American Academy of Pediatrics

10.1542/6376245954112Video AbstractPEDS-VA_2025-0712336376245954112BACKGROUND AND OBJECTIVES. The 2017 US Addendum Guidelines for the Prevention of Peanut Allergy encourage clinicians to recommend early introduction of peanut-containing foods to infants’ diets to prevent peanut allergy (PA). However, clinician guideline adherence has been low. The Intervention to Reduce Early Peanut Allergy in Children (iREACH) Trial aims to increase pediatric clinicians’ adherence to the guidelines.METHODS. iREACH is a practice-based, cluster randomized trial of 30 pediatric practices. Intervention practices received clinician education, a clinical decision support (CDS) tool embedded into electronic health record (EHR) systems, and visual aids, while those in the control arm did not. The primary outcome was clinician adherence to guidelines, documented in EHR data from 4- or 6-month well-child care visits. Clinicians were adherent for low-risk infants (no/mild/moderate eczema and no egg allergy) if they recommended the introduction of peanut-containing foods and, for high-risk infants (severe eczema and/or egg allergy), if they ordered a peanut-specific immunoglobulin E test and counseled appropriately or referred to an allergist.RESULTS. Overall, 18 480 infants (intervention, n = 9290; control, n = 9190) were seen by 290 clinicians. Among low-risk infants (n = 18 182), intervention clinicians were adherent for 83.7%, while control clinicians were adherent for 34.7% (odds ratio [OR], 14.6; 95% CI, 7.0–30.5; P < .001). Among high-risk infants (n = 298), intervention clinicians were adherent for 26.8%, while control clinicians were adherent for 10.4% (OR, 3.1; 95% CI, 1.1–8.8; P = .03).CONCLUSIONS. A multifaceted educational intervention improved clinician guideline adherence. Wide dissemination of the intervention and implementation of the guidelines could reduce the incidence of PA.

The AAP and American Heart Association have co-developed new and updated resuscitation and cardiovascular care guidelines for pediatric and neonatal life support. The 2025 update is the first time pediatric- and neonatal-focused CPR and ECC guidelines were developed through an equal partnership between the AHA and AAP.

A 10-year-old boy with speech delay and intellectual disability presents with decreased activity and reduced oral intake for 4 days. An interpreter assists in the evaluation and care of the patient because of a language barrier. His presenting vital signs include a temperature of 36.6°C, heart rate of 120 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 117/66 mm Hg, and oximetry at 96% in room air. At initial assessment, he is listless, with 1+ peripheral pulses and a capillary refill of 4 seconds. His skin examination shows a warm, hyperpigmented, macular rash with rough texture on his trunk and upper extremities (Figure 1). Given his ill appearance, a venous blood gas (VBG) is obtained with a pH of 7.04, Pco 2of 27, P o 2of 34, bicarbonate ion (HCO3) of 7, and base excess of −21.6. Additional laboratory values collected...

Pediatric insomnia is a common condition that can significantly impact a patient’s well-being. It typically involves difficulty falling asleep, staying asleep, or both. The prevalence of insomnia is notably higher among children with autism spectrum disorder (ASD) or attention-deficit hyperactivity disorder (ADHD). Two commonly recognized subtypes of pediatric insomnia are behavioral insomnia and psychophysiological insomnia. Because clinical symptoms and physical examination findings are often subtle, pediatricians should be familiar with the diagnosis and management of insomnia. Pediatricians should also consider and rule out underlying disorders such as sleep apnea, anxiety, or other medical conditions that may contribute to or mimic insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is currently regarded as the most effective treatment. While melatonin has shown benefits in children with autism or ADHD, additional research is needed to evaluate the efficacy of other pharmacologic options. Timely intervention is crucial, as pediatric insomnia can become chronic and negatively affect mental health and overall quality of life.

Mother’s own milk (MOM), appropriately fortified, provides optimal nutrition for hospitalized very low birth weight (VLBW [≤1500 g]) infants in the neonatal intensive care unit (NICU) and confers a myriad of other short- and long-term health benefits. Every family of a VLBW infant should receive information about the critical importance of MOM to the health of their infants and receive intensive support throughout the full course of their infant’s hospitalization to achieve their personal lactation goals. Provision of pasteurized donor human milk (PDHM) is recommended when MOM is not available, insufficient in volume, or is contraindicated. PDHM should optimally be continued until the infant’s risk to develop necrotizing enterocolitis is low (approximately 34–36 weeks’ postmenstrual age). Preterm infant formula is recommended when MOM is not available and PDHM is either not available or the family declines use. Promotion of human milk and breastfeeding for VLBW infants requires access to efficient, effective, and comfortable double electric breast pumps in the hospital and at home and multidisciplinary and system-wide adoption of lactation support practices, including early and frequent milk expression, skin-to-skin care (SSC), and direct breastfeeding. Addressing social inequities in provision of human milk at the local level requires access to PDHM, peer lactation support, maximizing use of interpreter services as appropriate, and implementation of standardized approaches to identify and address unmet basic needs.

Acute flaccid paralysis is a clinical syndrome referring to acute onset of weakness that can result from a variety of causes, including autoimmune diseases, viral infections, and neurological disorders. Management is largely supportive, but a multidisciplinary approach to treatment and rehabilitation is imperative.

The vast majority of youth use social media, which plays an important role in the lives of adolescents. Concerns around social media and mental health closely follow a previous pattern of concerns and cross-sectional studies that examined internet use and mental health. Social media and mental health study findings can be sorted into 3 categories: negative association, no population-level association, and a more complex association. Several critical mechanisms can be applied to understand the risks and benefits of social media for adolescents. Mechanisms explaining negative outcomes include problematic internet use (PIU) and exposure to negative content or experiences. Mechanisms to explain positive outcomes include social support, identity development, learning, and civic engagement. Screening for PIU and social media use with validated instruments and nonjudgmental approaches is critical. Prevention and management include ongoing communication and providing resources for families. In summary, population-level concerns about social media and adolescent health are not scientifically supported. However, pediatricians are charged with caring for individual adolescents who may experience a variety of positive and negative outcomes from their social media use that pediatricians can positively impact through communication and resources.

Eosinophilic fasciitis (EF), or Shulman syndrome, first described in 1974, is a rare fibrosing disorder characterized by painful, symmetric swelling and progressive woody induration of skin and subcutaneous tissues. Although the pathogenesis remains unclear, EF is considered immune-mediated, often triggered by physical exertion, infections, or medications. Pediatric EF, a particularly uncommon subset, can exhibit distinct clinical features, including pronounced extracutaneous manifestations, unpredictable disease progression, and variable therapeutic responses. Clinical presentations range from rapidly advancing fibrosis leading to joint contractures to fluctuating inflammatory episodes. Diagnosis is challenging because of the absence of universal criteria, although peripheral eosinophilia, elevated inflammatory markers, and imaging findings support clinical suspicion. Definitive diagnosis depends on deep skin and fascial biopsy, revealing eosinophil-rich lymphoplasmacytic infiltrates and fibrosis. Management primarily relies on systemic corticosteroids, supplemented by steroid-sparing immunosuppressive medications in refractory cases. Early diagnosis and treatment are critical because untreated EF can cause irreversible fibrosis and significant functional impairment. The disease’s rarity, heterogeneous presentations, and unclear etiology further complicate clinical management. Recent insights suggest EF may involve intricate interactions among environmental triggers, immune dysregulation, and fibrotic remodeling. This review aims to provide an updated overview of pediatric EF, highlighting current knowledge on clinical manifestations, diagnosis, differential diagnosis, therapeutic approaches, and outcomes, supported by an illustrative case, with emphasis on areas needing further research.

The clinical practice guideline uses the new term “faltering weight” instead of “failure to thrive,” which has no precise definition, is stigmatizing and has unclear standards of care.

A female infant is born at 39 weeks and 3 days’ gestation via vaginal delivery to a 21-year-old Gravida 1 now Para 1 woman. The prenatal course was benign. The infant has an Apgar score of 7 and 9 at 1 and 5 minutes of age, respectively. In the nursery, the nurse contacts the neonatology fellow because she notices that the infant is having atypical eye movements in the right eye while feeding (Video 1). The infant has bilateral red reflexes, and the pupils are equal and reactive to light.What is the most likely diagnosis in this infant with atypical right-eye movements? Congenital reflexes, of the extraocular muscles, bilateralCongenital ptosis, left eyeDuane retraction syndrome, right eyeJaw-winking syndrome, right eyeMarcus Gunn pupil, right eyeMarin-Amat syndromeWhat is the next step in the management to address this neonate’s physical examination finding? Brain magnetic resonance imaging of the brainObservation and outpatient ophthalmology referral for further evaluationOcclusion of the left eye as the neonate grows older to prevent amblyopia from occurringSurgical procedure involving levator palpebrae superioris excision and frontalis suspensionQuestion 1: D. Jaw-winking syndrome, right eyeQuestion 2: B. Observation and outpatient ophthalmology referral for further evaluationThe infant in this video has right eyelid elevation, which is synkinetic with jaw movements while bottle feeding, and the elevation returns to a baseline ptosis in the right eye. These subtle findings, which are best appreciated from second 9 to second 11 of the video, are consistent with Marcus Gunn jaw-winking syndrome. The infant also has ptosis in the left eye, but this is unrelated.Marcus Gunn jaw-winking syndrome is a rare cause of congenital eyelid ptosis occurring in 2%–6% of patients; however, it is the most common form of congenital ocular synkinesis.1,2 Synkinesis is when an involuntary movement occurs while a specific facial movement is performed. Most occurrences are sporadic, but, in rare cases, it can be attributed to hereditary factors or a genetic condition.3The jaw-winking syndrome occurs when there is abnormal innervation of the striated portion of the levator palpebrae superioris muscle by the motor branch of the trigeminal nerve instead of the oculomotor nerve; thus, there is an atypical connection between the trigeminal and oculomotor nerves.1,3 In this syndrome, various movements such as sucking (as depicted in the video at second 9), chewing, swallowing, smiling, and whistling cause different degrees of eyelid elevation because of pterygoid muscle (muscle of mastication) stimulation.1,3 The anomaly is further characterized by concurrent movement of the ipsilateral pterygoid muscle with upper eyelid retraction followed by a quick return to the lower position.3 Most often, this phenomenon is unilateral and reported in the left eye; however, it can be bilateral, although the infant in this vignette has involvement of the right eye.1,3 Associated ophthalmologic disorders include amblyopia (ie, decrease in best-corrected visual acuity), strabismus (ie, abnormal eye axis alignment), and anisometropia (ie, difference in refractive power between eyes).1Typically, management is conservative if the condition is mild. Surgical intervention is reserved for severe cases (ie, eyelid elevation >5 mm) or when there is amblyopia1 and when there is notable “visual dysfunction of the affected eye with evident differences in bilateral visual function and ptosis with or without levator dysfunction.”3 Goals of treatment include correcting ptosis and either weakening or eliminating synkinesis.3 When moderate ptosis is present, surgical advancement of the levator muscle is performed by exposing, isolating, and resecting the muscle to advance it to the upper border of the tarsal plate (a thick dense connective tissue that gives structure to the eye) after confirming eyelid contour and height the muscle is sutured in place.2 Levator plication is also suggested to prevent increased synkinesis and entails incising and cauterizing the medial and lateral margins of the muscle before advancing the muscle.2 Levator palpebrae superioris excision and frontalis suspension is reserved for cases of moderate or severe eyelid movement.4Congenital fibrosis of the extraocular muscles results from hypoplastic nerve development. Multiple phenotypes exist but all include ptosis and limited eye movements.3 Neurons may fail to develop or are “misguided.” Sometimes there is abnormal innervation of the muscles by 1 of the other cranial nerves.5 Because of the lack of innervation, the muscles become atrophied and fibrosis occurs, causing limitation of movement.5Congenital ptosis presents with a drooping upper eyelid at birth, which leads to reduction in the vertical palpebral fissure.6 However, a diagnosis of congenital ptosis alone does not account for this neonate’s synkinetic eyelid and jaw movements.6 This infant does have a possible ptosis in the left eye, but this does not explain the other finding.Duane retraction syndrome presents as strabismus rather than synkinetic jaw and eyelid movements. This disorder is also known as “co-contraction” syndrome. It is a congenital complex strabismus with globe retraction and narrowed palpebral fissures.7 It results from failure of cranial nerve VI to innervate the lateral rectus muscle, which is then supplementally innervated by cranial nerve III.7 The enlargement or reduction of eyelid fissures is unrelated to mandibular movement; instead, it is associated with the outward and inward rotation of the affected eye.3Marin-Amat syndrome is a condition described as involuntary eye closure when the patient smiles or opens the mouth caused by an abnormal neural pathway between the trigeminal nerve and frontal zygomatic branch of the facial nerve (Figure 1A and 1B) instead of eyelid elevation, as seen with Marcus Gunn jaw-winking syndrome.3 This is an acquired facial synkinesis that results from peripheral facial palsy.3Marcus Gunn pupil is an abnormal pupillary reaction to light. In this condition, the normal pupil shows contraction of the pupil when exposed to bright light; however, an affected pupil demonstrates pupillary dilation after initial constriction under sustained illumination.8