COVID-19 – RCPCH Guidance

This guidance has been prepared to provide members / health professionals working in paediatrics and child health with advice around the ongoing outbreak of COVID-19. It also provides signposts and links to further information developed by national bodies.

We will update this guidance on a regular basis as new data becomes available. We’ll work with others to bring together the best available information. Advice and guidance should be used alongside local operational policies developed by your organisation.

 

Link to RCPCH Guidance here

Inhaled Nitric Oxide Use in Pediatric Hypoxemic Respiratory Failure

Pediatric Critical Care Medicine: March 19, 2020 – Volume Online First – Issue –

doi: 10.1097/PCC.0000000000002310

Abstract

Objectives:

To characterize contemporary use of inhaled nitric oxide in pediatric acute respiratory failure and to assess relationships between clinical variables and outcomes. We sought to study the relationship of inhaled nitric oxide response to patient characteristics including right ventricular dysfunction and clinician responsiveness to improved oxygenation. We hypothesize that prompt clinician responsiveness to minimize hyperoxia would be associated with improved outcomes.

Design:

An observational cohort study.

Setting:

Eight sites of the Collaborative Pediatric Critical Care Research Network.

Patients:

One hundred fifty-one patients who received inhaled nitric oxide for a primary respiratory indication.

Measurements:

Clinical data were abstracted from the medical record beginning at inhaled nitric oxide initiation and continuing until the earliest of 28 days, ICU discharge, or death. Ventilator-free days, oxygenation index, and Functional Status Scale were calculated. Echocardiographic reports were abstracted assessing for pulmonary hypertension, right ventricular dysfunction, and other cardiovascular parameters. Clinician responsiveness to improved oxygenation was determined.

Main Results:

One hundred thirty patients (86%) who received inhaled nitric oxide had improved oxygenation by 24 hours. PICU mortality was 29.8%, while a new morbidity was identified in 19.8% of survivors. Among patients who had echocardiograms, 27.9% had evidence of pulmonary hypertension, 23.1% had right ventricular systolic dysfunction, and 22.1% had an atrial communication. Moderate or severe right ventricular dysfunction was associated with higher mortality. Clinicians responded to an improvement in oxygenation by decreasing FIO₂ to less than 0.6 within 24 hours in 71% of patients. Timely clinician responsiveness to improved oxygenation with inhaled nitric oxide was associated with more ventilator-free days but not less cardiac arrests, mortality, or additional morbidity.

Conclusions:

Clinician responsiveness to improved oxygenation was associated with less ventilator days. Algorithms to standardize ventilator management may improve signal to noise ratios in future trials enabling better assessment of the effect of inhaled nitric oxide on patient outcomes. Additionally, confining studies to more selective patient populations such as those with right ventricular dysfunction may be required.

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Short- and Long-Term Outcome in Critically Ill Children After Acute Interhospital Transport to a PICU in Sweden

Pediatric Critical Care Medicine: March 20, 2020 – Volume Online First – Issue –

doi: 10.1097/PCC.0000000000002319

Abstract

Objectives:

Data on long-term survival in children after interhospital transport to a PICU are scarce. The main objective was to investigate short- and long-term outcome after acute interhospital transport to a PICU for different age and risk stratification groups. Secondary aims were to investigate whether neonatal patients would have higher mortality and be more resource demanding than older patients.

Design:

Single-center, retrospective cohort study.

Setting:

Specialist pediatric transport team and a tertiary PICU in Sweden.

Patients:

Critically ill children 0–18 years old, acutely transported by a specialist pediatric transport team to a PICU in Sweden (January 1, 2008, to December 31, 2016).

Interventions:

None.

Measurements and Main Results:

A total of 401 acute transport events were included. Overall mortality was 15.7% with a median follow-up time of 3.4 years (range, 0–10.2 yr). Median predicted death rate was 4.9%. There was no mortality during transport. Cumulative mortality almost doubled within the first 6 months after PICU discharge, from 6.5% to 12.0%. Of late deaths, 66.7% occurred in the risk stratification group predicted death rate 0–10%, and 95% suffered from severe comorbidity. There were no deaths after PICU discharge in the neonatal group. Cumulative mortality in multiple transported patients was 36.4%.

Conclusions:

This is the first report on long-term survival after acute pediatric interhospital transport. For the entire cohort, there was significant mortality after PICU discharge, especially in multiple transported patients. In contrast, survival in the subgroup of neonatal patients was high after PICU discharge.

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Lung-Protective Mechanical Ventilation Strategies in Pediatric Acute Respiratory Distress Syndrome

Image: Flickr.com

Pediatric Critical Care Medicine: March 20, 2020 – Volume Online First – Issue –

doi: 10.1097/PCC.0000000000002324

Abstract

Objectives:

Reduced morbidity and mortality associated with lung-protective mechanical ventilation is not proven in pediatric acute respiratory distress syndrome. This study aims to determine if a lung-protective mechanical ventilation protocol in pediatric acute respiratory distress syndrome is associated with improved clinical outcomes.

Design:

This pilot study over April 2016 to September 2019 adopts a before-and-after comparison design of a lung-protective mechanical ventilation protocol. All admissions to the PICU were screened daily for fulfillment of the Pediatric Acute Lung Injury Consensus Conference criteria and included.

Setting:

Multidisciplinary PICU.

Patients:

Patients with pediatric acute respiratory distress syndrome.

Interventions:

Lung-protective mechanical ventilation protocol with elements on peak pressures, tidal volumes, end-expiratory pressure to FIO₂ combinations, permissive hypercapnia, and permissive hypoxemia.

Measurements and Main Results:

Ventilator and blood gas data were collected for the first 7 days of pediatric acute respiratory distress syndrome and compared between the protocol (n = 63) and nonprotocol groups (n = 69). After implementation of the protocol, median tidal volume (6.4 mL/kg [5.4–7.8 mL/kg] vs 6.0 mL/kg [4.8–7.3 mL/kg]; p = 0.005), PaO₂ (78.1 mm Hg [67.0–94.6 mm Hg] vs 74.5 mm Hg [59.2–91.1 mm Hg]; p = 0.001), and oxygen saturation (97% [95–99%] vs 96% [94–98%]; p = 0.007) were lower, and end-expiratory pressure (8 cm H₂O [7–9 cm H₂O] vs 8 cm H₂O [8–10 cm H₂O]; p = 0.002] and PaCO₂ (44.9 mm Hg [38.8–53.1 mm Hg] vs 46.4 mm Hg [39.4–56.7 mm Hg]; p = 0.033) were higher, in keeping with lung protective measures. There was no difference in mortality (10/63 [15.9%] vs 18/69 [26.1%]; p = 0.152), ventilator-free days (16.0 [2.0–23.0] vs 19.0 [0.0–23.0]; p = 0.697), and PICU-free days (13.0 [0.0–21.0] vs 16.0 [0.0–22.0]; p = 0.233) between the protocol and nonprotocol groups. After adjusting for severity of illness, organ dysfunction and oxygenation index, the lung-protective mechanical ventilation protocol was associated with decreased mortality (adjusted hazard ratio, 0.37; 95% CI, 0.16–0.88).

Conclusions:

In pediatric acute respiratory distress syndrome, a lung-protective mechanical ventilation protocol improved adherence to lung-protective mechanical ventilation strategies and potentially mortality.

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How 217 Pediatric Intensivists Manage Anemia at PICU Discharge Online Responses to an International Survey

 

Pediatric Critical Care Medicine: March 25, 2020 – Volume Online First – Issue –

doi: 10.1097/PCC.0000000000002307

Abstract

Objective:

To describe the management of anemia at PICU discharge by pediatric intensivists.

Design:

Self-administered, online, scenario-based survey.

Setting:

PICUs in Australia/New Zealand, Europe, and North America.

Subjects:

Pediatric intensivists.

Interventions:

None.

Measurements and Main Results:

Respondents were asked to report their decisions regarding RBC transfusions, iron, and erythropoietin prescription to children ready to be discharged from PICU, who had been admitted for hemorrhagic shock, cardiac surgery, craniofacial surgery, and polytrauma. Clinical and biological variables were altered separately in order to assess their effect on the management of anemia. Two-hundred seventeen responses were analyzed. They reported that the mean (± SEM) transfusion threshold was a hemoglobin level of 6.9 ± 0.09 g/dL after hemorrhagic shock, 7.6 ± 0.10 g/dL after cardiac surgery, 7.0 ± 0.10 g/dL after craniofacial surgery, and 7.0 ± 0.10 g/dL after polytrauma (p < 0.001). The most important increase in transfusion threshold was observed in the presence of a cyanotic heart disease (mean increase ranging from 1.80 to 2.30 g/dL when compared with baseline scenario) or left ventricular dysfunction (mean increase, 1.41–2.15 g/dL). One third of respondents stated that they would not prescribe iron at PICU discharge, regardless of the hemoglobin level or the baseline scenario. Most respondents (69.4–75.0%, depending on the scenario) did not prescribe erythropoietin.

Conclusions:

Pediatric intensivists state that they use restrictive transfusion strategies at PICU discharge similar to those they use during the acute phase of critical illness. Supplemental iron is less frequently prescribed than RBCs, and prescription of erythropoietin is uncommon. Optimal management of post-PICU anemia is currently unknown. Further studies are required to highlight the consequences of this anemia and to determine appropriate management.

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Efficacy of zinc sulfate on indirect hyperbilirubinemia in premature infants admitted to neonatal intensive care unit: a double-blind, randomized clinical trial

BMC Pediatrics volume 20, Article number: 130 (2020)

Abstract

Background

Hyperbilirubinemia is a common neonatal problem. Studies conducted on the effectiveness of zinc salts on serum indirect bilirubin levels in newborns have yielded different results, all calling for further research. This study aimed to determine the effect of oral zinc sulfate on indirect hyperbilirubinemia in preterm infants admitted to the neonatal intensive care unit.

Methods

A randomized double-blind clinical trial was performed in the neonatal intensive care unit of Vali-e-Asr Hospital in Birjand, Iran. The study population comprised neonates aged between 31 and 36 gestational weeks, who required phototherapy in the neonatal intensive care unit. A total of 60 neonates were selected by census and allocated into an experimental group and a control group. In addition to phototherapy, the experimental group received 1 cc/Kg zinc sulfate syrup (containing 5 mg/5 cc zinc sulfate; Merck Company, Germany), and the control group received a placebo syrup (containing 1 cc/kg sucrose). Data were analyzed in SPSS-21 software using the independent t-test, repeated-measures ANOVA, Bonferroni post-hoc test, and Mann-Whitney test. P-values smaller than 0.05 were considered significant.

Results

Bilirubin level changes in the experimental and control groups six hours after intervention were − 1.45 ± 3.23 and − 0.49 ± 0.37 (p = 0.024), respectively. The changes 24 and 48 h after intervention were-3.26 ± 2.78 and − 1.89 ± 1.20 (p = 0.017) in the experimental group and − 4.89 ± 2.76 and − 3.98 ± 2.32 (p = 0.23) in the control group, respectively. There was no significant difference in the phototherapy duration between the two groups (p = 0.24).

Conclusions

The results of this study showed that the use of zinc sulfate syrup in preterm infants with indirect hyperbilirubinemia significantly reduced bilirubin levels within 48 h of treatment.

Link to full text here

Diagnostic performance of individual characteristics and anthropometric measurements in detecting elevated serum alanine aminotransferase among children and adolescents

BMC Pediatrics volume 20, Article number: 131 (2020)

Abstract

Background

Screening for elevated serum alanine aminotransferase (ALAT) can help identifying individuals at the risks of chronic and metabolic diseases, but blood collection is invasive and cannot be widely used for investigations. Considered as simple and inexpensive screening indices, individual characteristics and anthropometric measurements can be measured in a large crowd and may be important surrogate markers for ALAT levels. This study aimed to examine the diagnostic performance of individual characteristics and anthropometric parameters as predictive factors for discerning an elevated ALAT activity among Shenzhen children and adolescents.

Methods

A school-based screening study was performed from 9 high schools in Shenzhen during February 2017 and June 2018. Receiver operating characteristic curve was used to examine the diagnostic performance of each variable for detecting elevated ALAT.

Results

Altogether 7271 students aged 9–17 years were involved. The proportion of elevated ALAT greatly increased with increasing classification of BMI-z. By the sex-specific cut-offs for elevated ALAT (30 U/L boys; 19 U/L girls), BMI showed the highest area under the curve of 0.789 (95% CI 0.765–0.812) and followed by weight (0.779 [0.755–0.802]), BMI-z (0.747 [0.722–0.772]), height (0.622 [0.597–0.647]), and age (0.608 [0.584–0.632]), while height-z was not capable. With the cut-off of 67.8 kg for weight and 22.6 kg/m² for BMI, the accuracy to identify elevated ALAT was 87.1% for weight and 82.9% for BMI.

Conclusions

The presence of elevated ALAT was more common in overweight or obese children and adolescents. BMI and weight had the superiority of detecting elevated ALAT, followed by BMI-z, height, and age.

 

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Efficacy of colistin in multidrug-resistant neonatal sepsis: experience from a tertiary care center in Karachi, Pakistan

Archives of Disease in Childhood Published Online First: 20 March 2020. doi: 10.1136/archdischild-2019-318067

Abstract

Objective Infections with multidrug-resistant organisms (MDROs) such as Gram-negative bacteria have high morbidity and mortality with limited treatment options. Colistin, an antibiotic active against MDRO, was rarely used due to frequent adverse effects, but its use has now been recommended among adults. In this study, we determined the efficacy of colistin for the treatment of sepsis in neonates.

 

Design/setting/patients/outcomes We conducted a retrospective record review of all neonates admitted to the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan, between June 2015 and June 2018, who had sepsis and received colistin by intravenous, inhalation and/or intrathecal routes. Predictors of colistin efficacy, for neonatal survival and microbial clearance, were assessed using multiple logistic regression.

 

Results 153 neonates received colistin; 120 had culture-proven sepsis; and 93 had MDR-GNB (84 colistin-sensitive). 111 (72.5%) neonates survived and were discharged from hospital; 82.6% had microbial clearance. Neonates with colistin-sensitive bacteria (adjusted OR (AOR)=3.2, 95% CI 2.8 to 4.0), and those in which colistin therapy started early (AOR=7.2, 95% CI 3.5 to 13.6) were more likely to survive. Neonates with increased gestational age (AOR=1.9, 95% CI 1.5 to 3.0), higher weight (AOR=5.4, 95% CI 3.3 to 11.8) and later onset of sepsis (AOR=4.3, 95% CI 2.0 to 9.0) had higher survival. Adverse events included nephrotoxicity in 5.2%; 13.7% developed seizures and 18.3% had electrolyte imbalance.

 

Conclusions Colistin therapy was associated with survival among neonates suffering from MDR-GNB sepsis. The frequency of side effects was moderate.

Link to abstract page here

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Paediatric empyema: worsening disease severity and challenges identifying patients at increased risk of repeat intervention

Archives of Disease in Childhood Published Online First: 24 March 2020. doi: 10.1136/archdischild-2019-318219

Abstract

Objective Empyema is the most common complication of pneumonia. Primary interventions include chest drainage and fibrinolytic therapy (CDF) or video-assisted thoracoscopic surgery (VATS). We describe disease trends, clinical outcomes and factors associated with reintervention.

 

Design/setting/patients Retrospective cohort of paediatric empyema cases requiring drainage or surgical intervention, 2011–2018, admitted to a large Australian tertiary children’s hospital.

 

Results During the study, the incidence of empyema increased from 1.7/1000 to 7.1/1000 admissions (p<0.001). We describe 192 cases (174 CDF and 18 VATS), median age 3.0 years (IQR 1–5), mean fever duration prior to intervention 6.2 days (SD ±3.3 days) and 50 (26%) cases admitted to PICU. PICU admission increased during the study from 18% to 34% (p<0.001). Bacteraemia occurred in 23/192 (12%) cases. A pathogen was detected in 131/192 (68%); Streptococcus pneumoniae 75/192 (39%), S. aureus 25/192 (13%) and group A streptococcus 13/192 (7%). Reintervention occurred in 49/174 (28%) and 1/18 (6%) following primary CDF and VATS. Comparing repeat intervention with single intervention cases, a continued fever postintervention increased the likelihood for a repeat intervention (OR 1.3 per day febrile; 95% CI 1.2 to 1.4, p<0.0001). Younger age, prolonged fever preintervention and previous antibiotic treatment were not associated with initial treatment failure (all p>0.05).

 

Conclusion We report increasing incidence and severity of empyema in a large tertiary hospital. One in four patients required a repeat intervention after CDF. Neither clinical variables at presentation nor early investigations were able to predict initial treatment failure.

 

Link to abstract here

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Paradigm Shift in Asthma Therapy for Adolescents Should It Apply to Younger Children as Well?

Image: Wikimedia Commons

JAMA Pediatr. 2020;174(3):227-228. doi:10.1001/jamapediatrics.2019.5214

Asthma is one of the most common chronic conditions of childhood and is associated with significant effect on quality of life. An ongoing controversy remains how to best treat asthma in children and adolescents. A provocative evolution in this controversy is the publication of new recommendations by the Global Initiative for Asthma (GINA), which present a significant change in asthma therapy.¹ Step 1 recommendations for mild asthma in adolescents 12 years and older and adults changed from as-needed short-acting β-agonist (SABA) to as-needed low-dose inhaled corticosteroid (ICS) formoterol (a long-acting β-agonist [LABA]). In children aged 6 to 11 years, GINA recommends that ICS therapy be used with SABA as needed or regular ICS with as-needed SABA as an alternative approach.

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