3 Top Papers You May Have Missed in October 2021
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
Vergano ST. 3 top papers you may have missed in October 2021. Consultant360. Published online November 10, 2021.
Challenging the status quo is a theme of the important articles that I read this month. Here are my selections. Although none is revolutionary, each has the potential to change in a small way the current practice of pediatrics. As always, please discuss them with your colleagues and share your thoughts with us: firstname.lastname@example.org.
Birth Hospital Length of Stay and Rehospitalization During COVID-191
The authors of this retrospective study in prepublication in Pediatrics have examined the Epic Cosmos database covering 35 health systems for length of stay in term singleton newborns discharged at younger than age 5 days. They compared length of stay in prepandemic years (2017 to 2019) with data from early in the COVID-19 pandemic (March to August 2020). In particular, the authors examined the proportion of newborns discharged early (fewer than 2 midnights for a vaginal delivery or 3 midnights for a Cesarian delivery) and compared the percentage of early discharges and the rate of hospital readmissions in the first week of life between the 2 cohorts.
This study group found that the rate of early discharge of term newborns increased during the early pandemic period. The percentage of newborns in their study with early discharge increased from 28.5% in the prepandemic years to 43.0% during the first months of the pandemic. Despite this increase, the rates of rehospitalization in the first week decreased slightly in comparing the 2 periods. The authors concluded that their data suggest, based on this natural experiment, that early discharge of select term newborns does not lead to increased early rehospitalization.
My experience mirrors the data that these authors reported. Early in the pandemic, the parents of newborns seemed eager to leave the hospital and reluctant to be readmitted. These data suggest that such early discharge appears to have been safe, at least in terms of hospital readmission. However, there may have been significant differences in approach between the 2 eras: the newborns in this study were not randomly assigned to early discharge, and the authors do not examine rates of breastfeeding and lactation services, completion of newborn screening protocols, numbers of subsequent outpatient visits and interventions, or parent satisfaction. More studies need to be completed before concluding that shorter birth hospitalizations yield similar results for newborns.
Update of the Blood Lead Reference Value -- United States, 20212
In a commentary published in MMWR on October 29, the Centers for Disease Control and Prevention have lowered the blood lead reference value to an upper limit of 3.5 µg/dL from 5.0 µg/dL. This new level should be used to decide upon interventions for individual patients, as well as in public health evaluations, to determine communities in most need of lead prevention efforts. Additionally, the commentary points out that no amount of lead in blood is considered safe, that even very low levels of lead may cause developmental harm, and that in the absence of detailed data on local housing and sociodemographic factors, screening should be dictated by Federal Medicaid requirements (universal testing at ages 12 and 24 months) and state and local law.
It has been gratifying to see the decrease in both the geometric mean blood levels and the definitions of elevated lead levels throughout my career. It was during my residency that the elevated lead level of 25.0 µg/dL was decreased to 10.0 µg/dL, which at the time vastly increased the number of children in my continuity clinic population who required intervention. It is important to remember that all lead exposures confer potential harm, that some children depending upon their exposure may still have dramatically high blood lead levels, and that changing exposures (as demonstrated, for instance, by the astute observations of a pediatrician in Flint, Michigan) can lead to increased community exposures.
I often joke with learners that the decrease in lead levels over time (the article points out that the geometric mean blood level among children aged 1 to 5 years declined from 15.2 µg/dL in 1976-1980 to 0.83 µg/dL in 2011-2016) means that their generation should be much more intelligent than mine. What do you think?
Long-Term Complications in Youth-Onset Type 2 Diabetes3
The authors of this study report long-term follow-up of adolescents enrolled from 2004 to 2009 in the TODAY clinical trial, which randomly assigned the participants into 3 treatment groups and followed them for a mean of 3.9 years on medication intervention. Of the 699 original participants, this report highlights long-term outcomes for 500 participants with an average age of 26.4 years who carried a diagnosis of adolescent-onset type 2 diabetes for an average of 13.3 years. In rigorous evaluation for complications, the authors found that 67.5% of the cohort had hypertension, 54.8% had diabetic kidney disease, 51.6% had dyslipidemia, 51.0% had retinal disease, and 32.4% had nerve disease. They report the incidence of any microvascular complication among their cohort was 50.0% at 9 years after diagnosis and 80.1% at 15 years after diagnosis.
It is surprising to me how many of these patients with adolescent-onset type 2 diabetes developed documented microvascular complications as young adults. The data support the early and aggressive pharmacologic management of these patients from the time of diagnosis, in addition to lifestyle management. They also support the urgency of screening for type 2 diabetes in adolescents, as recommended every 2 to 3 years for patients who are at risk, and may provide justification for intensive lifestyle management for those patients at risk for type 2 diabetes prior to progression to disease.
What has your experience been? How aggressively do you screen and counsel your patients who are at risk for type 2 diabetes? Please feel free to share your thoughts and approaches to diabetes screening or your comments about any of these articles.
1. Handley SC, Gallagher K, Breden A, et al. Birth hospital length of stay and rehospitalization during COVID-19. Pediatrics. 2021:e2021053498. https://doi.org/10.1542/peds.2021-053498
2. Ruckart PZ, Jones RL, Courtney JG, et al. Update of the blood lead reference value - United States, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(43):1509-1512. https://doi.org/10.15585/mmwr.mm7043a4
3. Bjornstad P, Drews KL, Caprio S, et al; TODAY Study Group. Long-term complications in youth-onset type 2 diabetes. N Engl J Med. 2021;385(5):416-426. https://doi.org/10.1056/nejmoa2100165