Children doi: 10.3390/children13081067

Authors: Theofili Kousi Afroditi Karafotia Vlasios Karageorgos Georgios Gkantinas Ioanna Sofianidou Meletios Kanakis Alexandra Smina Ioanna Zergioti Constantin Tamvakopoulos Theofani Antoniou

Background: Midazolam is widely used as a pediatric premedication, but evidence from direct comparisons of oral and sublingual administration in children with congenital heart disease remains limited, particularly that from pharmacokinetic and physiologic data analyzed together. Methods: We conducted a single-center prospective randomized study comparing oral midazolam 0.5 mg/kg with sublingual midazolam 0.3 mg/kg in children undergoing cardiac surgery or catheterization procedures under general anesthesia. Plasma midazolam and 1-hydroxymidazolam concentrations were measured approximately 30 min after administration. Log-transformed concentrations were compared using regression/ANCOVA models adjusted for dose and age. Changes in mean arterial pressure (MAP), heart rate (HR), and oxygen saturation (SpO2) were analyzed from baseline to 15 and 30 min. Behavioral outcomes included the sedation score, separation from parents, and mask acceptance. Results: Sixty-eight children were randomized; 65 had evaluable pharmacokinetic samples and formed the complete-case pharmacokinetic cohort. Adjusted plasma midazolam concentrations did not differ significantly between the groups, with an adjusted geometric mean ratio for sublingual versus oral administration of 0.98 (95% CI 0.53–1.79; unadjusted p = 0.940; Holm-adjusted p = 1.000). The corresponding ratio for 1-hydroxymidazolam was 1.37 (95% CI 0.55–3.41; unadjusted p = 0.494; Holm-adjusted p = 1.000). HR and SpO2 changes were non-significant between the groups. At 30 min, sublingual administration was associated with a lower adjusted change in MAP compared with oral administration (adjusted difference −12.08 mmHg, 95% CI −19.74 to −4.42; unadjusted p = 0.002, Holm-adjusted p = 0.012). Behavioral outcomes did not differ significantly between the groups. Conclusions: In this prospective randomized pediatric cardiac cohort, oral midazolam 0.5 mg/kg and sublingual midazolam 0.3 mg/kg produced comparable plasma concentrations and similar behavioral outcomes. Sublingual administration was not associated with worse HR or SpO2 responses, although an isolated lower MAP change at 30 min warrants confirmation in larger studies. Sublingual midazolam may represent a feasible lower-dose alternative for premedication in this population.

Children doi: 10.3390/children13081066

Authors: Sarah Hobson Amanda Krygsman Heather Brittain Anjalika Khanna Roy Tracy Vaillancourt

Background/Objectives: Youth who experience bullying victimization often report lower mattering, the perception of being valued by others; yet this association remains underexplored across intersections of gender and sexual identities. Methods: Using Spring 2025 data from the Health and Peer Relations Study, we examined whether gender identity and sexual orientation moderated the association between bullying and mattering among Canadian youth in Grades 7–12 (N = 54,181; racially/ethnically diverse = 65.2%, sexually diverse = 14.8%, gender diverse = 3.5%), controlling for grade and race/ethnicity. Results: After controlling for covariates, the three-way interaction between bullying, gender identity, and sexual orientation was statistically significant (p = 0.042). Bullying was negatively associated with mattering across most groups, and the association was strongest among straight girls, while associations were largely similar across other groups. In contrast, average mattering followed a clear social gradient wherein straight girls and boys reported the highest levels, and sexually and/or gender diverse youth reported the lowest. Conclusions: Bullying is associated with lower mattering among most youth. However, socially advantaged youth reported stronger associations between bullying and mattering, while socially marginalized youth reported lower mattering regardless of bullying exposure. Findings highlight the importance of addressing youth bullying and underlying drivers of social inequities in mattering.

Children doi: 10.3390/children13081065

Authors: Dinah S. Reddihough Gina Hinwood Angela Guzys Erich Rutz Susan M. Reid

Background: The Victorian Cerebral Palsy Register (VCPR) project collects information on all individuals born or living in Victoria since 1970. It is one of the largest cerebral palsy (CP) registers internationally, with over 6800 participants. Methods: This paper will explain how the VCPR was established, how data are collected and the main outcomes from its use over an extended period of time. Results: The knowledge generated through the VCPR has contributed to information about epidemiology including trends in prevalence over time, and rates and causes of death; the VCPR has been used to investigate causal pathways and potential avenues for prevention or amelioration. It has been valuable in identifying cohorts for multidisciplinary studies resulting in improved understanding of the management of associated problems. The VCPR has also been used in the development of measurement tools and has enabled data linkage studies contributing to knowledge about CP. Conclusion: The Register not only provides an efficient means of identifying eligible cohorts, but the population basis of the VCPR provides the ability to assess the generalisability of research cohorts and a means of adjusting for selection bias and potential misinterpretation of study results. The project has gained international recognition for the knowledge generated on prevalence, risk factors, mortality, clinical profiles, neuroimaging patterns, health service use, assessment tools, participation, epidemiology in paediatric orthopaedics, and quality of life. It has underpinned significant improvements in clinical care for children with CP by enabling researchers from diverse disciplines to complete 157 studies.

Children doi: 10.3390/children13081064

Authors: Roni Octavian Damian Lidia Boldeanu Mihai Gabriel Cucu Mirela Anişoara Siminel Mihai Alexandru Butoi Vlad Ionuț Belghiru Silvia Nica Vlad Pădureanu Mohamed-Zakaria Assani Virginia Maria Rădulescu Cristiana Geormaneanu Mihail Virgil Boldeanu Luciana Teodora Rotaru

Background/Objectives: Outborn neonates—those born outside tertiary perinatal centres and transferred postnatally—may experience higher mortality and morbidity than inborn infants. This systematic review without meta-analysis synthesised contemporary evidence on neonatal interfacility transfer to tertiary and quaternary neonatal centres, focusing on mortality, major morbidity, physiological instability, prognostic tools, and organisational determinants. Methods: Four electronic databases (PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library) were searched for English-language publications from January 2010 to December 2025. Study selection and data extraction were performed independently by two reviewers, with disagreements resolved by consensus. Narrative synthesis followed PRISMA 2020 and SWiM principles. Of the 2456 records identified, 44 publications were retained: 31 primary studies and 13 contextual or methodological sources. Results: Across the primary evidence, outborn status was generally associated with higher mortality and major morbidity, particularly among very preterm infants, although effect magnitude varied across healthcare systems. Hypothermia, respiratory deterioration, and haemodynamic instability were recurrent transport-related complications. Specialised teams, standardised stabilisation, and thermal-management bundles were associated with better physiological stability. TRIPS and TRIPS-II showed prognostic utility. Conclusions: Predominantly observational evidence suggests that neonatal transport outcomes reflect interactions between biological vulnerability, transport-related stress, and system organisation. Strengthening regionalised transport pathways and standardising stabilisation practices may improve outcomes, but causal inference remains limited.

Children doi: 10.3390/children13081063

Authors: Hassan Salah Ibrahim Abdulla Abdelwahab Girgis Saad Habib Al Ismaily

Background/Objectives: Closed reduction and percutaneous pinning is the standard surgical treatment for displaced pediatric supracondylar humerus fractures. Although crossed-pin fixation provides excellent biomechanical stability, medial pin insertion remains associated with the risk of iatrogenic ulnar nerve injury. The modified medial para-olecranon technique has been introduced as an alternative medial wire insertion strategy while preserving the principles of crossed-pin fixation. This study compared its clinical performance with conventional crossed pinning. Methods: A retrospective comparative cohort study was conducted at a tertiary referral trauma center between January 2017 and December 2024. Seventy children younger than 14 years with Gartland type II–IV supracondylar humerus fractures met the inclusion criteria. All patients treated with the modified medial para-olecranon technique (n = 35) were included. A comparison cohort of 35 patients treated with conventional crossed pinning was selected from 68 eligible conventionally treated patients by computer-generated random sampling stratified by Gartland type (frequency matching), after application of identical eligibility criteria. The primary outcome was functional outcome assessed using the Flynn criteria. Secondary outcomes included operative time, radiographic alignment, fracture union, and postoperative complications. Results: Baseline demographic and fracture characteristics were comparable between groups. Mean age was 6.7 ± 2.8 years in the modified medial para-olecranon group and 6.9 ± 2.6 years in the conventional crossed-pin group. The modified medial para-olecranon group had a lower mean Flynn score (6.80 ± 3.31 vs. 10.74 ± 3.70; mean difference, −3.94; 95% CI, −5.61 to −2.27; p < 0.001) and a higher proportion of excellent Flynn outcomes (77.1% vs. 28.6%). Operative time was shorter in the modified medial para-olecranon group (47.49 ± 7.50 vs. 66.00 ± 8.19 min; mean difference, −18.51 min; 95% CI, −22.26 to −14.76; p < 0.001). Fracture union occurred at a comparable time in both groups (27.71 ± 3.94 vs. 28.34 ± 4.12 days; mean difference, −0.63 days; 95% CI, −2.55 to 1.29), and postoperative Baumann angles were similar. No postoperative iatrogenic ulnar nerve injuries occurred in the modified medial para-olecranon group, whereas two occurred in the conventional crossed-pin group; both were transient sensory paraesthesia that resolved without exploration within six months. Overall complications occurred in 1 patient (2.9%) and 7 patients (20.0%), respectively (odds ratio, 0.17; 95% CI, 0.03 to 1.02; Fisher exact p = 0.055). Conclusions: In this retrospective comparative cohort, the modified medial para-olecranon technique was associated with favorable functional outcomes, shorter operative time, and fewer observed postoperative ulnar nerve injuries, although the difference in complications did not reach statistical significance, while maintaining comparable radiographic alignment and fracture healing. Because treatment was not randomized and potential confounders could not be adjusted for, these between-group differences should be interpreted as associations rather than as evidence of a causal treatment effect. Further prospective multicenter studies and dedicated anatomical investigations are required before broader recommendations can be made.

Children doi: 10.3390/children13081062

Authors: Chelsea Reynolds Paul J. Nietert Mileka Gilbert Emily Vara Natasha Ruth Joyce Chang

Background/Objectives: Childhood-onset systemic lupus erythematosus (cSLE) is a chronic, multisystem autoimmune disease that is associated with more severe organ involvement, more intensive drug therapy, and increased long-term organ damage compared with adult-onset disease. The objectives of this study were to evaluate the performance of widely used small area-level multidimensional indicators of neighborhood disadvantage in a mixed urban–rural cSLE cohort against disease outcomes. Methods: This retrospective cohort study utilized electronic health records to identify and evaluate pediatric patients with cSLE across a single center in South Carolina between 1 January 2020 and 31 December 2024. Primary outcomes included disease activity at diagnosis, measured by Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K); the achievement of a low lupus disease activity state (LLDAS) by the last visit; the development of major organ involvement; and the rates of unplanned hospitalizations and emergency department visits. The associations of the census tract-level Area Deprivation Index (ADI), Social Vulnerability Index (SVI), and Childhood Opportunity Index (COI) with clinical presentation and outcomes were estimated using generalized linear models and logistic regression. Results: A total of 85 patients with cSLE were included, of which 76% reported being of Black race, and 28% lived in rural areas. Lupus disease severity was inconsistent across the metrics of area-level social vulnerability, neighborhood deprivation, child opportunity, and rurality. Patients who lived in more socially vulnerable communities were more likely to attain LLDAS during follow-up, while those who lived in lower-opportunity areas were more likely to develop CNS lupus. Baseline disease activity, renal involvement, and healthcare use were not significantly associated with area-level social disadvantages or rurality. Conclusions: In this single-center, mixed urban–rural cohort of children with cSLE, indicators of neighborhood-level disadvantage and rurality alone explained little variation in disease severity and disease control overall. The utility of available small area-level metrics is likely context-dependent and influenced by regional features, population characteristics, and the outcomes being studied. Future work should integrate individual- and area-level factors across diverse settings to better understand the drivers of health disparities.

Children doi: 10.3390/children13081061

Authors: Timothy J. R. Panneflek Janneke Dekker Kristel L. A. M. Kuypers Douglas P. Derleth Graeme R. Polglase Lotte E. van der Meeren Merlijn Wind Remco Visser Stuart B. Hooper Thomas van den Akker Arjan B. te Pas

Background: Prostaglandin E2 (PGE2) suppresses perinatal breathing. Reducing antenatal PGE2 concentrations with paracetamol could stimulate spontaneous breathing in premature infants at birth. We aimed to assess feasibility and potential effects of antenatal paracetamol. Methods: In this randomised, placebo-controlled, triple-blind feasibility trial, pregnant women <31 weeks’ gestation were randomised to receive either intravenous paracetamol (intervention) or placebo (control). Multiple pregnancies were also eligible, and the number of infants could exceed the number of enrolled women. The primary outcome was feasibility of administering study medication within 30–120 min prior to birth. Secondary exploratory outcomes included measures of breathing and other physiological parameters of infants during the first 1–10 min after birth and were compared between infants from mothers who received paracetamol and infants from mothers who received a placebo irrespective of timing of administration. Planned enrolment was 40 women. Results: The trial enrolled 23 women before termination due to low recruitment. Five women did not receive study medication, while 18 did (9 per group). Overall, 11 of the 23 enrolled women (48%) received study medication within the specified timeframe. The nine women in the intervention group gave birth to 13 infants, while the nine women in the control group gave birth to 12 infants. Among infants, average minute volume did not differ significantly between groups (intervention (n = 13) vs. control (n = 12); mean ± SEM; 147 ± 12 vs. 114 ± 14 mL/kg/min, p = 0.093). However, the intervention group had a significantly higher area under the curve for minute volume, greater inspiratory drive, and a higher heart rate (1120 ± 410 vs. 707 ± 346 mL/kg, p = 0.020; 11.8 ± 1.0 vs. 8.4 ± 1.3 mL/kg/breath/s, p = 0.046; 137 ± 5 vs. 121 ± 5 beats/min, p = 0.037). Conclusions: Antenatal paracetamol administration 30–120 min prior to birth was feasible in only half of the women, below the pre-specified threshold of 80%, but the exploratory findings suggest that it may improve the breathing effort of premature infants.

Children doi: 10.3390/children13081060

Authors: Narcis Mihaiță Bugălă Adelina Smaranda Bugălă Mihaela Jana Țuculină Dana Maria Albulescu Alina Nicoleta Căpitănescu Dragoș Cadea Adrian Macovei Dragoș Alexandru Ana Maria Rîcă Ancuța Ramona Camen

Background/Objectives: Dental caries and gingival inflammation share several biofilm-related determinants. This study evaluated the association between Community Periodontal Index (CPI) screening categories and permanent-dentition caries experience in a consecutively recruited clinical sample of children and adolescents from Southwest Romania. Methods: The multicenter cross-sectional study included 638 participants aged 6–19 years, analyzed as 6–12 years (n = 407) and 13–19 years (n = 231). Analyses included nonparametric comparisons, adjusted Poisson models, a formal CPI-by-age-stratum interaction, continuous-age sensitivity analyses, and generalized Poisson models allowing underdispersion. Results: Mean DMF-T was 4.71 ± 2.55 and 4.93 ± 2.58 in the younger and older strata, respectively. CPI correlated strongly with DMF-T (rho = 0.743 and 0.749; both p < 0.001). Adjusted expected DMF-T counts were higher for CPI 1 and CPI 2 than for CPI 0 in both strata. There was no statistical evidence that the CPI–DMF-T association differed by age stratum (global interaction p = 0.749) or continuous age (p = 0.552). Plaque Index adjustment markedly attenuated CPI estimates; the extent of residual CPI association was sensitive to count-model specification. Conclusions: Higher CPI categories were associated with greater cumulative caries experience in this clinical sample, but the findings do not establish temporality, causality, or predictive validity. Unequal numbers of erupted permanent teeth and CPI-eligible sextants may have contributed to the observed gradient because these quantities were not retained analytically.

Children doi: 10.3390/children13081059

Authors: Mojca Železnik Petra Bratina Andreja Valcl Katja Lozar Manfreda Evgen Benedik Tanja Obermajer Bojana Bogovič Matijašić Aleksander Mahnič Darja Paro-Panjan Jana Lozar Krivec

Background/Objectives: Diaper dermatitis (DD) is a common dermatological condition that is often exacerbated by antibiotics. Probiotics may restore microbiota balance and influence the incidence of DD. This study aimed to evaluate whether 6 weeks of Limosilactobacillus (L.) reuteri DSM 17938 supplementation during and after antibiotic treatment affects the incidence of DD. Methods: A secondary analysis of a randomised, double-blind, placebo-controlled trial that included 89 term neonates treated with antibiotics during the first 3 weeks of life was conducted. Neonates were assigned to receive either a probiotic supplement or a placebo for a total of 6 weeks. DD incidence, onset of DD, and skin care data were collected for 87 infants. Faecal samples were collected 6 weeks after study enrolment to analyse the composition of gut microbiota. Results: Twenty-four (28%) infants developed DD, of whom six (25%) had fungal DD. There was no significant difference in the incidence of DD or fungal DD between the probiotic and placebo groups (30% vs. 25% and 7% in both groups, respectively). Probiotic supplementation had no significant effect on the gut microbiota composition or diversity. In an exploratory binary logistic regression analysis based on six fungal DD events, probiotic supplementation was not associated with fungal DD, whereas breastfeeding was associated with lower odds of fungal DD; however, the overall model was not statistically significant, and this finding should be interpreted with caution because of the small number of events. Conclusions: In this exploratory secondary analysis, supplementation with L. reuteri DSM 17938 was not associated with a reduced incidence of DD or alterations in gut microbiota composition in antibiotic-treated neonates. Breastfeeding was associated with lower odds of fungal DD; however, this finding should be confirmed in larger, adequately powered studies.

Children doi: 10.3390/children13081058

Authors: Ebru Guney Sahin Cansu Durak

Objective: Intentional pharmaceutical poisoning is one of the most common methods of self-harm among adolescents and frequently results in pediatric intensive care unit (PICU) admission because of the potential for severe pharmaceutical-related toxicity. Although mortality is generally low, a subset of patients may require advanced intensive care interventions. Methods: This retrospective observational cohort study was conducted in the pediatric intensive care unit of a tertiary referral hospital between January 2022 and January 2026 and included adolescents admitted to the PICU due to intentional pharmaceutical poisoning. Demographic characteristics, psychiatric history, clinical findings, laboratory parameters, administered treatments, and clinical outcomes were evaluated. The primary outcome measure was defined as the requirement for a major PICU intervention, including invasive or noninvasive mechanical ventilation, vasoactive support, continuous renal replacement therapy (CRRT), therapeutic plasma exchange, extracorporeal membrane oxygenation (ECMO), intensive care-level seizure management, or clinically significant arrhythmia requiring intensive care support. Patients with and without major PICU intervention requirements were compared. Results: A total of 125 adolescent patients were included in the study, and the majority were female. Multiple-pharmaceutical ingestion and a history of psychiatric diagnoses were common comorbidities. Although the clinical course was stable in most patients, 15 patients (12%) required major pediatric intensive care interventions. Patients requiring major interventions had lower Glasgow Coma Scale scores, higher lactate levels, more frequent symptomatic presentation, and higher rates of Poisoning Severity Score (PSS) ≥ 3. Overall mortality in the cohort was low. Conclusions: Although most adolescents admitted to the PICU due to intentional pharmaceutical poisoning experienced mild-to-moderate toxicity, a subgroup required advanced intensive care support. Neurological impairment at presentation, symptomatic clinical presentation, and markers of increased physiologic stress appeared to be associated with more severe clinical courses. In pediatric poisonings, evaluating the need for advanced intensive care support rather than focusing solely on mortality may better reflect clinical severity.

Children doi: 10.3390/children13081057

Authors: Niccolò Cenzato Alessia Tremolada Alessandra Comparini Fausto Zamparini Cinzia Maspero

Background: Maxillary transverse deficiency is a common skeletal discrepancy in orthodontic patients that often requires expansion therapy for correction. Failure to address this condition during growth may compromise the orthopedic prognosis, frequently necessitating surgically assisted rapid palatal expansion (SARPE) or other orthognathic surgical procedures after skeletal maturity. Methods: The studies in this systematic review were selected according to predefined inclusion criteria. Randomized controlled trials, controlled clinical studies, and cohort studies published within the last 10 years with a follow-up ≥ 6 months were included. The databases PubMed, Scopus, and Embase were searched. Orthodontic outcomes included midpalatal suture opening, skeletal transverse changes, intermolar width variations, dental tipping, and long-term stability. Thirteen studies met the eligibility criteria. Risk of bias was assessed using the RoB 2 and the Newcastle–Ottawa Scale. Results: All orthodontic devices produced significant transverse expansion in the short term. Bone-borne and hybrid systems showed a greater initial skeletal component, with greater expansion at the maxillary and nasal basal levels and limited relapse over time. Tooth-borne expansion was associated with greater dental tipping and reduction in buccal bone thickness, with partial recovery during retention. Over time, loss of expansion mainly affected the dentoalveolar component, whereas the skeletal component remained more stable. Long-term data (≥3–5 years) remain limited but suggest that relapse is predominantly related to dental uprighting rather than a true loss of skeletal base width. Conclusions: Long-term transverse stability improves when expansion is predominantly skeletal. Bone-supported and hybrid appliances may produce a greater initial skeletal contribution and reduce dental tipping in some clinical settings; however, current evidence does not demonstrate superior long-term stability compared with tooth-borne expansion. Additional prospective orthodontic studies with extended follow-up, particularly without prolonged retention, are required.

Children doi: 10.3390/children13081056

Authors: Liming Cai Zhengzheng Gao Zeyang Wang Xiaoxue Wang Jing Hu Lei Hua Wenya Fu Lanxin Qiao Jianmin Zhang Lijing Li Fang Wang Xiumin Qin

Background/Objectives: Propofol is effective for pediatric endoscopy but can depress ventilation. We compared three induction regimens in school-aged children undergoing bidirectional gastrointestinal endoscopy. Methods: This single-center, assessor-blinded randomized trial allocated children aged 6–12 years (1:1:1) to propofol 3 mg/kg (P), remimazolam 0.2 mg/kg plus propofol 1 mg/kg (R1), or remimazolam 0.4 mg/kg plus propofol 1 mg/kg (R2). All groups received sufentanil and standardized propofol maintenance. Respiratory depression was a respiratory rate < 10 breaths/min or peripheral oxygen saturation < 90% for >1 min. The trial was prospectively registered (ChiCTR2500096218), and analysis followed assigned groups. Results: The analysis included 120 children (40 per group). Respiratory depression occurred in 32/40 (80.0%) in P, 6/40 (15.0%) in R1, and 14/40 (35.0%) in R2 (overall p < 0.001). Compared with P, the risk difference was −65.0 percentage points for R1 (95% confidence interval [CI], −77.4 to −44.6; risk ratio, 0.19; 95% CI, 0.09–0.37) and −45.0 percentage points for R2 (95% CI, −61.0 to −23.6; risk ratio, 0.44; 95% CI, 0.27–0.66); both Holm-adjusted p values were <0.001. Mean time to eye opening was 12.7, 11.2, and 16.9 min, respectively. In the exploratory R1-versus-R2 comparison, time to eye opening was 5.75 min shorter with R1 (95% CI, 4.28–7.20). Conclusions: Both remimazolam–propofol regimens reduced monitor-defined respiratory depression compared with propofol 3 mg/kg. The 0.2 mg/kg remimazolam–propofol regimen combined this respiratory benefit with faster recovery than the 0.4 mg/kg regimen in exploratory analysis, supporting its further evaluation as an induction strategy for pediatric bidirectional endoscopy.

Children doi: 10.3390/children13081055

Authors: Okan Aslantürk Sultan Nisa Çabuk Emre Ergen Hüseyin Utku Özdeş Fırat Al Tahsin Sarıbas Murat Kılıç Hakan Ertem Mustafa Karakaplan Sevgi Demiröz Taşolar Hüseyin Ayvaz Aybars Kıvrak Şenol Bekmez

Background/Objectives: Pandemics and natural disasters may delay the diagnosis and treatment of developmental dysplasia of the hip (DDH). In this study, we evaluated the effect of 2023 Kahramanmaraş earthquake-induced healthcare disruption on the DDH screening program. Methods: Medical records of infants referred for DDH screening between February 2022 and February 2025 were retrospectively reviewed. Three consecutive twelve-month intervals: the pre-earthquake year (February 2022 to February 2023), the earthquake year (February 2023 to February 2024), and the post-earthquake year (February 2024 to February 2025) were evaluated to detect early and late effects of the earthquake on the DDH screening. Results: A thousand infants in the pre-earthquake year, 404 in the earthquake year, and 824 in the post-earthquake year were evaluated. A 60% reduction in referrals was detected during the earthquake year. DDH incidence in late presentations during pre-earthquake, earthquake, and post-earthquake years was 18.6%, 45.8%, and 22.2%, respectively. Pairwise analysis revealed a statistically significant increase in the post-earthquake year compared with the pre-earthquake period (Yates-corrected chi-square = 4.119, p = 0.042). No significant difference was found between the pre-earthquake year and the earthquake year (Yates chi-square = 1.362, p = 0.243), nor between the post-earthquake years (Yates chi-square = 0.084, p = 0.772). Conclusions: The earthquake caused significant disruption in healthcare and DDH screening. Health authorities planning post-disaster service recovery should proactively augment DDH screening capacity for infants who missed screening during the acute phase.

Children doi: 10.3390/children13081054

Authors: Xiaoxiao Song Yaohua Liu Xiaohong Qiao

Background: Tisagenlecleucel (tis-cel) is the sole chimeric antigen receptor T-cell (CAR-T) therapy approved for pediatric/adolescent relapsed/refractory B-cell acute lymphoblastic leukemia (r/r B-ALL). Infection-related adverse events (IRAEs) represent a leading cause of non-relapse mortality, yet dedicated analysis in patients <18 years remains limited. Objective: This study aimed to analyze the characteristics of IRAEs in pediatric and adolescent patients with r/r B-ALL treated with tis-cel, based on the FDA Adverse Event Reporting System (FAERS) database. The analysis included the reporting proportion, temporal distribution, pathogen spectrum, and overlapping features with other adverse events, generate hypotheses for infection prevention and control in patients aged <18 years. Research Design and Methods: We analyzed FAERS data (August 2017–March 2025) and included 492 cases of <18-year-old r/r B-ALL patients treated with tis-cel. Disproportionality analyses (reporting odds ratio, ROR; information component, IC), time-to-onset analysis, and co-occurrence assessments were performed on 149 infection-related reports. Results: Infection-related AEs occurred in 30.28% of cases, with significantly higher mortality in infected versus non-infected patients (40.27% vs. 12.83%, p < 0.001). Most infections (93.86%) occurred within one month (median time-to-onset = 4 days), peaking within 15 days (77.50%); 2.65% occurred after one year. Significant disproportionate reporting signals were observed for Clostridioides difficile (ROR025 = 5.45), influenza virus (ROR025 = 7.16), and adenovirus (ROR025 = 3.51). Hypogammaglobulinemia (52.94%) and hypoxia (54.90%) exhibited higher co-occurrence with infections than CAR-T-specific toxicities (23.08–35.41%). Conclusions: Infection-related AEs following tis-cel treatment are frequent and associated with significantly increased mortality in pediatric and adolescent r/r B-ALL patients. While most occur early, late infections warrant long-term vigilance. Disproportionality analyses identified signals suggestive of potential high-risk pathogens such as Clostridioides difficile,, influenza, and adenovirus, and hypogammaglobulinemia/hypoxia may serve as early warning indicators. These hypothesis-generating findings require validation in prospective studies.

Children doi: 10.3390/children13081053

Authors: Ziad D. Baghdadi

Background/Objectives: Early childhood caries (ECC) is a common, preventable, and socially patterned disease, yet the literature on ECC is vulnerable not only to limitations in evidence generation but also to errors in evidence translation. This conceptual framework paper focuses on evidence translation rather than estimating a new treatment effect. Methods: Literature and framework development were informed by targeted narrative searches of PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar, with an emphasis on ECC literature from 2010 onward and foundational methodological sources. Sources were purposively retained if they clarified an evidentiary domain, a cross-domain bridge, or a competing interpretation; priority was given to systematic reviews, trials, longitudinal and causal studies, natural experiments, clinical guidance, and implementation evaluations. No pooled effect estimates were produced. Results: Evidence drift is the movement of a finding into a stronger or different claim without adequate bridging evidence. The proposed framework comprises association, mechanism, causation, consequence, disease control, and policy implementation, with commercial and structural determinants operating as a cross-cutting upstream layer. It classifies the inference advanced rather than study design alone and permits primary and secondary domain tags. A four-question test asks whether the research question and conclusion occupy the same domain, what bridge supports the movement, and whether uncertainty is retained. Five trajectories illustrate the framework: vitamin D, dental rehabilitation under general anesthesia, oral microbiome research, silver diamine fluoride (SDF), and sugar taxation. In the SDF case, lesion-arrest evidence is explicitly separated from the still-unproven implementation hypothesis that endpoint-only pathways may create differential standards of care. Conclusions: The original contribution is an integrated vocabulary, decision procedure, and validation agenda for ECC evidence appraisal. The framework generates three prespecified, testable hypotheses: (1) trained raters will classify claims with reproducible inter-rater agreement (kappa ≥ 0.70); (2) claims judged to contain evidence drift will be significantly less likely than domain-concordant claims to include an explicit bridge; and (3) using the structured framework will improve the transparency and proportionality of reviews compared with usual appraisal. Prospective testing of content and construct validity, as well as practical utility, in peer review, guideline development, education, and policy evaluation is required before standardized implementation.

Children doi: 10.3390/children13081052

Authors: Yangmi Lim

Background/Objectives: Adolescents from multicultural families in South Korea, most with foreign-born mothers and Korean fathers, may be vulnerable to peer victimization due to cultural, linguistic, or appearance-related differences. Grounded in minority stress theory, this study examined whether acculturative stress mediated the prospective association between peer victimization and depressive symptoms and whether family support, perceived across T1 (Year 1 of middle school) and T2 (Year 2 of middle school), moderated these pathways among adolescents from multicultural families. Methods: The analytic sample comprised 1218 adolescents (50.8% girls) drawn from the Multicultural Adolescents Panel Study, a national longitudinal dataset from South Korea. Mediation and moderated mediation analyses were conducted using the PROCESS macro. Results: Peer victimization at T1 was associated with higher depressive symptoms at T2 through acculturative stress assessed concurrently at T2, warranting caution in interpreting the indirect association as causal. Family support moderated the peer victimization–acculturative stress and acculturative stress–depressive symptoms paths, but not the direct peer victimization–depressive symptoms path. Specifically, family support weakened the association between peer victimization and acculturative stress, whereas it strengthened the association between acculturative stress and depressive symptoms. No overall moderated mediation pattern was evident because the two path-specific moderation effects operated in opposing directions and offset each other. Conclusions: These findings suggest that family support may operate differently across stress pathways. This study underscores the importance of culturally responsive school–family collaboration to reduce peer victimization, address acculturative stress and depressive symptoms, and equip families to support adolescents’ constructive coping.

Children doi: 10.3390/children13081051

Authors: Sara Rinaldi Stefania Gazzola Claudia Maggiulli Sara Visentin Elisabetta Cane Sara Scotto Daniela Sarti Luca Andreoli Elisa Granocchio

Background: Individuals with complex communication needs (CCNs) require comprehensive communication profiles to guide effective interventions, yet the clinical literature offers limited tools to support this process. To address this gap, the “Italian CP & Language Network”—a multidisciplinary group of speech–language pathologists, psychologists, and child neuropsychiatrists—developed a novel, comprehensive clinical instrument specifically designed to evaluate the communication skills of children and adolescents with CCNs. Methods: The development process was informed by an initial preliminary survey conducted across participating clinical centres to map out the observation tools routinely used in daily practice. Results: Based on these insights, the network designed a structured clinical interview named the Italian IVCAA (Intervista sulla Valutazione delle Competenze e delle Abilità Comunicative). The instrument was structured to systematically assess four core areas: core communication abilities, communicative behaviours, communicative functions, and communicative modalities (vocal, gestural, graphic/symbolic, and written). The Italian IVCAA provides a structured framework that successfully describes an individual’s unique communication profile. It maps out specific strengths and weaknesses across diverse modalities, establishing a standardized baseline for clinical use. Conclusions: The Italian IVCAA serves as a valuable clinical tool for identifying communication profiles in individuals with CCNs. It offers a practical starting point for setting tailored goals in augmentative and alternative communication (AAC) interventions and establishes a reliable framework for monitoring changes in communicative competence over time.

Children doi: 10.3390/children13081050

Authors: Solomon Tatagiri Belinda Chan Yogen Singh

Background/Objectives: Hypoxic–ischemic encephalopathy (HIE) remains a leading cause of neonatal death and long-term neurodisability. Cardiovascular dysfunction commonly accompanies HIE and influences neurological recovery, yet it is difficult to recognize because conventional clinical signs correlate poorly with the myocardial function. This review summarizes the current evidence on cardiac dysfunction in neonates with HIE, with particular attention to the diagnostic tools used to evaluate cardiovascular function and the clinical outcomes associated with myocardial injury. Methods: We conducted a narrative review informed by a systematic, reproducible search of four databases (PubMed, Embase, Cochrane Library, and Web of Science) from 2000 to 2026, using a Population–Concept–Context framework to identify studies of term and near-term neonates (≥35 weeks gestation) with HIE or perinatal asphyxia reporting a measure of cardiac dysfunction (electrocardiographic, biomarker, echocardiographic, or clinical hemodynamic). Records were screened and selected using Covidence systematic review software; eligible studies were original, primary-data reports with a minimum sample size of 20 neonates. Findings were synthesized narratively and grouped thematically by diagnostic modality and clinical outcome. Results: Eighty-one studies met the pre-specified eligibility criteria following a systematic multi-database search and structured screening process. As a subset of included studies are secondary analyses or overlapping cohorts, an aggregate patient count is not reported. Reported prevalence of cardiac dysfunction varied widely with the definition applied, reaching 70–90% when multimodal assessment was used. Blood pressure, heart rate, urine output, and lactate were inconsistently reliable indicators of myocardial function, and ejection fraction and fractional shortening often remained normal despite injury. Tissue Doppler imaging and speckle-tracking strain appeared to be more sensitive, with impaired left ventricular global longitudinal strain associated with brain injury. The right ventricle was more commonly and severely affected, with reduced TAPSE, RV fractional area change, and RV strain associated with death or MRI-defined injury. Each additional 24 h of inotropic support was associated with increased odds of adverse short- and long-term outcomes by 14% and 12%, respectively. Conclusions: Cardiac dysfunction is common and prognostically important but remains underrecognized by the routine clinical assessment and cardiovascular monitoring. Multimodal monitoring centered on TnECHO, near infra-red spectroscopy, and specific biomarkers may enable earlier, physiology-based management.

Children doi: 10.3390/children13081048

Authors: İlhan Sengul Mustafa Utkun Mesut Kaygusuz Mehmet Emin Dogan Burcu Nur Turkoglu Mehmet Sinan Doğan

Objective: This study aimed to describe the CBCT-based positional measurements and morphological distribution of the mandibular foramen in growing individuals and to compare the M1, M2, and M3 measurements according to chronological age group, sex, and sagittal skeletal class. Materials and Methods: This retrospective cross-sectional study included 120 CBCT images of individuals aged 6–16 years (mean 10.31 ± 2.33 years; 67 male, 53 female) selected from 750 archived scans. Participants were divided into three age groups (6–8, 9–12, and 13–16 years) and classified using the ANB angle (Class I, II, and III). Three measurements were assessed: M1 (foramen to occlusal plane), M2 (to posterior ramus border), and M3 (to anterior ramus border). Foramen morphology was classified into five types: circular-, elliptical-, triangular-, rectangular-, and parallelogram-shaped. The Mann–Whitney U and Kruskal–Wallis tests were used, followed by Bonferroni-adjusted pairwise comparisons where appropriate. Results: Interobserver ICC values ranged from 0.75 to 0.81, indicating good interobserver reliability. In the unadjusted comparisons, no statistically significant differences in M1, M2, or M3 were detected according to sex or sagittal skeletal class (all p > 0.05). Significant age-related differences were identified in M2 between the 6–8 and 9–12 year groups (right p = 0.003; left p = 0.021) and between the 6–8 and 13–16 year groups (right p < 0.001; left p = 0.003). Elliptical morphology was most prevalent bilaterally (right 39.2%; left 40.0%). Conclusions: Statistically significant age-group differences were detected only for M2, whereas no statistically significant differences according to sex or sagittal skeletal class were detected in this sample. Greater M2 values in the older age groups represent a greater absolute linear distance between the fixed mandibular foramen reference point and the posterior ramal reference line and should not be interpreted as evidence of posterior displacement. Elliptical morphology was the most frequently observed form bilaterally. These findings provide anatomical information from clinically indicated CBCT examinations but do not support routine CBCT acquisition solely for mandibular foramen localization.

Children doi: 10.3390/children13081049

Authors: Lăcrămioara Fodor Gabriela Ghiga Gabriela Păduraru Nicoleta Gimiga Laura Bozomitu Bogdan Dragoș Rotaru Elena Țarcă Solange Tamara Roșu Laura-Mihaela Trandafir

Background/Objectives: Foreign body ingestion is a frequent gastrointestinal emergency in children. Although most ingested objects pass spontaneously, button batteries, multiple high-powered magnets, sharp objects, and superabsorbent polymers may cause rapid and severe complications. Recent reviews have often focused on individual categories of high-risk objects, whereas practical integration of time-critical diagnosis, comparative guideline recommendations, radiolucent objects, vulnerable pediatric populations, and prognostic risk factors remains limited. This narrative review aims to critically synthesized current evidence and to propose a clinically oriented, risk-stratified framework that distinguishes emergent, urgent, and observational management pathways according to object characteristics, anatomical location, symptoms, elapsed time, imaging findings, and patient-related factors. Methods: A structured narrative review was performed using PubMed/MEDLINE, Scopus and Web of Science. The final searches were performed in July 2026 and covered publications indexed from January 2000 to June 2026. The review included international guidelines, position papers, systematic reviews, meta-analyses and clinically relevant observational studies in patients up to 18 years of age with gastrointestinal foreign body ingestion. Exclusion criteria were studies only involving adults, foreign body aspiration, nasal or auricular insertion, ingestion of caustic substances, duplicate publications, isolated case reports with no broader clinical relevance and articles not available in full text. Evidence was synthesized according to object type, anatomical location, urgency of intervention, imaging strategy, prognostic factors, and patient-related risk. Results: Most ingested foreign bodies pass spontaneously; however, button batteries, multiple magnets, sharp objects, and superabsorbent polymers are associated with distinct mechanisms of injury and a disproportionate risk of severe complications. Time to intervention, object type and size, anatomical location, symptom severity, delayed presentation, and imaging evidence of complications consistently emerge as the principal determinants of outcome. Current international recommendations show broad agreement for immediate removal of esophageal button batteries and sharp objects causing obstruction, but important differences remain regarding gastric batteries, distal magnets, radiolucent objects, and selected asymptomatic patients. Evidence for predictive models is still limited, and most proposed risk factors have not undergone external validation. Vulnerable children (e.g., with neurodevelopmental disorders, pica or recurrent intentional ingestion) require individualized multidisciplinary assessment and follow-up. Conclusions: Pediatric foreign body ingestion should be approached in a time-critical and risk-stratified manner, combining object characteristics, anatomical location, presenting symptoms, time from ingestion, imaging findings, and patient-specific vulnerability. Differentiated triage for emergent intervention, urgent removal and structured observation may improve clinical triage and reduce delays for high-risk cases. Current guidelines offer a robust management framework, but there are significant evidence gaps relating to radiolucent objects, water beads, distal magnets and externally validated predictive models. More multicenter studies are required to support standardized prognostic tools and more consistent decision-making across pediatric emergency settings.

Children doi: 10.3390/children13081047

Authors: Felipe Montalva-Valenzuela Eduardo Guzmán-Muñoz Antonio Castillo-Paredes Iván Molina-Márquez Claudio Farias-Valenzuela Rodrigo Yáñez-Sepúlveda Guillermo Cortés-Roco Álvaro Farfán-Díaz Exal Garcia-Carrillo

Background: Attention-deficit/hyperactivity disorder (ADHD) is associated with cognitive, behavioral, emotional, and social difficulties that may increase vulnerability to bullying during childhood and adolescence. Although previous studies have examined different aspects of this relationship, the available evidence remains limited and heterogeneous, particularly regarding associated factors, profiles of bullying involvement, and implications for prevention and intervention. Objective: To analyze the available evidence regarding bullying involvement in children and adolescents with ADHD, focusing on victimization, perpetration, bully–victim profiles, associated factors, psychological consequences, and implications for prevention and intervention. Methods: A narrative review was conducted using studies identified in PubMed, Scopus, and Web of Science between January and March 2026, with no publication date restrictions. The search was performed in three independent and consecutive stages and included observational studies evaluating the relationship between ADHD and bullying in children and adolescents. Narrative reviews, systematic reviews, meta-analyses, editorials, and studies conducted exclusively in adults were excluded. Results: Seventeen studies were included. The evidence consistently showed that children and adolescents with ADHD have greater involvement in bullying than their peers without ADHD. Victimization was the most consistently reported outcome, although increased perpetration, bully–victim profiles, and cyberbullying were also identified. Bullying involvement appeared to be influenced by multiple interacting factors, including ADHD symptoms, emotional dysregulation, impulsivity, comorbidities, peer relationships, family characteristics, and school-related factors. Victimization was consistently associated with increased anxiety and depressive symptoms, emotional difficulties, and poorer quality of life. Emerging evidence also suggests sex-specific patterns of bullying involvement and bidirectional longitudinal relationships between ADHD symptoms and bullying experiences. Conclusions: Children and adolescents with ADHD may have greater involvement in multiple forms of bullying; however, this relationship appears to be multifactorial rather than solely explained by core ADHD symptoms. Family, peer, and school environments may play important protective roles, highlighting the need for comprehensive prevention and intervention strategies that address both individual and contextual factors.

Children doi: 10.3390/children13081046

Authors: Jirattikarn Jirawong Wanaporn Anuntasaree Kanokpan Ruangnapa Kantara Saelim Pharsai Prasertsan

Introduction: Despite the availability of the national clinical practice guideline (CPG) for croup treatment, adherence has not been evaluated in real-world settings. This study aimed to evaluate adherence to the national CPG for croup and to identify factors associated with incomplete adherence. Method: Patients aged 1 month to 15 years diagnosed with viral croup between 1 January 2014 and 31 December 2023 were retrospectively reviewed. Complete adherence was defined as follows: (1) corticosteroid prescription for any severity, (2) nebulised epinephrine for moderate-to-severe cases, and (3) observation for ≥4 h for moderate-to-severe croup. Furthermore, associated factors for incomplete adherence and unplanned revisits within 72 h were explored. Results: A total of 437 visits were included; 71.2% were male patients, with a mean age of 25.6 ± 19 months. Complete adherence increased from 46.7% in 2014 to 87.6% in 2023. Corticosteroid prescription showed the lowest adherence rates, particularly in mild cases. Factors associated with incomplete adherence by univariable analyses included the first croup episode (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.15–5.54), a paediatrician as the primary physician (OR, 2.61; 95% CI, 1.64–4.14), outpatient visits (OR, 2.36; 95% CI, 1.49–3.73), mild croup (OR, 1.89; 95% CI, 1.21–2.98), and earlier years of the study (OR, 2.41; 95% CI, 1.55–3.78). The unplanned revisit rate was 19.7% and was not associated with adherence. Conclusions: Adherence to the national guidelines increased over the past decade. However, suboptimal treatment practices underscore the need for targeted interventions to improve guideline-based care, particularly in paediatric and outpatient settings.

Children doi: 10.3390/children13081045

Authors: Laura Carreres Sanchis María Inmaculada Colorado Lluch Manuel Martí-Vilar Francisco González-Sala

Background/Objectives: The study of adverse childhood experiences (ACEs) has become increasingly important due to its impact on the physical and mental health throughout life. The aim of this study is to assess the psychometric quality of the instruments used to measure ACEs, following the COSMIN guidelines for reviewing patient-reported outcome measures. Methods: A PRISMA-adherent systematic search of scientific databases was conducted to identify empirical studies analysing the psychometric properties of ACE questionnaires used with children, adolescents, and adults. Ultimately, 20 studies were included, covering various instruments such as the ACE-10, ACE-Q, ACE-SQ, ACE-IQ, SC-ACE-IQ, ACE-IQ-10 and the ACE-THL. Results: The results show heterogeneous psychometric evidence. Whilst properties such as internal consistency generally show adequate results, other dimensions, such as responsiveness or measurement error, are scarcely evaluated. Furthermore, methodological limitations were identified, such as the predominant use of young female samples and the lack of longitudinal studies. Conclusions: In conclusion, most available ACE instruments demonstrate good psychometric properties, with the ACE-IQ being the one with the strongest evidence supporting these properties across different contexts.

Children doi: 10.3390/children13081044

Authors: Şenol Bozdağ Sabahattin Ertuğrul Mustafa Törehan Aslan Mustafa Aydın İbrahim Kaplan Sibel Tanrıverdi Yılmaz

Background/Objectives: It is unclear whether the type of intrauterine inflammatory exposure influences global oxidant/antioxidant status or neutrophil gelatinase-associated lipocalin (NGAL) in preterm infants. Methods: Ninety-four infants born before 32 weeks of gestation were enrolled prospectively at three centers and grouped as clinical chorioamnionitis (n = 31), preterm premature rupture of membranes (PPROM; n = 33), or controls (n = 30) delivered preterm chiefly for preeclampsia, growth restriction, or placental insufficiency. Groups were not matched, but gestational age and birth weight were comparable. Serum total oxidant status (TOS), total antioxidant status (TAS), and NGAL were measured at the 1st postnatal hour. Results: TAS, TOS, and the oxidative stress index did not differ among groups (p = 0.966, 0.525, and 0.729). NGAL differed (p = 0.031) and was lowest in the clinical chorioamnionitis group, confined to the clinical chorioamnionitis-versus-PPROM contrast (adjusted p = 0.029) and persisting after multivariable adjustment. After correction for multiple testing, no biomarker correlated with C-reactive protein, blood counts, or procalcitonin at the 1st or 24th postnatal hour, or with the first-hour Töllner sepsis score; the strongest single association was NGAL with the first-hour neutrophil count (ρ = 0.29). Necrotizing enterocolitis was more frequent in controls (p = 0.003); mortality (20.2%) did not differ among groups. Conclusions: A single early measurement of these biomarkers did not reliably classify the type of intrauterine inflammatory exposure; discrimination was modest (area under the curve, 0.689), so serum NGAL has no current clinical applicability. These hypothesis-generating findings require confirmation in adequately powered studies with serial sampling.

Children doi: 10.3390/children13081042

Authors: Fahad Alshayhan Mishari Alanezi Abdullah Addar Abdulaziz S. AlNahari Fahad Alhuzaimi Waleed Albishi

Background/Objectives: Congenital lower-limb deficiencies, including proximal femoral focal deficiency (PFFD), fibular hemimelia (FH), and tibial hemimelia (TH), are rare, phenotypically heterogeneous disorders with important implications for reconstructive planning. However, phenotypic data remain limited. This study aimed to characterize the clinical and radiological spectrum of these deficiencies and evaluate associated anomalies and limb-length discrepancy (LLD) across diagnostic groups. Materials and Methods: A retrospective cohort study included all patients diagnosed with PFFD, FH, or TH at a tertiary referral center between January 2021 and December 2025. Demographic, clinical, and radiographic data were extracted from electronic medical records. Patients were classified using established systems, and associated anomalies, distal morphology, laterality, and LLD were evaluated. Descriptive statistics and exploratory non-parametric comparisons across diagnostic groups were performed. Results: A total of 143 patients were included: 91 (63.6%) with PFFD, 23 (16.1%) with FH, 10 (7.0%) with TH, 18 (12.6%) with combined PFFD + FH, and 1 (0.7%) with combined PFFD + TH. Isolated PFFD was predominantly unilateral and clustered within the milder spectrum, most commonly Paley type 1a and Aitken type A. In contrast, FH was dominated by the severe Paley type 3b phenotype, whereas TH showed marked classification heterogeneity. Upper-limb anomalies were more common in FH and TH than in isolated PFFD. LLD differed significantly among diagnostic groups (p = 0.003), with the greatest median discrepancies observed in combined PFFD + FH and isolated PFFD. Conclusions: Congenital lower-limb deficiencies are highly heterogeneous, with combined deficiencies exhibiting greater LLD and anomaly burden. These findings provide structured regional data to support classification and reconstructive planning.

Children doi: 10.3390/children13081043

Authors: Emna Makni Mohamed Elloumi Achraf Ammar Mehdi Ben Brahim Younes Hachana

Background: The six-minute walk test (6MWT) assesses functional exercise capacity, but existing reference equations for children with obesity rely on traditional linear regression, potentially overlooking complex, non-linear relationships between anthropometric characteristics and functional exercise capacity. Objective: This study aimed to develop and internally validate machine-learning (ML) prediction models and preliminary prediction equations derived from explainable ML models for six-minute walk distance (6MWD) in Tunisian school-aged children with obesity and to compare their predictive performance with a conventional regression-based approach. Methods: We analyzed data from 236 school-aged children with obesity (104 females, 132 males; 6–12 years). Anthropometric measurements included body mass (BM), height, body mass index (BMI), waist circumference (WC), and hip circumference (HC). Five models were evaluated: linear regression, Ridge, Lasso, Elastic Net, and XGBoost. Performance was assessed using five-fold cross-validation and evaluated by the mean absolute error (MAE) and root mean square error (RMSE). Predictor importance was assessed using SHapley Additive exPlanation (SHAP) and Gini importance. Results: XGBoost achieved the best predictive performance, with the lowest MAE (17.4 ± 2.5 m in females and 19.5 ± 1.9 m in males) and RMSE (25.3 ± 3.1 m in females and 26.4 ± 2.2 m in males). Age was the strongest predictor across all models (SHAP: 54.2–62.0%; Gini importance: 0.52–0.69), followed by height and BMI. Sex-specific analyses indicated that, in females, age and BMI contributed ~80% to the cumulative SHAP analysis; whereas, in males, age, height, and WC were the primary factors. Conclusions: ML, particularly XGBoost, significantly improves 6MWD prediction in school-aged children with obesity compared with traditional linear regression. Explainable ML increases model interpretability by evaluating the relative importance of anthropometric predictors. These obesity-specific prediction models may better capture complex non-linear associations between anthropometrics and functional exercise capacity. These initial population-specific models should be validated in larger independent samples before routine use clinical or field settings.

Children doi: 10.3390/children13081041

Authors: Isabelle G. Houston Mark D. Heitzmann Rachel C. Robbins Katie L. Louka Erkan Demirkaya Olcay Y. Jones

Background/Objectives: Chronic recurrent multifocal osteomyelitis/chronic nonbacterial osteomyelitis (CRMO/CNO) is an auto-inflammatory bone disease for which optimal treatment and imaging-based monitoring remain incompletely defined. Methods: We conducted a single-center retrospective review of nine pediatric patients with CRMO/CNO treated with tumor necrosis factor inhibitors (TNFis). Clinical improvement was assessed using Visual Analog Scale (VAS) pain scores, erythrocyte sedimentation rate (ESR), and physical examination findings. Radiographic assessment used longitudinal, site-specific magnetic resonance imaging (MRI) scored with a simplified approach adapted from the Chronic Nonbacterial Osteomyelitis Magnetic Resonance Imaging Scoring (CROMRIS) system. Results: Our cohort was composed of six females and three males with a median age of seven years. TNFi monotherapy was initiated as a first-line therapy (n = 4) or step-up (n = 5). During a median follow-up time of 26 months, treatment was tolerated well, except for the emergence of psoriasis in three patients (n = 3), among whom one necessitated treatment change. Eight patients on TNFis achieved clinical remission, including five with complete resolution of MRI lesions. Conclusions: In this small, single-center case series, TNFi monotherapy was associated with sustained disease control, as reflected by clinical improvement and MRI-documented lesion resolution. These findings emphasize the need for validation of our observations in larger multi-center cohorts.

Children doi: 10.3390/children13081040

Authors: Eda Özaydın Seher Açar Bilge Tuğçe Özbilgiç Demiröz Handan Akkuş Karabacak Elif Benderlioğlu Aysun Yahsi

Background: Respiratory viral infections are a major cause of morbidity in children worldwide; however, several aspects remain incompletely understood. In particular, hematological changes associated with specific viral pathogens are not well defined, and their potential diagnostic value remains uncertain. In addition, the seasonal distribution of respiratory viruses may vary between years and geographical regions Methods: This retrospective study analyzed pediatric patients presenting to the outpatient clinics at Ankara Bilkent City Hospital between September 2024 and May 2025 who underwent multiplex PCR testing for respiratory viruses. Demographic characteristics, viral etiology, hematological parameters and hospitalization status were analyzed. Results: A total of 1143 patients tested positive for at least one viral pathogen; 91.1% had monoinfection and 8.9% had coinfection. The most commonly detected pathogens were rhinovirus/enterovirus, influenza A and respiratory syncytial virus, with frequencies of 23.7%, 17.7% and 13.7% respectively. Viral positivity peaked during winter, with distinct seasonal distribution patterns across pathogens. Coinfection and comorbid conditions were not significantly associated with hospital admission. In multivariable analysis, younger age and elevated CRP levels were identified as independent predictors of hospitalization. Significant differences in hematological parameters were observed among respiratory viruses, particularly in adenovirus and influenza infections. Conclusions: Respiratory viruses may exhibit distinct seasonal and hematological patterns. Younger age and elevated CRP levels are associated with an increased risk of hospitalization. Routine hematological parameters may provide additional value in clinical evaluation. Further studies are needed to validate these findings.

Children doi: 10.3390/children13081039

Authors: Christos-Georgios Kontovazainitis Dimitra Gialamprinou Alexandra Fleva Anastasia Giannakou Maria-Elina Bessina Maria Varsami Theodoros Theodoridis Christina Mitsiakou Elissavet Diamanti Georgios Mitsiakos

Background/Objectives: Preeclampsia (PE) may be associated with maternal endothelial activation and altered early neonatal inflammation. The primary objective was to compare maternal and early neonatal serum interleukin 2 (IL2), IL6, IL8, tumor necrosis factor α (TNFα), and endothelin 1 (ET1) concentrations between PE and control mother–neonate pairs. Methods: This secondary report from a single-center observational cohort included 31 women with PE (34 neonates) and 45 control women (47 neonates). Biomarker concentrations were log-transformed, and PE–control differences were estimated using linear models, with results expressed as geometric mean ratios (GMRs). Neonatal models used pregnancy-clustered standard errors to account for twins. The Benjamini–Hochberg procedure was applied to control the false discovery rate (FDR). Additional neonatal models adjusted for gestational age at birth served as sensitivity analyses. Selected biomarker–outcome associations were explored post hoc using univariable Firth bias-reduced logistic regression. Results: Maternal ET1 was higher in PE (GMR = 1.79, 95% confidence interval—CI—1.53–2.09; q < 0.001). Neonatal IL2 (GMR = 1.37, 95% CI 1.11–1.71; q = 0.016) and TNFα (GMR = 1.49, 95% CI 1.22–1.82; q < 0.001) were higher in PE-exposed neonates. After gestational age at birth adjustment, the TNFα difference persisted (GMR = 1.33, 95% CI 1.14–1.55; q = 0.003), whereas IL2 was attenuated (GMR = 1.20, 95% CI 0.99–1.45; q = 0.164). None of the exploratory Firth associations remained significant after FDR correction. Thrombocytopenia at birth occurred in 5/33 PE-exposed and 1/47 control neonates; intraventricular hemorrhage occurred in 2/34 and 2/47, respectively. Conclusions: PE was associated with between-group differences in maternal endothelial and early neonatal inflammatory biomarkers, with maternal ET1 and neonatal TNFα as the most robust signals. Complication-related findings remain hypothesis-generating and do not support predictive cut-offs, risk stratification, or causal inference.

Children doi: 10.3390/children13081038

Authors: Alessandro Frolli Giulia Savarese Francesca Di Carmine Antonia Bosco Emilio Saviano Angelo Rega Marco Carotenuto Maria Carla Ricci

The journal retracts the article titled “Children on the Autism Spectrum and the Use of Virtual Reality for Supporting Social Skills” [...]

Children doi: 10.3390/children13081037

Authors: Alessandro Frolli Francesco Cerciello Clara Esposito Maria Carla Ricci Rossana Pia Laccone Fabio Bisogni

The journal retracts the article titled “Universal Design for Learning for Children with ADHD” [...]

Children doi: 10.3390/children13081036

Authors: Hasan Deliağa Halil Tosun Bilge Karabulut Hüseyin Tuğrul Tiryaki

Background: Grade 1 vesicoureteral reflux (VUR) is generally considered a low-risk condition and is commonly grouped with other low-grade reflux categories in the literature. Consequently, long-term outcome data specifically addressing Grade 1 VUR remain limited. We evaluated the long-term renal and infectious outcomes of children with Grade 1 VUR and characterized their principal associated clinical phenotypes. Methods: This retrospective cohort study included children diagnosed with Grade 1 VUR between 2008 and 2025 at a tertiary pediatric urology center. Primary outcomes were breakthrough urinary tract infection (UTI), proteinuria, and new renal scar formation. Principal associated clinical phenotypes and factors associated with adverse outcomes were evaluated using univariable analyses. Results: A total of 132 children with Grade 1 VUR involving 154 refluxing renal units were included. Median age at diagnosis was 6 years (IQR 4–9.25), and median follow-up was 8 years (IQR 5–9). A principal associated clinical phenotype was identified in all patients, most commonly voiding dysfunction (38.6%), recurrent UTI (28.0%), and renal anomalies (25.0%). Breakthrough UTI occurred in 46 patients (34.8%), proteinuria in 6 (4.5%), and new renal scar formation was identified in 7 of the 70 patients who underwent paired baseline and follow-up DMSA examinations performed according to clinical indications (10.0%). Renal adverse outcomes (proteinuria and/or new renal scar formation) were identified in 10 patients. Incident renal scarring was assessable only in the selectively imaged paired DMSA subgroup. Older age at diagnosis (p < 0.001) and abnormal baseline DMSA findings (80.0% vs. 41.8%, p = 0.040) were associated with renal adverse outcomes, while female sex was associated with breakthrough UTI (p = 0.009). Conclusions: In this tertiary referral cohort of children with Grade 1 VUR and associated clinical conditions, heterogeneous clinical outcomes were observed during long-term follow-up. These findings highlight the importance of interpreting Grade 1 VUR within the broader clinical context of the child; however, the independent contribution of reflux itself cannot be determined from the present study. These findings should therefore be regarded as descriptive and hypothesis-generating.

Children doi: 10.3390/children13081035

Authors: Alicia Gomez-Merino Paloma M. Núñez-Yebra Rafael Lobato-López Natalia González-Martínez Elena García-González Pedro Piqueras-Rodríguez Desiree Alcaraz-Blanco Marta Romeral-Jiménez Marta Martín-Velasco Patricia Luna-Castaño

Objective: To explore nursing team perceptions of sleep and sleep-disrupting factors in critically ill pediatric patients. Methodology: Convergent mixed-methods study comprising an exploratory qualitative and descriptive cross-sectional quantitative. For the qualitative component, the population consisted of the PICU nursing team with ≥3 years of experience until theoretical saturation was reached. Semi-structured interviews were conducted regarding their perceptions of sleep in critically ill children. Data were analyzed using transcription, immersive reading, and coding. For the quantitative component, the population was selected using convenience sampling without exclusion. The variables were years of experience, professional category, and factors affecting rest. Data were collected using an ad hoc Likert-type questionnaire. For the analysis, the median and interquartile range were calculated for quantitative variables, and frequencies and percentages were calculated for categorical variables. Bivariate analysis was performed using the Mann-Whitney U test. Results: Ten interviews were conducted, revealing three main categories: “Factors Affecting Sleep,” with noise, nighttime interventions, and light as the most frequent codes; “Consequences of Sleep Disturbances,” with delirium and recovery as the most frequent codes; and “Perception of Sleep in the PICU and Need for Professional Awareness”. For the quantitative results, 78.3% (n = 65) of the nursing team participated. Among the factors affecting rest, the most relevant were “Inadequately controlled pain,” identified as “Highly relevant” by 84.6%, and “Delirium,” “Withdrawal syndrome,” “Light,” “Nocturnal environmental noise,” and “Nighttime interventions/procedures,” identified as “Highly relevant” by over 70%. In contrast, “Continuous nocturnal glucose administration” was identified as “Slightly/Not relevant” by almost 40%. Differences between nurses and nursing assistants were observed regarding the perceived relevance of nocturnal environmental noise, delirium, physical restraints and continuous nocturnal glucose administration (p ≤ 0.05). Conclusions: Qualitative and quantitative results concur in identifying, from the perspective of nursing professionals in a single PICU, noise, light, interventions, and delirium as negative factors for rest.

Children doi: 10.3390/children13081034

Authors: María Carmona-Santamaría María Isidora Sarciat Aguayo Laura Marqués-Martínez Juan Ignacio Aura-Tormos Clara Guinot-Barona Esther García-Miralles

Background/Objectives: Children with special healthcare needs (CSHCN) face significant barriers to conventional dental care and frequently require general anaesthesia (GA). Data characterising the clinical and therapeutic profile of this population in the Spanish public health system remain scarce. This study aimed to describe the systemic conditions, oral pathology, and dental procedures performed in CSHCN attending a tertiary-care paediatric oral and maxillofacial surgery service, and to characterise the subgroup of patients requiring treatment under GA relative to the wider clinic population. Methods: A retrospective, descriptive, observational study was conducted at the Hospital Universitario y Politécnico La Fe (Valencia, Spain) from November 2022 to February 2026. Data were extracted from electronic health records for 160 outpatient clinic patients aged 0–14 years (70.6% male), of whom 42—a subgroup, not an independent sample—subsequently underwent dental treatment under GA (76.2% male). Sex, age, and autism spectrum disorder (ASD) status were compared between the GA subgroup and a non-overlapping outpatient-only comparator (n = 118) using Fisher’s exact test and Welch’s t-test. Results: ASD was the most prevalent systemic condition in both the outpatient clinic (25.0%) and the GA subgroup (42.9%); a statistically significant association with ASD status was observed against the non-overlapping outpatient-only comparator (18.6% ASD; p = 0.003), while sex (p = 0.432) and age (p = 1.00) did not differ. Dental caries was the most common finding at outpatient assessment (61.0%), followed by root remnants (32.1%). Among GA patients, tooth extraction was performed in 78.6%, composite restoration in 71.4%, and professional dental cleaning in 50.0%. The mean number of procedure types per GA patient was 2.5 ± 1.0 (range 1–5); 81.0% received two or more procedure types in a single session. Conclusions: CSHCN attending this service present advanced oral disease, and those referred for GA had a significantly higher prevalence of ASD than the remaining clinic population, requiring complex, multi-procedure interventions in a single session. The wide geographic pattern of referrals suggests that further evaluation of the distribution of hospital dental services within the public health network may be warranted, and caregiver-targeted preventive programmes may represent a promising strategy to reduce the oral disease burden in this population.

Children doi: 10.3390/children13081033

Authors: Nadja Schmidt Clemens Memmel Christian Wulbrand Alexander Hanke

Background: K-wire osteosynthesis is a widely used, cost-effective technique for stabilizing pediatric and adolescent fractures. The beneficial effect of perioperative antibiotic prophylaxis (PAP) and burying the K-wires below skin level to reduce infectious complications is still controversial. The goal of this study was to evaluate if the omission of PAP and leaving K-wires unburied affected the complication rate. Materials and Methods: A retrospective analysis of pediatric and adolescent K-wire osteosyntheses over a period of 11 years was performed. Records were screened for general, infectious and implant-associated complications. Follow-up was performed until the implant was removed. Results: Between January 2014 and December 2024 a total of 1022 K-wire osteosyntheses were performed and 779 were eligible for this study. Median follow-up to implant removal was 30 days [28–36 days]. At least one complication was documented in 17.6% (137/779) of the cases. Infectious complications were low at 2.6%—including 11 (1.4%) wound healing disorders and 9 (1.2%) pin site infections—and did not show difference regardless of application of PAP. No cases of osteomyelitis were observed until follow-up. Furthermore, implant-associated complications were more frequent with buried wires (10.2%; 19/187) than with unburied wires (3.4%, 20/592). Conclusions: Omitting perioperative antibiotic prophylaxis and leaving K-wires unburied in pediatric and adolescent patients undergoing closed reduction and K-wire fixation of distal radial and distal humeral fractures does not seem to increase the risk for infectious complications. Furthermore, unburied K-wires can be removed without the need for a second general anesthesia. Level of Evidence: III (retrospective cohort study).

Children doi: 10.3390/children13081032

Authors: Isabella Leo Alfredo Marzano Martina Avesani

Congenital heart disease (CHD) is the most common congenital malformation, affecting close to 9 per 1000 live births, and progressive advances in prenatal detection, surgical palliation, and perioperative care have transformed what was once an early-lethal condition into a chronic disease with a steadily expanding population of survivors reaching adolescence and adulthood [...]

Children doi: 10.3390/children13081031

Authors: Didem Dizdar Yigit Sule Nur Kandemir Volkan Dericioglu Furkan Cam Yener Sahin Eren Cerman Adnan Dagcinar Hande Celiker

Background/Objectives: The primary aim of this study was to evaluate the rate of strabismus and surgical outcomes in pediatric hydrocephalus (HC) patients, and compare the results in patients with and without ventriculoperitoneal (VP) shunt surgery. Methods: This study includes pediatric HC patients who were followed at the pediatric ophthalmology and strabismus unit of a tertiary hospital. Detailed ophthalmological examinations including deviation angle were performed. Preoperative measurements and surgeries were carried out by one strabismus expert. Postoperative deviation of ≤10 prism diopters (PD) was considered successful. Results: In total, 64 subjects were included in this study (29 female, 35 male), and 42 had a VP shunt (shunt+), while 22 were shunt−. The mean age of participants was 8.5 ± 4.6 years, and 50% (n = 32) of them had strabismus (22 esotropia, 10 exotropia). Both groups had similar refractive error and visual acuities (p > 0.05). Amblyopia rates were 21% (9/42) vs. 23% (5/22) in the shunt+ and shunt− groups. In 40% of shunt+ patients (17/42) there was strabismus, compared to 68% of shunt− patients (15/22). Among 22 patients with esotropia, 12 underwent strabismus surgery. Surgical success was achieved in nine patients (75%). In exotropic patients only one had surgery and it was successful. The operation rate in the strabismus group was 41% (13/32). Others mostly did not have surgery due to systemic comorbidities. Patients with strabismus had approximately 3.7 times higher odds of having epilepsy or spina bifida compared to those without strabismus (p = 0.049; OR = 3.69; 95% CI: 1.13–12.11). Conclusions: These findings suggest that children with hydrocephalus may benefit from regular pediatric ophthalmologic follow-up to detect strabismus, amblyopia, and refractive errors at an early stage. Although acceptable alignment outcomes were observed in selected operated patients, the small surgical cohort limits definitive conclusions regarding surgical success or the influence of VP shunting; therefore, treatment decisions should be individualized within a multidisciplinary framework.

Children doi: 10.3390/children13081030

Authors: Areej Okasheh-Otoom

Purpose: To evaluate the visual, functional, educational, and mobility outcomes of a comprehensive pediatric low vision rehabilitation (LVR) program and determine whether electronic low vision aids (LVAs) provide additional benefit. Methods: A multicenter prospective observational cohort study was conducted across three tertiary low vision rehabilitation centers in Jordan. Two hundred children aged 6–16 years with moderate-to-severe visual impairment were enrolled. The intervention group (n = 150) received comprehensive multidisciplinary rehabilitation, including optical LVAs, rehabilitation training, educational support, and electronic LVAs when indicated, while the comparison group (n = 50) received routine low vision care without participation in the structured multidisciplinary rehabilitation program. Primary outcomes were LogMAR distance visual acuity (VA) and LV Prasad Functional Vision Questionnaire (FVQ) scores. Secondary outcomes included near VA, reading speed, mathematics performance, and mobility independence. Results: At 12 months, the intervention group demonstrated significant improvement in distance VA from 0.87 ± 0.13 to 0.65 ± 0.11 LogMAR (mean change −0.22; 95% confidence interval [CI], −0.25 to −0.19; p < 0.001), whereas the comparison group showed only minimal improvement. FVQ scores increased significantly from 42.3 ± 8.7 to 76.5 ± 9.1 (+34.2 points; p < 0.001). Within the intervention group, reading speed improved by 25.3 words/minute, mathematics scores by 15.7%, and mobility independence by 32% (all p < 0.001), whereas only minimal changes were observed in the comparison group. Multivariate regression analysis identified electronic LVA use as the strongest independent predictor of functional improvement (β = 0.41, p < 0.001). Conclusions: Comprehensive pediatric low vision rehabilitation improved visual, educational, and mobility outcomes. In an exploratory subgroup analysis, children using electronic low vision aids demonstrated greater functional improvement than those using non-electronic low vision aids.

Children doi: 10.3390/children13081029

Authors: Carmen Machuca-Portillo Cira Suárez-Marchena Lucy Chandler-Gutiérrez María José Barra-Soto Carolina Caleza-Jiménez Lydia López-del Valle Juan J. Segura-Egea

Background/Objectives: Historical concerns regarding permanent dental staining have restricted the use of tetracycline antibiotics in children younger than 8 years. However, newer-generation tetracycline derivatives, particularly doxycycline, differ pharmacologically from first-generation tetracyclines and may present a lower risk of discoloration. This systematic review and meta-analysis evaluated the risk of dental staining associated with newer-generation tetracycline derivatives. Methods: It was conducted according to the PRISMA 2020 statement and registered in PROSPERO. PubMed/MEDLINE, Scopus, and Embase were searched. Methodological quality was assessed, and the certainty of evidence using the GRADE approach. A random-effects meta-analysis of comparative studies was performed using the risk difference (RD) as the summary effect measure. Results: Six observational studies fulfilled the eligibility criteria. Three studies reported no cases of dental staining following doxycycline exposure, whereas one study identified parent-reported discoloration in 2 of 18 evaluated children (11.1%). Dental staining was reported in 2 of 41 children (4.9%) treated with minocycline and in 2 of 12 children (16.7%) with tigecycline. Meta-analysis of the three comparative studies demonstrated no significant increase in the risk of dental staining among exposed children compared with controls (RD = 0.007; 95% CI −0.015 to 0.028; I2 = 0%). Methodological quality ranged from moderate to high. According to GRADE, the certainty of evidence was low for doxycycline/minocycline and very low for tigecycline. Conclusions: Current evidence, although limited, suggests that short-course doxycycline is associated with little or no clinically relevant risk of permanent dental staining in children younger than 8 years. In contrast, the available evidence for minocycline and tigecycline remains insufficient to establish their dental safety.

Children doi: 10.3390/children13081028

Authors: Marco Walg Claudio Prado Daniel El-Wahsch Stephan Bender Gerhard Hapfelmeier

Background/Objectives: Time perspective and resilience are both relevant to adolescent mental health, yet their association has rarely been examined in clinical adolescent populations. This study investigated associations between resilience and time perspective and tested their independent associations with depressive, anxiety, and PTSD symptoms beyond trauma-related variables. Methods: A total of 105 adolescents aged 14 to 20 years were recruited from a child and adolescent psychiatric outpatient department. Participants completed self-report measures of resilience, time perspective, trauma exposure, and PTSD, depressive, and anxiety symptoms. Discrepancy from the optimal balanced time-perspective profile was quantified using the revised Deviation from a Balanced Time Perspective coefficient (DBTP-r). Spearman correlations and linear regression models were computed using DBTP-r alone, DBTP-r plus resilience, and extended models including trauma-related variables. Results: Higher DBTP-r was associated with lower resilience. Higher resilience was associated with higher Future and Past Positive scores and lower Past Negative scores. DBTP-r accounted for substantial variance in symptom severity. When resilience was added, both DBTP-r and resilience were independently associated with depressive, anxiety, and PTSD symptoms. In the extended models, DBTP-r and resilience remained significant for all three outcomes. Of the trauma-related predictors, physical sexual abuse was associated with PTSD symptoms in the extended model, but this association was no longer significant after controlling for biological sex. The cumulative number of other potentially traumatic experiences was not independently associated with symptom severity in the extended models. Conclusions: Time perspective and resilience appear to be related but distinguishable constructs. Both were independently associated with symptom levels of depression, anxiety, and PTSD in adolescents.

Children doi: 10.3390/children13081027

Authors: Natalia S. Escobar Reshma Amin

Pediatric obstructive sleep apnea (OSA) is a common disorder associated with significant neurocognitive, behavioral, cardiovascular, and metabolic consequences. Although adenotonsillectomy remains first-line therapy for many children, residual OSA is common, particularly among those with obesity, craniofacial abnormalities, genetic syndromes, neuromuscular disease, or other forms of medical complexity. Continuous positive airway pressure (CPAP) is the standard non-surgical treatment; however, long-term effectiveness is frequently limited by poor tolerance and adherence. Heated high-flow nasal cannula (HFNC) therapy has emerged as a potential alternative for selected children with sleep-disordered breathing, particularly those who are unable to tolerate conventional positive airway pressure therapy. Unlike CPAP, HFNC delivers heated, humidified gas through an open nasal interface and may improve sleep-disordered breathing through a combination of flow-dependent positive airway pressure generation, dead-space washout, improved ventilatory efficiency, enhanced gas conditioning, and reductions in inspiratory resistance. However, the relative contribution of these mechanisms during sleep remains incompletely understood. Current clinical evidence consists primarily of physiological studies, retrospective cohorts, case series, and a limited number of prospective comparative studies. Collectively, these data suggest that HFNC can reduce obstructive respiratory events and improve oxygenation in selected pediatric populations, including children with persistent OSA, CPAP intolerance, medical complexity, and syndromic conditions. Nevertheless, important uncertainties remain regarding optimal patient selection, titration strategies, patient monitoring, long-term adherence and comparative effectiveness relative to CPAP. This review summarizes the physiological basis of HFNC therapy, critically appraises the current clinical evidence, discusses practical considerations related to adherence and implementation, and highlights key knowledge gaps and future research priorities. Overall, HFNC should be viewed as an alternative for selected children who cannot tolerate CPAP, rather than as a universal substitute for pressure-based therapy.

Children doi: 10.3390/children13081026

Authors: Daniel J. Epstein Jitendra Balakumar Erich Rutz Kemble K. Wang

Background: Displaced pediatric radial neck fractures are challenging injuries. Adequate reduction can be difficult to achieve via closed methods. Open reduction has been associated with avascular necrosis and growth arrest due to soft tissue stripping during surgery. We describe a modified technique that adopts lessons learned from subcapital realignment procedures of the proximal femur, prioritising preservation of the periosteal sleeve with the aim of reducing complications associated with open reduction. Methods: The modified technique includes visualisation of the radial neck fracture through the torn periosteum, preserving intact periosteum, limited shortening of the diaphyseal fracture site, followed by open reduction and fixation with retrograde elastic intramedullary nailing. A retrospective chart review of 15 patients treated with this technique was undertaken to report early clinical and radiographic outcomes. Results: Mean age at injury was 7.7 years (range 4–11). Mean follow-up was 9.9 months (range 4.5 to 20 months). There was 100% fracture union achieved at mean 9.3 weeks (SD 4.9) post-surgery. Mean flexion was 139° (SD 9°), extension 1° (SD 7°), supination 66° (SD 23°) and pronation 79° (SD 21°). There were no cases of postoperative radial head deformity or instability. One patient showed radiological signs of avascular necrosis. Six of 15 patients experienced at least one complication, including heterotopic ossification, stiffness requiring release, physeal closure and nail migration requiring revision. Conclusions: We describe a technique that aims to preserve periosteal blood supply during open reduction and fixation of pediatric radial neck fractures. Early clinical experience suggests promising results, but longer-term follow-up is required before any advantage over existing open reduction techniques can be concluded.

Children doi: 10.3390/children13081025

Authors: Eva Sutera Alyssa Maximov Vívian Mara Gonçalves de Oliveira Azevedo Wissam Shalish Robert Kearney Guilherme M. Sant’Anna

Background: Vital sign monitoring immediately after birth is a necessity to aid the transition to life, especially in the context of resuscitation. Current monitoring systems pose challenges due to their wired nature. This scoping review aimed to identify and describe non-contact and wireless vital sign monitoring technologies used immediately after birth and summarize their capabilities and any research gaps to better understand the current state of wireless monitoring in the delivery room setting. Methods: The review followed the JBI 9-step framework and PRISMA-ScR guidance. Searches were conducted in Medline, Embase, Scopus, Web of Science, CINAHL, and Cochrane for studies published from 1 January 2015 to 1 October 2025, with additional reference screening of included articles. Study and device characteristics and study outcomes (i.e., accuracy, feasibility, safety) were collected via a data collection form and analyzed and presented by descriptive methods. Results: The search yielded 59,220 records; after duplicate removal and screening, seven full articles were included, one additional article was added through cross-reference screening. All eight studies were conducted in hospital delivery rooms, mostly as prospective observational designs, involving newborns of various gestational ages and weights, with a median of 29 [IQR:35] participants per study. All eight studies evaluated wearable devices. Heart rate was the most commonly monitored vital sign, and Bluetooth was the main data transfer method. Recording periods were mostly under 10 min. Conclusions: New monitoring technologies used immediately after birth are emerging, but data remains preliminary and limited by small studies with short recording periods. Future work should emphasize standardized device placement, larger samples with longer monitoring periods, rigorous accuracy and safety evaluation, and devices that can capture multiple vital signs reliably.

Children doi: 10.3390/children13081024

Authors: Yui Shiroshita Tetsuo Naramura Mio Kojima Tetsuya Yoneda Tomoko Sakaida Ikuko Sobue

Background: Research on preterm infant development during the coronavirus disease 2019 (COVID-19) pandemic has yielded inconsistent results and has not considered the impact of exposure to pain. This study aimed to investigate the association between neurodevelopment in very preterm infants and pain exposure during the COVID-19 pandemic. Methods: This retrospective study included very preterm infants born before 33 weeks’ gestation between 2017 and 2022. Their neurodevelopmental status was assessed using the Kyoto Scale of Psychological Development at corrected 18 months (n = 92) and 36 months (n = 82) (n = 35 and 23 during the COVID-19 pandemic, respectively). Results: Multiple regression analysis adjusted for confounding factors showed that the developmental quotient at corrected 18 months was not associated with parental visit frequency or invasive procedure count. At 36 months, it was also not associated with parental visit frequency; however, in the cognitive–adaptive domain, it showed a significant association with the number of invasive procedures (B = −0.10; β = −0.45; 95% confidence interval [−0.76, −0.14]; p = 0.0049). Conclusions: These findings highlight the importance of maintaining neonatal pain management during disease outbreaks to support neurodevelopmental outcomes in very preterm infants.

Children doi: 10.3390/children13081023

Authors: Donatella Di Fabrizio Edoardo Bindi Giovanni Cobellis

Pediatric surgery continues to incorporate minimally invasive techniques, image-guided procedures, artificial intelligence (AI), digital pathology, interventional radiology, and structured perioperative care [...]

Children doi: 10.3390/children13081022

Authors: Dwayne Mascarenhas Bonny Jasani

Necrotizing enterocolitis (NEC) is a major cause of morbidity and mortality in preterm infants, yet it remains one of the most challenging neonatal diagnoses to establish with certainty. No single clinical, laboratory, or radiographic finding is pathognomonic, and the modified Bell’s staging system is limited because features such as abdominal distension, bloody stools, pneumatosis intestinalis, and portal venous gas are common in preterm infants or are mimicked by other conditions. A wide range of disorders in preterm and term neonates can therefore resemble NEC, including spontaneous intestinal perforation, sepsis-associated ileus, dysmotility of prematurity, malrotation with or without volvulus, cow’s milk protein allergy, Hirschsprung-associated enterocolitis, cardiogenic colitis, viral enterocolitis, intussusception, neonatal appendicitis, meconium obstruction, incarcerated inguinal hernia, and food protein-induced enterocolitis syndrome. Misclassification of these mimics leads to over- and under-estimation of NEC incidence, contaminates outcome data, and may delay surgical intervention. This review summarizes the epidemiology, risk factors, pathophysiology, and distinguishing clinical, radiographic, and histopathological features of the common mimics of NEC, with particular emphasis on spontaneous intestinal perforation. We also highlight the inherent diagnostic challenges and future directions, including the need for reliable biomarkers and the evolving role of artificial intelligence.

Children doi: 10.3390/children13081021

Authors: Erick Fontenele Cristiane Faiad Ana Isabel Sani

Background/Objectives: Femicide-related orphanhood exposes children and adolescents to psychological distress and may disrupt their health-related quality of life (HRQoL). This study examined the relationships between anxiety, depression, and HRQoL among children and adolescents orphaned by femicide and tested whether depressive symptoms mediate the association between anxiety and HRQoL. Methods: A cross-sectional study was conducted with 57 children and adolescents aged 8 to 18 years who had been orphaned by femicide and were residing in the Federal District of Brazil. Participants completed the Revised Child Anxiety and Depression Scale (RCADS-25) to assess anxiety and depressive symptoms and the KIDSCREEN-27 to evaluate HRQoL. Data were analyzed using Spearman correlation coefficients, linear regression models with bootstrap procedures, and mediation analyses to explore direct and indirect relationships among variables. Results: Depressive symptoms were negatively associated with HRQoL, while anxiety symptoms showed a weaker negative association with HRQoL. In the regression analysis, depression emerged as the only significant predictor of HRQoL. Mediation analysis indicated that the relationship between anxiety and HRQoL was largely explained by depressive symptoms, suggesting a partial indirect effect of anxiety through depression. Conclusions: The findings indicate that depressive symptoms may play a central role in the relationship between anxiety and perceived quality of life among children and adolescents orphaned by femicide. These results highlight the importance of assessing both anxiety and depression in this population and suggest that interventions addressing depressive symptomatology may contribute to improving psychosocial well-being and HRQoL following exposure to severe family violence.

Children doi: 10.3390/children13081020

Authors: Giuseppe Accogli Giorgia Carlucci Antonio Trabacca Maria Gloria Rossetti Sara Scoditti Paolo Brambilla Roberto Sassi Antonella Delle Fave Cinzia Bressi Fabrizia Claudia Guarnieri Isabella Fanizza Marcella Bellani

Background: Problematic school attendance in adolescence is a heterogeneous phenomenon with academic, emotional, and developmental consequences. Although relational factors are increasingly recognised, the literature remains conceptually fragmented, with overlapping constructs such as social isolation, loneliness, social withdrawal, and peer difficulties examined under partially distinct frameworks. Objective: This systematic review aimed to synthesize empirical evidence on the association between social isolation, related constructs, and problematic school attendance during adolescence. Methods: Following PRISMA 2020 guidelines, searches were conducted in PubMed, Scopus, and Embase (final search: 20 January 2026). Eligible studies were observational or qualitative empirical investigations involving adolescents aged 11–18 years and examining at least one relational construct (objective/subjective social isolation, loneliness, social withdrawal, peer rejection) together with at least one school attendance outcome (school refusal, withdrawal, truancy, avoidance, dropout). Risk of bias was assessed with design-specific JBI tools and findings were synthesized narratively. Results: Eleven studies met the inclusion criteria: six cross-sectional, four longitudinal/cohort, and one qualitative. Loneliness, bullying, school alienation, and social isolation at school were most consistently associated with school refusal and absenteeism, whereas peer acceptance, reciprocal friendships, teacher emotional support, and school belonging were associated with reduced dropout intentions, higher graduation rates, and better school transition. Longitudinally, loneliness and low teacher support preceded increases in intention to quit, while supportive relationships appeared to protect against later disengagement. Conclusions: Social isolation and related constructs are meaningfully associated with problematic school attendance in adolescence. Social isolation and related constructs appear to be meaningfully associated with problematic school attendance in adolescence, although the evidence base remains limited and heterogeneous. These findings suggest that a relational perspective may usefully complement existing approaches to attendance difficulties, and point to the need for longitudinal, multi-informant studies disentangling subjective, interpersonal, and institutional disconnection across distinct attendance profiles.

Children doi: 10.3390/children13081019

Authors: Rosario Ceruso Giuseppe Giardullo Manuele Taleb Giuseppe Di Lascio Gaetano Raiola

Background/Objectives: Physical activity in primary school is increasingly recognized not only for developing skill-related fitness, but also for promoting well-being, motivation, and awareness of individual abilities. However, studies integrating quantitative performance data with qualitative perceptual data in school settings remain limited. This study aimed to explore the associations between objectively measured motor competence and students’ perceptions of enjoyment, motivation, and perceived competence during primary school physical education. Methods: This observational pilot study involved 17 students (mean age: 10.6 ± 0.5 years). The quantitative assessment included the Yo-Yo Test for intermittent endurance and the Sargent Test for lower-limb explosive strength, along with anthropometric measurements (mean height: 1.44 ± 0.09 m; mean weight: 39.9 ± 6.3 kg). A dichotomous (yes/no) questionnaire assessed enjoyment, motivation, perceived competence, and interest in physical activity. Data were analyzed using descriptive statistics, the Shapiro–Wilk test, Pearson’s correlation, and the Chi-square test. Results: Significant correlations emerged between height and body weight (r = 0.667; p = 0.003) and between body weight and Sargent Test performance (r = 0.544; p = 0.024). Biological sex was also significantly correlated with body weight (r = −0.562; p = 0.019). The Chi-square analysis showed significant associations between motivation and positive perception of physical activity (p < 0.05), particularly regarding sports participation and peer-related engagement. Conclusions: Despite differences in motor performance, students’ perceptions of physical activity were generally positive. Anthropometric characteristics influenced performance, while motivational and social factors were strongly associated with participation. Integrating performance and perceptual data provides a more comprehensive understanding of psychophysical development during school age.

Children doi: 10.3390/children13081018

Authors: Ceren Gürez Didem Dizdar Yiğit Asli İnal

Introduction: This study aimed to investigate the impact of strabismus on self-concept in school-aged children and to evaluate changes in self-concept six months after strabismus surgery. Subjects and Methods: This prospective multicenter study included children aged 7–15 years who underwent strabismus surgery at the Strabismus Units of Beyoğlu Eye Research and Training Hospital and Marmara University Hospital between December 2023 and June 2024. Self-concept was assessed using the validated Turkish version of the Piers–Harris Self-Concept Scale (PHSCS) before surgery and six months postoperatively. Only patients with complete preoperative and postoperative assessments were included in the final paired analysis. Results: A total of 116 children were enrolled, of whom 84 (42 boys and 42 girls; mean age, 10.9 ± 2.2 years) had complete data and were included in the final analysis. Overall, 73.6% of participants reported that strabismus affected their daily lives, with 77.4% describing this impact as negative. Furthermore, 65.5% stated that strabismus affected their relationships with friends. Following surgery, 80.9% of participants were satisfied with the surgical outcome, and 85.7% would recommend the procedure to others. The mean total PHSCS score increased from 58.2 ± 10.4 preoperatively to 59.0 ± 10.1 postoperatively, although this difference did not reach statistical significance (p = 0.05). In contrast, the Physical Appearance and Attributes subscale showed a significant improvement after surgery (8.3 ± 1.6 vs. 8.9 ± 1.9, p < 0.005), whereas no significant changes were observed in the remaining subscales. Conclusions: School-aged children with strabismus may experience psychosocial challenges related to their condition, particularly in their interactions with peers. Although overall self-concept remained largely unchanged, self-perception of physical appearance improved following strabismus surgery. These findings suggest that surgical correction may contribute to improvements in selected aspects of self-concept; however, larger prospective controlled studies are needed to confirm these observations.

Children doi: 10.3390/children13081017

Authors: Sungsu Jung Jisun Yoon Kyungmo Hong Hea Young Oh Eom Ji Choi Min Jee Park Song-I Yang Eun Lee Hyo-Bin Kim So-Yeon Lee Soo-Jong Hong on behalf of the PSKC Study Group on behalf of the PSKC Study Group

Background/Objectives: Atopic dermatitis (AD) and food allergy (FA) frequently coexist in the concept of atopic march; however, their combined associations with psychological problems remain poorly understood. This study aimed to investigate the associations of AD and FA with psychological outcomes at age 7 and evaluate whether respiratory allergies account for part of these associations. Methods: We enrolled 1577 children aged 7 years from the Panel Study of Korean Children. The Korean version of the Child Behavior Checklist was used to assess psychological and behavioral problems. Multivariable regression and parallel mediation analyses were used to evaluate independent and interactive associations. Results: AD and FA were associated with psychological and behavioral problems, most consistently with somatic problems on the Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented scale. These associations were more pronounced in children with comorbid AD and FA than in those with single allergies. Among the 9 children with concurrent AD and FA, an interaction between the two conditions on somatic problems was observed (P for interaction = 0.033). The comorbid group showed higher eosinophil counts and total IgE levels, but no differences in SCORAD indices or C-reactive protein levels. Mediation analysis identified a direct association of AD with somatic problems (B = 1.062; 95% CI, 0.601–1.562), with a portion accounted for by allergic rhinitis (AR) (B = 0.656; 95% CI, 0.306–1.241). Conclusions: Comorbid AD and FA were associated with higher odds of somatic problems than either condition alone in 7-year-old children, with a portion of the AD association accounted for by AR. Because exposures and outcomes were assessed concurrently, these associations are exploratory and hypothesis-generating rather than causal. Clinical attention may be warranted for children with both AD and FA.

Children doi: 10.3390/children13081016

Authors: Mariarosaria Matera Ilaria Cavecchia Maria Teresa Illiceto Matilde Morandin Maria Beatrice Lenzi Talia D’Ambrosio Valentina Biagioli

The human microbiota is increasingly recognized as a key contributor to pediatric and perinatal health. However, little is known about healthcare professionals’ preparedness to integrate microbiota-related concepts into routine pediatric and perinatal care. Methods: A cross-sectional online survey was conducted among Italian healthcare professionals involved in pediatric and perinatal care. The questionnaire explored microbiota-related training, self-perceived knowledge, attitudes, clinical practices, microbiota-testing-related approaches, and educational needs. Descriptive and inferential statistical analyses were performed. Results: A total of 441 participants were included in the final analysis. Participants expressed highly positive attitudes toward the clinical relevance of the microbiota, particularly regarding maternal–fetal programming, neonatal development, preventive medicine, and microbiota education. Self-perceived knowledge was generally higher for basic microbiota concepts and neonatal microbiota development, whereas lower confidence emerged for microbiota-related clinical applications, counseling competencies, and critical interpretation of scientific evidence. Significant variability in microbiota-related knowledge scores emerged across professional backgrounds and healthcare settings (p < 0.001). Previous microbiota-related training was independently associated with higher self-perceived knowledge scores and greater integration of microbiota-oriented approaches into clinical practice. Use of probiotics was reported by 72.6% of participants, whereas microbiota-related diagnostic tests were routinely used by 32.9%. Overall, 91.8% of respondents expressed interest in further microbiota-related education. Conclusions: Healthcare professionals involved in pediatric and perinatal care recognize the growing clinical relevance of microbiota science but report heterogeneous levels of translational preparedness and clinical confidence. Microbiota-related training emerged as a key factor associated with greater preparedness and implementation in clinical practice, highlighting the need for structured multidisciplinary educational pathways and evidence-based integration of microbiome science into pediatric healthcare.

Children doi: 10.3390/children13081015

Authors: Adriana Martins Margarida Simões Ana Paula Monteiro Catarina Pinheiro Mota Ana Isabel Sani Inês Carvalho Relva

Background: The study of cyberbullying has been growing worldwide; however, the literature is still scarce regarding risk and protection factors. Objectives: Therefore, the main objective of the present study was to analyze cyberbullying from the perspective of the aggressors and their association with authoritative and authoritarian parenting styles and with the two components of empathy. Methods: The sample consisted of 422 participants, students of the 2nd and 3rd cycles in schools and Secondary Education in the North region of Portugal, aged 12 to 17 years. For data collection, the Sociodemographic Questionnaire, the Cyberbullying Questionnaire (CBQ), the Parenting Styles & Dimensions Questionnaire: Short Version (PSDQ), and the Short Version of the Basic Empathy Scale (BES-A) were used. Results: It was found that positive associations were identified between cyberbullying behaviours and authoritarian style in the father figure and the mother figure. Low positive associations were also identified between the father figure’s authoritative parenting style and cognitive empathy, and moderate positive associations between the mother figure’s authoritative parenting style and cognitive empathy. There were differences between males and females in both empathy components, with females showing higher levels of affective and cognitive empathy than males. Regarding parental styles, the authoritarian style of the father figure stood out as the only predictor of cyberbullying behaviors. Conclusions: It is considered important to educate parents towards healthier family functioning and encourage the abandonment of punitive discipline to promote a reduction in the perpetration of cyberbullying and an increase in empathy levels in the younger generation. It will also be important to raise awareness among adolescents about the consequences of internet misuse.

Children doi: 10.3390/children13081014

Authors: Omar Anwar Sadat Michael Shi Haseeb Mahmud Geoffrey Bradford James Vernon Odom Monique Leys

Purpose: Knobloch syndrome (KS) is a rare autosomal recessive disorder caused by biallelic variants in COL18A1 and characterized by high myopia, vitreoretinal degeneration, and occipital defects. This study examines genotype–phenotype correlations in patients with KS and reports two previously unreported COL18A1 variants. Methods: Retrospective case series from January 2010 to December 2025. From a cohort of 627 patients with inherited retinal diseases (IRDs) seen at the West Virginia University Eye Institute (WVU), all patients with clinical features of KS and pathogenic, likely pathogenic, or candidate COL18A1 variants were identified. Clinical records, multimodal retinal imaging, and electrodiagnostic testing results were reviewed and compared. Results: Four patients with clinical features of KS and genetic variants classified as pathogenic, likely pathogenic, or variants of uncertain significance in COL18A1 were identified, representing 0.64% of this single-center IRD cohort at WVU. All patients demonstrated the core ophthalmic features of KS: nystagmus, high myopia, macular atrophy, and vitreous degeneration. Systemic manifestations included seizure disorder, aplasia cutis congenita, renal anomalies, occipital encephalocele, and global developmental delay. Four distinct COL18A1 variants were identified, including two previously unreported variants: c.2673dupC p.Gly892Argfs*9 and c.3827C > T p.Ser1276Leu (variant of uncertain significance). Conclusions: We describe two previously unreported COL18A1 variants in patients with clinical features of Knobloch syndrome. This series reinforces the consistent ophthalmic phenotype of KS and highlights phenotypic variability in systemic features. Genetic testing is essential for definitive diagnosis, and KS should be considered in any child presenting with early onset nystagmus, high myopia, macular atrophy, and profoundly abnormal electroretinography.

Children doi: 10.3390/children13081012

Authors: Anna Zanin Fernando Baratiri Gloria Brigiari Barbara Roverato Daniele Mengato Laura Camuffo Dario Gregori Francesca Venturini Franca Benini

Background/Objectives: Children with medical complexity (CMC) often suffer from chronic or evolving conditions that require increasingly complex treatment regimens over time, resulting in increased therapeutic and care burdens, costs, and the risk of adverse effects and medication errors. The study aimed to describe the variation in healthcare needs, medication regimens and medication burden over time and to describe the relationship between the number of drugs and healthcare needs. Methods: In this cohort study, conducted at the Pediatric Palliative Care Center of Padua, Italy, two repeated assessments were performed, respectively, in October 2021 (t0) and in February 2023 (t1). A total of 169 patients aged ≤23 years receiving at least one prescribed medication were enrolled. Longitudinal analyses were performed in the 147 patients with complete assessments at both time points. Data were collected from medical records and caregiver interviews. Drug costs were collected from the Italian Medicines Agency. Changes between baseline and follow-up were assessed using paired statistical tests (Wilcoxon signed-rank test for continuous variables and McNemar test for categorical variables). The associations between the number of drugs and the ACCAPED scale (Accertamento dei Bisogni Clinico Assistenziali Complessi in Cure Palliative Pediatriche) were assessed using linear regression models. Results: The study analyzed treatment regimens of 147 patients with a median age of 12.1 years at t0 and 14.1 at t1. The prevalence of patients with medication burden (42% vs. 50%, p = 0.022), do-not-resuscitate order (20% vs. 27%, p = 0.027) and an ACCAPED score > 50 (57% vs. 66%, p = 0.012) significantly increased on the second assessment. Also, the number of total daily administrations (5 [3–12] vs. 6 [3–14], p = 0.019) and the number of medications (4 [2–7] vs. 5 [3–8], p = 0.013) significantly increased. However, polypharmacy and the median daily cost per patient did not significantly increase between t0 and t1. The association between the number of drugs and the ACCAPED score showed that each additional prescribed drug is associated with an average increase of 3.2 points in the ACCAPED score (95% CI: 2.6, 3.9; p < 0.001). Conclusions: Over time, the degree of complexity in our population increased significantly, as evidenced by the increased healthcare needs, treatment regimens and burden on families. The number of prescribed drugs showed a strong and statistically significant relationship with patient care complexity. Treatment regimen characteristics were strongly associated with patient care complexity. Future studies should evaluate whether these pharmacological variables may have a role in supporting clinical assessment.

Children doi: 10.3390/children13081013

Authors: Siphosethu Mgwili-Qikani Guillermo Alfredo Pulido Estrada Constance Rufaro Sewani-Rusike

Background/Objectives: To determine user-reported comfort, function, and overall satisfaction among pediatric lower limb amputees with conventional prosthetic devices and to identify possible factors associated with overall satisfaction. Methods: A cross-sectional observational study was conducted at three tertiary orthotic and prosthetic centers in the Eastern Cape, South Africa. Caregiver–child dyads completed a structured questionnaire evaluating perceived prosthetic comfort, functionality, and satisfaction. There were fifty-two unilateral pediatric lower limb amputees aged 4–17 years who had used conventional prosthetic appliances for at least one year. Questionnaire responses were summarized using descriptive statistics. Spearman’s rank correlation and non-parametric tests were used to examine associations among study variables. Multiple linear regression analysis was performed to identify factors independently associated with overall satisfaction. Results: Mean comfort was 3.54 (SD = 0.87), functionality satisfaction was 3.42 (SD = 0.78), and overall satisfaction was 2.73 (SD = 0.79). Comfort had strong correlations with functionality (ρ = 0.63, p < 0.001) and overall satisfaction (ρ = 0.69, p < 0.001). The satisfaction difference between congenital and acquired amputations was statistically significant (p = 0.006), with those with congenital amputation reporting substantially greater satisfaction than those with acquired amputation. Multiple linear regression analysis showed that perceived prosthetic functionality (β = 0.383, p < 0.001) and comfort (β = −0.535, p < 0.001) were independently associated with overall satisfaction. Conclusions: Perceived comfort and prosthetic functionality were independently associated with overall satisfaction among pediatric users of conventional prosthetic devices. These findings support patient-centered prosthetic design and rehabilitation strategies that prioritize socket comfort and functional performance to improve children’s overall satisfaction with their prosthetic devices.

Children doi: 10.3390/children13081011

Authors: Sabrina Schaly Annemarie Murphy Darryl Chiu Alistair McEwan Petra Karlsson

Background/Objectives: Limited evidence exists on the use of eye-tracking technology in infants with disabilities, particularly with motor disabilities. This systematic review examines the eye-tracking metrics, protocols, and feasibility of eye-tracking technology in infants at risk or with a motor disability. Method: This systematic review was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD42024563282). PubMed, Web of Science, CINAHL, ERIC, Embase, Scopus, MEDLINE, and the Tobii database were systematically searched, with two independent reviewers screening studies, extracting data, and assessing methodological quality using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and Standard Quality Assessment Criteria. Results: A total of 15 studies were included with a total sample size of 667 (range 1–123), including 341 boys, 306 girls, and 20 infant genders unreported (M = 10.8 months; SD = 4.8; range 4–24 months). The infants included had brain injury as seen via MRI (4 studies), cerebral palsy (4 studies), or were born very preterm with varying risk factors (7 studies). In these studies, eye-tracking technology provided an objective measure of gaze patterns, gaze duration, fixation frequency, visual assessments, and saccades. Despite Tobii being the most common eye-tracking technology used, protocols varied by study design, duration, stimuli, metrics reported, and settings, making standardization challenging. Conclusions: Eye-tracking technology provides objective eye-tracking metrics that may be used to assess infant development. However, given the heterogeneity of studies, future research should follow standardized stimuli, protocols, and include diverse populations to make definitive conclusions and implications.

Children doi: 10.3390/children13081010

Authors: Jason Hollowell Tessei Kobayashi Shigeto Furukawa Aleisha Davis

Background: The Functional Listening Index—Paediatric (FLI-P) tracks functional listening development from birth to six years but lacks Japanese-language norms. This study translated the FLI-P into Japanese (FLI-P(J)) to generate normative developmental trajectories for typically hearing children. Methods: Following translation, the FLI-P(J) was administered as an online caregiver survey in Japan. After applying sequential exclusion criteria (removing developmental concerns, zero scores, and IQR outliers) to 2976 responses, a normative sample of 2512 typically hearing children (2–73 months) was retained. Four parameter logistic functions were fitted to empirical percentile trajectories (5th–95th). Results: FLI-P(J) scores demonstrated rapid growth across the first three years before gradually plateauing. Phase-level acquisition curves confirmed the expected developmental ordering. Most clinically flagged children scored at or below the 5th percentile. Conclusions: This study establishes the first Japanese normative reference curves for functional listening. This cross-linguistic alignment, together with preliminary evidence that clinically flagged children scored at the low end of the distribution, supports the potential of the FLI-P(J) as a clinical benchmark for evaluating Japanese children who are deaf or hard of hearing, pending further validation in independently confirmed clinical samples.

Children doi: 10.3390/children13081009

Authors: Tae Hyeong Kim Jae Myung Cha Sung-Hoon Chung

Background: Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular disorder that primarily affects the skin and gastrointestinal tract, driven predominantly by somatic mosaic mutations, most commonly in TEK. Here, we report a case of a child with BRBNS and autism spectrum disorder (ASD). Case presentation: A 13-year-old boy diagnosed with ASD at 3 years presented with recurrent abdominal pain, blood in the stool, and severe anemia persisting for 6 months. At admission, his hemoglobin level was 5.6 g/dL. He had received a transfusion at age 6 for unexplained anemia. On examination, he appeared pale but stable, with bluish, compressible nodules on the right index finger and great toe, typical of BRBNS. Laboratory findings were consistent with chronic bleeding-induced iron deficiency. Endoscopic findings revealed multiple vascular lesions in the stomach, duodenum, ileum, and colon. Several colonic lesions were removed and pathologically confirmed as cavernous hemangiomas. Magnetic resonance enterography revealed additional small intestinal lesions. Whole-exome sequencing performed on buccal swab-derived DNA identified a heterozygous PDGFRA variant (c.2075G>T, p.Ser692Ile) classified as a variant of uncertain significance; no variants were identified in TEK, PIK3CA, or GNAQ. The patient underwent endoscopic resection of the larger lesions and received oral iron and a proton pump inhibitor. Hemoglobin stabilized at 11–12 g/dL, and no further transfusions were required. Conclusions: This case raises, but does not confirm, the possibility that genes other than TEK may contribute to BRBNS. The coexistence of ASD may be coincidental; a mechanistic link remains unproven. Careful endoscopic therapy and medical management controlled bleeding and anemia in this child.

Children doi: 10.3390/children13081008

Authors: Zornitsa Lazarova Nadezhda Mitova

Background: Positive behavior during dental treatment does not necessarily indicate the absence of anxiety in children. Behavioral assessment scales, such as the Frankl Behavior Rating Scale, evaluate observable behavior but may fail to identify underlying emotional tension that may accompany dental treatment. Objectives: To evaluate indicators of underlying emotional tension in children classified as cooperative based on the Frankl Behavior Rating Scale (scores 3 and 4) undergoing conventional caries removal or chemo-mechanical excavation with Brix 3000. Methods: Sixty children aged 4–6 years with positive (score 3) or definitely positive (score 4) Frankl behavior were assigned to two treatment groups: conventional caries removal using rotary instruments (n = 30) and chemo-mechanical excavation with Brix 3000 (n = 30). Projective indicators potentially associated with emotional tension were indirectly assessed using the Draw-a-Person Test. Drawings were obtained at home (baseline), immediately before treatment, and immediately after treatment. Figure height was used as a projective indicator that may reflect emotional tension. Results: A marked reduction in figure height was observed immediately before treatment in both groups, consistent with increased emotional tension despite cooperative behavior. Baseline comparison revealed no statistically significant difference between the treatment groups (p = 0.842). Following treatment, figure height increased significantly in both groups. Children treated with Brix 3000 demonstrated significantly greater post-treatment figure heights than those treated with rotary instruments (p = 0.002), suggesting more favorable projective indicators that may reflect lower emotional tension and improved psychological comfort. Conclusions: Cooperative behavior classified by the Frankl Behavior Rating Scale does not exclude the presence of underlying emotional tension that may be associated with anxiety in children undergoing dental treatment. The findings suggest that chemo-mechanical excavation with Brix 3000 may provide greater psychological comfort and potential reduction in indicators consistent with projective indicators of emotional tension than conventional rotary instrumentation. Behavioral assessment alone may not fully capture emotional responses to fully evaluate the emotional state of pediatric dental patients.

Children doi: 10.3390/children13081007

Authors: Tayfun Bacaksiz Mehmet Maden Meliksah Uzakgider Serkan Erkus Mirac Kadir Turhan Ihsan Akan Fatih Surenkok Cemal Kazimoglu

Background: Cast removal is an essential but often stressful component of the Ponseti method for idiopathic clubfoot. The impact of different cast removal techniques on infant stress, parental anxiety, and treatment outcomes remains insufficiently explored. Methods: This prospective, quasi-randomized controlled trial included 84 infants with unilateral idiopathic clubfoot treated using the Ponseti method. Patients were allocated to cast removal by oscillating saw in the outpatient clinic (Group 1, n = 42) or by soaking and peeling at home prior to clinic visits (Group 2, n = 42). The primary outcome was the number of casts required to achieve correction and readiness for percutaneous Achilles tenotomy. Secondary outcomes included infant crying time, maximum heart rate during cast removal, parental anxiety assessed using the Short State Anxiety Inventory Scale (SAIS), cast removal time, hospital stay duration, and cast-removal–related complications. Results: There was no significant difference between groups regarding pre- or post-treatment Pirani and Dimeglio scores or the number of casts required (p > 0.05). Infant crying time, heart rate during cast removal, and parental anxiety scores were significantly higher in the oscillating saw group (p < 0.001). Cast-removal–related complications were more frequent in the oscillating saw group (p = 0.003). Conclusions: In this study, home-based soaking and peeling provided clinical outcomes comparable to oscillating saw removal and was associated with lower infant distress markers, lower parental anxiety scores, and fewer observed cast-removal–related complications. These findings suggest that soaking and peeling may represent a family-centered alternative for selected families receiving appropriate instruction.

Children doi: 10.3390/children13081006

Authors: Yasmine Tremblay Kyra McKinnon Jeneesha Dhaliwal Sandesh Shivananda

Background/Objectives: Communication about illness severity in the neonatal intensive care unit (NICU) occurs in settings of uncertainty and changing clinical status. Reviewing how the literature describes this communication may clarify current practices and identify gaps in how parents receive severity-related information. This scoping review aimed to describe how illness severity is communicated to parents in the NICU, including parental engagement, communication goals, informational content, framing, and communication across periods of clinical stability and deterioration. Methods: We conducted a scoping review using the Joanna Briggs Institute method and reported it according to PRISMA-ScR guidelines. MEDLINE (Ovid) was searched from 2010 to 2025. We included studies that reported empirical data on communication about infant clinical status or illness severity and included parental perspectives. A framework, informed by parental information behaviour and prognostic communication models, guided the data extraction. Results: We included 25 studies. Communication was most often clinician-led and often combined active and passive approaches. Communication primarily focused on information sharing rather than decision-making. Discussions were largely biomedical; however, several studies also included treatment- and care-related information. Studies inconsistently described prognostic communication and did not emphasize optimistic or pessimistic framing. Few studies examined communication across distinct phases of illness trajectory, such as clinical stability or deterioration. Conclusions: Illness severity communication in the NICU remains largely clinician-led, with limited attention to parental engagement and changes across the infant’s clinical course. Greater consideration of parental information needs, prognostic communication, and illness trajectory may support more responsive communication practices in NICU care.

Children doi: 10.3390/children13081005

Authors: Dominykas Varnas Vaidotas Urbonas

Background/Objectives: Fecal microbiota transplantation (FMT) is an established treatment for recurrent or refractory Clostridioides difficile infection (rCDI) and is increasingly investigated for other gastrointestinal and neuropsychiatric conditions in children. However, pediatric safety data remains limited. This study aimed to evaluate the short-term safety of colonoscopy-delivered FMT in a heterogeneous pediatric cohort. Methods: We conducted a retrospective single-centre cohort study of all FMT procedures performed at Vilnius University Hospital Santaros Klinikos between 2017 and 2025. Fecal material from three screened healthy pediatric donors was delivered to the caecum via colonoscopy under general anesthesia. Adverse events (AEs) arising within 72 h of each procedure were identified from the clinical records and assigned a severity grade using version 5.0 of the Common Terminology Criteria for Adverse Events (CTCAE). AEs were analyzed on a per-procedure basis. Associations between sex, age, and underlying indication and AE occurrence were assessed using Fisher’s exact test and the Mann–Whitney U test. Results: A total of 108 FMT procedures were performed on 73 children aged 2 to 17 years. The predominant indication was autism spectrum disorder (ASD) and other developmental disorders (80.6%). AEs were reported after 11 procedures (10.2%); all were classified as CTCAE grade 1 or 2, and no serious AEs occurred. The most common AEs were diarrhoea (5.6%) and vomiting (2.8%). In an exploratory comparison, procedures performed for ASD were associated with a lower AE rate compared with other indications combined (6.9% vs. 23.8%; OR 0.24, 95% CI 0.06–0.87). Conclusions: Colonoscopy-delivered FMT was well tolerated in pediatric patients, with a favorable short-term safety profile consistent with published pediatric FMT literature. As follow-up was largely passive and the cohort was predominantly children with ASD, the observed rate should be regarded as a lower bound, and these findings warrant confirmation in prospective studies.

Children doi: 10.3390/children13081004

Authors: Halil Kul Harun Demirci Sara Erol Avni Merter Keceli Sima Cebecik Çakır Mahmut Sami Çolak Pınar Özışık

Objective: Intraventricular hemorrhage (IVH) is a major cause of morbidity and mortality in premature infants. Early onset neonatal sepsis (EOS) may increase the risk and severity of IVH through inflammation and hemodynamic instability. This study evaluated the association between sepsis and IVH severity. Methods: This retrospective, single-center study included neonates diagnosed with IVH and followed in the Neonatal Intensive Care Unit of a tertiary hospital between January 2021 and December 2022. IVH grading was based on Papile’s classification, and patients were categorized as low-grade (Grades I–II) or high-grade (Grade III IVH and periventricular hemorrhagic infarction [PVHI], previously referred to as Grade IV IVH). Clinical and laboratory data, including cerebrospinal fluid (CSF) and blood culture results, were analyzed. Logistic regression was used to identify factors associated with high-grade IVH. Results: A total of 61 neonates were included, of whom 49 (80.3%) had high-grade IVH. Sepsis was detected in 33 of 49 patients (67.3%) with high-grade IVH, representing a statistically significant difference compared with the low-grade group (p = 0.047). Logistic regression analysis identified sepsis as an independent predictor of high-grade IVH, increasing the likelihood approximately fourfold. All patients with positive CSF cultures were in the high-grade IVH group, and CSF glucose levels were significantly lower (p < 0.05), suggesting central nervous system infection or inflammation. Conclusions: Sepsis significantly increases the risk of severe (high-grade) intraventricular hemorrhage in premature infants. Early diagnosis and prompt treatment of neonatal sepsis and meningitis are crucial for preventing infection-related brain injury and improving neurodevelopmental outcomes.

Children doi: 10.3390/children13081003

Authors: Alice Ranieri Vittorio Ferrari Rita Ortolano Egidio Candela Luca Bernardini Marcello Lanari Federico Baronio

Testicular adrenal rest tumors (TARTs) are a frequent and clinically relevant complication of congenital adrenal hyperplasia (CAH), particularly its classic forms due to 21-hydroxylase deficiency. Although histologically benign, these masses develop within the rete testis and can progressively compress the seminiferous tubules, leading to fibrosis and, when longstanding, permanent gonadal injury and obstructive azoospermia; they are the foremost cause of impaired fertility in men with classic CAH. Their frequency increases with age, from approximately 25% in childhood to 46% in adulthood. This narrative review summarizes current evidence on the pathogenesis, predisposing factors and diagnostic work-up of TARTs, focusing on two practical questions: the appropriate age to begin monitoring and the imaging tools best suited to it. Sustained ACTH excess is regarded as the dominant growth-promoting signal, while the salt-wasting phenotype, severe CYP21A2 variants and inadequate disease control emerge as the principal predisposing factors. Although current guidelines advise ultrasound monitoring from adolescence, a growing body of pediatric data shows that TARTs can be detected well before puberty in patients at greatest risk. Scrotal ultrasonography remains the first-line technique, complemented by CEUS, elastography and MRI in selected cases. We outline a pragmatic, risk-adapted monitoring scheme and argue that earlier, childhood assessment in the highest-risk patients may help to safeguard future fertility, an approach that still awaits prospective confirmation.

Children doi: 10.3390/children13081002

Authors: Burak Abay Alp Ozel Ibrahim Alatas

Background: Lower-limb deformities in Jarcho–Levin syndrome (JLS) have not been systematically characterized. This study aimed to determine the prevalence and recurrence of lower-limb deformities in patients with JLS and to evaluate factors associated with recurrence and functional outcomes. Methods: A retrospective cohort study was performed at a single center between 2013 and 2024. Patients with a clinical and radiographic diagnosis of JLS and a minimum 2-year follow-up were included. Demographic, neurologic, radiographic, treatment, recurrence, and functional outcome data were reviewed. Recurrence was defined as return of a treated deformity requiring repeat casting, bracing modification, additional surgery, or other intervention. Results: A total of 114 patients were included. Mean follow-up was 6.2 ± 4.3 years. Lower-limb deformity was identified in 94 patients (82.5%); 73 had bilateral involvement. Foot deformity occurred in 76 patients, most commonly pes equinovarus (64 patients), hip dislocation was identified in 79 patients, and hip flexion contracture was identified in 75 patients. Among treated deformities, recurrence was most common after treatment of pes equinovarus, occurring in 29 of 61 patients. Recurrence occurred in 12 of 35 treated hip dislocations, 17 of 49 hip flexion contractures, 9 of 28 knee flexion contractures, and 3 of 8 congenital patellar dislocations. Patients with more frequent recurrence had bilateral involvement, neural tube defects, and multiple deformities, and lower PODCI mobility and global functioning scores. Conclusions: Lower-limb deformities are common, frequently bilateral, and often recurrent in patients with JLS. These findings suggest that careful lower-limb evaluation and long-term follow-up after treatment are important in this population.

Children doi: 10.3390/children13081001

Authors: Burak Abay Alp Ozel Ibrahim Alatas Abdullah Eren

Background: Myelodysplastic clubfoot is rigid, recurrent, and may limit ambulation in children with myelomeningocele. This study evaluated early functional mobility after modified Turco posteromedial release. Methods: Thirty-nine children (55 feet) with myelodysplastic clubfoot who underwent modified Turco posteromedial release after failed conservative treatment were retrospectively reviewed. Functional outcomes were assessed preoperatively and at final follow-up using the Gross Motor Function Classification System (GMFCS) and Functional Mobility Scale (FMS) at distances of 5, 50, and 500 m. Deformity severity, quadriceps function, complications, recurrence, and reintervention were also recorded. Results: Mean age at surgery was 4.2 ± 2.4 years; mean follow-up was 3.7 years. Median preoperative GMFCS was III, and median preoperative FMS total score was 7. The FMS total score improved across the Dimeglio severity groups: 10–13 (moderate), 7–10 (severe), and 4–7 (very severe). Statistically significant gains were observed at 50 m across all Dimeglio severity groups, reflecting improved school-level mobility. Children with low lumbar involvement improved across all FMS distances; those with thoracic-level involvement showed limited gains. Children with sacral involvement reached higher postoperative FMS scores. Preserved quadriceps function was associated with better functional outcomes. Recurrence occurred in 14 feet (25.4%) and early wound problems in 12 feet (21.8%). Conclusions: Modified Turco posteromedial release was associated with improved distance-specific mobility, particularly in children with low lumbar or sacral neurological levels and preserved quadriceps function. The GMFCS remained largely stable, with limited changes compared to FMS gains.

Children doi: 10.3390/children13081000

Authors: Claudia Capurro Stefano Parodi Simone Buttiglieri Giulia Romanelli Caterina Del Buono Nicola Laffi

Background/Objectives: Self-injurious behavior (SIB) is one of the most disabling manifestations of Lesch–Nyhan disease (LND), frequently involving the oral cavity and severely affecting patients’ quality of life and caregiver burden. Evidence regarding the impact of dental interventions on patient- and caregiver-reported outcomes remains limited. This study investigated the characteristics of SIB in patients with LND and explored the perceived effectiveness, tolerability, and psychosocial impact of intraoral devices and dental extractions. Methods: A questionnaire-based observational study was conducted among patients with LND. A purpose-built 32-item questionnaire, developed by dentists with expertise in Special Care Dentistry at Mauriziano Umberto I Hospital (Turin, Italy), was administered to patients attending the Pediatric Dentistry and Orthodontics Unit at IRCCS Istituto Giannina Gaslini (Genoa, Italy). The questionnaire assessed demographic and clinical characteristics, SIB features, dental management strategies, treatment-related complications, and patient- and caregiver-reported outcomes. Results: Twenty-four questionnaires were analyzed. SIB was reported in 21 patients (87.5%). Fingers (80%) and lips (70%) were the most frequently affected sites, with multiple anatomical sites involved in 80% of patients. Intraoral devices were used in 14 patients (66.7%), whereas dental extractions were performed in 4 (19%). Among patients treated with intraoral devices, 78.6% reported increased reassurance and protection. Device-related complications occurred in three patients and were mainly periodontal. All patients and caregivers reported relief following dental extraction, although SIB persisted in 50% of cases. Conclusions: SIB is highly prevalent among individuals with LND and commonly affects multiple anatomical sites. Intraoral devices are the most frequently adopted treatment strategy and are generally well tolerated, whereas dental extractions were associated with substantial perceived relief but do not necessarily eliminate SIB. Patient- and caregiver-reported outcomes should be considered when evaluating treatment effectiveness.

Children doi: 10.3390/children13080999

Authors: Aytaç Göktuğ İhsan Özdemir Deniz Karakaya Şule Demir Göksel Vatansever Gülser Esen Besli Ergin Çiftçi Deniz Tekin

Background/Objectives: Non-invasive urine collection in the pediatric emergency department (ED) is frequently complicated by prolonged collection times and unacceptably high contamination rates associated with the traditional bag specimen urine (BSU) method. This prospective study aimed to compare the operational efficiency and diagnostic reliability of the bladder stimulation technique (BST)—a highly promising alternative—against the traditional BSU method. Methods: The study included 149 infants aged ≤ 6 months (BST group: n = 81; BSU group: n = 68) requiring urinalysis. We systematically evaluated procedural success rates, time-to-collection metrics, and sample contamination frequencies. Furthermore, we assessed the influence of patient age, weight, behavioral state, and sex on BST efficacy. Results: The BST demonstrated superior clinical performance, significantly reducing the total mean time-to-collection to 21 min, compared to 60 min—often extending up to 4 h—typically required for BSU. Notably, the actual stimulation maneuver required only about 78 s. While approximately half of the BSU samples were contaminated, BST markedly decreased this rate (16% vs. 58%). Factors associated with the highest procedural success included patient age ≤ 3 months, weight ≤ 6000 g, and remaining calm during the procedure. Infant sex did not significantly affect success rates. Conclusions: Functioning as both an “operational accelerator” and a “diagnostic firewall,” the BST mitigates the inherent limitations of conventional methods and has the potential to replace the traditional urine bag. By offering a rapid, predictable, and clean alternative, it facilitates the swift initiation of accurate treatment and helps prevent families from leaving the ED before sample collection.

Children doi: 10.3390/children13080998

Authors: Dejan Dobrijević Kristian Pastor Mirjana Stojšić

Introduction: Restrictive diets are increasingly encountered in pediatric practice and may be adopted voluntarily or prescribed for medical conditions. Although they can support normal growth when appropriately planned, exclusion of nutritionally important foods may increase the risk of nutrient inadequacy. This narrative review examined nutritional deficiencies and laboratory monitoring in children following plant-based, food-allergy elimination, gluten-free, ketogenic, and protein-restricted diets for inherited metabolic disorders. Methods: Targeted searches of PubMed, Scopus, and Web of Science were conducted through 30 June 2026 using pediatric, diet-specific, nutritional-status, and biomarker terms. Because this was a narrative review, the literature was selected and synthesized qualitatively rather than through a formal systematic-screening process; no fixed study count, duplicate independent screening, or formal risk-of-bias assessment was performed. Professional guidelines and position papers were prioritized when discussing monitoring considerations, while pediatric studies were used to describe dietary intake, biochemical findings, clinically manifest deficiency, and growth outcomes. Results: Nutritional risks differed according to the foods or nutrients restricted. Vitamin B12 and iron were major concerns in plant-based diets, whereas cow’s milk and multiple-food elimination increased the risk of inadequate calcium, vitamin D, iodine, protein, and energy intake. Gluten-free diets were commonly associated with low fiber, iron, folate, and B-vitamin intake, particularly when refined, non-fortified products predominated. Ketogenic dietary therapy required attention to selenium, vitamin D, bone-related minerals, carnitine in selected patients, and linear growth. In phenylketonuria and related disorders, nutritional adequacy depended strongly on protein-substitute adherence and appropriate provision of essential amino acids and micronutrients. Across all dietary patterns, laboratory results required interpretation in relation to dietary intake, growth, supplementation, inflammation, medication, and the underlying condition. Across dietary patterns, inadequate intake, biochemical abnormalities, clinically manifest deficiency, and impaired growth were considered related but distinct outcomes. Conclusions: Nutritional monitoring should be individualized and based on the actual dietary restriction and clinical risk. The principal contribution of this review is a practical, risk-based framework that links the specific dietary restriction and adequacy of replacement foods with growth, symptoms, supplementation, and targeted laboratory biomarkers.

Children doi: 10.3390/children13080997

Authors: Yukiko Osada Kosuke Nakano Masayoshi Nakakuni Jun Tsuchiya Madoka Watanabe Shinji Kobayashi Miki Akabane Yoshiaki Yamamoto Akimasa Yamatani

Background/Objectives: Epilepsy treatment often continues long-term from childhood. However, evidence comparing long-term treatment persistence and adverse events (AEs) between levetiracetam (LEV) monotherapy and LEV-containing combination therapy in pediatric patients is limited. This study compared the retention rate and the rate of AEs, including irritability and insomnia, between these treatment strategies. Methods: A retrospective cohort study was conducted using data from the Pediatric Medical Information Collection System database. Patients aged ≥0 to <15 years who were diagnosed with epilepsy and prescribed with LEV, based on records registered between 1 April 2016 and 30 September 2025, were included in the study. Results: In total, 3576 patients were analyzed. Among them, 2936 were classified under the monotherapy group and 640 under the combination therapy group. The monotherapy group had a significantly higher retention rate than the combination therapy group. The two groups did not significantly differ in terms of the rates of irritability or insomnia. Conclusions: In pediatric patients with epilepsy, the retention rate of LEV monotherapy was higher than that of LEV-containing combination therapy. Meanwhile, the rates of irritability or insomnia did not substantially differ between the two groups. Based on these findings, adding LEV to other anti-seizure medications was not associated with an evident increase in the rate of irritability or insomnia. Although anti-seizure medication polytherapy has traditionally been considered to increase the risk of psychiatric and behavioral symptoms, the current study showed a different trend.

Children doi: 10.3390/children13080995

Authors: Sab Siddiq Shabnam Cheetham Clare E. Pain Eve M. D. Smith Sizheng Steven Zhao Liza J. McCann David M. Hughes

Background/Objectives: Patients with childhood-onset rheumatic diseases may be at additional risk of developing other health conditions. This systematic review aimed to (i) identify and describe the comorbidities associated with three significant childhood-onset rheumatic diseases—Juvenile Idiopathic Arthritis (JIA), Juvenile-onset Systemic Lupus Erythematosus (jSLE), and Juvenile Dermatomyositis (JDM); (ii) describe comorbidity prevalence and incidence reported as apparent in childhood or adulthood, and (iii) compare these comorbidity estimates with control groups. Methods: PubMed, Web of Science, and Scopus databases were systematically searched without restrictions, in accordance with PRISMA guidelines. Where three or more studies reported the same comorbidity, a meta-analysis was performed using random-effect models. The risk of bias and study quality were assessed using an adjusted version of the Newcastle–Ottawa Scale. Results: Comorbidities were reported in 136,072 patients, of which 115,062 (84.56%) presented in childhood. There was significant heterogeneity within the results. The comorbidities presenting in childhood were uveitis (13.95%, 95% CI 11.79–16.43) in JIA patients, chronic kidney disease (48.38%, 95% CI 0.67–99.24) in jSLE patients, and calcinosis (29.70%, 95% CI 25.91–33.81) in JDM patients. The comorbidities identified in adult populations with childhood-onset rheumatic disease were uveitis (14.46%, 95% CI9.76–20.90) in JIA, hypertension (18.30%, 95% CI 7.52–38.16) in jSLE, and calcinosis (40.37%, 19.02–66.11) in JDM patients. Almost all comorbidities that were compared to control groups were more common in patients with childhood-onset rheumatic disease if statistically significant. Conclusions: Uveitis, chronic kidney disease/hypertension and calcinosis were most commonly identified among JIA, jSLE and JDM patients, respectively. Patients with the three childhood-onset rheumatic diseases evaluated in this systematic review were often found to be at higher risk of comorbidities compared to controls. This finding supports the need for the proactive, multidisciplinary management of comorbidities by clinicians and highlights the breadth of disease burden for patients.

Children doi: 10.3390/children13080996

Authors: Daniela Pia Rosaria Chieffo Federica Moriconi Valentina Delle Donne Valentina Arcangeli Valentina Massaroni Angelica Marfoli Luca Liberati Giulia Settimi Brenno Martelli Sofia Vannuccini Chiara Veredice Gabriele Sani Eugenio Maria Mercuri

Background: Neurodevelopmental disorders, including Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), and Specific Learning Disorder (SLD), as well as neuromuscular conditions such as Duchenne Muscular Dystrophy (DMD), are frequently associated with emotional and behavioral difficulties that may affect children’s functioning and family well-being. However, direct comparisons across these heterogeneous clinical populations remain limited. This study aimed to compare emotional and behavioral profiles across children and adolescents with ASD, ADHD, SLD, and DMD using the Child Behavior Checklist (CBCL/6–18). Methods: This cross-sectional comparative study included 197 children and adolescents (ASD: 47; SLD: 50; ADHD: 50; DMD: 50) assessed at the Clinical Psychology Unit of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Rome, Italy) between 2017 and 2024. Emotional and behavioral functioning was evaluated using the parent-report CBCL/6–18. Group differences were examined using one-way ANOVA or Welch’s ANOVA, as appropriate, followed by Tukey’s HSD or Games–Howell post hoc comparisons. Results: Significant group differences emerged for Internalizing Problems, Externalizing Problems, and Total Problems (all p < 0.001). ADHD showed the highest overall emotional and behavioral burden, with 76% of participants scoring in the clinical range for both Internalizing and Total Problems and 60% for Externalizing Problems. Elevated internalizing difficulties characterized ASD and SLD, whereas children with DMD showed generally lower CBCL scores, although 26% fell within the clinical range for Internalizing Problems. Effect sizes were moderate to large (η2 = 0.168–0.273), supporting the presence of both shared and disorder-specific emotional and behavioral patterns across heterogeneous developmental conditions. Conclusions: The findings highlight the heterogeneity of emotional–behavioral profiles across neurodevelopmental and neuromuscular conditions. The use of a common standardized assessment framework enabled the identification of both shared and disorder-specific patterns, supporting the potential value of a transdiagnostic approach to individualized assessment. Future longitudinal and multi-informant studies are warranted to clarify developmental trajectories and improve the identification of clinically meaningful emotional and behavioral needs across heterogeneous pediatric populations.

Children doi: 10.3390/children13080994

Authors: Biagio Nicolosi Emanuele Buccione Hamilton Dollaku Benedetta Virginia Difalco Eleonora Salutini Alessandra Martin Martina Certini Sara Cappelli Alessia Spano Gianluca Castiello Flavio Facchini Guido Ciprandi

Background/Objectives: Pediatric mild-to-moderate burns require careful management in the early phase, yet evidence guiding optimal initial dressing selection remains limited. Although topical medications and specialized dressings are routinely used, a universally accepted standard of care is lacking. Methods: We conducted a 1-year, real-world, retrospective, comparative, single-center study evaluating whether treatment with enzyme alginogel (Flaminal®) or NaOCl 0.05% antiseptic in the first 24 h led to different outcomes in terms of healing time, lesion progression, complication occurrence, scar quality, and burden of care. Medical records of 80 children with mild-to-moderate burns (Total Body Surface Area < 15%) treated between January and December 2024 were analyzed. Results: Despite a higher proportion of deep burns, early treatment with enzyme alginogel was associated with a 6.17-day [95% Confidence Interval: 4.71–7.63 days] shorter healing time (p < 0.001), with no observed lesion worsening or need for early surgery. The complication rate was 14% in the enzyme alginogel group, while all patients receiving antiseptic dressing had at least one complication (p < 0.001). Patients treated with enzyme alginogel also showed better Vancouver Scar Score [2.95 points, 95% Confidence Interval: 2.33–3.23, p < 0.001] and fewer follow-up visits, supporting a direct relationship between healing time and scar outcomes, and suggesting a potential reduction in the burden of care. Conclusions: Early management with alginogel favored healing, reduced complications, improved scar outcomes, and reduced burden of care in comparison to the initial treatment with NaOCl-based antiseptic dressings followed by treatment change when clinically indicated. Prospective, comparative, randomized studies are needed to confirm these findings.

Children doi: 10.3390/children13080993

Authors: Debopam Samanta

Developmental and/or epileptic encephalopathy with spike-wave activation in sleep (D/EE-SWAS), previously described as continuous spike-wave during slow-wave sleep (CSWS) or electrical status epilepticus in sleep (ESES), is a childhood-onset disorder characterized by cognitive, language, behavioral, and/or motor regression or stagnation associated with marked activation of epileptiform discharges during non-rapid eye movement sleep. Three themes are central to the evolving understanding of D/EE-SWAS. First, it is a network disorder in which thalamocortical dysfunction, impaired sleep-dependent synaptic homeostasis, and potentially neuroinflammatory mechanisms contribute to neurodevelopmental deterioration. Second, increasing recognition of its genetic and structural heterogeneity is reshaping diagnostic evaluation. Monogenic etiologies are identified in up to one-third of cases, with a higher yield in the developmental and epileptic encephalopathy subtype, supporting early genomic testing alongside prolonged sleep EEG, MRI, and serial neuropsychological assessment. Third, treatment remains empiric and constrained by limited comparative evidence. Corticosteroids retain the strongest evidence base for cognitive improvement, although the overall certainty of this evidence remains low to moderate. Benzodiazepines are commonly used alternatives, and epilepsy surgery can provide substantial benefit in appropriately selected patients with focal structural abnormalities. Emerging etiology-directed therapies, including L-serine for selected GRIN loss-of-function variants and primidone for TRPM3-related disease, illustrate a broader transition from syndrome-based to precision management. However, no pharmacological therapy is specifically approved for D/EE-SWAS, long-term neurodevelopmental morbidity remains common, and adequately powered trials using standardized EEG and neurocognitive outcomes are urgently needed.

Children doi: 10.3390/children13080992

Authors: Rossella D’Alessandro Francesca Re Martina Vacchetti Francesca Sertori Luca Arletti Alice Campagna Giulio Gadaleta Tiziana Enrica Mongini Federica Silvia Ricci

Background: Duchenne muscular dystrophy (DMD) is an X-linked disorder caused by out-of-frame variants in the DMD gene, resulting in dystrophin deficiency and progressive muscle degeneration. Beyond motor involvement, evidence links DMD to cognitive impairment and an emotional–behavioral (EB) burden, potentially related to the altered expression of brain dystrophin isoforms (Dp71, Dp140, Dp427). Objectives: To screen for major neurodevelopmental, cognitive and/or EB difficulties in a monocentric cohort of children with DMD. Methods: This cross-sectional study included 21 children with DMD. Neuropsychiatric difficulties were assessed using a multimodal psychometric battery. Cognitive, neurodevelopmental and genetic data were retrospectively collected and analyzed. Results: In the cohort, attention-deficit/hyperactivity disorder (ADHD)-related findings were predominantly inattentive, with 3/20 children (15.0%) scoring within the clinical range on at least one inattention subscale. For measures assessing autism spectrum disorder (ASD)-related features, scores above the normative cutoff emerged in 7/20 children (35.0%), while only 2/20 (10.0%) scored within the clinical range. Internalizing problems represented the predominant EB difficulties, and emotional dysregulation (ED) emerged as a plausible area of vulnerability in the cohort. Among the 11 of 21 children with available Full-Scale Intelligence Quotient (FSIQ) data, five (45.5%) had an FSIQ below 85. Of these, four of five (80.0%) presented the predicted Dp140−/Dp71+ brain dystrophin isoform expression pattern, whereas one of five (20.0%) presented the Dp140+/Dp71+ pattern. Conclusions: Children with DMD showed heterogeneous neuropsychiatric and cognitive features in the employed screening battery. These preliminary findings, if confirmed in larger cohorts, support the potential of a broader neuropsychiatric screening assessment to optimize care pathways.

Children doi: 10.3390/children13080991

Authors: Ju Ae Shin Min Soo Kim Moon-Yeon Oh

Background/Objectives: Pulmonary hemorrhage (PH) is a life-threatening complication of prematurity associated with patent ductus arteriosus (PDA). Whether PDA treatment timing reduces PH risk remains uncertain because treatment strategies reflect underlying illness severity. We examined PH risk across recorded PDA treatment strategy categories in a national very low birth weight (VLBW) cohort. Methods: We analyzed Korean Neonatal Network (KNN) registry data (2013–2024) using propensity score inverse probability weighting (IPW) to compare recorded PDA treatment strategies among VLBW infants. Sensitivity analyses addressed treatment-opportunity bias, temporal confounding, and positivity violations. Results: Among 23,500 VLBW infants, 1179 (5.0%) developed PH. PH rates were 4.5% (pre-symptomatic), 10.0% (symptomatic treated), 12.3% (symptomatic untreated), 9.9% (prophylactic), and 2.3% (asymptomatic untreated). In IPW analyses, pre-symptomatic treatment consistently showed lower PH risk versus symptomatic treatment (OR 0.57, 95% CI 0.46–0.72) and symptomatic untreated PDA (OR 0.51, 95% CI 0.39–0.66), across sensitivity analyses. Prophylactic treatment showed higher PH risk than pre-symptomatic treatment (OR 1.97, 95% CI 1.31–2.96) and did not differ from symptomatic treatment. Subgroup analyses showed stronger associations in moderately preterm infants, with significant effect modification by gestational age (interaction p = 0.011) and birth weight (interaction p = 0.007). Conclusions: In this national VLBW cohort, infants with a recorded pre-symptomatic PDA treatment strategy had lower observed pulmonary hemorrhage rates compared with those receiving symptomatic treatment, after propensity score adjustment. Prophylactic treatment was not associated with lower PH risk compared with symptomatic treatment but showed higher PH risk than pre-symptomatic treatment. Given the observational design and absence of PH event timing data, causal inferences cannot be drawn. These hypothesis-generating findings support prospective evaluation of risk-based, pre-symptomatic PDA treatment strategies and do not support universal prophylaxis as a pulmonary hemorrhage prevention measure in VLBW infants.

Children doi: 10.3390/children13080990

Authors: Florin Mihai Sandor Roxana Furau Florina Buleu Diana Camelia Bonte Daian-Ionel Popa Tiberiu Buleu Izabella Petre Oana Suciu Cristian George Furau Cris Virgiliu Precup Ion Petre

Background/Objectives: Adolescent pregnancy is associated with an increased risk of adverse neonatal outcomes, including low birth weight, preterm birth, and impaired neonatal adaptation. While maternal age is a well-established determinant, the independent role of parity in this population remains uncertain. This study aimed to assess the association between parity and neonatal outcomes in adolescent mothers. Methods: We conducted a retrospective cohort study including 751 singleton live-birth deliveries to adolescent mothers aged <18 years at a Romanian secondary-care hospital. The unit of analysis was the delivery episode recorded in the institutional birth registry. Mothers were classified according to parity at the time of the index delivery as primiparous or multiparous. Neonatal outcomes included low birth weight (<2500 g), preterm birth (<37 weeks), Apgar score < 7 at 5 min, and a composite adverse neonatal outcome. Multivariable logistic regression models were used to evaluate the association between parity and neonatal outcomes, adjusting for maternal age (<15 vs. ≥15 years), gestational age, and mode of delivery, as appropriate. Results: A total of 751 singleton live-birth delivery episodes were included; 609 (81.1%) occurred in primiparous adolescents and 142 (18.9%) in multiparous adolescents. Parity was not significantly associated with preterm birth (aOR 0.86, 95% CI 0.48–1.56, p = 0.622), Apgar score < 7 at 5 min, or the composite adverse neonatal outcome. Maternal age < 15 years and gestational age were independently associated with Apgar score < 7 at 5 min. Multiparity was associated with lower odds of low birth weight (aOR 0.40, 95% CI 0.17–0.92, p = 0.031). Conclusions: Parity was not independently associated with most neonatal outcomes in adolescent pregnancies. Multiparity was associated with lower odds of low birth weight, but this finding should be interpreted cautiously because residual confounding cannot be excluded.

Children doi: 10.3390/children13080989

Authors: Ronja Marquardt Simon Hundeshagen Felix Tilsen Frank Tavassol Waldemar Reich

Background: Neuroblastoma is a common extracranial solid malignant tumor of early childhood; however, mandibular involvement is rare and may mimic odontogenic or inflammatory disease. Case Presentation: We report an 8-month-old girl with left paramandibular swelling initially suspected to represent parotitis or odontogenic inflammation. Imaging revealed a destructive mandibular lesion with sunburst periosteal reaction, and histology confirmed undifferentiated neuroblastoma. Staging identified a left primary adrenal tumor with extensive bone marrow infiltration and MYCN proto-oncogene amplification. The patient received multimodal high-risk neuroblastoma therapy, including chemotherapy, surgery, autologous stem cell transplantation, proton therapy, antibody therapy, and Lorlatinib. Despite radiological remission, she developed severe pulmonary complications and died shortly before the age of five years. Methods: A focused literature review was conducted to identify published pediatric cases of metastatic neuroblastoma involving the mandible. Results: Through our review, we identified 31 published pediatric cases of mandibular metastatic neuroblastoma. Reported cases most commonly described mandibular swelling, pain, tooth mobility, and facial asymmetry. Most mandibular lesions represented metastatic disease from an adrenal or abdominal primary tumor. Conclusions: Mandibular involvement of neuroblastoma is rare but clinically important. In infants and young children, persistent or atypical (para-/peri)mandibular swelling should not be assumed to be odontogenic or inflammatory. Early imaging, biopsy, and interdisciplinary referral are essential for timely diagnosis and treatment.

Children doi: 10.3390/children13080988

Authors: Taekyung Lee Jihyun Kwon Yeonsu Oh Han Eol Cho Dong-wook Rha Juntaek Hong

Background: The timing and efficacy of Achilles tendon lengthening (ATL) in Duchenne muscular dystrophy (DMD) remain controversial because indiscriminate surgery can accelerate ambulation loss. Case Description: This report presents a 5-year longitudinal comparative analysis (2021–2026) of monozygotic twins with identical genetic backgrounds (DMD exon 30–43 deletion) who received comparable rehabilitation and pharmacological management, including concurrent gene therapy in 2025. Twin A was managed conservatively with orthosis and subsequent serial casting for progressive equinus contracture, whereas Twin B underwent early bilateral ATL during transition to the non-ambulatory phase. Despite a temporary postoperative decline, Twin B demonstrated a more stable longitudinal motor trajectory, outperforming Twin A in gross motor function (Gross Motor Function Measure-88: 38.60% vs. 32.85% in 2026) by preserving residual standing and crawling dimensions. Longitudinal KIDSCREEN-52 assessments revealed a clinically meaningful improvement in psychological well-being in Twin B (+10.9 points) relative to Twin A. Conclusions: This single-pair twin case serves as a hypothesis-generating observation, highlighting a potential longitudinal association between early surgery and attenuated progressive motor decline within a multi-disciplinary care regimen. Given highly variable psychosocial outcomes, these trends cannot be directly attributed to surgery alone. When evaluating such orthopedic interventions, clinical decisions may benefit from looking beyond immediate gait metrics toward broader, long-term functional trends, though the relative contributions of concurrent therapies remain to be elucidated.

Children doi: 10.3390/children13080987

Authors: Marion Comajuan Sabine Plancoulaine Caroline Demily Marie Noelle Babinet Julien Lioret Lisa Brunel Leana Rivet Carmen M. Schröder Aurore Guyon Patricia Franco

Background: Smith–Magenis syndrome (SMS) is a rare neurodevelopmental disorder characterized by severe sleep disturbances, circadian rhythm dysregulation, and prominent behavioral difficulties. Objective: To examine associations between subjective and objective sleep and circadian characteristics and behavioral difficulties in children with SMS in real life. Methods: Children aged 5–13 years with genetically confirmed SMS were included in a prospective single-center cohort study. Sleep and circadian rhythms were assessed using parent-reported questionnaires (Sleep Disturbance Scale for Children (SDSC), Horne and Östberg Morningness–Eveningness Questionnaire (H&O)) and 15-day home-based wrist actigraphy. Behavioral difficulties were evaluated using the Aberrant Behavior Checklist-Community (ABC-C). Associations between subjective and objective sleep and circadian measures with behavioral difficulties were studied using Spearman correlations for each ABC-C subscale. Results: Among the 20 children included (55% female, mean age 10 ± 2.5 years), 75% were carriers of a 17p11.2 microdeletion and 25% had an RAI1 mutation. Overall, 95% of children were treated with melatonin, 55% with psychostimulants and 20% with beta-blockers. According to the SDSC results, pathological sleep disturbances were present in 14/20 (70%) children and concerned mainly complaints of insomnia (10/20, 50%) and excessive daytime sleepiness (8/20, 40%). The H&O chronotypes confirmed the morning type in 70% of patients. Sleep and circadian measures obtained by actigraphy showed reduced total sleep time in 71% of the children, reduced sleep efficiency in 88%, long wake after sleep onset (WASO > 60 min) in 59%, as well as an early L5 onset (5 h period with the least movements < 23:38) and M10 onset (10 h period with the highest activity levels < 09:12) in 92% and 62% of children, respectively. The behavioral domains of the ABC-C with the highest scores were hyperactivity (mean 52.1, range 2.1–97.9) and irritability, agitation, and crying (mean 46.9, range 17.8–82.2). In the analysis of the relationship between behavior and sleep, a positive correlation was found between sleep disorders and stereotyped behaviors (r = 0.472, p = 0.048), insomnia and irritability, social withdrawal and stereotyped behaviors (r = 0.472, p = 0.048; r = 0.701, p = 0.001; and r = 0.648, p = 0.004, respectively), and non-restorative sleep and inappropriate speech (r = 0.476, p = 0.046). No significant association was found between objective sleep measures and behaviors. While subjective assessments suggested that a stronger morning chronotype was associated with lower irritability (r = −0.565, p = 0.015), actigraphy-derived circadian rhythm analyses revealed that an earlier L5 onset was associated with greater social withdrawal and hyperactivity (r = −0.556, p = 0.048 and r = −0.560, p = 0.049, respectively). Conclusions: The present cohort study of children with SMS studied in real-life conditions, using both objective and subjective measures, shows that patients continued to experience sleep and behavioral disturbances despite treatment. Exploratory analyses identified distinct associations between subjective sleep disturbances, circadian rhythm characteristics, and specific behavioral domains. While subjective sleep disturbances were associated with irritability, stereotypic behavior, and inappropriate speech, circadian rhythm parameters are specifically associated with hyperactivity. Both were also associated with social withdrawal. As these findings arise from an exploratory observational secondary analysis, they should be considered hypothesis-generating and require confirmation in larger prospective studies. If confirmed, they may help identify sleep and circadian rhythm characteristics as potential targets for future interventions in children with SMS.

Children doi: 10.3390/children13080985

Authors: Derya Azim Sevde Betül Kara Muhammed Emre Güvey Ecenur Aydemir Sümeyra Gündem Salim Yılmaz

Background/Objectives: Adolescent somatic symptoms such as headache, irritability, and sleep difficulties are common and closely tied to adolescent mental health, yet they are typically studied as a single dimension and as individual complaints detached from the psychosocial adversity surrounding the adolescent. Drawing on the nationally representative 2022 Türkiye Child Survey (n = 3523, ages 13–17), we examined whether these symptoms are patterned by the psychosocial risk and support surrounding the adolescent. Methods: Measurement models, multiple correspondence analysis, survey-weighted ordinal regression, a mixed graphical model, and machine-learning algorithms were applied in sequence. Results: Somatic symptoms were organized around a dominant general factor, alongside closely correlated physical and psychological dimensions that showed differential external associations. The three relational microsystems formed a coherent psychosocial adversity gradient along which somatic burden increased. The two dimensions were linked to different factors: peer victimization, a risk factor, and parental support, a protective factor, were associated primarily with psychological burden (odds ratios per standard deviation 1.84 and 0.88), whereas female sex and chronic illness were linked more strongly to physical burden (2.35 and 1.61); body mass index, income strain, and housing problems showed no independent associations. Regression, network, and machine-learning analyses converged on this dissociation while indicating modest individual-level predictability. Conclusions: Adolescent somatic symptoms are thus systematically patterned by psychosocial risk and support at the population level, an association that may inform monitoring and psychosocially informed assessment rather than individual prediction, and that requires longitudinal work to interpret directionally.

Children doi: 10.3390/children13080986

Authors: Franziska Markel Bettina Lück Michael Sasse Philipp Jung Florian Hoffmann Ellen Heimberg Martin Olivieri Sebastian Brenner Bernd Landsleitner Francesco Cardona Eva Maria Jordi-Ritz Benjamin W. Ackermann

Background: Implementing recommendations to improve in-hospital resuscitation is a complex process. The extent to which an advisory statement formulating ten theses to improve resuscitation quality in paediatrics is applied in clinical practice across Germany, Austria, and Switzerland (D-A-CH-region) remains unclear. Methods: A web-based cross-sectional survey was conducted among paediatric physicians in the D-A-CH region between November 2022 and May 2023, comprising 50 questions focusing on experience and safety in paediatric emergency management and on the structural conditions at hospitals required to implement the ten theses. Ethics approval was obtained from the Ethics Committee Leipzig, Germany (218/19-ek). Results: Structural recommendations were implemented to varying and often limited degrees: An emergency telephone chain was available in 91% of workplaces, 19% had a Paediatric Early Warning System, and 38% had a designated resuscitation supervisor. Although in-house training was available to 89% of respondents, 31% had not participated in in-house training in the preceding 12 months, and 37% had not attended a certified resuscitation course in the last five years. A total of 48% of respondents reported that structured debriefings following emergency events were rarely or never conducted. Internal guidelines for post-resuscitation care were available in 26% of institutions. Only seven respondents (less than 1%) worked in a setting where all the recommendations surveyed were in place. No significant differences were observed according to hospital size or type. Conclusions: Structural implementation of paediatric resuscitation recommendations remains markedly inadequate across the D-A-CH region, with likely multifactorial causes that are not yet fully understood.

Children doi: 10.3390/children13080984

Authors: Ayfer Aydın Merve Ertunç Soycan Özlem Şensoy Hülya Dalkılıç Bingöl Rejin Kebudi

Background/Objectives: Empathy is a fundamental component of pediatric oncology nursing. This study aims to examine in depth how nurses working in pediatric oncology define empathy, experience it in clinical practice, and manage emotional and professional boundaries in the empathetic care process. Methods: A qualitative research design was used. Semi-structured individual interviews were conducted with 17 nurses with at least 2 years of experience in pediatric hematology-oncology units. The interviews were conducted via Zoom. Data were analyzed using Braun and Clarke’s thematic analysis, and data collection continued until thematic saturation was achieved. Results: Three main themes were identified: Understanding Empathy, The Journey of Empathy, and The Cost of Empathy. Nurses defined empathy as an indispensable part of high-quality pediatric oncology care; however, they reported conceptual uncertainty in distinguishing empathy from sympathy and indecision regarding appropriate emotional boundaries. Empathy was perceived as a dynamic process shaped more by clinical experience than formal education. Early professional experiences were often characterized by emotional distress, while increasing experience enabled nurses to regulate their emotions and adopt more sustainable empathic practices. Despite this adaptation, prolonged exposure to children’s suffering and death was associated with compassion fatigue and emotional exhaustion. The absence of structured empathy training and formal emotional support systems further intensified these challenges. Conclusions: In pediatric oncology nursing, empathy is a complex, evolving professional competency that demands continuous emotional regulation and boundary management. Structured empathy training, reflective supervision, and strengthening institutional support mechanisms are essential to promote sustainable empathic care while protecting nurses’ emotional well-being.

Children doi: 10.3390/children13080983

Authors: Mattia Pasquinucci Martina Avesani Anna La Rosa Maria Elena Derchi Davide Meneghesso Davide Buffi Federico Prefumo Laura Tralli Michela Marchesini Anna Nocerino Alessandra Grison Claudia Santagati Giulia Bordin Gabriele De Tonetti Elena Sofia Milandri Giovanni Di Salvo Gianluca Trocchio

Background/Objectives: Isolated Left Ventricular Apical Hypoplasia (ILVAH) is a rare congenital anomaly characterized by a truncated, spherical left ventricle (LV) with fibro-fatty apical replacement. Historically considered a benign condition of asymptomatic adults, its hemodynamic behavior under physiological stress remains poorly characterized. We present two distinct cases and a comprehensive literature review (n = 59) to redefine the clinical spectrum of ILVAH. Methods: To contextualize our findings, a comprehensive review of the literature was performed up to February 2026. We searched the PubMed/MEDLINE database using the terms “Isolated Left Ventricular Apical Hypoplasia”, “ILVAH”, “truncated left ventricle”, and “left ventricular apical hypoplasia”. The literature search and study selection were conducted in accordance with the PRISMA guidelines. Case presentations: Case 1 describes a male infant with ILVAH and muscular ventricular septal defects who unexpectedly developed transient systolic heart failure at one month of life, requiring prompt medical therapy (ACE inhibitors and diuretics) for functional recovery. Case 2 describes a 33-year-old woman with a known diagnosis of ILVAH. Serial echocardiography during her first pregnancy revealed progressive left atrial dilation and the onset of mild post-capillary pulmonary hypertension. Immediately following an elective cesarean section at 37 weeks, she experienced acute heart failure. She was successfully managed with pre-emptive volume offloading. Conclusions: ILVAH is not a universally benign anomaly. The morphologically deficient and rigid ventricle is vulnerable to afterload shifts in infancy and rapid volume expansion in adulthood. A review of all previously reported pregnancies in ILVAH reveals a consistent pattern of severe, unrecognized postpartum pulmonary edema. Proactive, multidisciplinary management is suggested to prevent clinical decompensation. Our findings suggest that ILVAH may act as a stress-sensitive restrictive congenital left ventricle disease rather than a universally benign anatomical variant, a hypothesis that warrants further investigation.

Children doi: 10.3390/children13080982

Authors: Tobias Jhala Lea Berger Jonathan Aichner Markus Lehner Justus Lieber Jörg Fuchs

Topic: What are the epidemiology, mechanisms, management strategies, and visual outcomes of traumatic orbital compartment syndrome (OCS) in children? Clinical relevance: Traumatic OCS is a rare but vision-threatening emergency requiring rapid recognition and intervention. In children, diagnosis and management are challenging due to age-specific anatomy, limited cooperation, and heterogeneous trauma mechanisms. Current management strategies are largely extrapolated from adult data, and no pediatric-focused systematic synthesis is available. Methods: A systematic review was conducted in accordance with PRISMA guidelines. Embase, PubMed, and Web of Science were searched from inception to 10 December 2023, with an update on 9 October 2024 and 8 April 2025 using terms related to orbital compartment syndrome, orbital hematoma, trauma, and a validated pediatric search filter. Eligible studies included case reports and case series describing traumatic OCS in patients younger than 18 years. Three reviewers independently screened studies, extracted data, and assessed risk of bias using the Joanna Briggs Institute critical appraisal checklists for case reports and case series. Due to substantial heterogeneity, results were synthesized descriptively. The review protocol was registered prospectively in PROSPERO (CRD420251028845). Results: Of 1317 screened records, 90 studies were included, comprising 126 pediatric patients. Mean age was 10 years, with a male predominance (3.8:1). Falls and direct head trauma were the most common injury mechanisms. Subperiosteal hematoma was the predominant underlying pathology. Eleven patients had documented coagulopathies, frequently associated with extensive extracranial hematomas. Clinical presentation commonly included proptosis and visual symptoms, with onset either immediately after trauma or delayed by 4–7 days. Management strategies included observation (18/126), medical therapy (24/126), and surgical intervention (103/126; 70 as primary treatment). At a mean follow-up of 109 days, visual impairment was reported in 21 patients. Earlier surgical intervention was consistently associated with more favorable visual outcomes, although certainty of evidence was very low. Conclusions: Evidence limited to case reports and small case series suggests that pediatric OCS differs from adult disease with regard to epidemiology and underlying pathophysiology. Despite very low certainty of evidence, consistent patterns support a time-critical, clinically driven management approach. A pragmatic diagnostic and treatment algorithm is proposed to support early recognition and timely intervention in children with suspected OCS.

Children doi: 10.3390/children13080981

Authors: Susmitha Nagula Nasreen Ahmed Kryss Shane Anthony D. Slonim

Medical gaslighting has emerged as a widely used term describing situations in which patients or caregivers perceive that their symptoms are minimized, dismissed, or prematurely attributed to psychological causes without adequate clinical evaluation. Although the term has gained prominence through patient narratives and public discourse, many of the underlying mechanisms correspond to well-established contributors to diagnostic error, including cognitive bias, communication failures, and diagnostic overshadowing. In pediatric care, these challenges are amplified because clinicians frequently rely upon caregiver-mediated histories while children may have a limited ability to communicate evolving symptoms. This narrative review examines medical gaslighting through the framework of diagnostic safety and explores how epistemic injustice, cognitive bias, and failures in information gathering and interpretation may contribute to delayed, missed, or incorrect diagnoses. Relevant literature was identified through a structured narrative review of publications addressing diagnostic error, cognitive bias, epistemic injustice, diagnostic safety, and pediatric communication. The literature was synthesized conceptually to develop an integrated framework linking patient experiences with established diagnostic safety models. We propose that reframing medical gaslighting as a diagnostic safety vulnerability rather than an allegation of clinician misconduct provides opportunities for measurable quality improvement through enhanced communication, structured reassessment, cognitive debiasing strategies, and integration of patient- and caregiver-reported information into diagnostic reasoning.

Children doi: 10.3390/children13080979

Authors: María Fernández-Guarido María Pilar Diéguez-Poncela Laura Ruiz-Azcona

Background/Objectives: Children with autism spectrum disorder (ASD) present unique challenges in pain assessment and management because of differences in communication, sensory processing, and pain expression, increasing the risk of pain underrecognition and inadequate treatment. This scoping review aimed to map and synthesize current evidence on pain processing, expression, assessment, and management in children with ASD, identify available pain assessment tools and interventions, and examine the contribution of individualized therapeutic environments to pain management. Methods: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). PubMed, Scopus, and Web of Science were systematically searched for studies published between January 2020 and December 2025. Search strategies combined Medical Subject Headings (MeSH) and free-text terms. Two reviewers independently screened studies extracted data using a standardized form, and synthesized findings narratively. No formal methodological quality appraisal was undertaken, consistent with PRISMA-ScR recommendations. Results: Included studies demonstrated substantial heterogeneity in pain perception and expression, with atypical behavioral responses, sensory differences, and communication difficulties frequently hindering pain recognition. Individualized, multidimensional pain assessment integrating behavioral observation, caregiver reports, and validated assessment tools was consistently supported. Sensory adaptations, tailored communication strategies, caregiver involvement, distraction techniques, and virtual reality showed potential to improve pain-related experiences and reduce procedural distress. However, evidence remained predominantly observational, methodologically heterogeneous, and limited by few psychometrically validated ASD-specific assessment instruments and the absence of standardized clinical protocols. Conclusions: Current evidence supports individualized, multidisciplinary pain assessment and management for children with ASD. Nevertheless, substantial evidence gaps remain, highlighting the need for validated ASD-specific assessment tools, standardized clinical protocols, and high-quality studies evaluating pharmacological, non-pharmacological, and technology-assisted interventions.

Children doi: 10.3390/children13080980

Authors: Yasuaki Kusumoto Eri Takahashi Yasuhiro Endo Kanako Okazaki Akihiko Asao Yoshinobu Tanaka

Background/Objectives: This study evaluated the impact of short-duration physical exercise sessions and daily exercise recordings on the physical health and psychological health of junior high school students in Japan. Methods: A 3-month longitudinal school-based intervention initially enrolled 235 students, and the final analysis included 127 students who completed the program. The study was conducted using a single-arm pre–post design without a control group. The intervention included biweekly group exercise sessions and daily activity recordings. Students were separated into two groups based on their screen time (≥4 h per day or <4 h per day). Results: After the intervention, a significant decrease in screen time was observed in the group with baseline screen time of 4 h or more, whereas the group with baseline screen time of less than 4 h showed an increase in daily screen time. The results indicated a significant increase in body mass index and trunk muscle mass in both groups. For psychological measures, including the General Self-Efficacy Scale and Communicative and Critical Health Literacy scale, no significant changes over time or group × time interactions were observed, although post-intervention scores were significantly higher in the lower screen time group compared to the higher screen time group. However, significant changes in skeletal muscle index, eHealth literacy, and sleep duration were not observed. Conclusions: Due to the lack of a control group, these findings remain preliminary, and observed changes cannot be definitively attributed solely to the intervention. However, the program showed potential in reducing excessive screen time and increasing trunk muscle mass. Future randomized controlled trials are required to confirm the true efficacy of the intervention.

Children doi: 10.3390/children13080978

Authors: Harshkumar R. Patel Mohan Pammi

Necrotizing enterocolitis (NEC) remains one of the most devastating gastrointestinal disorders affecting preterm infants, with substantial mortality and long-term morbidity despite advances in neonatal care. Increasing evidence implicates intestinal dysbiosis, impaired intestinal barrier function, and dysregulated immune responses as central drivers of NEC pathogenesis, making microbiome-targeted interventions a promising preventive strategy. Collectively termed “biotics,” these interventions include probiotics, prebiotics, synbiotics, and postbiotics, each aimed at modulating the developing gut ecosystem. This narrative review summarizes current evidence on the efficacy, safety, and clinical applicability of biotics for NEC prevention in very preterm and very-low-birth-weight infants. Randomized controlled trials and meta-analyses involving more than 10,000 infants demonstrate that specific multi-strain probiotic formulations, particularly those combining Lactobacillus and Bifidobacterium species, reduce NEC incidence and all-cause mortality, although benefits are less consistent in extremely low-birth-weight infants. Prebiotics alone showed a limited impact on NEC prevention, while emerging evidence suggests synbiotics may offer additive or superior protection compared with probiotics alone. Postbiotics represent a novel and potentially safer alternative, especially for the most vulnerable infants, though clinical data remain limited. Despite favorable effectiveness in meta-analyses, probiotics adoption remains variable due to strain heterogeneity, variable product quality, regulatory challenges, and rare but serious safety concerns. Precision microbiome approaches, pharmaceutical-grade formulations, personalized therapies informed by multi-omics profiling, and next-generation delivery systems may drive the future in this field.

Children doi: 10.3390/children13080977

Authors: Cheng-Yu Lee Dau-Ming Niu Chia-Feng Yang Yann-Jang Chen

Background/Objectives: Whole exome sequencing (WES) has emerged as a clinically valuable second-tier test following abnormal biochemical newborn screening (NBS). However, population-specific data on diagnostic yield, secondary findings (SFs), and exome-wide carrier burden remain scarce in East Asian neonates, particularly since the release of the ACMG SF v3.3 gene list. We aimed to characterize these metrics in a Taiwanese neonatal cohort. Methods: We retrospectively analyzed 118 consecutive neonates referred to Taipei Veterans General Hospital between August 2021 and August 2022 following abnormal biochemical NBS. WES was performed on the Illumina NovaSeq 6000 platform; variants were classified per the 2015 ACMG/AMP framework and re-evaluated under ACMG SF v3.3. Referral categories comprised lysosomal storage diseases (n = 61), amino acid disorders (n = 38), fatty acid oxidation disorders (n = 13), and organic acid disorders (n = 6). Results: Fifty neonates (42.4%) received confirmed molecular diagnoses and 45 (38.1%) were carriers (combined molecular resolution 80.5%). Five participants (4.2%) harbored pathogenic/likely pathogenic variants in ACMG SF v3.3 genes (TTN, LDLR, PTEN, RYR1, TP53). Incidental findings occurred in 51.7%, and at least one recessive-carrier variant was detected in 99.2% (mean 4.15 per individual; median 4). The Taiwanese-specific c.639+919G>A cardiac Fabry variant accounted for 24/25 confirmed male Fabry cases, and the p.Gly576Ser pseudodeficiency allele confounded all suspected Pompe cases. Conclusions: Second-tier WES substantially improves diagnostic precision, discriminating confirmed diagnoses from carrier, pseudodeficiency, and biochemical false-positive states. The high carrier burden and incidental-finding rate underscore the importance of comprehensive pre- and post-test genetic counseling in East Asian neonatal genomic programs.

Children doi: 10.3390/children13080976

Authors: Iulia Stratulat-Chiriac Raluca Ozana Chistol Elena Țarcă Lăcrămioara Perianu Viorel Țarcă Alina Mariela Murgu Solange Tamara Roșu Ioana-Alina Halip Valeriu Chisălău Cristina Furnică

Background/Objectives: Congenital gastrointestinal malformations (CGIMs) remain a significant cause of pediatric mortality, particularly during the neonatal period in resource-limited settings. Mortality varies widely, across conditions and healthcare systems, yet data from Eastern European centers remain limited. We aimed to determine mortality during index admission and identify baseline factors associated with death among children with CGIMs treated at our tertiary surgical center, including the COVID-19 pandemic years. Methods: We conducted a single-center retrospective study (January 2020–December 2024) of all consecutive children admitted with congenital gastrointestinal malformations. The primary outcome was death during index admission. Secondary mortality outcomes included death within 30 days of admission and 30-day postoperative mortality. Comparisons were performed between survivors and non-survivors. Data were extracted from medical records and potential risk factors of mortality were evaluated using univariable analyses and multivariable logistic regression. Statistical analysis was performed using SPSS version 31 (IBM) and a p-value of <0.05 was considered statistically significant. Results: Overall, index-admission mortality was 11.7% (27/231), with 55.6% of deaths occurring within 30 days from admission and 85.2% occurring postoperatively. Mortality was highest among patients with cloacal malformations, duodenal atresia/stenosis, and esophageal atresia ± tracheoesophageal fistula. Deaths occurring during the neonatal period accounted for 85% of all deaths. Compared with survivors, non-survivors had significantly lower birth weight, gestational age, and Apgar scores, increased ASA score, and higher rates of prematurity, syndromic conditions, associated anomalies, and sepsis. In multivariable analysis, prematurity remained independently associated with index-admission mortality (adjusted OR 3.20, 95% CI 1.23–8.31; p = 0.017). In an exploratory multivariable analysis including in-hospital complications, sepsis was strongly associated with mortality (adjusted OR 8.63, 95% CI 3.16–23.55, p < 0.001). Conclusions: Mortality during index admission remained substantial among children with congenital gastrointestinal malformations. Prematurity was the only baseline characteristic independently associated with mortality. In an exploratory analysis, sepsis identified from retrospective clinical documentation was associated with mortality. Improved care for preterm infants and prevention of severe infection may improve outcomes. Larger multicenter studies are needed to validate these findings and refine risk stratification strategies for high-risk patients.

Children doi: 10.3390/children13080975

Authors: Taner Adıgüzel Erdin Kalyoncuoğlu Gülsüm Kaya

Background: We compared biochemical, micronutrient-related and complete blood count (CBC)-derived inflammatory profiles among children with obesity, undernutrition and normal weight, and explored the discriminatory performance of selected routine laboratory markers for the obesity phenotype. Methods: In this single-centre retrospective comparative study, medical records of children aged 2–17 years evaluated between January 2023 and December 2025 were reviewed. Participants were classified as obese, undernourished or normal weight using World Health Organization (WHO) body mass index-for-age (BMI-for-age) references. Liver enzymes, lipid parameters, iron-related indices, micronutrient levels, zinc, insulin and CBC-derived inflammatory indices were compared across groups using non-parametric omnibus tests. Exploratory receiver operating characteristic (ROC) analyses were performed for selected markers. Results: A total of 690 children were included: 100 with obesity, 90 with undernutrition and 500 with normal weight. The obesity group was significantly older than the normal-weight group (median 11.0 vs. 7.5 years; p < 0.001). Obesity was characterised by higher alanine aminotransferase (ALT), insulin, triglycerides, neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI), together with lower high-density lipoprotein (HDL) cholesterol, 25-hydroxyvitamin D [25(OH)D] and aspartate aminotransferase-to-alanine aminotransferase (AST/ALT) ratio (all p < 0.05). In exploratory, age-unadjusted ROC analyses, the AST/ALT ratio yielded the highest AUC among the evaluated biomarkers (AUC 0.859; 95% CI 0.823–0.895; optimal cut-off ≤ 1.52; sensitivity 77.0%; specificity 77.6%), followed by SIRI (AUC 0.751; 95% CI 0.700–0.802). Conclusions: Pediatric obesity was associated with a distinct liver enzyme-metabolic-inflammatory laboratory profile, whereas undernutrition exhibited a different micronutrient-biochemical pattern. Because the study was retrospective and age-unadjusted, these findings should be interpreted as exploratory and hypothesis-generating. Prospective studies with age-balanced sampling, pubertal staging and liver imaging are required before clinical implementation.

Children doi: 10.3390/children13080974

Authors: Ceren Gürez Zahid Hüseyinhan

Background/Objectives: To evaluate the long-term outcomes of strabismus treatment in children with cerebral palsy (CP) and to investigate factors associated with postoperative alignment success and the development of consecutive strabismus. Methods: The retrospective, single-center study included 73 children with CP and strabismus who were followed from January 2015 to December 2024. Demographic characteristics, ophthalmological findings, treatment methods, and postoperative outcomes were assessed. Ocular deviation was measured through prism and alternate cover testing or a modified Krimsky test, and surgical success was defined as a final deviation of ≤10 prism diopters (PD). Patients were assessed at the patient level. Comparisons between exotropic and esotropic patients and between patients who had consecutive exotropia and those who had successful alignment were made using appropriate statistical tests. Results: Study participants included 55 patients with esotropia (75.3%) and 18 patients with exotropia (24.7%). The mean follow-up period was 32.6 ± 7.18 months. A successful ocular alignment was achieved in 32 of 46 patients (69.6%) with esotropia and in 10 of 17 patients (58.8%) with exotropia following surgical treatment and/or BTA. Consecutive exotropia developed exclusively in patients initially treated for esotropia (39.1% vs. 0%, p = 0.001). Patients with consecutive exotropia underwent surgery at a younger age and had larger preoperative deviation angles than those who had successful alignment, but these differences were not statistically significant. Conclusions: Strabismus treatment provides satisfactory long-term motor alignment in many children with cerebral palsy. However, consecutive exotropia following esotropia surgery remains a common postoperative condition and is the principal source of alignment instability in this population. Younger surgical age and larger preoperative deviations were more common among patients with consecutive exotropia, but no statistically significant associations between the evaluated clinical variables and consecutive exotropia were identified in the exploratory univariate analyses.

Children doi: 10.3390/children13070973

Authors: Nerea Blanco-Martínez Daniel González-Devesa Eva María Doval-Garabatos Carlos Ayán-Pérez

Background/Objectives: Early handwriting and motor skills underpin later academic success, yet robust evidence for psychomotor programs in preschoolers is limited. This study examined whether participation in a six-week psychomotor intervention was associated with changes in graphomotor performance, writing proficiency, and motor competence in preschool children. Methods: This non-randomized quasi-experimental study included pre- and post-intervention assessments and a control group. Thirty-four preschoolers were assigned by class to an intervention group (n = 19) or a control group (n = 15). For six weeks, the intervention group completed three 50 min psychomotor sessions per week targeting fine- and gross-motor abilities, whereas the control group continued its usual school routine. Graphomotor performance (Pascual Graphomotor Test), writing proficiency (seven-item teacher scale) and motor competence (Movement Assessment Battery for Children-2) were assessed one week before and after the program. Results: The intervention group showed significant improvements in graphomotor performance and all motor-skill tasks assessed. Between-group comparisons of pre–post change favored the intervention group for the total graphomotor score (mean difference = −3.14 points, 95% CI [−4.59, −1.68]; p < 0.001; Hedges’ g = −1.48) and for all four motor-skill tasks (p ≤ 0.019). At post-intervention, pencil grip was the only writing proficiency item showing a significant between-group difference (p = 0.002; Cramér’s V = 0.617), whereas no significant differences were observed for the remaining items. Conclusions: A psychomotor intervention was associated with greater improvements in motor competence and graphomotor performance compared with the control condition. However, evidence for broader improvements in writing proficiency, including handwriting legibility, was limited. Although pencil grip differed between groups at post-intervention, this finding should be interpreted cautiously because the groups already differed at baseline.

Children doi: 10.3390/children13070972

Authors: Georgios Giannakopoulos Afroditi Prassou

Background/Objectives: Non-suicidal self-injury (NSSI) in adolescence is associated with emotion dysregulation, experiential avoidance, psychiatric morbidity, and later suicidal risk. Interventions based primarily on acceptance and commitment therapy (ACT) target psychological flexibility, acceptance, cognitive defusion, and values-based action, whereas emotion regulation individual therapy for adolescents (ERITA) and internet-delivered emotion regulation individual therapy for adolescents (IERITA) principally target emotion dysregulation while incorporating selected acceptance-related and ACT-consistent components, making these approaches theoretically relevant to adolescent NSSI. Methods: We conducted a systematic review and exploratory meta-analysis informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. PubMed, Scopus, Web of Science, and EBSCO were searched on 10 April 2026. Eligible studies included adolescents or predominantly adolescent samples in which NSSI was the central clinical target or NSSI-specific outcomes were separately extractable and evaluated primarily ACT, ACT-informed, acceptance-based, ERITA, or IERITA interventions. Quantitative syntheses were restricted to controlled studies with extractable data. Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), trial registries, and dedicated regional or gray literature sources were not searched; 15 reports remained unretrieved, so the evidence base may be incomplete. Results: Six full-text primary adolescent NSSI intervention studies met inclusion criteria: two controlled primarily ACT studies, one randomized ERITA feasibility trial, two uncontrolled ERITA feasibility/open studies, and one randomized IERITA trial. The strongest single-study evidence came from therapist-guided IERITA, which reduced masked assessor-rated NSSI frequency more than treatment as usual, with an incidence rate ratio of 0.34 (95% confidence interval [CI] 0.20 to 0.57). Two-study exploratory random-effects syntheses yielded estimates in the direction of benefit for continuous NSSI outcomes, Hedges’ g = −0.45 (95% CI −0.85 to −0.05; k = 2), and process outcomes, Hedges’ g = 1.25 (95% CI 0.83 to 1.68; k = 2). These estimates are hypothesis-generating and imprecise as estimates of a generalizable treatment effect because each synthesis contained only two clinically and methodologically heterogeneous studies. Although I2 was 0% in both syntheses, these estimates are highly uncertain with only two studies and should not be interpreted as evidence of true homogeneity. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, certainty was moderate for the single masked clinician-rated IERITA outcome and very low for the pooled continuous NSSI and process-outcome evidence. Conclusions: Primarily ACT, ERITA, and IERITA interventions may be promising for adolescent NSSI, but the evidence remains preliminary and mostly of very low certainty. The pooled estimates are exploratory, hypothesis-generating, and imprecise and should not be interpreted as evidence of treatment efficacy. The strongest single-study evidence concerns therapist-guided IERITA and was rated as moderate in certainty, whereas the evidence for primarily ACT interventions and pooled process outcomes was very low in certainty and requires confirmation in larger preregistered randomized trials with standardized outcomes, longer follow-up, active comparators, and process measures.

Children doi: 10.3390/children13070971

Authors: Annabella Lewis Nadia Badawi Rod Hunt Esther Tantsis James Christie Hannah Dalrymple

Background/Objectives: Fetal MRI is used increasingly to detect fetal brain anomalies despite limited high-quality evidence. The common anomaly, ventriculomegaly, exemplifies the challenge of using fetal MRI for neurodevelopmental prognostication. Methods: This scoping review followed JBI guidelines. Four electronic databases were searched without restriction. Screened studies were eligible where they included primary data with fetal MRI showing ventriculomegaly and clinical investigations, management, or fetal outcomes. A descriptive numerical summary with data-driven bivariate and multivariate analysis of case-level data was undertaken. Results: A total of 345 studies were included (1027 cases, 121 cohorts). Fetal MRI was performed at a mean of 28 weeks’ gestation. It yielded additional or different imaging findings to US in 60.1%. Fetal results differed from neonatal MRI in 52.8%. Discrepancy between imaging modalities has increased from 1986–2025. About 69.1% of fetuses were liveborn, 28.9% were terminated and 1.9% died in utero. Postnatal neurosurgery was common after severe ventriculomegaly (36.7%). Neurodevelopmental issues were common (63.5%), especially where additional brain anomalies were detected on fetal MRI (OR 6.40 (95% CI 4.02–10.2), p < 0.001). Conclusions: Fetal MRI may contribute to neurodevelopmental prognostication in fetal ventriculomegaly in conjunction with other investigations. Available evidence is of mixed quality with variable reporting, relying on retrospective studies and non-standardized outcome measures. Long-term prospective studies are required.

Children doi: 10.3390/children13070970

Authors: Rafael Clavero-Prados Flavia Estefanía Amar-Cantos Javier Murillo-Moraño José Manuel Armada-Crespo Álvaro Morente-Montero Juan de Dios Benítez-Sillero

Background/Objectives: Bullying represents a serious threat to the physical, psychological, and social well-being of students, with particular relevance in Physical Education (PE) contexts, where the physical and competitive nature of the setting may facilitate specific forms of aggression. Despite growing research interest, evidence on the prevalence and distribution of bullying roles and typologies within PE remains limited, particularly in primary education. This study aimed to analyse the prevalence of bullying victimisation, perpetration, and bully-victim profiles among primary school pupils in PE, as well as to examine differences by sex and year group across the different forms of bullying behaviour. Methods: A cross-sectional study was conducted with an analytical sample of 831 pupils from Year 3 to Year 6 of compulsory primary education in Córdoba, Spain. Bullying roles and typologies were assessed using a validated self-report instrument. Differences by sex and year group were examined through appropriate inferential analyses. Results: A total of 21.1% of pupils were identified as victims, 5% as perpetrators, and 8.5% as bully-victims. The most frequent form of perpetration was exclusion/rejection (7.9%), surpassing physical and verbal aggression. Boys showed greater physical victimisation and a higher tendency towards the pure perpetrator role, whilst exclusion showed no significant differences by sex. Physical and verbal behaviours decreased as year group advanced, whereas exclusion remained stable throughout the entire primary stage. The bully-victim profile was more prevalent in lower year groups. Conclusions: The findings highlight the particular relevance of exclusion/rejection as the predominant form of bullying in PE, which persists across year groups regardless of sex. These results underscore the need to design inclusive groupings, promote cooperative tasks, and implement early intervention strategies. Specific training for PE teachers in bullying detection and intervention is identified as a priority to address this phenomenon effectively within the PE context.

Children doi: 10.3390/children13070969

Authors: Alexander S. Atalay Benjamin T. Newman T. Jason Druzgal

Background: A growing body of literature associates increases in electronic screen time with a vast array of psychological consequences amongst adolescents, but little is known about the neurological underpinnings of this relationship. Methods: This longitudinal study examines structural and diffusion brain MRI scans from two timepoints collected from the Adolescent Brain Cognitive Development (ABCD) Study—a large, multi-site study with thousands of participants. By assessing both gray matter density (GMD) and gray matter measurements of diffusion microstructure in the adolescent brain, we describe how the developmental trajectory of the brain changes with screen-based media consumption at the subcellular level. Gray matter microstructure was measured across 13 bilateral regions functionally implicated with screen time use and associated with either the control or reward system. Results: After controlling for age, sex, total brain volume, scanning site, sibling relationships, physical activity, and socioeconomic status, this study finds significant positive correlations between increased screen time and axonal signal across six of the 13 regions selected, while also finding significantly decreased intracellular signaling in eight regions, primarily in regions functionally associated with cognitive control. Comparing these associations to normal developmental trajectories suggests adolescent age-related brain development may be accelerated by increased screen time in brain areas associated with reward processing, while age-related brain development may be decelerated in regions of the control system. Highlighting the sensitivity of microstructural analysis, no significant relationships with increased screen time were found using GMD or fractional anisotropy. Conclusions: This work suggests that increased screen usage during adolescent development has a complex association with brain tissue that cannot be completely described by traditional quantifications of tissue microstructure.

Children doi: 10.3390/children13070968

Authors: Halil Ugur Hatipoglu Birgul Livaoglu Say Nurdan Uras

Background/Objectives: Caffeine citrate is widely used in very preterm infants, but whether initiation during the first postnatal hours is independently associated with respiratory outcomes remains uncertain. We evaluated the association between caffeine initiation within versus after the first 2 h of life and respiratory outcomes in infants born at <32 weeks’ gestation. Methods: This single-center observational cohort study included 84 infants born at <32 weeks’ gestation and with a birth weight of ≤1500 g who received caffeine citrate within the first 24 h of life. The 2 h threshold represented the unit’s protocol-defined target for caffeine loading rather than a biologically validated cutoff. The primary outcome was bronchopulmonary dysplasia (BPD) at 36 weeks’ postmenstrual age. Secondary outcomes included BPD or death, moderate/severe BPD or death, respiratory support requirements, and neonatal morbidities. Conventional multivariable logistic regression and expanded gestational age- and birth weight-based propensity score models with stabilized inverse probability of treatment weighting (IPTW) were used. The expanded propensity score models incorporated maternal, placental, perinatal, and early respiratory variables, including first-hour invasive mechanical ventilation and surfactant administration within the first hour. Results: Caffeine was initiated within the first 2 h in 41 infants and after the first 2 h in 43 infants. BPD occurred in 10/41 (24.4%) and 24/40 (60.0%) infants, respectively, while BPD or death occurred in 10/41 (24.4%) and 27/43 (62.8%), respectively. In expanded IPTW analyses, caffeine initiation after the first 2 h remained associated with BPD in both the gestational age-based model (OR 3.40, 95% CI 1.22–9.48) and the birth weight-based model (OR 3.23, 95% CI 1.16–9.00). Corresponding ORs for BPD or death were 3.89 (95% CI 1.41–10.71) and 3.68 (95% CI 1.34–10.12). Additional adjustment for residual imbalance in pretreatment respiratory support produced similar estimates. Conclusions: Caffeine initiation after the first 2 h of life was associated with higher odds of BPD and BPD or death. These findings support further investigation of very early caffeine timing but do not establish a causal effect because of the observational design, modest sample size, and potential residual confounding.