This week in Pediatrics

This AudioScholar briefing is generated by artificial intelligence for healthcare professionals and trainees. It is not medical advice.

Welcome to This Week in Pediatrics. This week we're covering 10 notable papers spanning critical care and airway management, the evidence base of neonatal intensive care, and the infectious disease and care-delivery questions facing general pediatrics. Let's dive in.

We start in the intensive care unit and the operating room, where two large trials tested respiratory and airway interventions that many centres already use. The biggest paper of the week is PROSpect, published in The Lancet, led by Curley and colleagues [1]. This was an international factorial trial across 75 pediatric intensive care units in 18 countries. It enrolled children with early, moderate-to-severe pediatric acute respiratory distress syndrome and randomised them to prone or supine positioning and to high-frequency oscillatory ventilation or conventional ventilation. The trial was stopped early for futility and slow enrolment after 424 of a planned 600 patients. Neither intervention changed ventilator-free days through day 28. Prone and supine groups both landed at a median of around 17 to 18 days, and oscillation offered no advantage over conventional ventilation. About one in ten children had died by day 28, with no difference between groups. The harms did differ. Airway plugging or obstruction and stage 2 or worse pressure injuries were each several times more common with prone positioning, and haemodynamic instability was more frequent with oscillation. Because enrolment stopped early, small effects cannot be fully excluded. Even so, this is the largest randomised evidence to date, and it does not support routine use of either strategy in this population. The setting was unmasked, but the outcome is fairly objective. A more positive airway result comes from The Lancet Child and Adolescent Health, where Garcia-Marcinkiewicz and colleagues ran the NasoVISI trial across eight pediatric cardiac centres in the United States [2]. In 673 infants without anticipated difficult airways who needed nasotracheal intubation for cardiac surgery or catheterisation, videolaryngoscopy raised first-attempt success by about eight percentage points, to 83 percent. Complication rates were similar in both arms, and there were no cardiac arrests or deaths. The authors frame this as adding to growing evidence favouring videolaryngoscopy as the first-line technique in infants. They are clear about the limits: the trial excluded difficult airways and was run in specialist centres under elective conditions. Rounding out this theme, Sundaram, Medina and Pons-Òdena offer a narrative review in the European Journal of Pediatrics on non-invasive ventilation for general paediatricians [3]. It is not new data. Its useful points are the distinction it draws between high-flow nasal cannula as an oxygenation device and CPAP and BiPAP as ventilatory support, and its ICEMAN framework. That framework covers indications, contraindications, equipment, mode and settings, assessment and monitoring, and next steps. The authors argue that safe use outside intensive care rests on trained staff, monitoring, reliable oxygen and a clear escalation plan.

Our second theme is the neonatal unit, where this week's papers question two widely used therapies and support a third. In The Lancet Child and Adolescent Health, Villamor and colleagues pooled ten randomised trials of pharmacological treatment for patent ductus arteriosus, covering 2365 preterm infants, in a Bayesian meta-analysis [4]. They asked whether the risks of treatment differ above and below 26 weeks' gestation. Across the whole population, treatment was associated with roughly a fifth higher mortality before 36 weeks' postmenstrual age, and the model put the probability of harm at about 97 percent. The direction was the same in both gestational age groups, though the signal within each subgroup alone was less certain. Treatment brought no compensating reduction in bronchopulmonary dysplasia; the data fit best with no effect on that outcome. The authors conclude that the randomised evidence questions routine pharmacological closure and supports more selective approaches. This is a trial-level synthesis, so it cannot identify which individual infants, if any, benefit. A complementary meta-analysis in the European Journal of Pediatrics, from Minamitani and colleagues, looked at budesonide mixed with surfactant across 15 trials and more than 3500 infants [5]. Overall, bronchopulmonary dysplasia at 36 weeks fell, but heterogeneity between trials was substantial. When trials were split by timing, the benefit was confined to trials that restricted treatment to the first four hours after birth, where the risk fell by roughly 40 percent. Trials allowing later dosing showed no benefit at all. Mortality did not differ. The authors are candid that this split was post hoc and may simply reflect older, smaller trials compared with recent large ones. They conclude that current evidence does not support routine use and that a large trial of early administration is needed. Taken together, these two meta-analyses point the same way: therapies once adopted to protect the lungs are not showing lung benefit in the best randomised data. Probiotics tell a more encouraging story. Also in the European Journal of Pediatrics, van Wesemael and colleagues compared extremely preterm infants in six Dutch units before and after a three-strain probiotic became standard care [6]. Among 481 infants, the odds of necrotising enterocolitis were roughly halved after implementation. Full enteral feeds came about two days sooner, and growth velocity improved. Late-onset sepsis and mortality did not differ significantly. Only one infant developed probiotic-associated sepsis. This is a before-and-after design, so changes in practice over time could contribute. Still, it adds real-world support in the gestational age group where the safety debate has been sharpest. Finally for neonates, Walsh and colleagues report in the Journal of Pediatrics on a national rollout of standardised early cerebral palsy detection across every tertiary neonatal follow-up programme in Ireland [7]. Among 1161 high-risk infants, the median age at diagnosis fell from 24 months to 7 months corrected age. Standardised assessments were completed in roughly nine in ten infants by the end of the project, and parent feedback was generally positive. The authors note that feasibility outside tertiary settings and long-term sustainability are still unproven.

Our third theme is prevention and how care is delivered, starting with vaccines. In the BMJ, Wilson and colleagues describe the Ontario measles outbreak that contributed to Canada losing its measles elimination status [8]. Over 49 weeks there were 2377 cases. About nine in ten cases occurred in historically under-vaccinated communities, and about three quarters of cases were in people aged 19 or younger. Most patients were unvaccinated. There were 166 hospital admissions, 51 infections during pregnancy, 10 congenital measles infections and one infant death. Sequencing identified a novel strain that was later detected in the United States, Mexico and the Netherlands. The authors highlight how fragile elimination is when immunity gaps persist in connected communities, and they emphasise culturally appropriate community engagement. Notably, spillover into the broader, well-vaccinated population was limited. On influenza, Toledo and colleagues in the European Journal of Pediatrics ran a Spanish case-control study over three seasons in hospitalised children with underlying medical conditions [9]. With only 274 children enrolled, vaccine effectiveness against hospitalisation was not statistically significant overall. In immunocompetent children with chronic conditions, however, vaccination was associated with about 80 percent protection. No significant protection was seen in immunocompromised children. Only about a fifth of enrolled children were vaccinated. The small sample means the estimates are imprecise, but the findings sharpen two gaps: vaccine uptake, and prevention for immunocompromised children. Lastly, a scoping review in Pediatrics from Slemmer and colleagues mapped 34 studies of pediatric hospital at home [10]. Programmes reported low escalation and readmission rates, infrequent serious adverse events, high caregiver satisfaction and comparable or lower costs. Most studies were observational, programme designs varied widely, and few studies directly measured clinical effectiveness. The authors describe the model as promising but not yet rigorously evaluated.

If you only have time for one paper this week, make it PROSpect in The Lancet [1]. It is the largest randomised test of prone positioning and oscillatory ventilation in pediatric respiratory distress syndrome. It found no benefit and measurable harm, which reopens the question of why these strategies remain common in pediatric intensive care.

Here is what this week's evidence adds up to in Pediatrics. First, in early moderate-to-severe pediatric respiratory distress syndrome, randomised data now show no gain in ventilator-free days from prone positioning or oscillation, alongside more airway and pressure complications. The trial stopped early, but the signal is consistent. Second, for elective nasotracheal intubation in infants at cardiac centres, videolaryngoscopy improves first-attempt success without more complications; difficult airways and urgent settings remain untested. Third, the randomised evidence on routine drug treatment for patent ductus arteriosus leans toward harm without lung benefit. Budesonide with surfactant shows no overall support for routine use, and its early-timing signal is only hypothesis-generating. Fourth, observational Dutch data support probiotics in extremely preterm infants for reducing necrotising enterocolitis, and national early detection of cerebral palsy appears feasible within tertiary programmes. Fifth, the Ontario measles outbreak and the Spanish influenza data both point to immunisation gaps among vulnerable children, while pediatric hospital at home still lacks rigorous effectiveness evidence.

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

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