medicaid Analytic eXtract (MAX) from 1999 through 2013, which linked 16,778,281 deliveries to mothers enrolled in Medicaid during pregnancy. Furthermore, we assess the sensitivity of our results to violations of our key identification assumptions.

( Br J Anaesth . 2024;132(5):899–910. doi: 10.1016/j.bja.2024.01.025) This study investigates the potential link between prenatal exposure to general anesthesia and the increased risk of children developing disruptive or internalizing behavioral disorders (DIBD). It stems from growing concerns about the safety of anesthesia, particularly for children under 3 years old and pregnant women in their third trimester, as outlined by the Food and Drug Administration (FDA) in 2016. Anesthetic agents cross the placenta and may impact neurodevelopment, with studies suggesting they can affect brain development during critical periods of gestation. This study focuses on the effects of prenatal exposure, considering that such exposures often result from maternal medical conditions rather than conditions in the child, which may help reduce confounding bias.

( Int J Obstet Anesth . 2025; 61:104318. DOI: 10.1016/j.ijoa.2024.104318) Emerging evidence increasingly highlights the impact of early life exposures—including those during pregnancy—on long-term health and development. The fetal period is particularly sensitive due to the ongoing development of organs and neural systems. While many environmental chemicals have been linked to developmental harms, some medications (including anesthetics, which can be medically necessary during pregnancy) may also pose a safety risk for children. Anesthetics, both general and regional (such as labor epidural analgesia or LEA), provide critical medical benefits and have come under scrutiny for their possible long-term effects on child neurodevelopment.

Children with autism spectrum disorder (ASD) are at heightened risk of unintentional drowning. We examined the epidemiological patterns of unintentional drowning incidents involving children diagnosed with ASD treated in US emergency departments (EDs). Data for this study came from the 2016–2020 Nationwide ED Sample. Children aged 1–19 years diagnosed with ASD and treated in EDs were identified using ICD-10-CM code F84.0. Weighted multivariable logistic regression models were used to estimate the adjusted odds ratio (aOR) and 95

Objectives Previous studies have reported that mode of delivery, particularly cesarean delivery (CD), is associated with neurodevelopmental outcomes in children. This study evaluates behavioral and neuropsychological test scores in children based on mode of delivery.Methods Children enrolled in the Raine Study from Western Australia, born between 1989 and 1992 by instrumental vaginal delivery (IVD), elective CD, and non-elective CD, were compared to those with spontaneous vaginal delivery (SVD). The primary outcome was the Child Behavior Checklist (CBCL) administered at age 10. Secondary outcomes included evaluations of language, motor function, cognition, and autistic traits. Multivariable linear regression was used to evaluate score differences by mode of delivery adjusted for sociodemographic and clinical characteristics, and Poisson regression was used to evaluate for increased risk of clinical deficit.Results Of 2,855 children, 1770 (62.0 %) were delivered via SVD, 480 (16.8 %) via IVD, 346 (12.1 %) via elective CD, and 259 (9.1 %) via non-elective CD. Non-elective CD was associated with higher (worse) CBCL Internalizing (+2.09; 95 % CI 0.49, 3.96; p=0.01) scores, and elective CD was associated with lower (worse) McCarron Assessment of Neuromuscular Development (MAND) (-3.48; 95 % CI -5.61, -1.35; p=0.001) scores. Differences were not seen in other outcomes, and increased risk of clinical deficit was not observed with either the CBCL Internalizing or MAND scores.Conclusions Differences in behavior and motor function were observed in children delivered by CD, but given that score differences were not associated with increased incidence of clinical deficit, clinical significance may be limited.

CONTEXT:While specialist palliative care is associated with improved end-of-life quality metrics for patients with advanced cancer, its effectiveness may differ between hospitals. OBJECTIVES:To examine variation in palliative care program performance on end-of-life care quality metrics. METHODS:Retrospective cohort study of palliative care programs that participated in the National Palliative Care Registry, 2018-2019. Medicare data for patients age ≥65 who died with metastatic cancer were aggregated on a program-level. Variation in program performance on outcomes (use of hospice, hospice enrollment ≥3 days, use of intensive care in the last 30 days of life, and use of chemotherapy in the last 14 days of life) was quantified by risk-standardized outcome rates (RSOR) and adjusted median odds ratios (aMOR). RESULTS:The cohort comprised 235 palliative care programs who delivered care to 33,015 patients. There was substantial variation in use of hospice (median RSOR 65.6%, interquartile range (IQR) 57.5%-74.3%), hospice enrollment ≥3 days (median RSOR 53.6%, IQR 48.6%-58.2%), and use of intensive care (median RSOR 14.1%, IQR 13.1%-15.3%), but not use of chemotherapy (median RSOR 1.5%, IQR 1.4%-1.5%). Variation was greatest for hospice use (aMOR 1.48 [1.39-1.57]), suggesting that patients at programs with high hospice use would be 48% more likely to use hospice than if they received care at programs with low use. CONCLUSION:We found variation in most end-of-life quality metrics for patients with metastatic cancer. Further work is needed to better understand why variations exist and whether such variations reflect a difference in quality of care.

CONTEXT:For patients with advanced cancer, high intensity treatment at the end of life is measured as a reflection of the quality of care. Use of specialist palliative care has been promoted to improve care quality, but whether its use is associated with decreased treatment intensity on a population-level is unknown. OBJECTIVES:To determine whether receipt of specialist palliative care use is associated with differences in end-of-life quality metrics in patients with metastatic cancer. METHODS:Retrospective propensity-matched cohort of patients age ≥ 65 who died with metastatic cancer in U.S. hospitals with palliative care programs that participated in the National Palliative Care Registry in 2018-2019. Cox proportional hazards regression was used to assess the impact of specialist palliative care on use of chemotherapy in the last 14 days of life, use of intensive care unit (ICU) in the last 30 days of life, use of hospice, and hospice enrollment ≥ three days. RESULTS:After 1:2 matching, our cohort consisted of 15,878 exposed and 31,756 unexposed patients. Receipt of specialist palliative care was associated with a decrease in use of chemotherapy (adjusted hazard ratio (aHR) 0.59 [0.50-0.70]) and ICU at the end of life (aHR 0.86 [0.80-0.92]), and an increase in hospice use (aHR 1.92 [1.85-1.99]) and hospice enrollment for ≥three days (aHR 2.00 [1.93-2.07]). CONCLUSION:On a population-level, use of specialist palliative care was associated with improved metrics for quality end-of-life care for patients dying with metastatic cancer, underscoring the importance of its integration into cancer care.

BACKGROUND:The association between prenatal exposure to general anaesthesia for maternal surgery during pregnancy and subsequent risk of disruptive or internalising behavioural disorder diagnosis in the child has not been well-defined. METHODS:A nationwide sample of pregnant women linked to their liveborn infants was evaluated using the Medicaid Analytic eXtract (MAX, 1999-2013). Multivariate matching was used to match each child prenatally exposed to general anaesthesia owing to maternal appendectomy or cholecystectomy during pregnancy with five unexposed children. The primary outcome was diagnosis of a disruptive or internalising behavioural disorder in children. Secondary outcomes included diagnoses for a range of other neuropsychiatric disorders. RESULTS:We matched 34,271 prenatally exposed children with 171,355 unexposed children in the database. Prenatally exposed children were more likely than unexposed children to receive a diagnosis of a disruptive or internalising behavioural disorder (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.23-1.40). For secondary outcomes, increased hazards of disruptive (HR, 1.32; 95% CI, 1.24-1.41) and internalising (HR, 1.36; 95% CI, 1.20-1.53) behavioural disorders were identified, and also increased hazards of attention-deficit/hyperactivity disorder (HR, 1.32; 95% CI, 1.22-1.43), behavioural disorders (HR, 1.28; 95% CI, 1.14-1.42), developmental speech or language disorders (HR, 1.16; 95% CI, 1.05-1.28), and autism (HR, 1.31; 95% CI, 1.05-1.64). CONCLUSIONS:Prenatal exposure to general anaesthesia is associated with a 31% increased risk for a subsequent diagnosis of a disruptive or internalising behavioural disorder in children. Caution is advised when making any clinical decisions regarding care of pregnant women, as avoidance of necessary surgery during pregnancy can have detrimental effects on mothers and their children.

Background Observational studies of anesthetic neurotoxicity may be biased because children requiring anesthesia commonly have medical conditions associated with neurobehavioral problems. This study takes advantage of a natural experiment associated with appendicitis to determine whether anesthesia and surgery in childhood were specifically associated with subsequent neurobehavioral outcomes. Methods This study identified 134,388 healthy children with appendectomy and examined the incidence of subsequent externalizing or behavioral disorders (conduct, impulse control, oppositional defiant, attention-deficit hyperactivity disorder) or internalizing or mood or anxiety disorders (depression, anxiety, or bipolar disorder) when compared to 671,940 matched healthy controls as identified in Medicaid data between 2001 and 2018. For comparison, this study also examined 154,887 otherwise healthy children admitted to the hospital for pneumonia, cellulitis, and gastroenteritis, of which only 8% received anesthesia, and compared them to 774,435 matched healthy controls. In addition, this study examined the difference-in-differences between matched appendectomy patients and their controls and matched medical admission patients and their controls. Results Compared to controls, children with appendectomy were more likely to have subsequent behavioral disorders (hazard ratio, 1.04; 95% CI, 1.01 to 1.06; P = 0.0010) and mood or anxiety disorders (hazard ratio, 1.15; 95% CI, 1.13 to 1.17; P < 0.0001). Relative to controls, children with medical admissions were also more likely to have subsequent behavioral (hazard ratio, 1.20; 95% CI, 1.18 to 1.22; P < 0.0001) and mood or anxiety (hazard ratio, 1.25; 95% CI, 1.23 to 1.27; P < 0.0001) disorders. Comparing the difference between matched appendectomy patients and their matched controls to the difference between matched medical patients and their matched controls, medical patients had more subsequent neurobehavioral problems than appendectomy patients. Conclusions Although there is an association between neurobehavioral diagnoses and appendectomy, this association is not specific to anesthesia exposure and is stronger in medical admissions. Medical admissions, generally without anesthesia exposure, displayed significantly higher rates of these disorders than appendectomy-exposed patients. Editor’s Perspective What We Already Know About This Topic What This Article Tells Us That Is New