Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Many chemical exposures during pregnancy can have an impact on the offspring’s health. An 

 examines whether exposure to maternal labor epidural analgesia during a vaginal delivery is linked to the risk of autism spectrum disorder in children.

The investigators ran a retrospective longitudinal birth cohort study. The data were taken from electronic medical records from a population-based clinical birth cohort. Children who were delivered vaginally between January 2008 and December 2015 in a single integrated health care system were included in the study. Each child was followed up from 1 year of age until one of the following occurred: a clinical diagnosis of autism spectrum disorder, last date of health plan enrollment, death, or the study’s end date of December 31, 2018.

The cohort had 147,895 singleton children and 109,719 of the children had been exposed to maternal labor epidural analgesia. Fever during the course of labor was seen in 13,055 of the mothers who received a labor epidural analgesia and 510 of the mothers who did not receive an epidural. A diagnosis of autism spectrum disorder was given to 2039 children in the labor epidural analgesia group and 485 children who were not exposed to a labor epidural analgesia. Following an adjustment for a number of confounders including maternal age at delivery, parity, gestational age at delivery, and history of comorbidity, the hazard ratio linked to labor epidural analgesia exposure versus no exposure was 1.37 (95% CI, 1.23-1.53). In the group exposed to labor epidural analgesia, a significant trend of risk for autism spectrum disorder was linked with an increasing duration of exposure to labor epidural analgesia, following adjustment for covariates (HR for linear trend, 1.05 [95% CI, 1.01-1.09] per 4 hours). Including fever did not change the HR estimate linked with exposure to labor epidural analgesia (adjusted HR for labor epidural analgesia vs non- labor epidural analgesia, 1.37 [95% CI, 1.22-1.53]).

The researchers concluded that exposure to labor epidural analgesia appears to be linked to an increased risk of autism spectrum disorder in children and that risk is not directly tied to maternal fever linked to the epidural. They urged further research to confirm the findings and to begin understanding the mechanism behind the association.

1. Qiu C, Lin J, Shi J, et al. Association between epidural analgesia during labor and risk of autism spectrum disorders in offspring. 

. October 12, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.3231

Articles

An investigation looks into whether exposure to maternal epidural during delivery has an impact on risk for autism spectrum disorder.

Does exposure to an epidural during delivery increase autism risk?

Infant mortality remains high in the United States. Previous research indicates that government spending on services that aren’t linked to health care can lead to a reduction in infant mortality. However, which area of spending has the greatest impact remains unknown. A 

 examines how spending impacted infant mortality rates.

The researchers used the most recent data available, which was state and local government spending for 2000 to 2016. They looked at spending on education, social services, environment, and housing. They used linear regression models to assess how spending changes impacted infant mortality over time, overall and stratified by race and ethnicity and maternal age group.

They found that during the period 2000 to 2016, the average infant mortality was 6.6 per 1000 live births. When compared to their peers, infant mortality was twice as high among Black infants with 12.2 per 1000. The researchers found that the average governmental spending per person was $9. A per-person increase of $0.73 in social services spending was linked with a decrease of 0.02 deaths per 1000 live births. Additionally, a $0.30 per-person increase in environmental spending was linked with a decrease of 0.03 deaths per 1000 live births. Children born to mothers aged <20 years saw the greatest benefit from increases in governmental spending when compared to all other groups. Overall, increasing funding for public health, parks and recreation, housing, and solid waste management were linked with the highest reduction in the infant mortality rate.

Researchers noted some of their study’s limitations, which included the ecologic approach, which reduced their ability to control for individual factors as well as make causal inferences. They also noted that inefficiencies in the current spending could mean that people who most need them may not be able to receive them. Additionally, using geopolitically broad state boundaries could have prevented understanding subtle differences in populations.

The investigators concluded that governmental spending in nonhealth areas was tied to lower infant mortality rates, particularly in some high-risk populations. Continuing investments in these areas, social and environmental, could continue reducing the disparities seen in infant mortality rates.

1. Goldstein N, Palumbo A, Bellamy S, Purtle J, Locke R. State and local government expenditures and infant mortality in the United States. 

. October 19, 2020. Epub ahead of print. doi:10.1542/peds.2020-1134

An investigation examines how governmental spending, in both health and nonhealth areas, can impact infant mortality rates.

 How governmental spending can impact infant mortality

Public opinion on neonatal circumcision has shifted over the years and a number of states do not offer Medicaid coverage for the procedure, in spite of the recommendation from the American Academy of Pediatrics that supports access to neonatal circumcision for families that choose to have their child get the procedure. A 

 examines the trends for circumcision and the impact of changes in Medicaid coverage for the procedure.

The researchers used the State Inpatient Databases to determine the rates of neonatal male circumcision in Colorado, Florida, Michigan, and New York during 4 different years: 2001, 2006, 2011, and 2016. During the study period, the procedure was defunded by Medicaid in Florida in 2003 and Colorado in 2011.

The researchers found that during the study period 54.5% of male neonates received a circumcision. They found that the rate of circumcision decreased in the years following the defunding of neonatal circumcision by Medicaid, 47.4% to 37.5% in Florida; 61.9% to 52.0% in Colorado. When compared to neonates who were covered by public insurance, neonates who were privately insured had higher odds of undergoing circumcision (adjusted odds ratio [aOR] 2.23; 95% CI 2.21–2.25). If Medicaid covered neonatal circumcision, Black neonates were found to have higher odds of circumcision than white neonates (aOR 1.44; 95% CI 1.42–1.46). However, when Medicaid did not cover the procedure, Black neonates were found to have lower odds of getting the procedure than white neonates (aOR 0.40; 95% CI 0.39–0.41).

The investigators concluded that overall the state-specific data indicate that the neonatal circumcision rates remain at levels similar to previous national estimates. However, defunding by Medicaid does lead to a reduction in the procedure, with Colorado seeing a 20.9% reduction and a 16.0% reduction in Florida. Additionally, Black neonates are the infants most likely to be impacted by a lack of Medicaid funding because they were overly affected by changes in Medicaid coverage of neonatal circumcision.

1. Zambrano Navia M, Jacobson D, Balmert L, et al. State-level public insurance coverage and neonatal circumcision rates. 

. October 14, 2020. Epub ahead of print. doi:10.1542/peds.2020-1475

A report examines the impact of Medicaid funding on how many neonates undergo circumcision.

Medicaid funding impacts circumcision utilization

Poll

As patients enter adolescence, the need for creating a confidential space for them grow. Is your practice offering that?

Is there a plan for teen confidentiality at your practice?

A report looks at the recent guidelines for diagnosing and managing children’s heads that are misshapen.

We have a new poll. We want to know whether your practice has a plan in place to ensure confidentiality for adolescent patients.

Plus, a look at how public health coverage can impact neonatal circumcision rates.

A look at what to expect from Contemporary Pediatrics this week

What's new on Contemporary Pediatrics: October 19 to October 23

Over the years the push to perform extended newborn screenings have increased the number performed and helped improve outcomes for a number of children. The impact of screenings on long-term clinical outcomes among individuals who had inherited metabolic diseases is not particularly well-known. An 

 examines the impact of the screens on those future outcomes.

The investigators used a prospective multicenter observational study to look at the clinical outcomes of people with inherited metabolic diseases that were identified by newborn screening programs. There were a total of 306 people with inherited metabolic diseases who were followed for a median time of 6.2 years. There were 115 people with phenylketonuria and 191 with other inherited metabolic diseases with a lifelong risk for metabolic decompensation. The risk for metabolic decompensation was disease-specific and the screenings were not able to prevent decompensations in every person who was at risk, but the majority of the participants did not develop permanent disease-specific signs (75.9%), showed normal development (95.6%) and normal cognitive outcome (87.7%; mean IQ: 100.4), and mostly attended regular kindergarten (95.2%) and primary school (95.2%).

The results show that individuals with phenylketonuria, who served as the benchmark, as well as those with a lifelong risk of metabolic decompensation had favorable long-term outcomes and that a high newborn screening process quality was a necessity for this positive result. This belief was supported by 28 people who presented with first symptoms at a median age of 3.5 days before the screening results were available, by the absence of neonatal decompensations following the report of the screening results, and by the challenge of keep all relevant process parameters at a consistently high level.

The investigators concluded that using newborn screening is a highly successful element of secondary prevention for inherited metabolic diseases. However, the screenings may not be successful in completely preventing clinical presentation in all individuals.

1. Mütze U, Garbade S, Gramer G, et al. Long-term outcomes of individuals with metabolic diseases identified through newborn screening. 

. October 13, 2020. Epub ahead of print. doi:10.1542/peds.2020-0444

Newborn screenings can help with a number of conditions. An investigation examines the impact of them on the outcomes of children with inherited metabolic diseases.

Can newborn screening improve outcomes of inherited metabolic diseases?

Early GI upset can be a red flag for later food allergies

Immunoglobulin E–mediated food allergies are on the rise across the United States, and can be fatal for some children. A recent report examines how early gastrointestinal (GI) reactions can raise red flags for future allergy development.

Examining efficacy of flu shot in preventing severe flu

The influenza vaccine has been recommended as a key way to reduce severe influenza in children. An investigation examines how effective the 2018-2019 vaccine was in preventing hospitalization and emergency department visits.

Improving asthma outcomes with a multipronged approach

Minority children often have worse asthma outcomes than their white peers and many of them attend Head Start preschool programs. An investigation examines whether an intervention including both school and home components improves asthma outcomes.

Trends in catheter-related infections in critically ill kids

Quality improvement initiatives frequently tackled catheter-related infections. A report examines the trends over the past several years on these infections in critically ill children.

It was a very busy week for the Contemporary Pediatrics team.

In case you missed it: October 12 to October 16

As the COVID-19 pandemic has progressed in the United States, it has become increasingly apparent that minority populations are more heavily impacted than their White peers by the disease. A 

 examines whether this was true among pediatric patients as well.

The researchers ran a cross-section study of children who tested for COVID-19 at a drive-through that was exclusively for pediatric patients. The drive-through tested both patients in vehicles and patients who walked up to the clinic. The clinic was within 1 mile of a hospital in an outdoor enclosed parking lot. It offered testing 2 to 3 times a week between 10 am and 2 pm. Testing times also included some weekends. The site could not provide any medical management and ill-appearing patients were immediately told to go to the hospital before receiving a test. The tested patients received the test between March 21, 2020, and April 28, 2020.

A total of 1000 children received a COVID-19 test at the testing drive-through. Among these children, 20.7% tested positive for COVID-19. When compared with non-Hispanic white children (7.3%), minority children were found to have higher infection rates (non-Hispanic Black: 30.0%, adjusted odds ratio [aOR] 2.3 [95% CI 1.2–4.4]; Hispanic: 46.4%, aOR 6.3 [95% CI 3.3–11.9]). When looking at income, the investigators found that when compared to children who had the highest median family income quartile (8.7%), the rates of infection were higher among children in the other quartiles quartile 3 (23.7%; aOR 2.6 [95% CI 1.4–4.9]), quartile 2 (27.1%; aOR 2.3 [95% CI 1.2–4.3]), and quartile 1 (37.7%; aOR 2.4 [95% CI 1.3–4.6]).

The investigators concluded that at the community-based testing site utilized for the study that children who were parts of racial and/or ethnic minorities as well as socioeconomically disadvantaged carried the highest burden of COVID-19 infection. Researchers stated that finding out and addressing the reasons for these differences could help reduce the disparities as well as reduce the spread of infection.

1. Goyal M, Simpson J, Boyle M et al. Racial and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children. 

. 2020;146(4):e2020009951. doi:10.1542/peds.2020-009951

Overall, COVID-19 is disproportionately impacting minority populations in the United States. A report examines if this holds true in the pediatric population.

Is COVID-19 impacting minority children more heavily?

Technology has rapidly changed over the past few decades and radically changed the day-to-day life of everyone. This technological boom has also been felt in medicine, making paper charts and waiting days of lab reuslts a thing of the past.



 sat down with Andrew Schuman, MD, FAAP, to discuss how to effectively use technology in the pediatric practice and what upcoming tech has him interested.

Podcasts

Contemporary Pediatrics sat down with Andrew Schuman, MD, FAAP, to discuss the effectively use of technology in pediatrics.

Utilizing technology in the pediatric practice

The economic fallout of the COVID-19 pandemic has caused many to wonder what the effect will be on children’s health, as the connection between economics and child health can be complex. A 

 that looked at county-level unemployment and pediatric hospitalizations for several years could offer some guidance.

The researchers at the National Institutes of Health ran a population-level repeated cross-sectional study of all pediatric hospitalizations, which included 14 states, in 2002, 2005, 2008, 2011, and 2014. The years were chosen to encompass any employment growth following the 2001 mini-recession, the Great Recession of 2007 to 2009 , and the recovery following. The 14 states included in the research were Colorado, Florida, Iowa, Kentucky, Michigan, Nebraska, New Jersey, New York, North Carolina, Oregon, Rhode Island, Utah, Vermont, and Washington, and they were selected because they record the zip code of every hospitalized patient to Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project State Inpatient Databases. The county unemployment data were acquired from the Department of Labor’s Bureau of Labor Statistics.

Following an adjustment for any state-specific effects on unemployment for all counties and year, the investigators found that increased unemployment was linked with increased hospitalizations for 4 conditions that could be economy sensitive. With diabetes mellitus, a 1 percent increase in unemployment was tied to a 4 percent increase in hospitalizations. Medical complexity as well as poisoning and burns saw a 2 percent increase in hospitalizations for each percent increase in unemployment. Hospitalizations for substance abuse saw a 5 percent increase for each 1 percent increase in unemployment. However, hospitalizations for mental health programs did not appear to be linked with unemployment. Overall the average all-cause pediatric hospitalizations increased by 2% for every 1 percent increase in unemployment.

The investigators concluded that there were some hospitalizations for certain conditions that appeared to be sensitive to the economy such as substance abuse and diabetes mellitus. They believe that further research is needed to look at programs and policies that could help moderate the effect of economic downturns on children’s health.

1. Colvin J, Richardson T, Ginther D, Hall M, Chung P. Economy-sensitive conditions: are some pediatric hospitalizations triggered by economic recessions?. 

. 2020;39(10):1783-1791. doi:10.1377/hlthaff.2020.00732

Economic downturns have an impact on not just adult health, but pediatric health. A report examines the effect that such downturns have on pediatric hospitalizations.

Can newborn screening improve outcomes of inherited metabolic diseases?

In case you missed it: October 12 to October 16

Is COVID-19 impacting minority children more heavily?

Utilizing technology in the pediatric practice

Impact of economic downturn on pediatric hospitalizations