Shared decision-making (SDM), which has become a core principle of patient-clinician communication, emphasizes respect for autonomy, partnership, and transparency. In neonatal practice—where decisions often carry profound ethical and emotional weight—SDM helps align medical recommendations with the family's values, fosters trust, and may reduce moral distress for both parents and clinicians. However, in Korea, the systematic recognition and formalization of SDM remains limited, underscoring the need for practical guidance and institutional support in neonatal and pediatric care. This review discusses key principles of SDM and illustrates their application in real clinical communication through hypothetical neonatal case vignettes. SDM is best understood not as a single model but as a continuum shaped by the balance between medical judgment and parental values. Drawing on Opel’s stepwise framework, SDM is most appropriate when more than one medically reasonable option exists and value considerations meaningfully influence the choice. Physicians must also remain aware of personal biases that can shape how options are framed and discussed. Building on this conceptual foundation, this paper describes how meaningful SDM can be practiced using the 4 conversational phases outlined by Madrigal and Kelly: (1) acknowledging the need for a decision and inviting participation; (2) sharing information while listening; (3) uncovering values, hopes, and fears; and (4) reaching a balanced and ethically grounded decision. Through clinical examples, these phases demonstrate how empathy, pacing, and reflective dialogue can transform information exchange into shared moral reasoning. Finally, structural and cultural barriers continue to hinder the implementation of SDM in Korea, including time constraints, limited training, and restrictive legal frameworks. Policy reform, education, and team-based strategies are essential to support its broader adoption. SDM ultimately offers an ethically robust and relational framework for navigating complex, value-laden decisions in neonatal and pediatric care that is grounded in communication that recognizes bias and engages families as true partners.

Postnatal corticosteroids can facilitate ventilator weaning and reduce the risk of bronchopulmonary dysplasia (BPD); therefore, they are commonly used to prevent or treat BPD in preterm infants, particularly those born extremely preterm. Despite their frequent use in high-risk infants with severe BPD, no clear guidelines have been established for the optimal timing of administration, dosage, corticosteroid type, route of delivery, and indication based on the infant’s baseline risk of BPD. Early systemic corticosteroid administration, particularly dexamethasone within the first week of life, appears to be associated with adverse neurodevelopmental outcomes and is generally not recommended. Dexamethasone and hydrocortisone exhibit distinct biological and clinical effects, yet evidence from direct comparative studies is limited. Dexamethasone may improve cerebral palsy-free survival of infants at high risk of BPD but poses potential harm in those at low risk, highlighting the need for individualized risk-based decision-making. Optimal dosing remains unclear: lower doses may reduce systemic side effects despite the uncertainty of their neurodevelopmental safety, whereas higher doses may be more effective in selected high-risk infants. Inhaled corticosteroids have inconclusive benefits compared with systemic therapy. The intratracheal administration of corticosteroids with surfactant improves distal airway delivery and reduces death or BPD rates; however, short- and long-term safety data remain limited. Overall, postnatal corticosteroids should be used cautiously and selectively in high-risk, ventilator-dependent infants with severe BPD. Future high-quality trials are needed to evaluate long-term survival free of neurodevelopmental impairments.

Background: Malignant vasovagal syncope (VVS) is characterized by cardiac arrest lasting more than 3 seconds during a syncope episode or head-up tilt test (HUTT). We aim to conduct a risk assessment for potential malignant VVS before the HUTT by using economic, simple and convenient demographic data, in order to prevent adverse outcomes for pediatric VVS.Purpose: To explore the correlation between demographic factors and pediatric malignant VVS, and verify the value of these factors in early risk assessment for malignant VVS before HUTT, so as to optimize test safety and reduce adverse events. Methods: We conducted a retrospective analysis of the clinical data of 3,734 children who were initially diagnosed with VVS due to unexplained syncope and presyncope. Finally, 122 children who met the diagnostic criteria for malignant VVS were included in the malignant VVS group, and 661 children who did not meet the criteria during the same period were matched as the control group. By analyzing demographic data and other factors, we attempted to clarify the association between these factors and malignant VVS. Results: Linear relationship: age and body mass index (BMI) have independent protective effects on malignant VVS. For every 1-year increase in age and every 1 kg/m2 increase in BMI, the risk of malignant VVS decreases by 12% and 9%, respectively. Nonlinear relationship: When the age is <12.9 years old, for every additional year of age, the risk of malignant VVS decreases by 20%. For ages 12.9 years and above, the efficacy is not significant. There is no significant nonlinear relationship between BMI and malignant VVS. Conclusion Age and BMI are independent protective factors for pediatric malignant VVS. Before the age of 12.9 years, the incidence of malignant VVS gradually decreases with the increase in age, and thereafter there is no significant impact.

Background: Cerebral hypoxia-ischemia impairs brain development in extremely preterm infants and is associated with poor neurological outcomes. Near-infrared spectroscopy (NIRS) is a noninvasive continuous monitoring method for regional cerebral oxygen saturation (rcSO2).Purpose: This study evaluated the clinical feasibility and neurological impact of a neurocritical care bundle that incorporates prolonged multidisciplinary hemodynamic monitoring and a stepwise management algorithm. Methods: Preterm infants with a gestational age (GA) ≤28 weeks or birth weight (BW) ≤1,000 g were prospectively enrolled in a bundle group subjected to NIRS for rcSO2, electrical cardiometry for cardiac output, and daily brain and cardiac echography during the first 72 hours of life. Monitoring was repeated weekly in the first month and then monthly until discharge or the term-equivalent age (TEA) was reached. We implemented a stepwise management algorithm for treating cerebral hypoxia. The primary outcome was a composite of mortality and adverse neurological events (structural abnormalities or electroencephalogram-confirmed seizures) before discharge. The secondary outcomes were the physiological pattern of rcSO2 within the initial 72 hours and up to discharge or TEA. Results: Thirty preterm infants (GA, 27.1±2.0 weeks; BW, 830±225 g) were enrolled in the bundle group. The mean time-averaged rcSO2 (66.8%±10.3%) was not associated with GA or BW. However, postnatal age appeared to influence physiological rcSO2 changes, given that rcSO2 values were higher during the initial 72 hours than at subsequent intervals. Seven infants (23.3%) had poor outcomes and significantly lower time-averaged rcSO2 (51.1% [50.0%–65.2%] vs. 71.8% [67.1%–73.1%], P=0.002). Multivariate regression indicated that a lower rcSO2 was an independent risk factor, and a 65% threshold showed an optimal predictive value for poor outcomes. Conclusion The neurocritical care bundle helped identify preterm infants at risk of cerebral hypoxia, and lower rcSO2 was an independent risk factor for composite mortality and adverse neurological outcomes.

Background: Hematopoietic stem cell transplantation (HSCT) is a curative treatment for patients with transfusion-dependent thalassemia (TDT), and the outcomes are influenced by multiple factors.Purpose: We retrospectively evaluated the clinical characteristics, risk factors, complications, and treatment outcomes in Thai patients aged <20 years using 30-year multicenter HSCT data. This study sought to evaluate the contributing factors affecting survival outcomes and complications, provide insights into the evolution of HSCT for TDT, and inform practice guidelines in developing countries. Methods: The outcomes of 266 HSCT procedures from related and unrelated donors in 249 Thai patients with TDT performed from 1988 to 2016 (median follow-up, 102 months) were analyzed. Results: The median age at HSCT was 6.9 years (range, 1−19 years). Most HSCT procedures used human leukocyte antigen-matched related donors (MRDs; 71.8%), with bone marrow serving as the primary graft source (69.5%). The thalassemia recurrence rate was 11.6%, whereas the mortality rate was 9.0%, primarily due to Gram-negative sepsis. The 5-year overall (OS) and event-free survival (EFS) were 91.3% and 81.0%, respectively. The outcomes did not differ significantly between MRDs and matched unrelated donors (MUDs: OS rate, 91.5% vs. 88.0%, P=0.52; EFS rate, 82.0% vs. 76.2%, P=0.45). Since 2000, advances in pre-HSCT transfusion, iron chelation, graft-versus-host disease prophylaxis, and supportive care have been implemented, with intravenous busulfan adopted after 2009. Over three periods (1988−1999, 2000−2009, and 2010−2016), the OS rate rose from 89.4% to 93.0% (P=0.74), and the EFS rate rose from 67.7% to 87.2% (P=0.01). Age ≤10 years was associated with better overall OS and EFS, although significance was limited to the earliest period. A multivariate analysis identified a pre-HSCT ferritin level >2,500 ng/mL, low CD34+ doses, and the use of oral busulfan conditioning as factors associated with unfavorable survival. Long-term complications, primarily endocrine disorders, affected 22.7% of survivors. Conclusion Our results broaden the donor pool by demonstrating comparable outcomes between MRD and MUD transplantation. Optimizing pretransplant care, such as regular pre-HSCT transfusion, adjusting conditioning intensity, and improving posttransplant supportive care, may mitigate age-related risks in older recipients.

Background: The impact of arterial blood pressure on cerebral oxygenation during immediate postnatal transition is poorly understood.Purpose: Here we investigated the association between arterial blood pressure (BP), cerebral tissue oxygenation index (cTOI), and cerebral fractional tissue oxygen extraction (cFTOE) during the immediate postnatal transition in preterm and full-term neonates. Methods: This prospective observational study included preterm and term neonates who did versus did not require respiratory support. Oscillometric BP was measured at 5, 10, and 15 minutes after birth. cTOI was continuously monitored using near-infrared spectroscopy, while arterial oxygen saturation (SpO2) was recorded using pulse oximetry. cFTOE was calculated from cTOI and SpO. cTOI and cFTOE values were correlated with systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) at all time points. Correlation and mixed-model analyses were then performed. Results: A total of 102 neonates were enrolled: 51 preterm (33 with, 18 without respiratory support) and 51 term (14 with, 37 without respiratory support). In preterm neonates requiring respiratory support, cTOI was positively correlated with DABP at all time points and with MABP at 15 minutes. cFTOE was negatively correlated with MABP and DABP throughout the experiment and with SABP at 5 minutes. No significant correlations were observedamong the other groups. A mixed-model analysis showed that MABP and DABP were significantly associated with cFTOE but not cTOI independent of gestational age or respiratory support. Conclusion Among preterm neonates requiring respiratory support, cTOI and cFTOE were associated with arterial BP during the immediate neonatal transition. Only cFTOE showed a slight association with BP among stable preterm and full-term neonates. These findings suggest impaired cerebral autoregulation in compromised preterm infants during the immediate postnatal transition.

Background: Patients with coarctation of the aorta (CoA) and an interrupted aortic arch (IAA) may present with small mitral valves (MVs) and a reduced left ventricular (LV) volume. Biventricular repair (BVR) in these patients is dependent on adequate size of the left cardiac structures.Purpose: This study evaluated the impact of the hemodynamic characteristics of atrial septal defects (ASDs) on MV growth following surgical repair. Methods: We retrospectively reviewed the data of patients diagnosed with CoA or IAA between 2007 and 2024. The z score for MV size measured 6 months postoperatively (Z2) was compared with the preoperative MV size (Z1). The factors associated with MV growth were also studied. Results: A total of 161 patients with CoA or IAA were included. Transthoracic echocardiography was used to assess the MV and LV dimensions preoperatively and 6 months postoperatively. Of the cohort, 155 (96.3%) underwent initial BVR and 6 underwent single-ventricle palliation. MV z scores significantly increased following BVR (mean change: +0.45±1.35; P<0.001) but decreased after single-ventricle repair (-0.56±0.49, P=0.04). Multivariate analysis identified the initial MV z score and ASD pressure gradient as independent predictors of MV growth (R2=0.39). Conclusion Annular growth of the MV was not observed in patients who underwent single-ventricle palliation. In contrast, among patients who achieved BVR, those with a small preoperative MV annulus and low ASD pressure gradient demonstrated subsequent catch-up MV growth, suggesting that adequate left-sided preload is essential for MV development.