Lifelong learning in paediatrics – A final part 2025

1. Rethinking blood pressure in the young: Insights from a global meta-analysis (2000–2025)

Source: Zhou J, Shan S, Wu J, Song Y, Zhu L, Li Q, et al. Global prevalence of hypertension among children and adolescents aged 19 years or younger: An updated systematic review and meta-analysis. Lancet Child Adolesc Health. 2025; DOI:10.1016/S2352-4642(25)00281-0.

Hypertension in children has traditionally been regarded as a rare clinical finding, often attributed to anxiety or measurement error and usually deferred for review at a later visit. This assumption has shaped both training and routine practice in India. The updated systematic review by Zhou et al. challenges this view quite directly. The authors analysed 96 population-based studies published between 2000 and 2025, covering more than 44,000 children and adolescents aged 19 years or younger across 21 countries. The breadth of this evidence and the consistency of its observations make it difficult to dismiss childhood hypertension as an occasional concern.

The majority of studies relied on repeated in-office blood pressure readings, the same method used in most paediatric outpatient settings in India. With this approach, the pooled global prevalence of hypertension was 4.28%. The number becomes more meaningful when seen across age groups. Prevalence rises steadily through childhood, reaches a peak around 14 years, and then shows a slight decline, which aligns with changes we already observe among Indian adolescents who experience rapid weight gain, higher dietary salt intake, and lower physical activity.

What is more striking in the review is the temporal trend. Between 2000 and 2020, the prevalence of childhood hypertension nearly doubled. Rates in boys rose from 3.40% to 6.53% and in girls from 3.02% to 5.82%. Such a pattern over two decades suggests a real epidemiological shift and not merely improved detection. An additional 8.2% of children were found to have prehypertension, which is an early risk category that often receives limited attention during routine clinical visits in India.

A smaller group of studies, 15 in total, included both in-office and out-of-office measurements, such as ambulatory or home monitoring. These methods help identify sustained hypertension more accurately. Across nine countries and more than 12000 participants, the prevalence of sustained hypertension was 6.67%. Even with fewer studies, this finding indicates that in-office readings alone may be missing a significant proportion of children with genuine hypertension.

The review also notes differences across regions, devices, and measurement practices, which reflects the absence of standardised diagnostic guidelines in paediatric hypertension research. In India, the availability of appropriate cuff sizes, the time needed to obtain repeated readings, and the limited use of ambulatory monitoring add further challenges. These practical barriers contribute to underdiagnosis and make it difficult to compare data across states or institutions.

The implications of this global synthesis are relevant for India. Childhood hypertension is becoming more common and is rising at a pace that should prompt closer attention. With increasing levels of childhood overweight, metabolic concerns, and changing dietary habits, many children may be entering adulthood with early vascular changes already in place. The findings by Zhou et al. underline the need for more consistent screening, clearer diagnostic standards, and better follow-up practices in paediatric care.

2. Should delirium be the sixth vital sign in paediatric emergency care?

Source: Leng T, Ali HH, McKone JE, Sullivan G, Kirkpatrick TR, Homme JL, et al. Retrospective cohort study of emergency department to PICU transfers: Emergency department factors associated with delirium development within 24 h of hospitalisation. Paediatric Critical Care Medicine. 26(11):p e1314-e22, November 2025. |DOI: 10.1097/PCC.0000000000003824

Paediatric delirium is still treated as an event that ‘belongs’ to the Paediatric Intensive Care Unit (PICU), something that emerges after prolonged ventilation, sedation, or the stress of critical illness—the retrospective study examining emergency department (ED)-to-PICU transfers challenges this belief very clearly. A large proportion of children admitted to the PICU showed features of delirium within the first 24 h. Two factors from the emergency department stood out: Mechanical ventilation and urinary catheterisation. These are routine procedures, yet they carry a measurable association with early delirium. It is difficult to read these findings without reconsidering our assumptions about where delirium begins.

The emergency department is the first neurological environment for a critically ill child. Noise, bright lights, hurried procedures, sedation, airway manipulation, pain left inadequately addressed, and sleep disruption all accumulate in those early minutes and hours. When a child is ventilated in the ED or undergoes invasive procedures before reaching the PICU, the brain is already experiencing stress. The fact that delirium emerges so early suggests that the ED phase is not merely preparatory. It may be formative.

In India, this has particular relevance. Many EDs operate under high load, limited space, and variable staffing. Sedation is often guided by immediate need rather than long-term risk. Catheterisation is done quickly so that monitoring is easier. Neurological checks are focused on the sensorium and basic reflexes. Subtle behavioural changes, restlessness, altered interaction, or fluctuating attention are rarely documented because they are not part of standard ED assessment. We look for stability of the heart, lungs, and circulation. Brain function is often assumed to be stable until proven otherwise.

The study raises an important question: if so much of early delirium can be traced to what happens in the ED, should delirium be treated as the sixth vital sign in paediatric emergency care? We routinely check temperature, pulse, respiration, heart rate, and oxygen saturation. We seldom check the child’s behaviour, attention, or sleep-wake cycle. Yet delirium, when present, predicts prolonged PICU stay, higher morbidity, and poorer recovery. If a parameter can alter outcomes so profoundly, is it still acceptable to ignore it in the 1^st h of care?

The question is a challenge to our workflow. If delirium begins early, then screening must begin early. If ventilatory or catheter-related discomfort contributes to risk, then use must be intentional and accompanied by vigilance. It simply requires us to add neurological observation to routine ED practice.

We can improve outcomes not only through better equipment and beds but through better attention. Delirium is preventable in many cases. And it may begin much earlier than our current systems recognise.

3. Rethinking height-therapy strategies in idiopathic short stature – a new meta-analysis in view

Source: Zhang T, Si Y, Wang X. Comparative effects of growth hormone, testosterone and aromatase inhibitors on height gain in children and adolescents with idiopathic short statures: A network meta-analysis. Annals of Human Biology. 2025;52:2551531. https://doi.org/10.1080/03014460.2025.2551531

The treatment of idiopathic short stature (ISS) remains one of the more contested areas in paediatric endocrinology. The new network meta-analysis examining the comparative effects of growth hormone (GH), testosterone, and aromatase inhibitors (AIs) brings fresh data to re-examine clinical practice. The authors synthesise multiple trials and cohorts, comparing GH monotherapy, AI monotherapy, and combination therapies (GH + AI) using standardised mean differences in height gain and height standard deviation scores.

A few findings deserve our attention. First, all active treatments outperformed placebo, suggesting that intervention in ISS is not futile; a reassurance in contexts where treatment uptake is low or delayed. Second, among the treatment modalities, letrozole (an AI) appeared to show the greatest effect size [Standardised mean difference (SMD) ~ 0.83], but the confidence intervals overlapped with GH and other therapies. In other words, while there may be a modest edge, superiority is not statistically decisive. Third, the evidence base remains heterogeneous, with varying ages, pubertal stages, bone ages, intervention durations, and outcome definitions. The authors rightly call for caution in extrapolating these findings to adult height outcomes or to diverse populations.

For the Indian setting, the implications are both practical and ethical. Many children with ISS are referred late, often during early puberty or when bone age advancement is significant, thereby reducing the growth window and potential benefit. Introducing AIs, or combining GH with AIs, may theoretically delay epiphyseal fusion and enhance height outcomes. Still, there are caveats: cost, long-term safety (particularly bone health, fertility, and psychosocial outcomes), regulatory approval, and the need to individualise treatment according to age, puberty status, and genetic potential. The meta-analysis underscores that ‘one size fits all’ therapy is not justified.

Moreover, in resource-constrained settings, the cost-benefit question is pressing. GH therapy is already expensive; adding AIs makes therapy more complex. The modest incremental benefit suggested by the meta-analysis must be weighed against opportunity costs; could those resources instead improve nutritional status, address missed diagnoses of GH deficiency, or strengthen systems for growth monitoring? Clinical decision-making must stay grounded in local realities, not just global effect sizes.

Finally, the meta-analysis highlights a broader epistemic issue: The final adult height, long considered the ‘gold standard’ outcome, remains inadequately studied in many trials included in the network. Surrogate outcomes dominate. In India, where healthcare follow-up is often fragmented, and long-term tracking of treated children is scarce, this gap matters. We must ask whether our enthusiasm for pharmacological height-augmentation risks overshadows robust follow-up and outcome assessment.

In conclusion, this meta-analysis does not resolve all questions around the treatment of ISS, but it provides an updated map of options, effect sizes, and limitations. For the Indian setup, the message is clear: intervention is possible, but must be selective, contextualised, and accompanied by long-term monitoring.

4. The 2025 paediatric basic life support update brings important shifts for everyday clinical response

Source: Joyner BL Jr., Dewan M, Bavare A, de Caen A, DiMaria K, Donofrio-Odmann J, et al. Part 6: Paediatric basic life support: 2025 American Heart Association and American Academy of Paediatrics Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025;152(16_suppl_2):S424-47. doi:10.1161/ CIR.0000000000001370

The 2025 American Heart Association-American Academy of Paediatrics guidelines for paediatric basic life support (BLS) come at a time when outcomes from cardiac arrest in children continue to depend heavily on timely recognition, early ventilation, and high-quality chest compressions. The updated recommendations provide clarity and reinforce long-standing principles while introducing a few significant changes.

One of the most important reminders in the guideline is that respiratory compromise continues to be the dominant pathway to cardiac arrest in children. Early support of ventilation and oxygenation remains central. The guideline emphasises that for out-of-hospital arrest, breaths should not be omitted. Lay rescuers who are able and willing should provide rescue breaths along with chest compressions, as this improves survival. This distinction is important in our context, where bystander cardiopulmonary resuscitation (CPR) training is growing but remains uneven, and where hands-only CPR is often promoted for simplicity.

The guideline also provides specific respiratory rate targets. For infants and children with an advanced airway during CPR, and for those with a pulse who are receiving ventilatory support, a rate of 20–30 breaths/min is recommended. This standardisation is useful for teams in emergency, transport, and PICU settings, where ventilation rates often vary widely.

A major change concerns the technique of chest compressions in infants. The traditional two-finger method has been removed because it does not reliably achieve adequate depth. The preferred approaches now include the one-hand technique or the two-thumb encircling technique. If the chest cannot be encircled, the heel-of-one-hand method may be used. This update has practical implications for training, simulation, and assessment in Indian hospitals where the two-finger technique is still commonly taught.

Foreign-body airway obstruction management has been clarified. In infants with severe obstruction, repeated cycles of five back blows followed by five chest thrusts are recommended. Abdominal thrusts are not advised in infants. In children, however, cycles of back blows and abdominal thrusts are appropriate. These distinctions are essential for lay responders, nurses, and primary care doctors who often encounter choking events in schools, homes, and outpatient areas.

The guideline reinforces fundamental elements of high-quality CPR. Adequate depth and rate, full chest recoil, minimal interruptions, and avoidance of excessive ventilation remain the cornerstones of effective resuscitation. Cardiac arrest recognition is described with practical criteria: An unresponsive child with abnormal breathing, including gasping, should trigger activation of emergency services and immediate CPR beginning with chest compressions.

Defibrillation guidance is clear. Automated external defibrillators (AEDs) should be applied as soon as possible, ideally with paediatric attenuators and paediatric pads. In many Indian hospitals, adult AED pads are more readily available. The guideline makes it clear that early defibrillation is still critical, and peri-shock pauses must be minimised.

Perhaps the most meaningful aspect of the 2025 update is its clarity. The core principles of paediatric BLS remain, but the refinements are practical and evidence-based. For India, where gaps persist in early recognition, bystander response, and consistent CPR performance, these updates provide an opportunity to review training programmes, update curricula, and standardise protocols across settings.

The message is simple: Children arrest for different reasons, respond differently, and require techniques tailored to their physiology. The 2025 guideline makes these distinctions clearer and strengthens the foundation on which effective paediatric resuscitation rests.

Top 10 Take-Home Messages

• Respiratory conditions remain the major cause of cardiac arrest in infants and children, and, as such, appropriate interventions to support ventilation and oxygenation should be initiated quickly.

• For out-of-hospital cardiac arrest in infants and children, providing breaths in addition to chest compressions improves survival; thus, lay rescuers are encouraged to provide breaths if able and willing.

• A respiratory rate of 20–30 breaths/min is recommended for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving breaths and have a pulse.

• For infants with severe foreign-body airway obstruction (FBAO), repeated cycles of five back blows alternating with five chest thrusts are recommended. Abdominal thrusts are not recommended in infants.

• For children with severe FBAO, repeated cycles of 5 back blows alternating with 5 abdominal thrusts are recommended.

• Immediate recognition of cardiac arrest is vital to improving outcomes. For infants and children who are unresponsive with abnormal breathing, including gasping, rescuers should activate emergency medical services and initiate high-quality CPR beginning with chest compressions.

• High-quality CPR is the foundation of resuscitation. The key components of high-quality CPR include providing adequate chest compression rate and depth, minimising interruptions in CPR, allowing complete chest recoil between compressions, and avoiding excessive ventilation.

• For infants, the recommended compression techniques include either the 1-hand technique or the two-thumb encircling hands technique. If the rescuer cannot physically encircle the chest, it is recommended to compress the chest with the heel-of-one-hand technique. The use of two fingers along the sternum was eliminated due to ineffectiveness in achieving proper depth.

• For infants and children in cardiac arrest, an AED should be attached as soon as possible using a paediatric attenuator and paediatric pads if available.

• Prompt defibrillation for ventricular fibrillation and pulseless ventricular tachycardia is critical, with minimisation of peri-shock pauses.

5. THE 2025 paediatric advanced life support update strengthens the continuum of care from pre-arrest to post-arrest

Source: Lasa JJ, Dhillon GS, Duff JP, Hayes J, Kamath-Rayne BD, Levy A, et al. Part 8: Paediatric advanced life support: 2025 American Heart Association and American Academy of Paediatrics guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2025;152(16_ suppl_2):S479-S537. doi:10.1161/CIR.0000000000001368

The 2025 Paediatric Advanced Life Support (PALS) guidelines mark an important update in the care of infants and children who experience life-threatening cardiovascular or respiratory emergencies. Unlike BLS, which focuses on immediate recognition and CPR, these guidelines cover the full continuum from prevention and early recognition to intra-arrest management and post-cardiac arrest care.

The most consistent message through the guideline is the reaffirmation of high-quality CPR. Adequate compression depth and rate, full recoil, minimal interruptions, and appropriate ventilation remain critical determinants of survival. In practice, this means structured team roles, clear communication, and a disciplined approach to airway and circulation management. It also means avoiding excessive ventilation, which remains a frequent error in real-world resuscitation.

The guideline reinforces early epinephrine for initial nonshockable rhythms. Administering it as soon as possible is associated with better outcomes. For shockable rhythms such as ventricular fibrillation or pulseless ventricular tachycardia, rapid defibrillation remains the priority. Epinephrine is added when defibrillation is not immediately achievable, but not as a replacement for early shocks.

A notable addition is the introduction of target diastolic pressures for patients with invasive arterial monitoring during CPR. Diastolic values above 25 mmHg in infants and above 30 mmHg in older children are now included as haemodynamic goals, which reflects the growing emphasis on physiology-guided resuscitation rather than technique alone. End-tidal carbon dioxide (ETCO₂) remains a useful measure of CPR quality, but no specific cutoffs should guide termination decisions.

Post-cardiac arrest care receives clearer guidance. Hyperthermia prevention is emphasised because temperatures above 37.5°C worsen neurological outcomes. Maintaining systolic and mean arterial pressures above the tenth percentile for age and sex is supported by new evidence. These recommendations are workable in most Indian ICUs, provided that temperature and blood pressure monitoring are reliable and consistent.

Neurological prognostication is addressed with appropriate caution. The guideline advises that no single test should be used in isolation. Imaging, electroencephalogram, neurological examination, and biomarkers must be interpreted together and across time points, which is particularly relevant in India, where families often seek prognostic clarity early, and premature conclusions may lead to inappropriate decisions about continuing care.

Survivorship after discharge, often overlooked, is recognised as a key phase of recovery. Many children continue to experience behavioural, cognitive, or physical challenges long after hospital discharge. Rehabilitation, school reintegration, and long-term follow-up are recommended, though these services remain unevenly available in India.

Treatment of arrhythmias is updated with new evidence supporting the use of intravenous sotalol for supraventricular tachycardia (SVT) with haemodynamic compromise when usual first-line treatments fail, and expert help is not immediately available. This addition is useful for centres without paediatric electrophysiology support.

Overall, the 2025 PALS guideline strengthens the chain of survival by integrating physiology-based targets, clearer airway strategies, structured monitoring, and thoughtful post-arrest care. For Indian practitioners, the message is clear: focus on strong fundamentals while adopting newer strategies that improve stability and neurological recovery. Updated training, simulation, and team-based practice will be essential if these guidelines are to translate into better outcomes for children across diverse clinical settings.

Top 10 Take-Home Messages

• High-quality CPR is the foundation of PALS resuscitation for health care professionals. We reaffirm the key components of high-quality CPR: Providing adequate chest compression rate and depth, minimising interruptions in CPR, allowing full chest recoil between compressions, and providing sufficient ventilation for the paediatric patient population while avoiding excessive ventilation.

• For initial non-shockable rhythms, administering epinephrine as soon as possible is associated with favourable outcomes for infants and children in cardiac arrest.

• Rapid defibrillation remains the priority for cardiac arrest with initial shockable rhythms. Administer epinephrine if defibrillation is not immediately possible.

• For infants and children with continuous invasive arterial blood pressure monitoring in place during CPR, diastolic blood pressure targets of ≥25 mmHg in infants and ≥30 mmHg in children aged at least 1 year are now included as haemodynamic goals of high-quality CPR.

• ETCO₂ can be an indicator of CPR quality, although the use of specific ETCO₂ cutoff values to guide termination of resuscitation in infants and children is not advised.

• Preventing hyperthermia is a critical component of post-cardiac arrest care. Avoiding central temperatures >37.5°C can improve neurological outcomes in infants and children who remain comatose following cardiac arrest.

• For infants and children, new data support maintaining post-cardiac arrest systolic and mean arterial blood pressure greater than the 10^th percentile for age and sex.

• Neuroprognostication after cardiac arrest in infants and children requires multiple modalities to be assessed at various time points throughout the post-cardiac arrest period. Single tests conducted in isolation can lead to inaccurate predictions of neurologic outcomes.

• After discharge from the hospital, cardiac arrest survivors often have ongoing physical, cognitive, and behavioural challenges and require evaluation for appropriate therapies and interventions.

• New data support the use of IV sotalol as an anti-arrhythmic to treat infants and children with SVT and cardiopulmonary compromise that is unresponsive to vagal manoeuvres, IV adenosine, and electrical synchronised cardioversion, when expert consultation is not available.

6. The 2025 neonatal resuscitation update re-centres the basics while strengthening system preparedness

Source: Lee HC, Strand ML, Finan E, Illuzzi J, KamathRayne BD, Kapadia V, et al. Part 5: Neonatal resuscitation: 2025 American Heart Association and American Academy of Paediatrics Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2025; 10.1542/peds.2025-074352

The 2025 American Heart Association-American Academy of Paediatrics Neonatal Resuscitation guidelines arrive at a time when outcomes in the delivery room still hinge on two elements: Anticipation and competence. Unlike paediatric or adult resuscitation, where cardiac arrest is usually the final common pathway of disease, newborn resuscitation is a transition problem. The movement from the intrauterine environment to air-breathing life is delicate, rapid, and uneven across infants. The new guideline, therefore, places equal emphasis on supporting the normal transition and on responding decisively when that transition falters.

A central idea in the document is the ‘newborn chain of care’, which begins long before delivery. Prenatal care, risk assessment, team readiness, equipment checks, thermoregulation plans, and clear workflow all contribute to outcomes. In India, where deliveries occur in a wide variety of settings, from high-volume tertiary centres to small facilities with limited staff, this reminder is important. Readiness is not simply equipment; it is predictable processes.

Most newborn infants do not require active resuscitation. This simple fact is sometimes forgotten in busy labour rooms. The guideline reinforces that infants who are vigorous at birth benefit from deferred cord clamping for at least 60 s and uninterrupted skin-to-skin contact. These low-tech practices improve haemodynamic stability, temperature control, and breastfeeding initiation. They deserve protection even in crowded units.

For infants who do require help, the priority remains effective ventilation. Rising heart rate is the clearest sign of success. If the heart rate does not improve, corrective ventilation steps must be taken early. The guideline reminds us that alternative airways, including laryngeal mask devices, play an important role when mask ventilation is ineffective or intubation is delayed, particularly useful in settings where experienced intubators are not always available.

Temperature management receives prominent attention. Both hypothermia and hyperthermia are associated with adverse outcomes. Routine temperature monitoring during resuscitation is a simple yet often neglected step. For Indian delivery rooms where radiant warmers, room temperature control, and staffing vary widely, this recommendation is highly relevant.

Pulse oximetry guidance continues to evolve. The guideline recommends using pulse oximetry to titrate oxygen therapy and achieve target saturations, acknowledging the harms of both under-oxygenation and hyperoxia, which aligns with current neonatal practice but encourages stricter adherence.

Chest compressions remain indicated only when the heart rate stays below 60 beats per minute after adequate ventilation and corrective steps. Epinephrine follows if compressions and ventilation do not improve heart rate, with intravascular administration preferred. The guideline recognises that vascular access can take time and notes that endotracheal epinephrine may be used while access is obtained.

A sensitive but important recommendation concerns redirection of care. If all resuscitation steps have been completed effectively and no heart rate is detected at 20 min, a discussion with the family and team is appropriate. In India, where cultural, ethical, and communication challenges often intersect in the delivery room, this reminder supports more structured decision-making.

Overall, the 2025 neonatal resuscitation guidelines reaffirm core principles while integrating newer evidence on ventilation, oxygen titration, temperature, and team preparedness. For Indian clinicians, the message is steady and practical: protect the normal transition, recognise delay early, and treat ventilation as the central intervention. Skill, readiness, and thoughtful communication remain the backbone of newborn care in the first minutes of life.

Top 10 Take-Home Messages for Neonatal Life Support

• The newborn chain of care starts with prenatal care. It extends to recovery and appropriate follow-up in the postnatal period to ensure optimal short- and long-term health for the infant and family.

• Newborn resuscitation requires clinicians to anticipate and prepare, both individually and as teams.

• Most newborn infants do not require resuscitation. They can be evaluated and monitored for 60 s or more during deferred cord clamping and can maintain skin-to-skin contact with their parents after birth.

• Effective ventilation of the lungs, as indicated by an increasing heart rate, is the priority in resuscitating newborn infants.

• Ventilation corrective steps, including the use of an alternative airway (laryngeal mask or endotracheal intubation), may be required if the heart rate does not rise with assisted ventilation with a face mask.

• Monitoring temperature during resuscitation helps to avoid hypothermia and hyperthermia, both of which are associated with adverse outcomes.

• Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation target ranges.

• Chest compressions are indicated if the heart rate remains <60 beats/min after appropriate ventilation corrective steps, which preferably include endotracheal intubation.

• If the heart rate remains <60 beats/min after chest compressions, epinephrine is indicated, preferably through an intravascular route. Endotracheal epinephrine may be considered while obtaining vascular access.

• If all steps of resuscitation are effectively completed and there is no heart rate detected by 20 min, redirection of care may be discussed with the team and family.