The Year’s Hottest Topics in Pediatric Medicine

Mycoplasma

Respiratory infections dominated the news in the summer and fall of 2024, but unlike in recent years, COVID did not top the list. Instead, pediatricians throughout the United States saw a notable rise in Mycoplasmapneumoniae infections. 

Mycoplasma infections are historically more common among school-age and older children, but this surge of M pneumoniaeinfections has affected all ages, including infants and children aged 2-4 years. Despite a peak in August, the prevalence of M pneumoniae among children discharged from the emergency department has remained quite high, at 7%-8% (1 in 14 discharges) as recently as mid-November. 

The increase in M pneumoniae infections could be nothing more than a historical fluctuation; alternatively, it could represent an opportunistic expansion following the COVID-19 pandemic. Infection prevention efforts aimed at COVID-19 probably also suppressed M pneumoniae transmission, resulting in very low rates of the M pneumoniae infection during that time. 

Fortunately, most symptoms of the infection are mild, but M pneumoniae should be considered in the following circumstances:

• Gradual onset of respiratory symptoms (incubation period is up to 4 weeks);
• Bilateral findings on exam or radiography; and
• Lack of response to beta-lactam antibiotics, considered first-line treatment for pediatric community-acquired pneumonia.

Clinicians should also know their local resistance patterns of M pneumoniae. Resistance to macrolides is typically < 10% across the United States but is higher in certain areas. Treatment options for macrolide-resistant M pneumoniae include fluoroquinolones or tetracycline (restricted to appropriate age groups). 

Among children, M pneumoniae can also present with gastrointestinal symptoms. Detection can be improved by swabbing both the nasopharynx and throat.

Bird Flu

Although not nearly as prevalent as M pneumoniae, another respiratory illness that is increasing at alarming rates in the United States is H5N1 (avian influenza). More than 65 individuals (and counting) have been infected. The majority of these cases have been among adult agricultural workers, primarily those working with cattle, but also among those working with poultry. 

Three pediatric cases have been identified in North America, with two of those three children being severely ill. To date, household transmission does not appear to have occurred. The affected adults have had mild symptoms, with a predominance of conjunctivitis and overall mild respiratory symptoms. Infections disease experts note that this virus has been under surveillance for more than 20 years, and it is unclear why more humans are being infected now. 

Routine influenza vaccination is unlikely to offer much protection because the hemagglutinin protein (H5) is not the same as that contained in current vaccines. Patients should be asked about potential exposures to animals, and avian influenza should be considered if a parent or household member works in the livestock industry. In fact, the outbreak of H5N1 in cattle in the United States has led to the US Department of Agriculture ordering testing of unpasteurized milk samples across the nation. With this more widespread testing, we may find that the outbreak is even more prevalent than suspected, so stay tuned and be vigilant! 

GLP-1 Agonists 

The expanding interest in and use of glucagon-like peptide 1 (GLP-1) receptor agonists has filled reams of medical and pediatrics articles. With the US Food and Drug Administration approval of weekly semaglutide for treatment of obesity and growing use of these medications in adults, pediatricians are increasingly faced with questions about patient eligibility. 

The randomized, double-blind, placebo-controlled trial of weekly semaglutide resulted in clinically notable reductions in weight — an average of 15.3 kg in the treatment group compared with a 2.4 kg weight gain in the placebo group. The changes in weight were also associated with improvements in comorbid conditions such as elevated blood pressure and cholesterol levels, along with improved quality-of-life measures. 

As patients and pediatric providers consider whether to access these medications, some of the lessons of the research are worth reviewing. First, the placebo and the treatment groups weren’t simply prescribed a GLP-1 drug; they also participated in a lifestyle program that included nutritional counseling and physical activity. The eligibility for participation in the randomized clinical trials included having a body mass index at or above the 95th percentile, or at or above the 85th percentile with at least one weight-related comorbidity. 

Now, however, patients who do not meet these criteria are seeking treatment with these medications. A Medscape Medical News article in September 2024 raised the point that providers need to be aware of the potential for disordered eating among patients seeking GLP-1 treatment. Others have noted that adherence can be a challenge and that availability of the drug and insurance coverage denials make prescribing and utilizing these drugs a real challenge at this stage

It has been interesting to follow the discussions in the medical press about whether the loss of fat-free mass (essentially, skeletal muscle mass) is problematic for children. Although the loss of muscle mass in some of the GLP-1 clinical trials was substantial, authors point out that muscle mass loss also occurs with other weight loss approaches, although to a lesser degree. 

Artificial Intelligence

The literature on the medical applications of artificial intelligence (AI) has truly become a flood. Some of you may be involved with electronic health record (EHR) add-on programs that record the provider-patient interaction in the room, producing a clinical note in almost real time. AI certainly has much potential for improving pediatric care, including risk prediction (eg, sepsis or asthma) or diagnosis (eg, radiology or even autism). 

In a recent study, Liu and colleagues surveyed 140 clinicians who were utilizing an AI-powered clinical documentation tool. to determine how much the tool helped them, comparing their responses with clinicians who did not use the tool. Participation was not randomized. More than 47% of the participant group felt that the tool had reduced overall time spent on EHR documentation and time spent on EHR documentation at home, compared with < 20% among those who did not adopt the tool. Similarly, AI clinical documentation tool users were more than twice as likely to express lower EHR frustration and much less time using the EHR outside of work hours. Although it is unfortunate that this study relied on subjective assessment of the outcomes, the differences are striking and suggest notable time savings, with the caveat that clinical notes will still likely need careful editing. 

A more in-depth assessment of one organization’s 2-week pilot of the technology can be found here. Future studies to identify pitfalls of the use of this technology in ambulatory clinical practice will be helpful in further tailoring this tool for pediatric use. 

Clinical Guidelines

I’ll finish up by reminding colleagues about two recent pediatric guidelines to take a look at: updated recommendations for critical congenital heart disease screening in newborns and a clinical report on pediatric acute-onset neuropsychiatric syndrome.