This Week in Pediatrics — Jun 30, 2026

Welcome to This Week in Pediatrics. This week we're covering 10 notable papers spanning neonatal care and preventive strategies, prenatal exposures and long-term offspring safety, critical updates in pediatric gastroenterology, and key trends in adolescent development and public health. Let's dive in.

We begin with a critical look at routine preventative strategies in neonatal care, where two recent trials challenge existing practices. First, a major secondary analysis of the Hypoglycaemia Prevention With Oral Dextrose, or hPOD, trial published in JAMA Pediatrics evaluated the long-term neurocognitive effects of prophylactic buccal dextrose gel [2]. In this multicenter, double-blind, placebo-controlled trial, researchers followed late preterm and term infants who had at least one risk factor for transitional neonatal hypoglycemia, such as maternal diabetes, prematurity, or being small or large for gestational age. At one hour of age, infants had received either a single dose of 0.2 grams per kilogram of buccal dextrose gel or a placebo gel. The primary outcome for this follow-up study was neurocognitive impairment at six to seven years of age, defined as a standard score more than one standard deviation below the normative mean on at least one of seven items from the National Institutes of Health Toolbox. Out of over one thousand eligible children assessed, the proportion with neurocognitive impairment was nearly identical between the two groups, at 59% in the dextrose gel group and 57% in the placebo group. However, exploratory outcomes revealed a concerning signal: children who received prophylactic dextrose gel were more likely to have emotional-behavioral difficulties, at 24% compared to 18% in the placebo group, and low psychosocial functioning, at 17% compared to 12%. Based on these findings, the authors conclude that a single prophylactic dose of dextrose gel does not improve long-term neurocognition and may have adverse effects on psychological well-being, meaning current evidence does not support its routine use for preventing transitional neonatal hypoglycemia.

In a similar vein of questioning routine preventive strategies, the Babies in Blankets, or BiB trial, published in Acta Paediatrica, investigated whether phototherapy blankets prevent the need for overhead phototherapy in clinically well term and late preterm neonates [5]. This single-center randomized trial in a tertiary maternity unit included 97 infants of at least 35 weeks' gestation who were more than 24 hours of age and had total serum bilirubin levels within 35 micromoles per liter, or about 2 milligrams per deciliter, of their treatment thresholds. Infants were randomized to receive either a phototherapy blanket or routine care. The primary outcome was the subsequent need for overhead phototherapy. The results showed no benefit to using the blanket: 16% of the infants in the phototherapy blanket arm and 15% in the routine care arm eventually required overhead phototherapy, a difference that was not statistically significant. Furthermore, there was no difference in the length of hospital stay between the groups. Alarmingly, infants in the phototherapy blanket group were significantly more likely to be discharged receiving formula feeds exclusively. This suggests that using phototherapy blankets in well infants with bilirubin levels below treatment thresholds does not prevent the need for overhead phototherapy, has no impact on hospital stay, and may actively interfere with breastfeeding.

While these trials urge caution with early interventions, early and accurate diagnostic tools remain vital for long-term prognosis. A systematic review and meta-analysis published in Developmental Medicine and Child Neurology evaluated the predictive ability of the Hammersmith Infant Neurological Examination, or HINE, global scores for neurodevelopmental outcomes at or beyond two years of age [9]. Analyzing 21 studies involving nearly 7,300 infants, the researchers found that HINE scores below specific cutoff points at corrected ages of 3, 6, 9, and 12 months were highly predictive of atypical motor development, impaired cognitive performance, atypical neurodevelopment, and cerebral palsy. Specifically, using a HINE score of less than 58 at 3 months corrected age to predict cerebral palsy yielded a pooled sensitivity of 79.6% and a pooled specificity of 88.7%. These findings strongly support the broader clinical adoption of HINE global scores to identify infants at high risk for atypical outcomes, enabling clinicians to initiate targeted early interventions when they are most effective.

Moving from neonatal interventions to prenatal exposures, two new studies offer crucial insights into how maternal factors and medications affect long-term infant health. First, a landmark population-based cohort study published in JAMA Internal Medicine provides highly reassuring data regarding prenatal paracetamol, or acetaminophen, exposure and the risk of neurodevelopmental disorders [4]. While prior observational studies have reported associations between prenatal paracetamol and an increased risk of autism spectrum disorder and attention-deficit/hyperactivity disorder, these studies are often heavily confounded by unmeasured maternal and familial factors. To address this, researchers in Hong Kong utilized a sibling-matched design, comparing siblings from families with discordant prenatal paracetamol exposure. From an initial cohort of over 700,000 mother-child pairs, they constructed sibling-matched cohorts of over 124,000 children for autism analysis and over 97,000 children for ADHD analysis. In the sibling-matched analyses, prenatal paracetamol exposure was not associated with the risk of autism, with an adjusted hazard ratio of exactly 1.00, or ADHD, with an adjusted hazard ratio of 1.01. These null associations remained consistent regardless of exposure timing, cumulative dose, or usage patterns. Interestingly, conventional cohort analyses and negative control analyses of prepregnancy exposure did show positive associations, which confirms that the positive signals seen in previous studies were likely the result of residual familial confounding rather than the medication itself. This study provides robust reassurance to clinicians and families that paracetamol remains a safe and appropriate first-line analgesic and antipyretic during pregnancy.

Another prenatal exposure of growing interest is the use of biological response modifying drugs, or BRMDs, during pregnancy. A nationwide cohort study published in the Archives of Disease in Childhood evaluated the impact of antenatal BRMD exposure during the second or third trimester on infant infection risk and vaccination rates during the first year of life [6]. Using data from nearly 300,000 live births in Israel, the study compared 395 infants exposed to BRMDs in utero to unexposed infants, using propensity score matching to adjust for maternal comorbidities and delivery characteristics. The researchers found no significant differences in infection risk during the first year of life, with an adjusted odds ratio of 1.11 and a hazard ratio of 1.00. Rates of antibiotic use and hospitalization were also similar between the groups. However, the study revealed a major clinical gap: the rotavirus vaccination rate was significantly lower in the exposed group compared to the unexposed group. Because the rotavirus vaccine is a live-attenuated vaccine, clinicians often hesitate or delay administration in infants exposed to biologicals in utero, despite the lack of evidence showing an increased infection risk. This highlights a clear need for standardized clinical protocols and better provider education to ensure these infants receive vital immunizations on schedule.

In the field of pediatric gastroenterology and nutrition, we have three major updates this week, starting with a new European Society for Paediatric Gastroenterology, Hepatology, and Nutrition, or ESPGHAN, position paper on metabolic dysfunction-associated steatotic liver disease, or MASLD [3]. Published in the Journal of Pediatric Gastroenterology and Nutrition, this paper highlights that MASLD is now the most common cause of elevated liver enzymes in European children, affecting more than 5% of the pediatric population. The consensus guidelines recommend that alanine aminotransferase, or ALT, at a threshold of 30 units per liter or higher, is the most suitable screening test for MASLD. Screening should be performed in children over 10 years of age with obesity, defined as a body mass index z-score of 2 or more, or in children of any age who have additional risk factors. The paper advises that while liver biopsy remains the diagnostic gold standard, it should be reserved for cases with diagnostic uncertainty, to guide treatment, or for risk stratification before transitioning to adult care. For monitoring disease severity over time, the guidelines suggest that a combined change of 20% or more in both ALT and gamma-glutamyl transferase serves as a useful non-invasive monitoring tool. Most importantly, the position paper emphasizes that the majority of these patients are best managed by non-specialists, with a primary focus on the holistic management of obesity and its associated comorbidities.

Another critical diagnostic update in gastroenterology, published in the European Journal of Pediatrics, focuses on the frequency and characteristics of ultra-short celiac disease in children [8]. Because celiac mucosal involvement can be highly patchy, histopathological changes can sometimes be entirely confined to the duodenal bulb, a condition known as ultra-short celiac disease. In a single-center study of 78 pediatric patients diagnosed with celiac disease using separate biopsy specimens from the duodenal bulb and distal duodenum, the researchers discovered that over 20% of the children had histopathologically confirmed ultra-short celiac disease. Crucially, these patients had significantly lower median tissue transglutaminase IgA levels than those with classic celiac disease, at 22.5 units per liter compared to 162 units per liter. Additionally, 75% of the ultra-short celiac group had antibody levels below ten times the upper limit of normal, and nearly 88% lacked classic malabsorptive symptoms, presenting instead with isolated growth retardation. These findings demonstrate that without systematic duodenal bulb biopsies placed in separate containers, approximately one in five pediatric celiac patients may go undiagnosed.

Rounding out our gastroenterology and nutrition updates, ESPGHAN has also published a commentary in the Journal of Pediatric Gastroenterology and Nutrition regarding the safety of infant formulas following recent precautionary recalls in Europe [7]. Since late 2025, several batches of infant and follow-on formulas were recalled due to contamination with cereulide, a highly stable emetic toxin produced by Bacillus cereus. The contamination was traced back to arachidonic acid-containing algal oil from a single supplier, though no viable bacteria were found in the final products. While the European Food Safety Authority established a conservative acute reference dose, monitoring data indicate that the detected cereulide concentrations were generally low and unlikely to pose a significant health risk to infants. ESPGHAN emphasizes that while cereulide must be minimized, risk management must remain proportionate. Clinicians should reassure parents and avoid recommending nutritionally inadequate formula substitutes, while supporting continued access to regulated formulas containing essential long-chain polyunsaturated fatty acids like docosahexaenoic acid and arachidonic acid.

Finally, we turn to major developments in pediatric therapeutics and adolescent public health. In the New England Journal of Medicine, a phase 3, multicenter, double-blind, randomized, placebo-controlled trial evaluated oral infigratinib in children with achondroplasia [1]. Achondroplasia is caused by gain-of-function mutations in the fibroblast growth factor receptor 3 gene, and infigratinib is an oral tyrosine kinase inhibitor that down-regulates this pathway. The trial randomized 114 children aged 3 to 17 years in a two-to-one ratio to receive either once-daily oral infigratinib at a dose of 0.25 milligrams per kilogram or a placebo for 52 weeks. The primary endpoint was the change from baseline in the annualized height velocity. At week 52, children treated with infigratinib experienced a highly significant increase in annualized height velocity compared to the placebo group, with a least-squares mean difference of 1.74 centimeters per year. Height z-scores also significantly improved by 0.32. The treatment was well tolerated; while adverse events occurred in 96% of the infigratinib group and 95% of the placebo group, serious adverse events were low, occurring in 5% of the infigratinib group and 3% of the placebo group, and none led to treatment discontinuation or were deemed drug-related. This trial establishes oral infigratinib as a highly effective and safe oral option for improving growth velocity in children with achondroplasia.

In adolescent public health, the 2025 National Youth Tobacco Survey data published in Pediatrics highlights both progress and emerging challenges in youth nicotine use [10]. While overall youth tobacco use continued to decline, reaching 7.2% in 2025, the survey revealed a doubling in the use of nicotine pouches, which rose from 0.8% in 2021 to 1.7% in 2025. Nicotine pouches are now the second most common tobacco product used by youth, trailing only e-cigarettes, which are used by 5.2% of middle and high school students. Alarmingly, the intensity of e-cigarette use has risen dramatically over the last decade, with daily use among youth e-cigarette users skyrocketing from 9.4% in 2014 to 35.4% in 2025. Furthermore, dual and poly-product use is highly common among these users, and the vast majority use flavored products. With shifting regulatory landscapes and the elimination of key federal tobacco control offices, the author stresses that state and local policies, such as comprehensive flavor bans and consistent taxation, are more critical than ever for pediatricians to advocate for.

If you only have time for one paper this week, make it the population-based sibling-matched cohort study on prenatal paracetamol exposure and neurodevelopmental risk in JAMA Internal Medicine [4]. This paper provides definitive, high-quality reassurance that first-line prenatal paracetamol use does not increase the risk of autism or ADHD, elegantly proving that prior observational concerns were the result of residual familial confounding rather than the medication itself.

Here are the key takeaways from this week in Pediatrics:

First, do not routinely use prophylactic dextrose gel in at-risk neonates, as it does not improve long-term neurocognitive outcomes and may increase the risk of emotional, behavioral, and psychosocial difficulties at school age [2].

Second, avoid using phototherapy blankets as a preventive measure in well term infants with bilirubin levels below treatment thresholds; they do not reduce the need for subsequent overhead phototherapy and may negatively impact breastfeeding rates [5].

Third, always obtain a separate biopsy specimen from the duodenal bulb when evaluating a child for suspected celiac disease, as over 20% of pediatric celiac cases present with ultra-short disease confined strictly to the bulb, often with low antibody levels and isolated growth failure [8].

Fourth, screen children over 10 years of age with obesity for MASLD using an ALT threshold of 30 units per liter, and refer patients who are under 8 years of age, not overweight, or presenting with red flags to a specialist [3].

Fifth, actively screen adolescents for both e-cigarettes and nicotine pouches, keeping in mind that nicotine pouch use has doubled and over a third of youth e-cigarette users are now daily users [10].

That's your roundup for This Week in Pediatrics. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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