Celeste Krewson, Assistant Editor

The American Academy of Pediatrics (AAP) has provided a policy statement for ensuring the water children drink from private wells is safe.

Water quality can be affected by factors such as climate change, with children being more susceptible to illness from water quality than adults. There are over 23 million households in the United States relying on water from private wells which risk contamination without proper maintenance and testing.

The AAP’s policy statement, “Drinking Water from Private Wells and Risks to Children,” provided updated recommendations for inspecting, testing, and remediating private wells. This policy statement also noted how many wells are still unregulated by federal or state government.

“It’s important to know, when children drink well water at home, childcare, school, or a travel destination, whether that well water has been regularly tested for coliform bacteria, nitrates, and other chemicals,” said Alan D. Woolf, MD, MPH, FAAP. “Families may not be aware that natural disasters, such as floods, can affect well water, as well as chemical spills or new agricultural, fracking, or industrial operations nearby.”

According to the policy statement, children are more likely than adults to become ill because of contaminated water. Various regions also have different natural chemical compositions of water, which can also be affected by underlying geologic formation and type of aquifer. 

Chemicals such as nitrate and nitrite, heavy metals, organic chemicals, and radionuclides can cause illness, hospitalization, and death.

Recommendations for pediatricians include familiarizing themselves with how issues such as climate change and fracking affect water quality, becoming familiar with well water considerations in the area and advocating for safe water practices, and asking families whether they drink from a private well in any context.

The AAP also recommended testing well water for fluoride levels, along with encouraging health care providers to counsel families on safe drinking and families to stop using water from private wells and consult their local or state health department if they are concerned about contamination.

American Academy of Pediatrics updates policy statement on safety of water from private wells. January 30, 2023. Accessed January 30, 2023. 

https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-updates-policy-statement-on-safety-of-water-from-private-wells/

Articles

In an updated policy statement, the American Academy of Pediatrics has provided recommendations for providing children with safe drinking water from private wells. 

AAP: Drinking safe water from private wells

Vaginal metabolites may be early predictors of spontaneous preterm birth (sPTB), according to a recent study.

Despite sPTB being a leading cause of maternal and neonatal morbidity, there are few options for early risk identification and prevention. While the vaginal microbiome has been associated with sPTB, the relationship between these 2 factors remains unclear.

Metabolites have been observed to cause local and systemic effects, having associations with the microbiome, inflammation, and preterm birth. Investigators conducted a study to further understand the role of metabolites on sPTB.

The second-trimester vaginal metabolome was measured in 232 pregnant women. Of these, 80 pregnancies ended preterm. There were 635 metabolites identified, 549 of which were seen in over half of the study population, and 108 of which were seen in the entire population. 

Associations were found between the metabolome and microbiome, but community state types (CSTs) were not well separated. Microbiomes however were well separated. This indicated a strong but imperfect correlation between the vaginal microbiome and metabolome.

Six metabolite clusters (MC) were found, without as significant of separation as that between the vaginal microbiome and CSTs. Polyamine metabolism was the most enriched metabolite sub-pathway within each MC. Also, investigators found various enrichments of CSTs in MCs.

There was a significant difference between the metabolome of Black and White women, but only mild differences when looking at the correlation to MCs. Several MCs were significantly associated with sPTB in Black women but not White women. This indicated prematurity in Black women rather than with the microbiome structure.

Four metabolites were significantly associated with sPTB, 3 of which were of exogenous source. These 3 were ethyl β-glucopyranoside, tartrate, and diethanolamine. Investigators found these metabolites in over 95% of the study population.

Choline, an essential nutrient, was found to have lower levels in women with subsequent sPTB. Low levels of choline have also been linked to low betaine levels. As diethanolamine has been associated with disrupted choline metabolism, investigators hypothesized higher diethanolamine levels in sPTB may lower choline and betaine levels.

There were 13 vaginal metabolites associated with earlier sPTB. This included sugar or sugar alcohol metabolites found to be higher in early preterm birth. Interactions were found with both race and sPTB timing, with an additional sPTB-associated xenobiotic found as well.

These results showed enriched metabolite signatures among Black women with sPTB. Exogenous metabolites were also strongly associated with sPTB, indicating important risk factors.

Kindschuh WF, Baldini F, Liu MC, Liao J, Meydan Y, Lee HH, et al. Preterm birth is associated with xenobiotics and predicted by the vaginal metabolome. 

In a recent study, an association was found between vaginal metabolites and spontaneous preterm birth.

Vaginal metabolites may be early predictors of spontaneous preterm birth

The risk of sudden infant death syndrome (SIDS) is greater among siblings of children who died of SIDS, according to a recent study.

SIDS is defined as the death of an infant aged under 1 year after an extensive postmortem investigation. It is the leading cause of death in the first year of life, but its causes remain unclear. Hypothesized risk factors of SIDS include an exogenous stressor, a critical development period, and an underlying vulnerability.

As SIDS risk still cannot be predicted, determining the association between a family history of SIDS and subsequent SIDS is needed to identify children at risk of SIDS. A study was conducted to determine if SIDS risk increases in siblings of children who died of SIDS.

Health and administrative registries in Denmark were used to conduct the study. These registries contained registration data on parents and siblings of individuals born in Denmark, along with complete data on hospital diagnosis and cause of death. 

Information on those who had died from SIDS was collected from the Danish Cause of Death Register. If an infant aged under 1 year died to a cause unknown after thorough autopsy, their death was registered as SIDS.The Danish Medical Birth Registry was used to determine siblings of children who had died of SIDS. 

The study population included all births in Denmark between January 1, 1978, and December 31, 2016, aged under 1 year at the time of death. Stillborn babies and adopted children were excluded. Data was also collected on household income and mothers’ educational status.

Ninety percent of SIDS cases occurred within the first 6 months of life, with a median age of 3 months. Of children experiencing SIDS, 61% were male. 

While sex and mother’s age at birth did not lead to a significant difference in SIDS cases between the 2 study groups, sibling SIDS cases more often lived in low-income households and had mothers with only elementary school education.

Of 2,666,834 births, 1540 cases of SIDS were identified. The rate of SIDS was higher among siblings of children who died of SIDS compared to a general population. A 4-fold higher risk was found among this group, indicating that family history of SIDS should be considered when determining SIDS risk.

Glinge C, Rossetti S, Oestergaard LB, Stampe NK, Lynge TH, Skals R, et al. Risk of sudden infant death syndrome among siblings of children who died of sudden infant death syndrome in Denmark. 

2023;6(1):e2252724. doi:10.1001/jamanetworkopen.2022.52724

In a recent study, siblings of children who died of sudden infant death syndrome (SIDS) were at an increased risk of SIDS.

Risk of sudden infant death syndrome among siblings of victims

The rate of active postnatal care has a direct association with the survival rate of periviable infants, according to a recent study.

Multiple factors impact the decision on whether periviable infants born at 22 to 25 weeks’ gestation should be given active care, such as individual bias, fear of adverse outcomes, medical ethics, local and national policies, and communication between parents and caregivers. An individualized approach is recommended by professional societies in the United States.

There is little evidence on why infant mortality rates differ based on geographic variation, but data from Sweden has associated lower infant mortality rates among periviable infants in areas with higher rates of active perinatal care. Therefore, regional differences in mortality may be impacted by regional differences in rates of active perinatal care.

Investigators conducted a cohort study to determine the association between active perinatal care and infant mortality for periviable infants. Data on live births and infant deaths was gathered from a US Centers for Disease Control and Prevention database.

Infants were divided into subgroups based on gestational age. Subgroups included 22 weeks’ 23 weeks’ 24 weeks’, and 25 weeks’ gestation. The birth weight of included infants was 400 to 999 g.

Ten United States regions were included in the study. Active postnatal care involved using assisted ventilation, neonatal intensive care unit (NICU), surfactant replacement therapy, antibiotics for suspected neonatal sepsis, or seizures. Aside from seizures, these conditions indicated active postnatal care had been administered.

Race characteristics, insurance status, early prenatal care, and higher-risk pregnancy data were also collected. There were 41,707 periviable infants included in the study, 78% of which were of singleton birth and 46.7% of which were female.

The gestational age of 13.7% of infants was 22 weeks, 23 weeks for 23.1%, 24 weeks for 30.5%, and 25 weeks for 32.7%. About 19% of infants were Hispanic, and about 30% were non-Hispanic black. Established prenatal care by 3 months was seen from 69.5% of mothers, and 15.4% of pregnancies were considered higher risk. Medicaid covered about 42% of births.

There was evidence of active postnatal care in 83.9% of infants, with rates varying by region and gestational age. Infants born at 25 weeks’ gestational age were given active postnatal care more often than those born at 22 weeks’ gestational age, 93.5% and 41.5% receiving care respectively.

Survival through infancy was seen in 62.6% of infants overall, 18.9% born at 22 weeks’ gestational age, 50.8% born at 23 weeks’ gestational age, 70.7% born at 24 weeks' gestational age, and 81.7% at 25 weeks' gestational age. Survival rates differed between various regions.

A moderate positive correlation was found between region rate of active postnatal care and survival rate at 22 weeks’ gestation. Rates of active care did not have a significant effect on survival rate at 23 weeks’, 24 weeks’, or 25 weeks’ gestation. A positive correlation was also found between regional NICU admission and survival rate at 22 weeks’ gestation. 

While assisted ventilation immediately after birth also had a positive correlation with survival at 22 weeks’ gestation, a negative correlation was found at 25 weeks’ gestation. Surfactant administration therapy also had a negative correlation with survival at 25 weeks’ gestation. Antibiotics for suspected sepsis had no correlation with survival rate.

For perinatal care, a positive correlation was found between regional cesarean delivery rates and survival at 23 weeks’ gestation, but not 22 weeks’, 24 weeks’, or 25 weeks’ gestation.The correlation between antenatal corticosteroid administration and survival was moderately positive at 22 weeks’ gestation and moderately negative at 24 weeks’ gestation.

Silva ER, Shukla VV, Tindal R, Carlo WA, Travers CP. Association of active postnatal care with infant survival among periviableinfants in the US. 

 2023;6(1):e2250593. doi:10.1001/jamanetworkopen.2022.50593

In a recent study, the infant survival rate among periviable infants varied based on the type of active postnatal care received at certain gestational ages.

Active postnatal care associated with periviable infant survival rate

Prolonged absences from school and other life activities following a concussion may cause harm to recovery in pediatric patients aged 5 to 17 years, according to a recent study.

Current guidelines recommend 24 to 48 hours of rest for students following concussion, before a gradual return to school (RTS). However, strong evidence supporting the period spent away from school is lacking. Studies have found 72% of children will miss at least 1 day of school, with many absent for 2 to 5 days.

While prolonged rest has been associated with a potential delayed recovery, 1 study showed higher symptom levels in students spending more time at school. However, there is also evidence that early return to physical activity improves symptom recovery.

Investigators conducted a study to determine the average duration of absence from school following concussion and the associations between RTS timing and symptom burden 14 days postinjury. Data was gathered from the Predicting Persistent Postconcussion Problems in Pediatrics study, examining pediatric patients following concussion.

Exclusion criteria for the original study included not having an injury based on trauma, having a Glasgow Coma Score of 13 or less, and requiring hospital admission for multisystemic injury or neurosurgical intervention. The recent study also required a valid and specific RTS date, with children whose injury occurred during common school closure periods excluded.

Demographic, developmental, and psychiatric data were gathered. Follow-ups occurred at 7, 14, and 28 days postinjury, where participants provided information on their RTS date and current symptom behavior. Patients aged 5 to 7 years had responses given for them by their parents. 

The Post-Concussion Symptom Inventory (PCSI) was used to report symptom severity. Symptom burden, the primary outcome of the study, was measured by PCSI score at 14 days postinjury. The number of school days missed was assessed, with 0 to 2 days missed considered early RTS and 3 or more days missed considered late RTS.

There were 1630 participants included in the final sample, about 38% of which were female. The average age of participants was 11.8 years, and individuals were divided into 3 age groups: 5 to 7.9 years, 8 to 12.9 years, and 13 to 17.9 years.

On average, students missed 3.74 school days following a concussion. Older children often missed more days than younger children. About 54% of participants experienced an early RTS, and about 46% experienced a late RTS. Those aged 13 to 17 years most often experienced a late RTS, followed by those aged 8 to 12 years, then those aged 5 to 7 years.

Overall, significant associations between early RTS and reduced average symptom levels 14 days postinjury were recorded in individuals aged 8 to 12 years and those aged 13 to 17 years. This association was stronger in individuals with a greater symptom burden. However, it was not recorded in children aged 5 to 7 years.

These results indicated younger children return to school sooner than older children on average, but early RTS could lead to reduced symptom burden and faster recovery.

Vaughan CG, Ledoux A, Sady MD, Tang K, Yeates KO, Sangha G, et al. Association between early return to school following acute concussion and symptom burden at 2 weeks postinjury. 

2023;6(1):e2251839. doi:10.1001/jamanetworkopen.2022.51839

In a recent study, children returning to school earlier following a concussion experienced reduced symptom burdens at 14 days postinjury.

Early return to school reduces concussion symptoms

Artificial neural network (ANN) may be an efficient tool for predicting neonatal metabolic bone disease (MBD) during prenatal and postnatal periods, according to a recent study.

MBD is often seen in infants born preterm and lacking fetal mineral accumulation. Hypophosphatemia, hyperphosphatemia, and skeletal demineralization are all characteristics of MBD. Osteopenia, osteoporosis, rickets, and pathologic fractures can also all occur in MBD, increasing bone fragility and potentially impacting short- and long-term bone growth.

While infants at risk of MBD receive screening, there is a wide variety of diagnostic methods, and early recognition can be difficult because of the late onset of clinical symptoms and a lack of specific biochemical markers. This has led to a need for predictive tools for MBD.

A flexible and accurate machine learning algorithm, the ANN, has been able to predict multiple diseases. Investigators developed serial ANN models for the risk of MBD to determine the most efficient and accurate model for prediction.

Pregnant Chinese women gave written consent to participate in a diagnostic study, conducted from January 1, 2012, to December 31, 2021. Recruitment occurred early in pregnancy, and follow-up continued until 1 month after parturition.

To be included, participants needed to have a singleton pregnancy, complete clinical data during the antenatal, delivery, and postpartum periods, and surviving infants with detailed values of alkaline phosphatase. A peak serum alkaline phosphatase level above 500 U/L 72 hours after birth was used to determine MBD.

Data on maternal and neonatal characteristics was gathered from electronic health records. These characteristics included demographic data and prior pregnancy history, nutritional conditions during pregnancy, complications and comorbidities, medication use during pregnancy, birth outcomes, and neonatal disorders.

Five predictive models were build using an ANN, with a receiver operating characteristic curve used to evaluate the model performance.

There were 10,801 Chinese women participating in the study, 65.8% of which were local residents, 98.1% of Han ethnicity, and 9.3% had uterine scanning. Of the infants, 55.1% were male and 44.9% female. MBD presented in 138 infants, only 6 of which were term infants. In comparison, 75.9% of control infants were term infants.

In putative predictive factors, offspring of women with inadequate folic acid during pregnancy were 2.31 times more likely to develop MBD, compared to 3.26 times higher when born to women taking calcium supplementation and 0.38 times lower when born to women taking iron supplements. 

MBD risk factors included magnesium sulfate use in pregnancy and infants with low birth weight, anemia, septicemia, or respiratory distress syndrome.

The area under the receiver operating characteristic curve (AUC) was calculated for ANN models. Model 1 showed the highest AUC, followed by model 5, model 4, model 3, and model 2. As model 1 had a net reclassification improvement of 0.205 compared to model 5, it showed an improved discriminative ability.

Results also indicated improved identification of neonates at high risk of MBD with less instances of misclassification in model 1. Overall, model 1 showed the best performance for significant prenatal and postnatal factors and model 5 for postnatal factors, making them viable for use in clinical practice.

Jiang H, Guo J, Li J, Li C, Du W, Canavese F, et al. Artificial neural network modeling to predict neonatal metabolic bone disease in the prenatal and postnatal periods. 

 2023;6(1):e2251849. doi:10.1001/jamanetworkopen.2022.51849

Artificial neural network models have been developed which are able to accurately and efficiently predict neonatal metabolic bone disease.