Trends in Pediatrics: Articles I’m Still Thinking About

As we hit the mid-point of 2026, here are some articles from 2025 that I still think about and use in my teaching of medical students and residents! Nirsevimab Effectiveness First, there are some very encouraging recent data on the effectiveness of nirsevimab and prevention of respiratory syncytial virus (RSV)-related disease and healthcare utilization. A study in Pediatrics evaluated health system data from Northern California, included over 31,000 infants, and compared outcomes of the roughly half of the infants who received nirsevimab to the outcomes of those who did not. The main outcome was the effectiveness of the immunization in preventing lower respiratory tract illness caused by RSV. Nirsevimab was very effective and reduced RSV-caused lower respiratory tract illness by 87%. Among those who received the immunizations, hospitalizations due to RSV were also reduced by 98%. The infants who received nirsevimab even had a lower number of all-cause visits during the follow-up period by about 0.86 fewer visit per child. So, as we enter the fall 2026 season, these data should provide reassurance to parents that this immunization can be very effective. Home Ondansetron A randomized, double-blind trial across six Canadian pediatric emergency departments evaluated postdischarge ondansetron in children with acute gastroenteritis. Among over 1000 participants randomized to receive up to 6 doses of ondansetron vs placebo over the first 48 hours post-discharge, provision of ondansetron reduced the risk for moderate-to-severe gastroenteritis measured on a symptom scale. Perhaps more importantly, repeat healthcare visits of all types occurred in 13.2% of placebo participants vs 9.3% of intervention participants, meaning that all healthcare follow-up visits were reduced by about 30% in the ondansetron group. In addition, the frequency of actual emergency department re-visits within 7 days was lower in the treatment group. The authors concluded that limited dosing of ondansetron post-discharge is beneficial.Febrile Infant Risk for Bacterial Infections A registry study that incorporated patients seen in 17 US emergency departments between 2012 and 2024 assessed bacterial infection prevalence in febrile infants aged 61-90 days with and without respiratory viral infections. This study focused on infants in the third month of life because prior studies had provided the greatest clarity for infants 0-60 days, with fewer data in this age group. The study ultimately included over 3500 infants. The detection of a respiratory virus was associated with a lower relative risk for any of the three bacterial illnesses studied. For example, the prevalence of urinary tract infection was 4.4% among viral-positive febrile infants vs 12.5% among viral-negative infants. The prevalence of bacteremia without meningitis was 1% among viral-positive febrile infants vs 3% among viral-negative febrile infants. Finally, the prevalence of bacterial meningitis was 0.4% among the viral-negative infants, with no meningitis cases in viral-positive infants. The only caveat is that rhinovirus-positive patients were not as protected, with 1.4% of them having bacteremia compared to < 1% for infants with SARS-CoV-2, RSV, or influenza. These data suggest that it may be reasonable for clinicians to limit invasive testing in viral-positive infants if the infants otherwise look well on exam and follow-up is assured. Concussion Recovery Current recommendations suggest a gradual return to exertion and physical activity after a concussion, but this approach can seem slow to parents, children, and schools, prompting studies to better delineate the value of staged return to activity. A multicenter randomized controlled trial evaluated early physical activity in youth with acute concussion. The study included 239 children who were randomized within 72 hours of concussion. The intervention group was instructed to begin light-to-moderate physical activity to reach daily step targets of 10,000 per day for at least 3 days in the first week and at least 5 days in the second week. They were also instructed to increase activity regardless of current symptoms but not to push through worsening symptoms. The study found no significant difference in symptom severity or quality of life at 14 days. However, the early return to activity (intervention) group had higher symptom burden in the first 7 days and longer recovery (median, 10 vs 5 days). The authors concluded that early prescribed activity despite symptoms may delay recovery and that individualized, subthreshold activity remains recommended. I’m sympathetic to the need for this trial, as the individualized care plan post-concussion and detailed tracking of symptoms can be quite time-consuming. It would have been much more efficient for ambulatory practice had the study found that generalized and nonvariable advice of “just get active quickly” would have worked for a large segment of the population. However, the results indirectly reinforce the need to remain active, but only to a level that does not induce or exacerbate post-concussion symptoms. As a reminder, the Sport Concussion Assessment Tool – 6 provides a guide to track symptoms and help patients stage their return to activity. Adenotonsillectomy for Mild Sleep-Disordered Breathing A JAMA Pediatrics study randomly assigned 459 children with mild sleep-disordered breathing to either early adenotonsillectomy or watchful waiting. The children were 3-13 years of age and were followed for at least 12 months each. The early adenotonsillectomy group had 32% fewer healthcare encounters and 48% fewer prescriptions over 12 months (mean, 2.65 vs 3.89 with watchful waiting). The greatest reductions in prescriptions were for respiratory, sleep-related, and pain medications. The implications for practice are that early intervention may improve outcomes even in mild cases of sleep-disordered breathing, though cost-effectiveness studies are needed. In the meantime, the reductions in visits and symptoms seem to be clinically meaningful, suggesting that pediatric providers can be supportive of parents making decisions about whether to proceed with adenotonsillectomy in patients with only mild symptoms.