Long COVID is a complex infection-associated chronic condition that affects 10-25% of children after SARS-CoV-2 infection. Multiple underlying pathophysiologic mechanisms, including persistence of viral antigens, aberrant immune response, and endovascular dysfunction, are suspected to contribute to the heterogeneity of symptoms associated with this condition. Some symptoms (i.e. fatigue) are present in nearly all patients, while others appear to present in clusters, suggesting different pathophysiologic processes within subpopulations. In this retrospective study, we reviewed the clinical and demographic data of 254 patients seen in the Post COVID Program Clinic from May 2021- January 2024. We determined the frequency of 48 symptoms reported by patients at intake. Multiple Correspondence Analysis (MCA) was used to reduce dimensionality and generate groups of patients with similar symptom profiles. MCA analyses with average-linking clustering of MCA coordinates was conducted on symptoms present in > 10% of the cohort. Chi square or Fisher’s exact test were used to identify statistically significant patterns in the cohort. In 254 pediatric patients (56% female, average age 12.9 years [range 2-20]), the most frequently reported symptoms at the time of clinic intake (median 317 days after acute SARS-CoV-2 infection) were fatigue (91%), decreased exercise tolerance (77%), headache (75%), cognitive dysfunction (67%) and lightheadedness (61%). MCA revealed 4 symptomatic clusters. Two clusters, representing 13% (Cluster2) and 7% (Cluster3) of patients, were characterized by higher incidence of gastrointestinal, musculoskeletal and neurologic symptoms (C2) and cardiopulmonary symptoms (C3). Cluster4 patients (7%) presented with high incidence of symptoms of an active inflammatory process, including fever, night sweats, cough and diarrhea. C2 and C3 patients were slightly older on average (average 14 vs 12.9 years) and C3 was disproportionately female (89% vs 56%). Children and adolescents with Long COVID may present with distinct phenotypes, potentially informing underlying processes and ideal management. Research and clinical evaluation of these clusters is in progress. Alexandra B. Yonts, MD, Pfizer: Grant/Research Support

Point-of-care ultrasound (POCUS) is a bedside diagnostic and procedural tool with growing relevance in clinical medicine. While widely integrated into adult emergency medicine and increasingly introduced in undergraduate medical education, its adoption in pediatric residency programs remains limited. There is a lack of standardized curricula, and little is known about pediatric attending physicians’ perspectives on POCUS education — who are key to curriculum development, supervision, and institutional implementation. This study aimed to assess attitudes, training experiences, and perceived barriers among pediatric faculty regarding POCUS integration into pediatric residency training. A cross-sectional survey was distributed to pediatric attending physicians at two large, urban, tertiary care centers. The survey included demographic data, clinical POCUS use, prior training, perceived importance, and barriers implementing a POCUS program. Data was collected using REDCap and analyzed using descriptive statistics and subgroup comparisons. Of 1,000 invited faculty, 134 responded (13.4

The Fluid Expansion as Supportive Therapy (FEAST) clinical trial determined that African children with impaired perfusion receiving bolus intravenous (IV) fluids had increased mortality compared to children with impaired perfusion not receiving bolus IV fluids. Malaria was common in FEAST enrollees, but no stratified analysis for children with cerebral malaria (CM), a common cause of febrile coma in Africa, was reported. We investigated whether bolus fluid expansion changed mortality risk in children with CM. To evaluate this association, we performed a propensity score matched retrospective cohort study with data collected from 1,674 children with CM admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi from 2000 to 2018. After matching of participants by covariate balancing propensity score weighting, children who received an IV fluid bolus had increased mortality risk (odds ratio [OR]: 1.92; 95% CI: 1.36-2.71) compared with those who did not. When stratified by admission systolic blood pressure (SBP), children with an SBP greater than 100 mm Hg receiving bolus fluids had increased mortality (OR: 3.15; 95% CI: 1.81-5.48) compared with those not receiving bolus fluids. In children with an SBP ≤100 mm Hg at admission, receiving bolus IV fluids did not change mortality (OR: 1.44; 95% CI: 0.91-2.26). Bolus IV fluids are an ineffective therapeutic intervention in children with CM and are harmful in those with normal or elevated admission SBPs. Our results confirm the lack of efficacy and potential harm of IV bolus fluid administration in Malawian children with CM.

OBJECTIVES:To evaluate blood culture sample volumes, identify factors linked to insufficient samples, and compare volumes among neonates treated for culture-negative-sepsis, sepsis-rule-outs, and bloodstream infections (BSI). METHODS:Observational cohort of blood cultures collected during NICU stay. Association of age, weight, gender, source, and collection time with lower-than-recommended volumes was determined by logistic regression. Blood culture inocula of patients with culture-negative-sepsis, sepsis rule-out, and BSI were compared using ANOVA. RESULTS:742 blood cultures were obtained from 292 neonates. Median inoculum was 1 mL (IQR:0.6-1.4), and 259 bottles (35%) had inocula <0.9 mL. Night shift sample collection was associated with lower-than-recommended volumes (p = 0.006). No difference in sample volumes was observed between culture-negative-sepsis, sepsis-rule-outs, and BSI (p = 0.5). CONCLUSIONS:Median NICU blood culture volumes align with recommendations. Night shift collections correlate with lower volumes. Sample volumes don't differ in patients with culture-negative-sepsis, BSI, and sepsis-rule-out, and should not be a justification for longer duration of antibiotics.

BACKGROUND:Chronic red blood cell (RBC) transfusion is an established therapy to prevent stroke in patients with sickle cell anemia (SCA). It is unclear if adding daily hydroxyurea treatment to chronic transfusion is beneficial. STUDY DESIGN AND METHODS:We conducted a phase 2 clinical trial (NCT03644953) investigating the addition of dose-escalated hydroxyurea to chronic transfusion for patients with SCA receiving simple chronic transfusion for stroke prevention. Simple chronic transfusion therapy was administered as per the same protocol before and after hydroxyurea treatment in which the volume transfused was dependent on the pretransfusion hemoglobin (Hb). RESULTS:A total of 14 participants enrolled with nine completing one year of combination hydroxyurea and transfusion (HAT) therapy after reaching hydroxyurea target dose. No participant who discontinued the study prematurely had a serious adverse event attributed to HAT. Among the nine participants who completed the study, eight participants achieved a reduction in RBC transfusion volume with a median reduction of -19.4 mL/kg/year (interquartile range -31.8, -2.8 mL/kg/year), p = .02, when comparing pre- and post-HAT time periods. With the addition of hydroxyurea participants had a significant increase in pretransfusion Hb S% but this was balanced by an increased Hb F% and decreased lactate dehydrogenase. One participant developed a pretransfusion Hb >11 g/dL and Hb S > 45% that required holding hydroxyurea and changing to partial manual exchange transfusions. No patient had evidence of cerebrovascular disease progression. DISCUSSION:Hydroxyurea added to chronic transfusion therapy for patients with SCA is feasible and decreases RBC transfusion volume requirements.

BackgroundPECOS is an ongoing study aimed to characterize long-term outcomes following pediatric SARS-CoV-2 infection.MethodsThis is a cross-sectional analysis of infected and uninfected cohorts at baseline. Participants (0-21 years) with laboratory-confirmed SARS-CoV-2 infection were enrolled as infected. Uninfected were defined as individuals without history or laboratory evidence of SARS-CoV-2 infection. Outcome measures included demographics, medical history, review of symptoms, physical exam, cardiopulmonary evaluation and validated psychological and developmental surveys. Primary outcomes were cohort comparisons for abnormalities on all measures.Results654 participants (541 infected, 113 uninfected) completed baseline visits by June 30, 2023. Infected participants were more likely to report constitutional (OR: 2.24), HEENT (OR: 3.74); respiratory (OR: 2.41), or gastrointestinal (OR: 2.58) symptoms. Infected had worse scores in domains of Pain, Fatigue, Global Health, Physical and Cognitive functioning, Mobility and Sleep disturbances when compared to uninfected controls using Patient Reported Outcomes. Cardiopulmonary findings were similar among cohorts.ConclusionsThe first report of this ongoing longitudinal study demonstrates that infected participants were more likely to report symptoms compared to uninfected controls, which may affect performance and quality of life of these individuals. Longitudinal data will increase understanding of long-term effects of SARS-CoV-2 infection in children. ClinicalTrials.gov Identifier: NCT04830852ImpactThis study establishes a large, diverse, prospective, longitudinal, multi-center cohort of children with history of SARS-CoV-2 infection compared to an uninfected cohort to be followed for 3 years.Cross-sectional cohort analysis at study entry showed infected participants were more likely to report constitutional, respiratory, and GI symptoms compared to uninfected controls.Infected participants were more likely to have significantly worse parent-reported performance in 6 of 10 Patient Reported Outcome Measures domains.Continued study of this cohort will help identify clinical sequelae of COVID-19, characterize the immune response to SARS-CoV-2 infection, and identify potential genetic/immunologic factors associated with long-term outcomes.

The aim of the study was to evaluate the effectiveness of a novel e-learning module in teaching the physical exam of the temporomandibular joint (TMJ) in Juvenile idiopathic arthritis (JIA.). An e-learning module was developed to convey the TMJ physical examination maneuvers that are considered to be best practice in JIA. Pediatric rheumatology fellows were randomized to two groups. One group received an article describing the physical examination skills while the second group received both the article and module. All participants completed a written pre-test, an in-person objective structured clinical examination (OSCE), a written post-test, and a follow-up survey. Twenty-two pediatric rheumatology fellows enrolled, with 11 per group. Written test: The two groups improved equally, although there was a trend toward improved defining of maximal incisal opening (MIO) in the module group. OSCE: The mean OSCE score was 11.1 (SD 3.3) in the article group and 13.5 (SD 1.9) in the module group (p = 0.06); significant differences were seen in measuring MIO (p = 0.01), calculating maximal unassisted mouth opening (MUMO; p = 0.01), and assessment of facial symmetry (p = 0.03), all favoring the module. Enjoyment scores in the module group were higher than in the article group (mean 7.7/10 vs. 5.9/10, p = 0.02). The two groups self-reported performing TMJ examinations at comparable rates three months following the intervention. The study demonstrated that a formalized educational program improved knowledge of the physical exam of the TMJ in JIA. Learners viewing the module were more adept at obtaining quantitative TMJ measurements.

Introduction Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure. Methods Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics. Results In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery. Discussion We demonstrate that a brief session can create improvement in pediatric providers’ perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

Context Treatment for transmasculine youth (TMY) can involve testosterone treatment and is sometimes preceded by gonadotropin-releasing hormone agonist (GnRHa) treatment for puberty blockade. GnRHas can increase final height in birth-assigned females with central precocious puberty. Maximizing final adult height (FAH) is an important outcome for many TMY. Objective Our objective was to determine how GnRHa treatment before testosterone impacts FAH. Methods Retrospective cohort study at 5 US transgender health clinics. Participants were 32 TMY treated with GnRHas in early to midpuberty before testosterone (GnRHa + T group) and 62 late/postpubertal TMY treated with testosterone only (T-only group). Results The difference between FAH minus midparental target height (MPTH) was +2.3 +/- 5.7 cm and -2.2 +/- 5.6 cm in the GnRHa + T and T-only groups, respectively (P < .01). In the GnRHa + T group, FAH was 1.8 +/- 3.4 cm greater than predicted adult height (PAH) (P < .05) and FAH vs initial height (IH) z-score was 0.5 +/- 1.2 vs 0.16 +/- 1.0 (P < .05). After adjusting for patient characteristics, each additional month of GnRHa monotherapy increased FAH by 0.59 cm (95% CI 0.31, 0.9 cm), stage 3 breast development at start of GnRHa was associated with 6.5 cm lower FAH compared with stage 2 (95% CI -10.43, -2.55), and FAH was 7.95 cm greater in the GnRHa + T group than in T-only group (95% CI -10.85, -5.06). Conclusion Treatment with GnRHa in TMY in early puberty before testosterone increases FAH compared with MPTH, PAH, IH, and TMY who only received testosterone in late/postpuberty. TMY considering GnRHas should be counseled that GnRHas may mildly increase their FAH if started early.

Black recipients of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) have low breastfeeding rates. The aim of this pilot study was to determine if prenatal education by a breastfeeding peer counselor in an academic obstetric clinic is feasible and could improve WIC-eligible participants’ breastfeeding self-efficacy and in-hospital breastfeeding rates. Pregnant participants ( N = 57) were randomized into either an intervention group, which spoke briefly with a breastfeeding peer counselor immediately after their clinic appointment, or a comparison group, which received usual prenatal obstetric care only. Integrating a breastfeeding peer counselor into an academic obstetric clinic proved feasible and improved the intervention group’s overall pre- to postscores on the Breastfeeding Self-Efficacy Scale. This small pilot study showed no significant difference in in-hospital exclusive breastfeeding rates between the groups.

INTRODUCTION:Quality of life (QOL) is critical in screening and management of chronic medical conditions, including celiac disease (CD). The aim of this project was to develop a CD-specific pediatric QOL measure (Celiac Disease Life Inventory of Family Experiences [CDLIFE]) with parallel self-report and parent-report forms by generating items through concept elicitation interviews, iterative refinement using cognitive debriefing interviews, and evaluating its psychometric properties and validity. METHODS:Concept elicitation interviews were conducted to develop items (9 youth ages 8-19 years with CD; 10 parents of youth with CD), followed by cognitive interviews with additional stakeholders (3 youth with CD, 3 parents, and 8 clinicians) and item administration (parent/youth reports: n = 103/102). Analyses included response frequencies, internal consistency reliability, exploratory factor analyses, and correlations with related measures (Patient-Reported Outcomes Measurement Information System, Pediatric Quality of Life Inventory, and Gluten-Free Diet-Visual Analog Scale). RESULTS:From concept elicitation interviews, 42 youth and 45 parent items were developed. Cognitive debriefing interviews yielded 36 refined items. Psychometric analyses identified 15 items to remove due to ceiling/floor effects, poor item-to-test correlations, and youth-parent mismatch or conceptual mismatch. Total score internal consistency was high (αs = 0.89-0.90). A 4-factor model solution had the best fit (Social Impact, External Support, Adaptive Vigilance, Eating Behaviors/Adjustment) with a fifth single-item domain (Financial Resources). The final CDLIFE (21 items) total scores correlated with most related measures in expected directions for parent and youth forms. DISCUSSION:The CDLIFE may facilitate insight into CD-specific QOL for youth ages 2-18 years, capturing important dimensions of physical and socioemotional health. Administering the CDLIFE will help identify and track families needing support.

Background Lyme disease is common among children and adolescents. Antibiotic treatment is effective, yet some patients report persistent symptoms following treatment, with or without functional impairment. This study characterized long-term outcome of pediatric patients with Lyme disease and evaluated the case definition of post-treatment Lyme disease (PTLD) syndrome. Methods The sample included 102 children with confirmed Lyme disease diagnosed 6 months—10 years prior to enrollment (M = 2.0 years). Lyme diagnosis and treatment information was extracted from the electronic health record; parent report identified presence, duration, and impact of symptoms after treatment. Participants completed validated questionnaires assessing health-related quality of life, physical mobility, fatigue, pain, and cognitive impact. Results Most parents reported their child’s symptoms resolved completely, although time to full resolution varied. Twenty-two parents (22%) indicated their child had at least one persistent symptom >6 months post-treatment, 13 without functional impairment (PTLD symptoms) and 9 with functional impairment (PTLD syndrome). Children with PTLD syndrome had lower parent-reported Physical Summary scores and greater likelihood of elevated fatigue. Conclusions In the current study, most children with Lyme disease experienced full resolution of symptoms, including those who initially met PTLD syndrome criteria. Effective communication about recovery rates and common symptoms that may persist post-treatment is needed. Impact The majority of pediatric patients treated for all stages of Lyme disease reported full resolution of symptoms within 6 months. 22% of pediatric patients reported one or more symptom persisting >6 months, 9% with and 13% without accompanying functional impairment. Effective communication with families about recovery rates and common symptoms that may persist post-treatment of Lyme disease is needed.

ABSTRACTBackground Critical thinking is essential for the accurate diagnosis and management of patients. It is correlated with academic success.Objective Our objective was to design a novel tool for interactive online learning to improve knowledge and to assess trainees’ critical thinking skills using the framework of the American Philosophical Association (APA).Methods Residents, fellows and students participated in an online, self-directed case-based vignette activity to learn malaria diagnosis and management. Pre and post-tests with multiple choice and open-ended case-based questions assessed knowledge and critical thinking. Comparison between pre and post-test scores across subgroups were performed using paired t-tests or one-way ANOVA.Results Between 4 April 2017 to 14 July 2019, 62 of 75 (82%) eligible subjects completed both the pre and the post-test. Improved post-test scores occurred in 90% of medical students, p=0.001, 77% of residents, p<0.001, 60% of fellows, p=0.72 and 75% of trainees overall, p=<0.001. Fellows had higher pre-test scores than students or residents but there was no difference by level of training on the post-test.Conclusions This interactive online learning activity effectively imparted medical knowledge and improved trainee responses to questions requiring critical thinking. To our knowledge, this is the first time the APA’s critical thinking framework has been incorporated into interactive online learning and assessment of critical thinking skills in medical trainees. We applied this innovation specifically in global health education, but there is obvious potential to expand it to a wide variety of areas of clinical training.

Objective: Augmented reality devices are increasingly accepted in health care, though most applications involve education and pre-operative planning. A novel augmented reality ultrasound application, HoloUS, was developed for the Microsoft HoloLens 2 to project real-time ultrasound images directly into the user's field of view. In this work, we assessed the effect of using HoloUS on vascular access procedural outcomes.Methods: A single-center user study was completed with participants with (N = 22) and without (N = 12) experi-ence performing ultrasound-guided vascular access. Users completed a venipuncture and aspiration task a total of four times: three times on study day 1, and once on study day 2 between 2 and 4 weeks later. Users were random-ized to use conventional ultrasound during either their first or second task and the HoloUS application at all other times. Task completion time, numbers of needle re-directions, head adjustments and needle visualization rates were recorded.Results: For expert users, task completion time was significantly faster using HoloUS (11.5 s, interquartile range [IQR] = 6.5-23.5 s vs. 18.5 s, IQR = 11.0-36.5 s; p = 0.04). The number of head adjustments was significantly lower using the HoloUS app (1.0, IQR = 0.0-1.0 vs. 3.0, IQR = 1.0-5.0; p < 0.0001). No significant differences were identified in other measured outcomes.Conclusion: This is the first investigation of augmented reality-based ultrasound-guided vascular access using the second-generation HoloLens. It demonstrates equivalent procedural efficiency and accuracy, with favorable usability, ergonomics and user independence when compared with traditional ultrasound techniques.

Background: Cardiac complications of serious SARS-CoV-2 infections, especially Multisystem Inflammatory Syndrome of Children (MIS-C) are well described, however current studies have not considered pediatric patients hospitalized with no cardiac concerns. We established a protocol for cardiac evaluation of all admitted COVID-19 patients three weeks post-discharge, irrespective of cardiac concerns. We assessed cardiovascular outcomes and hypothesized that patients with absent cardiac concerns are at lower risk for cardiac abnormalities. Methods: This was a retrospective study of 160 patients admitted for COVID-19 (excluding MIS-C) between March 2020 and September 2021 with subsequent echocardiogram(s) performed at our center. Patients were divided into 4 subgroups: Group 1 included patients with absent cardiac concerns, admitted to acute care (1a) and intensive care unit (ICU) (1 b). Group 2 included patients with cardiac concerns, admitted to acute care (2a) and ICU (2 b). Groups were compared based on clinical endpoints and echocardiographic measurements, including tissue Doppler imaging (TDI) assessment of diastolic function (z-score of septal Mitral E/TDI E′ and lateral E/TDI E′). Chi-squared, Fisher's exact, and Kruskal-Wallis tests were used. Results: Traditional cardiac abnormalities varied significantly between the groups; with Group 2 b having the most (n = 8, 21%), but still found in Group 1a (n = 2, 3%) and Group 1 b (n = 1, 5%). No patients in Group 1 demonstrated abnormal systolic function, compared to Group 2a (n = 1, 3%) and Group 2 b (n = 3, 9%, p = 0.07). When including TDI assessment of diastolic function, the total incidence of abnormalities found on echocardiogram was increased in all groups. Conclusion: Cardiac abnormalities were found in pediatric patients admitted with COVID-19, even those without apparent cardiovascular concerns. The risk was greatest in ICU-admitted patients with cardiac concerns. The clinical significance of diastolic function assessment in these patients remains unknown. Further studies are needed to assess long-term cardiovascular sequelae of children with COVID-19, irrespective of cardiac concerns.

BACKGROUND:Since 2013, the cardiac intensive care unit (CICU) at Children's National has conducted annual extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) simulations that focus on team dynamics, room setup, and high-quality CPR. In 2019 and 2020, the simulations were expanded to include the surgical and extracorporeal membrane oxygenation (ECMO) teams in an effort to better understand and improve this process.METHODS:During a 4-week period in 2019, 7 peripheral ECPR simulations were conducted, and through a 3-week period in 2020, 7 central ECPR simulations were conducted. Participants in each session included: 8 to 10 CICU nurses, 1 CICU attending, 1 to 2 ICU or cardiology fellows, 1 cardiovascular surgery fellow or attending, and 1 ECMO specialist. For each session, the scenario continued until the simulated patient was on full cardiopulmonary bypass. An ECMO trainer was used for peripheral simulations and a 3-dimensionally-printed heart was used for central cannulations. An ECMO checklist was used to objectively determine when the patient and room were fully prepared for surgical intervention, and simulated cannulation times were recorded for both groups. A retrospective chart review was conducted to compare actual cannulation times before and after the intervention period, and video was used to review the events and assist in dividing them into medical versus surgical phases. Control charts were used to trend the total ECPR times before and after the intervention period, and mean and P values were calculated for both ECPR times and for all other categorical data.RESULTS:Mean peripheral ECPR times decreased significantly from 71.7 to 45.1 minutes ( P = 0.036) after the intervention period, and this was reflected by a centerline shift. Although we could not describe a similar decrease in central ECPR times because there were only 6 postintervention events, the times for each of these events were shorter than the historical mean of 37.8 minutes. There was a trend in improved survival, which did not meet significance both among patients undergoing peripheral ECPR (15.4% ± 10% to 43.8% ± 12.4%, P = 0.10) and central ECPR (36.4% ± 8.4% to 50% ± 25%, P = 0.60). The percentage of time dedicated to the medical phases of the actual versus simulated procedures was very consistent among both peripheral (33.0% vs. 31.9%) and central (39.6% vs. 39.8%) cannulations.CONCLUSIONS:We observed a significant decrease in peripheral cannulation times at our institution after conducting interprofessional ECPR simulations taken to the establishment of full cardiopulmonary bypass. The use of an ECMO trainer and a 3-dimensionally-printed heart allowed for both the medical and surgical phases of the procedure to be studied in detail, providing opportunities to streamline and improve this complex process. Larger multisite studies will be needed in the future to assess the effect of efforts like these on patient survival.