TM

DECEMBER 2023 • VOL. 50 NO. 6 • PAGES 61–72 aapgrandrounds.org

Identifying the Pathogen in Acute

Hematogenous Osteomyelitis

Cold Air Exposure Can Be a

Therapeutic Adjunct for Viral Croup

Antibiotic Therapy of Acute Sinusitis

Turn Off the Tap When Giving a Child

a Bath!

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 Table of Contents
ORTHOPAEDICS
Editorial Board Marilynn Chan, San Francisco, CA
Benjamin Doolittle, New Haven, CT p63 Identifying the Pathogen in Acute Hematogenous Osteomyelitis
EDITOR
Mike Dubik, Portsmouth, VA
James A. Taylor, Seattle, WA
Patricia Fechner, Seattle, WA PULMONOLOGY
DEPUTY EDITOR William L. Hennrikus, Hershey, PA
Leslie L. Barton, Tucson, AZ Gloria Higgins, Columbus, OH
p64 Cold Air Exposure Can Be a Therapeutic Adjunct for Viral Croup
CME QUESTION EDITOR Mary-Jane Staba Hogan, New Haven, CT
Daniel Lesser, San Diego, CA MEDICINE/PEDIATRICS
Robert Wittler, Wichita, KS
Laura Ann Miller-Smith, Portland OR p65 Antibiotic Therapy of Acute Sinusitis
EDITORIAL BOARD Ranjit Philip, Memphis, TN
Rana Alissa, Jacksonville, FL Meghna Raphael, Houston, TX
Deborah Badawi, Baltimore, MD EMERGENCY MEDICINE
Philip Rosenthal, San Francisco, CA
Kirsten Bechtel, New Haven, CT Cheryl Sanchez-Kazi, Loma Linda, CA p66 Turn Off the Tap When Giving a Child a Bath!
Rebecca Brady, Cincinnati, OH Isabelle Von Kohorn, Washington, DC
Meghan Candee, Salt Lake City, UT Jeffrey Winer, Memphis, TN GASTROENTEROLOGY
p67 Atopic Dermatitis Increases the Risk for IBD

DEVELOPMENTAL/BEHAVIORAL
Mission: To provide pediatricians with timely synopses and p68 Is Timing Really Everything?
critiques of important new studies relevant to pediatric practice,
reviewing methodology, significance, and practical impact, as part GENERAL PEDIATRICS
of ongoing CME activity. p69 Benefits of Antenatal IV Magnesium After 30 Weeks’ Gestation

SLEEP MEDICINE
p70 The Effects of OSA Among Children With Down Syndrome
AAP Grand RoundsTM is published monthly by the American
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©2023 American Academy of Pediatrics. All rights reserved. p71 Non-pharmacological Management of SVT in Infants
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 ORTHOPAEDICS
Identifying the Pathogen in Acute Hematogenous
Osteomyelitis
Source: Burns JD, Upasani VV, Bastrom TP, et al. Age and CRP associated
with improved tissue pathogen identification in children with blood culture
negative osteomyelitis: results from the CORTICES multicenter database.
J Pediatr Orthop. 2023;43(8):e603-e607; doi: 10.1097/BPO.0000000000002448.
Investigators from multiple institutions conducted a retrospec-
tive study to identify predictors of a positive tissue culture in
children with acute hematogenous osteomyelitis (AHO) in whom
blood cultures were negative. For the study, clinical and demo-
graphic data were abstracted from the medical records of
patients with a diagnosis of AHO who were treated at 1 of 18 pedi-
atric medical centers in the US between 2010 and 2016. For
patients with a negative blood culture in whom a tissue culture
was obtained, the rate of identification of a pathogen on tissue
culture was determined. Multiple demographic, clinical, and lab-
oratory characteristics were evaluated as possible predictors of
a positive tissue culture by univariate analyses using chi-square
tests. Characteristics associated with a positive tissue culture
result were included in a multivariate regression model to iden-
tify independent predictors. For the identified characteristics,
receiver operator curves (ROC) were used to identify optimal
threshold values. In addition, using the threshold value to clas-
sify a positive or negative test, the odds ratio (OR) for obtaining
a positive tissue culture result in children with a positive test was
calculated for each characteristic.
Data on 1,003 children with AHO were reviewed. Of these, blood
cultures were obtained in 938 (93.5%), and a tissue biopsy was
performed in 737 (73.5%). There were 688 patients with both
blood and tissue culture results. In the 385 children with negative
blood cultures, tissue cultures were positive in 267 (69.4%). With
univariate analyses, age (P <0.001), length of stay (P = 0.018),
white blood cell count (P = 0.05), erythrocyte sedimentation rate
(P = 0.028), and C-reactive protein (CRP) (P = 0.004) were associ-
ated with tissue culture results. In the multivariate model, older
age (P < 0.001) and higher CRP (P = 0.004) were independent pre-
dictors of a positive tissue culture. With ROC analysis, the opti-
mal threshold value for age in predicting tissue culture results
was 3.1 years, and for CRP the best cutoff value was 4.1 mg/dL. The
OR for a positive tissue culture in children >3.1 years was 11.6 (95%
confidence interval [CI], 4.4, 31), and the OR for a CRP >4.1 mg/dL
was 3.0 (95% CI, 1.9, 4.8). For children <3.1 years old and with a CRP
<4.1, only 7.1% had a positive tissue culture. Conversely, 87.3% of
those who were >3.1 years old and had a CRP >4.1 mg/dL had a
positive tissue culture result.
The authors conclude that in children with AHO and a negative
blood culture, those younger than 3.1 years who have a CRP ≤4.1
mg/dL are unlikely to have a positive tissue culture result.
• December 2023
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COMMENTARY BY
William L. Hennrikus, MD, FAAP, Pediatric Orthopaedics and
Rehabilitation, Penn State College of Medicine, Hershey, PA
Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commen-
tary does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
Identifying the offending pathogen with blood or tissue culture is
key in the diagnosis and management of AHO in children.1 Blood
cultures are frequently non-diagnostic. 2 Pathogen identification
in cases of negative blood cultures is very important. 3 Positive
tissue cultures in the setting of negative blood cultures changes
antibiotic management in 72% to 85% of cases.4,5 The authors
of the current study evaluated the variables associated with
positive tissue cultures in cases of blood culture-negative
osteomyelitis.
In the current study of 385 patients who had negative blood
cultures, 69% had a positive tissue culture. Patient age and CRP
were independent predictors of a positive tissue culture by
multivariate analysis.
If blood cultures are negative and surgery is not otherwise indi-
cated, a tissue biopsy is considered controversial.6 In the current
study, the authors conclude that patients >3.1 years old with a
CRP >4.1 mg/dL, tissue cultures are indicated despite the poten-
tial morbidity of an open surgery or a CT guided procedure.
Patients <3.1 years old with a CRP of ≤4.1 mg/dL may not benefit
from an intervention to obtain tissue.
Consultation with an orthopaedic surgeon or interventional
radiologist for help in a case of blood culture-negative AHO when
the CRP is >4.1 mg/dL and the child is older than 3.1 years of age
is advisable.
Bottom Line: Tissue biopsy, directed by patient age and CRP, can
optimize medical treatment of children with blood culture-
negative AHO. (See AAP Grand Rounds. 2023;50[4]:44.)7
EDITORS’ NOTE
Pediatric Infectious Disease Society guidelines recommend
tissue biopsy for all patients with culture-negative AHO. 3
Although the current retrospective study is limited by lack
of information on pre-biopsy antibiotic therapy, the results—
if confirmed—would support a more focused approach to
pathogen identification.
References
1. Wheeler AM, et al. J Pediatric Infect Dis Soc. 2012;1(2):152-156; doi: 10.1093/jpids/pis035.
2. Upasani VV, et al. J Pediatr Orthop. 2022;42(5):e520-e525; doi: 10.1097/BPO.0000000000002123.
3. Woods CR, et al. J Pediatric Infect Dis Soc. 2021;10(8):801-844; doi: 10.1093/jpids/piab027.
4. McNeil JC, et al. Pediatrics. 2016;137(5):e20154616; doi: 10.1542/peds.2015-4616.
5. Yen C, et al. Skeletal Radiol. 2023;52(1):39-46; doi: 10.1007/s00256-022-04131-4.
6. Burns JD, et al. J Pediatr Orthop. 2023;43(8):e603-e607; doi: 10.1097/BPO.0000000000002448.
7. Bimo J, et al. Hosp Pediatr. 2023;13(7):579-591; doi: 10.1542/hpeds.2022-006822.
63
 PULMONOLOGY
Cold Air Exposure Can Be a Therapeutic
Adjunct for Viral Croup
Source: Siebert JN, Salomon C, Taddeo I, et al. Outdoor cold air versus room
temperature exposure for croup symptoms: a randomized controlled trial.
Pediatrics. 2023;152(3):e2023061365; doi: 10.1542/peds.2023-061365.
Investigators from Geneva Children’s Hospital and the University
of Geneva, both in Geneva, Switzerland, conducted an open-
label randomized controlled trial to assess the effectiveness of
exposure to cold outdoor air in children with croup. Study partic-
ipants were patients 3 months to 10 years old with a diagnosis of
croup and a Westley Croup Score (WCS) ≥2 seen at a single pedi-
atric emergency department (ED). Children were enrolled in the
study only when the outside temperature was <10°C. WCS is a
validated instrument to assess severity of croup symptoms.
Scores range between 0–17, with scores of 0–2 indicative of mild
croup, 3–5 considered moderate, and ≥6 severe. Immediately
after enrollment and receipt of oral dexamethasone (0.6 mg/kg),
participants were randomized to 30 minutes of exposure to cold
outdoor air with their parents (intervention group) or to remain
in the ED for 30 minutes (controls). The primary study outcome
was a decrease in WCS of ≥2 points at 30 minutes. A chi-square
test was used to assess differences between treatment groups.
Subgroup analyses, limited to children with mild or moderate
croup, also were conducted. Secondary outcomes included
decrease of ≥2 points at 60 minutes and heart rate (HR) and
respiratory rate (RR) at 30 and 60 minutes. Parents of study par-
ticipants were contacted 7 days after the index visits to obtain
information on further health care visits. Differences between
children in the 2 groups were compared.
There were 118 children enrolled in the study, including 59 ran-
domized to the intervention group and 59 controls. The mean age
of participants was 32 ±25 months. Overall, 50% of study patients
were classified with mild and 50% with moderate croup, based on
WCS. After 30 minutes, 29 (49.2%) children exposed to cold out-
door air had a decrease in WCS ≥2 points, compared to 14 (23.7%)
controls (P = 0.007). Among those with moderate croup, 19 of 30
(63.3%) patients in the intervention group and 5 of 29 (17.2%) of
those in the control group had a decrease in WCS ≥2 points
(P <0.001). There was no significant difference between treatment
groups for children with mild croup (P = 0.93). At 60 minutes,
62.7% of participants in the intervention group and 66.1% of con-
trols had a decrease from baseline in WCS of ≥2 points (P = 0.86).
There also were no significant differences between groups in HR
or RR at 30 or 60 minutes. Among those in the intervention group,
20 of 52 (38.4%) had a return health care visit within 7 days vs 20
of 56 (35.7%) controls.
The authors conclude that exposure to cold outdoor air was
beneficial in reducing symptoms in children with moderate croup.
64
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COMMENTARY BY
Marilynn Chan, MD, FAAP, Pediatric Pulmonology, Kaiser
Permanente Downey Medical Center, Downey, CA
Dr Chan has disclosed no financial relationship relevant to this commentary. This commentary
does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
Croup is a common respiratory infection in children 6 years old
and younger that carries a high medical burden, accounting for
approximately 350,000–400,000 croup-related ED visits per
year.1,2 Typical management includes racemic epinephrine and
dexamethasone. Nonpharmacological alternatives, such as mist
therapy, have previously been recommended, though studies
have not shown clear benefit. (See AAP Grand Rounds. 2006;15[6]:
65–66.)3,4 Cold air exposure has been anecdotally reported to be
helpful, though without evidence.
The current authors sought to compare exposure to cold outdoor
air (temperature <10°C) for 30 minutes compared to ambient
indoor room air (24°C to 25°C) for children with mild to moderate
croup after they were given a single 0.6 mg/kg dose of oral dexa-
methasone. They found that a 30-minute exposure to cold out-
door air was beneficial for reducing the severity of croup
symptoms in children, thought to be unrelated to the oral dexa-
methasone, as the medication takes effect 30 minutes after
ingestion. 5
Strengths of this study include its design as a randomized clini-
cal trial and its originality as a first to investigate the benefit of
cold air exposure for pediatric croup patients.
Limitations include possible bias, as it was not possible to blind
the investigators in the study due to patient care prioritization;
the lack of difference at 60 minutes may indicate a general lack of
clinical significance once the corticosteroids take effect.
Bottom Line: Outdoor cold air exposure may be a short-term
therapeutic modality for children with mild to moderate croup.
References
1. Cherry JD. N Engl J Med. 2008;358(4):384-391; doi: 10.1056/NEJMcp072022.
2. Hanna J, et al. Int J Pediatr Otorhinolaryngol. 2019;126:109641; doi: 10.1016/j.ijporl.2019.109641.
3. Scolnik D, et al. JAMA. 2006;295(11):1274-1280; doi: 10.1001/jama.295.11.1274.
4. Moore M, Little P. Cochrane Database Syst Rev. 2006;(3):CB002870;
doi: 10.1002/14651858.CD002870.pub2.
5. Dobrovoljac M, Geelhoed GC. Emerg Med Australas. 2012;24(1):79-85;
doi: 10.1111/j.1742-6723.2011.01475.x.
aapgrandrounds.org
 MEDICINE/PEDIATRICS
Antibiotic Therapy of Acute Sinusitis
Source: Shaikh N, Hoberman A, Shope TR, et al. Identifying children likely
to benefit from antibiotics for acute sinusitis: a randomized clinical trial.
JAMA. 2023;330(4):349-358; doi: 10.1001/jama.2023.10854.
Investigators from multiple institutions conducted a randomized
controlled trial to assess the effectiveness of antibiotics in treat-
ing children with acute sinusitis and identify subgroups of chil-
dren who were most likely to benefit. Participants were patients
2–11 years old, presenting to primary care practices in the US with
symptoms of an upper respiratory tract infection, who met spe-
cific criteria for acute sinusitis. To be eligible, children had to
have a baseline score on the Pediatric Rhinosinusitis Symptom
Scale (PRSS) ≥9. The PRSS measures the severity of 8 symptoms
on a score of 0–5, with higher scores representing worse symp-
tom severity. At enrollment, participants were randomized to
receive amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d)
for 10 days or placebo. Randomization was stratified by whether
a child’s nasal discharge was clear or colored (yellow or green). At
baseline, nasopharyngeal cultures were obtained to document
colonization with Streptococcus pneumoniae, Haemophilus influ-
enzae, or Moraxella catarrhalis. Parents completed the PRSS
daily for 10 days. The primary study outcome was daily scores,
which were compared in children in the antibiotic and placebo
groups using regression analyses, adjusting for baseline PRSS
score, study day, site, and colored nasal discharge. Additional
analyses were performed to assess the interaction between
presence of colonization and PRSS scores and between colored
nasal discharge and PRSS scores. A similar analysis was used
to evaluate differences between treatment groups in time to
symptom resolution.
A total of 510 eligible children were enrolled in the study, with 254
randomized to antibiotic treatment and 256 to placebo. The
median ages of participants in the 2 treatment groups were 4.9
and 5.1 years, respectively. Overall, 71% of study patients had a
bacterial pathogen cultured from their nasopharynx. Data on the
primary outcome were obtained on 496 children. PRSS scores
were significantly lower in those receiving antibiotics than in
patients randomized to placebo (mean scores, 9.04 and 10.60,
respectively; between group difference, -1.69; 95% CI, -2.07, -1.31).
Median time to symptom resolution was 7.0 days for children ran-
domized to antibiotics and 9.0 days for those receiving placebo
(P = 0.003). PRSS scores were significantly lower in children
receiving antibiotics than in those randomized to placebo, both
among those with and without nasopharyngeal colonization
(between group differences, -1.95; 95% CI, -2.40, -1.51 for those
colonized; -0.88; 95% CI, -1.63, -0.12 for those not colonized).
However, the effect was significantly greater in those with bac-
terial pathogens (P = 0.02). There was no difference in the effect
of antibiotics among participants with clear or colored nasal
discharge (P = 0.52).
The authors conclude that antibiotic treatment of children in
acute sinusitis was of minimal benefit in reducing symptom bur-
den among those without nasopharyngeal bacterial pathogens
at presentation.
• December 2023
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COMMENTARY BY
Benjamin R. Doolittle, MD, M Div, FAAP, FACP, Internal Medicine &
Pediatrics, Yale University School of Medicine, New Haven, CT
Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commen-
tary does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
The current investigators crafted a well-designed trial to identify
those children who might benefit from antibiotics for acute
sinusitis. Unfortunately, this project raises several more ques-
tions than it answers. The decision to treat suspected bacterial
sinusitis remains as vexing as ever. Between 28% and 50% of
antibiotics are over-prescribed inappropriately in the pediatric
outpatient setting.1,2
First, the symptom score was lower among those who were
treated with antibiotics, but only by 1.54 points. This is the differ-
ence between a nocturnal cough improving from “some” to “a
little” and acting fussy during the day improving from “some” to
“a little.”3 On average, symptoms improved among the children
who received antibiotics 2 days sooner. However, those treated
with antibiotics were twice as likely to develop diarrhea. Second,
the authors demonstrated that those with an identified bacterial
pathogen also improved compared to those without a bacterial
pathogen. Several studies, however, have shown that such cul-
tures may be colonization and not true infection.1,2,4,5 Further,
checking nasopharyngeal cultures is not practical in clinical
practice. 4,5 Third, there was no difference between those with
clear and colored nasal discharges, which had been an indication
for antibiotics in AAP guidelines.6 The authors do conclude that
the decision to treat with antibiotics requires careful shared
decision making with families.
Bottom Line: The decision to treat acute sinusitis with antibi-
otics remains complicated. Children may benefit with a short-
ened duration and severity of symptoms, especially those with a
bacterial pathogen identified.
EDITORS’ NOTE
The evidence of benefit of antibiotics for treating sinusitis in this
trial is unequivocal. Given this, the conclusion by the authors
that only a subgroup of children should be treated seems per-
verse. Parents bring their children to the pediatrician in hopes
that the physician can make their child feel better. Why should
there be an aversion to prescribing antibiotics when this worth-
while goal can be accomplished and the duration of illness short-
ened by 2 days (or 22% in this case)?
References
1. Fleming-Dutra KE, et al. JAMA. 2016;315(17):1864-1873; doi: 10.1001/jama.2016.4151.
2. Hersh AL, et al. Clin Infect Dis. 2021;72(1):133-137; doi: 10.1093/cid/ciaa667.
3. Shaikh N, et al. J Pediatr. 2019;207:103-108.e1; doi: 10.1016/j.jpeds.2018.11.016.
4. Shay SG, Shin JJ. JAMA Otolaryngol Head Neck Surg. 2023;149(10):864-865;
doi: 10.1001/jamaoto.2023.2612.
5. Caballero TM, et al. JAMA. 2023;330(4):326-327; doi: 10.1001/jama.2023.11365.
6. Wald ER, et al. Pediatrics. 2013;132(1):e262-e280; doi: 10.1542/peds.2013-1071.
65
 EMERGENCY MEDICINE
Turn Off the Tap When Giving a Child a Bath!
Source: Moser WJ, Bilka KR, Vrouwe SQ, et al. Running water while
bathing is a risk factor for pediatric scald burns (published online ahead of
print March 23, 2024). Burns. 2023;S0305-4179(23)00058-X;
doi: 10.1016/j.burns.2023.03.014.
Investigators from Northwestern University and the University of
Chicago, both in Chicago, IL, conducted a retrospective study to
evaluate the role of running water as a risk factor for scald burns
in young children. Study participants were patients <3 years old
admitted to a burn center in a large metropolitan area between
2010 and 2019 with scald burns. Participants were identified by
reviewing the Child Advocacy and Protective Services (CAPS) team
database at the center. The CAPS team consults on all children <3
years old at the center with burns. Patients with scald burns
occurring during bathing were included for analysis. Information
abstracted from the database on study patients included demo-
graphics, extent of burn, location of bathing (eg, tub), whether a
caregiver was present during the entire bath, whether a caregiver
tested the temperature of the bath water, and whether running
water was involved. Children in whom the injuries were consid-
ered abusive or indeterminate were excluded from the analysis.
The primary study outcome was the percentage of scald burns
associated with running water. The secondary outcome was the
number and type of risk factors, including a caregiver not present
during the entire bath, a caregiver not checking bath water tem-
perature, and running water, associated with the scald injury.
Data were analyzed on 101 children with scald burns associated
with bathing. The mean age of study patients was 13 months
(range 1–34 months), and mean total body surface area of the
burn was 7% (range 1% to 40%). A total of 61 (60%) burns occurred
while bathing in a sink, 39 (39%) in a bathtub, and 1 (1%) in an
infant tub. Running water was associated with 96 (95%) of all the
scald burns, 55 (54%) involved a caregiver not checking the water
temperature, and a caregiver was not present during the entire
bath in 39 (39%) cases. None of the 3 risk factors were involved in
2 cases, and all 3 were associated with 29 (29%) cases. Among 37
scald burns with a single associated risk factor, running water
was the risk factor identified in 35.
The authors conclude that running water was a commonly identi-
fied risk factor for scald burns in young children.
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COMMENTARY BY
Kirsten A. Bechtel, MD, FAAP, Pediatric Emergency Medicine, Yale
University School of Medicine, New Haven, CT
Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commen-
tary does not contain a discussion of an unapproved/investigative use of a commercial prod-
uct/device.
Scald burns cause considerable morbidity in young children;
therefore, prevention is paramount.1 This study’s principal find-
ing that running water in a bathtub or sink is a risk factor for
scald burns in young children is practical information for care-
givers. However, the current study does have limitations that
should be addressed.
Most non-abusive scald burns in young children are from hot
liquids in cups or utensils; scald burns from bathing are less
common and raise concern for child abuse. (See AAP Grand
Rounds. 2022;47[3]:35.)2 Therefore, it may be helpful for the
reader to know what criteria were used to classify these burns
as non-abusive by the Child Protection Team. It also would be
helpful to know how these non-abusive burns differed from the
indeterminate and abusive burns in terms of body location and
total body surface area (TBSA) involved; such characteristics
have been demonstrated to aid in the recognition of abusive
burns. 3 It is inferred but not explicitly stated that most of these
burns likely did not require hospitalization, as they typically
were less than 10% TBSA. Such information would be necessary
for clinicians to differentiate abusive versus non-abusive scald
burns in young children.
Bottom Line: Running bathwater from a faucet is a risk factor
for scald burns in young children.
EDITORS’ NOTE
Despite the current study’s limitations, the results support
updating the American Academy of Pediatrics bathing safety
recommentations 3 to include the risks of running water—
especially in bathing locations (ie, sinks) in which there is close
proximity of hot and cold water faucet handles.4
References
1. Shah M, et al. Burns. 2013;39(7):1474-1478; doi: 10.1016/j.burns.2013.03.022.
2. Javaid AA, et al. Arch Dis Child. 2021;106(11):1111-1117; doi: 10.1136/archdischild-2020-320710.
3. Nigro LC, et al. AMA J Ethics; 2018;20(6):552-559;
doi: 10.1001/journalofethics.2018.20.6.org1-1806.
4. American Academy of Pediatrics. Parents plus: how to keep your baby safe during bath
time. AAP News. Published November 11, 2015. https:// publications.aap.org/aapnews/
news/12480/Parent-Plus-Howto-keep-your-baby-safe-during-bath
aapgrandrounds.org
 GASTROENTEROLOGY
Atopic Dermatitis Increases the Risk for IBD
Source: Chiesa Fuxench, ZC, Wan, J, Wang S, et al. Risk of inflammatory
bowel disease in patients with atopic dermatitis [published online ahead
of print August 30, 2023]. JAMA Dermatol. 2023;e232875;
doi: 10.1001/jamadermatol.2023.2875.
Investigators from multiple institutions conducted a retrospec-
tive cohort study to assess the risk of inflammatory bowel dis-
ease (IBD) in children and adults with atopic dermatitis (AD). For
the study, they abstracted data from The Health Improvement
Network (THIN) database, which includes diagnostic and treat-
ment information on patients registered with general practices
in the UK. Cohorts of children and adults with AD were identified
using diagnostic codes. Each participant with AD was matched
with up to 5 controls. Patients with AD were classified as having
mild disease unless they received a second prescription for a
topical corticosteroid within 1 year or received a topical calci-
neurin inhibitor, in which case they were classified with moder-
ate disease. Those prescribed an immunosuppressant drug or
phototherapy or were referred to a dermatologist were classified
with severe AD. Children and adults with IBD at the time of study
entry were excluded. Demographics and medical history data on
study participants also were abstracted. The primary study out-
comes were diagnosis of IBD, Crohn’s disease (CD), or ulcerative
colitis (UC) during the follow-up period. The cumulative incidence
rate (IR) per 1,000 person-years in controls and those with mild,
moderate, and severe AD in children and adults were determined.
Multivariate Cox proportional hazard regression was used to
compare the risk of each of the outcomes in patients with AD to
that of controls. Separate analyses were conducted for children
and adults.
Data on 1,809,029 control children and 381,678 pediatric patients
with mild, 22,433 with moderate, and 5,320 with severe AD were
analyzed. The IR for IBD was 0.16 in control children and 0.20,
0.48, and 0.71, respectively, for those with mild, moderate, or
severe AD. After adjusting for confounders, the risk of IBD and CD
were significantly higher in children with AD than in controls
(adjusted hazard ratio [aHR], 1.44; 95% CI, 1.31, 1.58; and aHR, 1.74;
95% CI, 1.54, 1.97, respectively). The risk of IBD increased with
increasing AD severity in children, with aHRs ranging from 1.36 for
those with mild AD to 2.59 for those with severe AD. A similar
trend was seen with CD. Overall, the risk of UC was not signifi-
cantly increased in children with AD (aHR, 1.09; 95% CI, 0.94, 1.27),
but those with severe AD were at greater risk (aHR, 1.65; 95% CI,
1.02, 2.67). The results were similar in the adult cohort, which
included 2,678,888 controls and 625,083 patients with AD. The
risk of IBD, CD, and UC were all significantly increased in adults
with AD compared to controls.
The authors conclude that AD is associated with an increased risk
of IBD in children and adults, with the risk varying by AD severity
and IBD subtype.
• December 2023
TM
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by Almoosa Hospital user
COMMENTARY BY
Philip Rosenthal, MD, FAAP, Pediatric Gastroenterology, University
of California, San Francisco, San Francisco, CA
Dr Rosenthal has disclosed no financial relationship relevant to this commentary. This commen-
tary does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
AD is the most common inflammatory skin condition and affects
about 223 million people worldwide.1 AD is a chronic condition in
which a disordered immune system causes inflammation that
damages the skin barrier. 2 Skin disorders are common among IBD
patients. 3
To assess the correlation between AD and IBD, investigators col-
lected data from the THIN database. Participants were stratified
into pediatric or adult cohorts based on age at baseline. Using
these data, investigators performed logistic regression to exam-
ine the risk for IBD, UC, and CD in children and adults with AD
compared with controls.
In fully adjusted models, the pediatric group had a 44% increased
risk of IBD and a 74% increased risk of CD, which increased with
AD severity. Notably, patients with AD in the pediatric group did
not have an increased risk of UC, except those with severe AD.
Adults with AD had a 34% increased risk of IBD, a 36% increased
risk of CD, and a 32% increased risk of UC, with the risk increasing
with worsening AD. The finding that this risk increases with wors-
ening severity of AD suggests a possible causal association.
The researchers acknowledged that their study had several lim-
itations. They used treatments to represent severity, which made
it difficult to separate the effects of treatment exposure from AD
severity. Also, the researchers treated AD severity as a time-up-
dated variable. This allowed for escalation of severity but not
de-escalation, meaning severe AD was not reclassified as moder-
ate, even if AD improved.
Studies examining the association between AD and IBD are
important because they investigate common pathophysiologic
mechanisms that could influence treatments with the advent of
targeted therapeutic approaches.
Bottom Line: Both children and adults with AD have an increased
risk of IBD.
EDITORS’ NOTE
The association of inflammatory skin and gastrointestinal dis-
eases, previously well described with psoriasis and its therapy,
now extends to AD and IBD, suggesting common environmental,
genetic, and immunologic factors—yet to be defined. (See AAP
Grand Rounds. 2017;37[5]:58.)4
References
1. Global Atopic Dermatitis Atlas. Global Report on Atopic Dermatitis 2022. Flohr C, ed. London,
United Kingdom; International League of Dermatological Societies; 2022.
2. Facheris P, et al. Cell Mol Immunol. 2023;20(5):448-474; doi: 10.1038/s41423-023-00992-4.
3. Crohn’s & Colitis Foundation. Skin complications. News from the IBD help center.
CrohnsColitisFoundation.org website. https://www.crohnscolitisfoundation.org/sites/
default/files/legacy/assets/pdfs/skin.pdf. Updated January 2015.
4. Eickstaedt JB, et al. Pediatr Dermatol. 2017;34(3):253-260; doi: 10.1111/pde.13081.
67
 DEVELOPMENTAL-BEHAVIORAL
Is Timing Really Everything?
Source: Gamble, C, Persson C, Willadsen E, et al. Timing of primary surgery
for cleft palate. N Engl J Med. 2023;389:795-807; doi: 10.1056/NEJMoa2215162.
Investigators from multiple institutions conducted a randomized
trial to compare outcomes in children with isolated cleft palate
who had primary surgical repair at 6 or 12 months of age. Study
participants were infants with non-syndromic cleft palate who
presented to 1 of 23 centers in Brazil, Denmark, Norway, Sweden,
and the United Kingdom. At enrollment, study infants were ran-
domized to undergo surgery at 6 or 12 months of age. Surgeons at
all sites used the same surgical technique. Standardized assess-
ments of speech and hearing were performed when study partic-
ipants were 1, 3, and 5 years old. The primary outcome was
velopharyngeal insufficiency (VPI) at 5 years of age, defined as a
velopharyngeal composite summary score (VPC-Sum) ≥4, as mea-
sured by speech and language therapists. VPC-Sum assesses
speech hypernasality, symptoms of VPI, and non-oral speech
errors, with a score of 0–2 on each of the 3 components, with
higher scores indicative of greater severity. Multiple other speech
assessments were performed, including canonical babbling ratio
at 1 year (ratio of canonical syllables to total syllables). Hearing
sensitivity also was evaluated at 1, 3, and 5 years of age. Outcomes
between treatment groups (repair at 6 vs 12 months) were
assessed with risk ratios (RR) and 95% confidence intervals (CI).
A total of 558 infants were randomized for the trial, including 281
assigned to the cleft-palate repair group at 6 months and 277 to
the 12-month surgery group. Data on the primary outcome were
obtained on 235 children (83.6%) in the 6-month group and 226
(81.6%) of those in the 12-month surgery group. At 5 years of age,
8.9% of participants in the 6-month surgery group were classi-
fied with VPI compared to 15.0% of those who underwent surgery
at 12 months (RR, 0.59; 95% CI, 0.36, 0.99; P = 0.04). The canonical
babbling ratio at 12 months was significantly higher among those
who had surgery at 6 months vs those with a surgical repair at 12
months of age. There were no other significant differences
between treatment groups for other speech outcomes. At 1 year
of age, hearing sensitivity was abnormal in 39.2% of infants in the
6-month surgery group compared to 78.1% of those who had sur-
gery at 12 months (RR, 0.50; 95% CI, 0.35, 0.72), but there were no
significant differences between groups for hearing outcomes at 3
and 5 years of age.
The authors conclude that infants with isolated cleft palate who
underwent primary surgical closure at 6 months of age were less
likely to have VPI when they were 5 years old than those who
underwent repair at 12 months of age.
68
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COMMENTARY BY
Deborah Badawi, MD, FAAP, Development/Behavioral, University
of Maryland School of Medicine, Baltimore, MD
Dr Badawi has disclosed no financial relationship relevant to this commentary. This commentary
does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
The results of this large, elegant study indicate that fewer chil-
dren who receive early correction of non-syndromic cleft palate
have VPI at 5 years of age. Two factors bear consideration: hear-
ing sensitivity at age 12 months and early intervention services.
The children who had correction at 12 months had their baseline
evaluation prior to their surgery and a greater percentage had
abnormal hearing sensitivity than in the early repair group. PE
tube placement and timing was not considered in the current
study; however, Shaffer and colleagues1 found that PE tube
placement and its timing did not impact VPI in children at 5 years
of age.
Only 20% of children in both groups were seen by a local speech
therapist, and about three quarters of these received direct ser-
vices by 3 years of age and 40% by 5 years. Studying the impact of
early speech therapy on intelligibility and VPI is challenging due
to the multiple modes of therapy provided in naturalistic set-
tings. Lane and colleagues2 found weak evidence that speech
therapy prior to age 3 improved speech outcomes for children
with cleft palate +/- cleft lip; however, VPI was not specifically
addressed.
There also is a difference between statistically significant and
clinically relevant results. 3 Sand and colleagues attempted to
evaluate speech outcomes in this population with a meta-
analysis. 3 Again, the evidence was weak due to the variability in
intensity and approaches of therapy. Another review of interven-
tion for children with marginal or mild VPI revealed individual
variation in response to speech therapy.4 Clearly, we do not have
strong evidence-based recommendations to make regarding the
potential impact of type or intensity of speech therapy.
The authors note challenges in recruitment for this study. It is
difficult to agree to randomize your child when 1 option may
appear on the surface to be better (eg, earlier or more intensive
intervention). This plagues research in both surgical and nonsur-
gical interventions such as speech, physical, or occupational
therapies for children.
Bottom Line: Early palate repair appears to mitigate early hear-
ing loss and result in decreased VPI at age 5 years.
References
1. Shaffer AD, et al. Otolaryngol Head Neck Surg. 2017;157(3):504-514; doi: 10.1177/0194599817703926.
2. Lane H, et al. Int J Lang Commun Disord. 2022;57(1):226-245; doi: 10.1111/1460-6984.12683.
3. Sand A, et al. J Speech Lang Hear Res. 2022;65(2):555-573; doi: 10.1044/2021_JSLHR-21-00367.
4. Mao Q, et al. Front Pediatr. 2023;11:1187224; doi: 10.3389/fped.2023.1187224.
aapgrandrounds.org
 GENERAL PEDIATRICS
Benefits of Antenatal IV Magnesium After
30 Weeks’ Gestation
Source: Crowther CA, Ashwood P, Middleton PF, et al. Prenatal intra-
venous magnesium at 30-34 weeks’ gestation and neurodevelopmental
outcomes in offspring: the MAGENTA randomized clinical trial.
JAMA. 2023;330(7):603-614; doi:10.1001/jama.2023.12357.
Investigators from multiple institutions in Australia conducted a
randomized controlled trial to assess the effectiveness of magne-
sium sulfate, administered to mothers at risk of imminent preterm
delivery, in preventing death or cerebral palsy in infants born
between 30–34 weeks’ gestation. For the trial, pregnant individu-
als being treated at 1 of 24 centers in Australia and New Zealand
who were 30 to 34 weeks pregnant and expected to deliver within
the next 24 hours were enrolled. Study participants were random-
ized to receive intravenous magnesium sulfate (4 g) or placebo.
Clinical data on the mothers and their offspring during the hospi-
talization were collected. For infants who survived, a neurodevel-
opmental assessment was completed at 2 years corrected age. A
diagnosis of cerebral palsy required documentation of loss of
motor function and abnormalities of muscle tone. The primary
study outcome was a composite of death by 2 years corrected age
or diagnosis of cerebral palsy. Secondary outcomes included
death and cerebral palsy assessed separately, multiple other
neurodevelopmental outcomes at 2 years, and clinical course
during the birth hospitalization. Negative binomial regression
was used to assess differences in outcomes among infants in the
intervention and placebo treatment groups, after adjusting for
multiple covariates. Perinatal outcomes in mothers randomized
to magnesium treatment or placebo also were compared.
A total of 1,433 pregnant individuals, who gave birth to 1,679
infants, were randomized. Data for the primary outcome were
obtained on 691 of 858 (80.5%) infants in the intervention group
and 674 of 821 (82.1%) of those in the placebo group. Death by 2
years corrected age or cerebral palsy occurred in 3.3% of children
whose mothers received magnesium compared to 2.7% of those in
the placebo group (adjusted risk ratio [aRR], 1.19; 95% CI, 0.65, 2.18;
P = 0.57). There also were no significant differences in the rate of
death (1.4% in the intervention group and 0.9% for those receiving
placebo; aRR, 1.50; 95% CI, 0.58, 3.86; P = 0.40) or cerebral palsy
(1.6% and 1.7%, respectively; aRR, 0.98; 95% CI, 0.43, 2.23; P = 0.96).
There were no differences between groups for other neurodevel-
opmental outcomes. Newborns whose mothers received magne-
sium had a significantly lower rate of neonatal respiratory distress
syndrome than those in the placebo group (34% and 41%, respec-
tively; P = 0.01) and were less likely to develop chronic lung
disease (5.6% and 8.2%, respectively; P = 0.04). Mothers receiv-
ing magnesium were significantly less likely to have a cesarean
delivery than those in the placebo group (56% vs 61%; P = 0.03)
but more likely to have a major postpartum hemorrhage (3.4% vs
1.7%; P = 0.05).
The authors conclude magnesium administration to mothers
prior to preterm birth at 30 to 34 weeks’ gestation was not asso-
ciated with improved rates of survival of their offspring or reduced
risk of cerebral palsy at 2 years corrected age.
• December 2023
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by Almoosa Hospital user
COMMENTARY BY
Neera Goyal, MD, MSc, FAAP, General Pediatrics, Nemours Children’s
Health, Philadelphia, PA
Dr Goyal has disclosed no financial relationship relevant to this commentary. This commentary
does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
Preterm birth less than 37 weeks’ gestation is the leading cause
of infant morbidity, mortality, and adverse neurodevelopmental
outcomes, including cerebral palsy, in the United States.1 While
terminology such as “early preterm” or “late preterm” often is
used to classify births based on specific gestational age cutoffs,
in actuality preterm birth is a spectrum, with each additional
week of gestation resulting in fewer complications and better
survival. 2 Many advances in obstetrical and neonatal care have
contributed to improved outcomes across this continuum. (See
AAP Grand Rounds. 2016;35[1]:10). 3
One intervention with high quality evidence is IV magnesium sul-
phate administered to women at risk of imminent preterm birth
for infant neuroprotection.4,5 While the use of antenatal IV
magnesium sulphate for this indication is recommended as
standard practice, there remains clinical uncertainty and practice
variation regarding the optimal gestational age range. The results
of this large clinical trial demonstrated no reduction in cerebral
palsy associated with IV magnesium sulphate for infants ≥30–34
weeks’ gestation. As pointed out by the authors of an accompa-
nying editorial, the development of cerebral palsy is multifacto-
rial, and neonatal interventions to reduce neurologic injury in
this later gestational age interval are likely to be more
impactful.6
Bottom Line: For pregnant patients at immediate risk of preterm
delivery ≥30 weeks’ gestation, IV magnesium is unlikely to pro-
vide infant neuroprotective benefit.
References
1. Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy
Outcomes. Preterm Birth: Causes, Consequences, and Prevention. Behrman RE, Butler AS, eds.
Washington, DC. National Academies Press (US). 2007.
2. Manuck T, et al. Am J Obstet Gynecol. 2016;215(1):103.e1-103.e14; doi: 10.1016/j.ajog.2016.01.004.
3. Stoll BJ, et al. JAMA. 2015;314(10):1039-1051; doi: 10.1001/jama.2015.10244.
4. Wolf H, et al. BJOG. 2020;127(10):1180-1188; doi: 10.1111/1471-0528.16238.
5. Shepherd E, et al. Cochrane Database Syst Rev. 2017;8(8):CD012077;
doi: 10.1002/14651858.CD012077.pub2.
6. Louis JM, Randis TM. JAMA. 2023;330(7):597-598; doi: 10.1001/jama.2023.10673.
69
 SLEEP MEDICINE
The Effects of OSA Among Children With
Down Syndrome
Source: Soltani A, Schworer EK, Amin R, et al. Executive functioning,
language, and behavioral abilities related to obstructive sleep apnea in
Down syndrome. J Dev Behav Pediatr. 2023;44(6):e429-e435;
doi: 10.1097/DBP.0000000000001189.
Investigators from multiple institutions conducted a cross-
sectional study to assess the association between obstructive
sleep apnea (OSA) and multiple behavioral and developmental
measures in children with Down syndrome (DS). Study partici-
pants were youths 6–17 years old with DS who were enrolled at 2
centers in the US. Using medical record review and parental
report, participants were classified as having no OSA, untreated
OSA, or treated OSA, with treatment consisting of medications,
oxygen, or continuous positive airway pressure (CPAP) for the
symptoms of OSA. Standardized tests and questionnaires were
administered to study children and their parents to assess the
following parameters: IQ, behavioral and emotional regulation,
memory, receptive and expressive language, internalizing and
externalizing behavior problems, social responsiveness, and
sleep problems. Analysis of variance (ANOVA) and multivariate
analysis of covariance (MANCOVA), with the analyses adjusted for
age, were used to evaluate differences in scores on the various
measures between participants in the no OSA, untreated OSA,
and treated OSA groups. Pairwise comparisons also were
conducted.
A total of 100 youths with DS were enrolled, with 38 in the no OSA
group, 28 with untreated OSA, and 34 with treated OSA. The mean
IQ of study participants was 50 ±7, with no significant difference
between the 3 groups. The mean ages of youths in the 3 groups
were 11.1 ±3.4, 11.6 ±3.5, and 13.3 ±2.9 years, respectively, for those
in the no OSA, untreated OSA, and treated OSA groups (P = 0.02).
After controlling for age, there were significant differences
between groups for scores for emotional regulation (P = 0.03) and
internalizing behaviors (P = 0.01). In pairwise comparisons, scores
for emotional regulation among children with untreated OSA
were significantly worse than in those with no OSA (P = 0.01) and
those with treated OSA (P = 0.02). Similarly, scores for internaliz-
ing behaviors were significantly worse for participants with
untreated OSA than for those with no OSA or treated OSA (P = 0.01
and P = 0.01; respectively). Although scores assessing social
responsiveness were not significantly different between the 3
groups, in a pairwise comparison, those with untreated OSA had
significantly worse scores for social responsiveness than
children without OSA (P = 0.03).
The authors conclude that the results of the study suggest that
youths with DS and untreated OSA may experience increased
challenges in emotional regulation and internalizing behaviors
than those with no OSA or treated OSA.
70
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COMMENTARY BY
Mike Dubik, MD, FAAP, Pediatrics and Sleep Medicine, Naval
Medical Center Portsmouth, Portsmouth, VA
Dr Dubik has disclosed no financial relationship relevant to this commentary. This commentary
does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
OSA is more common among children with DS for various rea-
sons, including midface hypoplasia, macroglossia, and hypoto-
nia.1 Untreated OSA has been associated with cognitive deficits2
and behavioral issues 3 among children in the general population.
The literature for children with DS is less robust but does suggest
the same patterns.4,5
Soltani and colleagues explored the relationship between OSA
and DS regarding executive functioning, language, and behavior.
They hypothesized that those with untreated OSA would show
more difficulties with these domains than those treated OSA or
no OSA. Their results corroborate prior findings.
Limitations include the relatively small sample size and not con-
trolling for body mass index percentile. Further, the age range
was broad, and additional studies should consider subdividing
based on age and possibly degree of maturation. The authors
report 3 types of treatment for their patients with OSA: CPAP,
oxygen, and medications. CPAP, of course, is the standard. Oxygen
typically is prescribed when CPAP has failed, to mitigate the SpO2
desaturations often seen with OSA; however, simple nasal canula
O2 does not treat OSA. Medications can be prescribed to treat the
symptoms of OSA but not the OSA itself. Thus, some of the com-
parisons in the current study are between children with DS with
untreated OSA and those receiving treatments for the symptoms
of OSA. Curiously, surgical treatments were not included. A cate-
gory of successfully treated OSA versus simply treated OSA would
have been preferred.
The authors conclude that children with DS and untreated OSA
in their study may have more challenges with internalizing behav-
iors and regulating emotions than those with treated OSA or
no OSA. They recommend that clinicians not simply assume that
behavioral issues among children with DS are just a straight-
forward function of genetics and that untreated OSA should be
considered.
Bottom Line: It is important that children with DS and OSA have
their sleep-disordered breathing treated. (See AAP Grand
Rounds. 2023;49[1]:7.)6
References
1. Anand V, et al. Pediatr Neurol. 2021;116:7-13; doi: 10.1016/j.pediatrneurol.2020.10.007.
2. Torcelli F, et al. Neuroimage. 2011;54(2):787-793; doi: 10.1016/j.neuroimage.2010.09.065.
3. Jackman AR, et al. Sleep Med. 2012;13(6):621-631; doi: 10.1016/j.sleep.2012.01.013.
4. Joyce A, et al. Behav Sleep Med. 2020;18(5):611-621; doi: 10.1080/15402002.2019.1641501.
5. Yu PK, et al. Sleep. 2022;45(5):1-8; doi: 10.1093/sleep/zsac035.
6. Tapia IE, et al. Chest. 2022;162(4):899-919; doi: 10.1016/j.chest.2022.06.026.
aapgrandrounds.org
 CRITICAL CARE
Non-pharmacological Management of
SVT in Infants
Source: Pompa G, LaPage MJ. Outcomes of infant supraventricular tachy-
cardia management without medication [published online ahead of print
August 10, 2023]. Pediatr Cardiol. doi: 10.1007/s00246-023-03263-1.
Investigators from Washington University School of Medicine, St.
Louis, MO, and the University of Michigan, Ann Arbor, MI, con-
ducted a retrospective study to evaluate the effectiveness and
safety of non-pharmacologic management after a first episode of
supraventricular tachycardia (SVT) in infants and to compare
outcomes in patients managed without and with drug treat-
ment. Participants were children <1 year old presenting with a
first episode of SVT to a single center between 2014 and 2021. SVT
was defined as a short-RP relationship narrow complex tachy-
cardia that had an abrupt termination, either spontaneously or
with treatment. Infants were managed with medication or with
non-pharmacologic treatment at the discretion of the attending
cardiologist. For those managed without drugs, parents received
education on heart rate (HR) measurement that was recom-
mended to be performed daily. The medical records of study
participants were reviewed and data on demographics, clinical
presentation, and drug treatment (if applicable) abstracted.
Clinical information for the year following the initial presen-
tation also was collected. The primary study outcome was
re-presentation with documented SVT or SVT based on parental
report of sustained HR above physiologic range with an abrupt
termination, either spontaneously or with vagal maneuvers.
Secondary outcomes included ED visits for SVT and development
of tachycardia-induced cardiomyopathy. Differences in these
outcomes among infants with non-pharmacologic management
and those with drug treatment were compared with Fisher
exact tests.
Data on 64 infants, including 36 managed without medications
and 28 who were prescribed an antiarrhythmic drug, were ana-
lyzed. The median age at presentation was 9 days for those in the
non-pharmacologic treatment group and 8.5 for those treated
with drugs. Among infants managed without medication, the ini-
tial episode of SVT resolved spontaneously in 25% and with a
vagal maneuver in 53%; adenosine was used in 22%. For those
subsequently managed with drugs, 7% had spontaneous resolu-
tion, 36% after a vagal maneuver, and 57% with adenosine treat-
ment. For the 28 patients treated with drugs following the initial
presentation, 23 (82%) received propranolol, 4 (14%) nadolol, and
1 atenolol. Recurrent SVT occurred in 10 (28%) infants in the
non-pharmacologic treatment group compared to 14 (50%) of
those on antiarrhythmic drugs (P = 0.12). Infants managed with-
out medications were significantly less likely than those in the
drug treatment group to have a subsequent ED visit for recur-
rence of SVT (6% vs 32%; P <0.01). No patients in either group
developed tachycardia-induced cardiomyopathy.
The authors conclude that non-pharmacologic management of
infants after an initial episode of SVT did not lead to worse out-
comes than those managed with antiarrhythmic drugs.
• December 2023
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by Almoosa Hospital user
COMMENTARY BY
Laura Miller-Smith, MD, FAAP, Pediatric Critical Care Medicine,
Doernbecher Children’s Hospital, Oregon Health and Sciences
University, Portland, OR
Dr Miller-Smith has disclosed no financial relationship relevant to this commentary. This commen-
tary does not contain a discussion of an unapproved/investigative use of a commercial product/
device.
Wide practice variation exists in treatment for neonatal and
infant SVT, including drug choice (See AAP Grand Rounds.
2017;37[3]:33.)1 and duration of treatment. Recurrent and inces-
sant SVT, hard to diagnose in infants, may rarely lead to cardio-
myopathy. This concern has historically led to experts
recommending at least 12 months of therapy following first event. 2
Recent studies, however, have called the need for prolonged
treatment into question. This includes 1 study in which infants in
whom medication was stopped before 6 months of age had simi-
lar rates of recurrence as those treated longer. 3 Another study
found that most recurrences occurred in the first few weeks after
birth, with most infants not experiencing recurrence following
4 months after birth.4 These emerging data indicate that it is
reasonable to reconsider the approach to SVT management in
otherwise well infants.
A pharmacological approach to treatment is not necessarily
benign. Beta-blockade medication, the most common drug
choice, incurs risk. In a study evaluating nadolol, for example, 10%
of patients had side effects including wheezing, irritability, diar-
rhea, and bradycardia.1 Hypoglycemia is another known risk.
In the current single-center retrospective cohort study, infants
treated with an observational approach, coupled with parental
education, had similar rates of SVT recurrence as those treated
with medications. Infants not on medication re-presented less
frequently to EDs. While a selection bias may exist, these findings
support the growing literature that infants may be safely moni-
tored without medication. The study institution has developed a
process for providing parents education on heart rate checks in
addition to receiving a stethoscope. The authors emphasize the
importance of finding a strategy that best fits the needs of the
child and family. Some families may find peace of mind with
scheduled medications. On the other hand, some parents may
feel comfortable with providing their own close observation, and
the results of this study indicate they can be empowered to do
so safely.
Bottom Line: In infants with first-time uncomplicated SVT and
structurally normal hearts, a non-pharmacological approach
including robust parental education may be safe.
EDITORS’ NOTE
A significant limitation to the study is that the pharmacologic and
non-pharmacologic treatment groups were dissimilar in terms of
the level of therapy needed to terminate the initial episode of SVT.
References
1. von Alvensleben JC, et al. Pediatr Cardiol. 2017;38(3):525-530; doi: 10.1007/s00246-016-1544-y.
2. Garson A Jr, et al. J Pediatr. 1981;98(6):875-882; doi: 10.1016/s0022-3476(81)80578-1.
3. Aljohani OA, et al. Pediatr Cardiol. 2021;42(3):716-720; doi: 10.1007/s00246-020-02534-5.
4. Sanatani S, et al. Circ Arrhythm Electrophysiol. 2012;5(5):984-991;
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doi: 10.1161/CIRCEP.112.972620.

CME QUESTIONS
The following continuing medical education questions cover the content
of the December 2023 issue of AAP Grand Rounds. Please keep this issue.
Each year’s material is worth up to 18 AMA PRA Category 1 Credit(s) ™.
Complete and claim credit online at www.aapgrandrounds.org. Need
username and password? Contact customer service at 866/843-2271.
CME OBJECTIVES
1. Understand the utility of tissue culture for identifying the pathogen
with acute hematogenous osteomyelitis in children who have a
negative blood culture.
2. Explain the effect of cold air exposure for viral croup.
3. Describe the role of running water as a risk factor for scald burn in
young children.
1. A 5-year-old girl presents with acute hematogenous osteomyelitis of the right
distal tibia. Based on the study by Burns et al about improving tissue pathogen
identification in blood culture-negative acute hematogenous osteomyelitis,
which of the following is most accurate?
a. 97% of children with acute hematogenous osteomyelitis demonstrate
negative blood cultures.
b. A tissue biopsy was positive in 87.3% of children older than 3.1 years and
with the CRP >4.1 mg/dL.
c. An elevated erythrocyte sedimentation rate was significantly associated
with an increased probability of a positive tissue culture in the multivariate
statistical model.
d. A tissue biopsy is never needed, because wide-spectrum empiric antibiotics
are sufficient.
e. Blood cultures are needed only if the patient is under <3.1 years of age and
the erythrocyte sedimentation rate is elevated.
2. A 2-year-old girl is seen in the office, accompanied by her parents, for follow
up of an ED visit yesterday for croup. She received dexamethasone in the ED
and is doing much better today. The parents read on the internet that cold air
is beneficial for croup and ask if exposing their child to cold air is something
they should do if she has croup in the future. Based on the study by Siebert
et al concerning the effectiveness of cold air in children with croup as an
adjunct to dexamethasone, which of the following is the most accurate
conclusion or finding?
a. A significant reduction in the Westley Croup Score (WCS) was noted in the
intervention group (cold air for 30 minutes) 30 minutes after receipt of
dexamethasone compared to controls (remained in the ED) for children
with moderate croup.
b. A significant reduction in the WCS was noted in the intervention group at
60 minutes after receipt of dexamethasone.
c. Patients with mild croup improved the most from the intervention.
d. Children in the intervention group were more likely to have a return health
care visit within 7 days.
e. There was a significant reduction in respiratory rate in the intervention
group at 30 minutes after receipt of dexamethasone.
3. You are evaluating a child who has had 7 days of a purulent nasal discharge,
worsening congestion and cough, and new onset of fever the past day. You
make the diagnosis of sinusitis and consider prescribing antibiotics through
shared decision making with the family. Which of the following is most accurate
based on the study by Shaikh et al concerning children with acute sinusitis who
are likely to benefit from antibiotic therapy?
a. Patients with a purulent nasal discharge had greater benefit from antibiotics
compared to those with a clear nasal discharge.
b. Patients who received antibiotics had a significant reduction in symptom
score.
c. Only those with an identified bacterial pathogen benefitted from antibiotics.
d. There was no difference in symptom score between those with and without
an identified bacterial pathogen.
e. Treatment duration was non-inferior between 5 days and 10 days of
treatment.
4. In the study by Moser et al, which of the following was associated with the
greatest number of scald burns during bathing of young children?
a. Bathing in an infant tub.
b. Running water from a faucet.
c. Caregiver was not present for the entirety of the bath.
d. Older sibling in the bathtub.
e. Caregiver not checking the water temperature of the bath.
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5. A 7-year-old boy with severe atopic dermatitis presents to your office. His
physician parents have been scouring the medical literature for any associa-
tions of atopic dermatitis with other medical disorders. Based on the study by
Chiesa Fuxench et al, which of the following statements is most accurate?
a. The risk of IBD is not dependent upon the severity of the atopic dermatitis.
b. In children, there was a 74% increased risk of Crohn’s Disease in patients
with atopic dermatitis.
c. As an adult, the risk of IBD in patients with atopic dermatitis is almost 95%.
d. In adults, there was not an increased risk of Crohn’s Disease in patients with
atopic dermatitis.
e. Children with mild to moderate atopic dermatitis have an increased risk of
developing ulcerative colitis.
6. The parents of a newborn girl with nonsyndromic isolated cleft palate are
asking about the timing of surgery. According to the article by Gamble and
colleagues, children who receive their cleft palate repair at 12 months of age
versus 6 months of age have a statistically significant higher prevalence of
which of the following at age 5?
a. Severe hearing impairment.
b. Speech delay as determined by percent consonants correct.
c. Structural facial changes.
d. Velopharyngeal insufficiency.
e. Moderate hearing impairment.
7. Based on the study performed by Crowther et al concerning antenatal IV
magnesium versus placebo at 30 to 34 weeks’ gestation, which of the
following is most accurate?
a. Neonates in the magnesium group were more likely to have respiratory
distress syndrome.
b. There was no difference in the rates of chronic lung disease.
c. There was no significant difference in death or cerebral palsy at 2 years
of age.
d. The incidence of postpartum hemorrhage was reduced in the magnesium
group.
e. There was an increase in cesarean delivery in the magnesium group.
8. A 12-year-old girl is seen in the office for a well child exam. Mom states that she
was involved in an online chat group of parents of children with Down syndrome
(DS) concerning obstructive sleep apnea (OSA) and asks about the possibility of
her daughter having OSA and its effect on her cognitive, behavioral, and social
functioning. Which of the following is the most accurate finding or conclusion
of the research presented by Soltani et al for children with DS and OSA?
a. After controlling for age, there were no significant differences between
groups (without OSA, with untreated OSA, and with treated OSA) for scores
for emotional regulation.
b. After controlling for age, there were no significant differences between
groups for scores for internalizing behaviors.
c. In pairwise comparisons, scores for emotional regulation among children
with untreated OSA were no different than in those with no OSA.
d. Youths with DS and untreated OSA may experience increased challenges
in emotional regulation and internalizing behaviors compared to those
without OSA or treated OSA.
e. There was no difference in scores for emotional regulation between those
with untreated OSA and treated OSA.
9. A 4-week-old infant presents to the ED due to parental concerns for poor
feeding and decreased alertness for less than 1 day. Initial vital signs measure
a heart rate of 223, and an EKG is obtained, confirming supraventricular tachy-
cardia (SVT). A single dose of adenosine of 0.1 mg/kg is given, and she converts
to a sinus rhythm. She is admitted for further observation and evaluation by the
cardiology service. An EKG confirms normal anatomy and function. What is most
accurate in discussing with family about long-term management based on the
study by Pompa and LaPage concerning outcomes of infant SVT?
a. The infant is at high risk (>70%) for recurrence without pharmacologic
management.
b. Medication will be required for a minimum of 1 year.
c. Tachyarrhythmia-induced cardiomyopathy is common in infants with SVT
with or without pharmacologic management.
d. It is reasonable for families to choose education and observation
(non-pharmacologic) for management strategy.
e. A non-pharmacologic approach will lead to a higher rate of ED visits for SVT.
9. d 8. d 7. c 6. d 5. b 4. b 3. b 2. a 1. b
Answer key
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