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An editorial is presented which expresses the views on peer review processes, emphasizing its importance in ensuring the quality and validity of academic manuscripts. Topics include the definition and types of peer review, its significance in critical care nursing for advancing clinical practice through high-quality evidence, debates on the necessity of peer review, and the future of peer reviewing with considerations of artificial intelligence (AI) integration.

Background: Establishing and sustaining enteral feeding in critically ill children is challenging and has met with many problems. Aims and objectives: The aim of this study was to investigate (a) how actual calorie intake compared with estimated caloric requirements and (b) whether feeding guideline adherence resulted in improved nutritional intake. Design and methods: A prospective observational study was undertaken over 1 month in a tertiary referral paediatric intensive care unit (PICU) in the northwest of England. Results: Forty-seven children were studied, with a wide range of diagnoses in a 1-month period. Only 47% of the children had enteral feeds started within our 6 h post-admission target. Over half (55%) of the children received less than half of their estimated calorie requirements, but if feeding guidelines were followed, this resulted in a significantly higher ( p = 0·004) delivery of the child's estimated requirements. Conclusions: This study found that many children are not receiving adequate nutrition in PICU and that the use of feeding guidelines significantly improves calorie delivery in PICU patients. Relevance to clinical practice: This paper highlights the dearth of research related to enteral feeding in critically ill children. We found that the use of feeding guidelines improved calorie delivery and so units should be encouraged to develop their own guidelines based on the best evidence available. [ABSTRACT FROM AUTHOR]

AIM: This paper aims to present an overview of the literature relating to the effects of endotracheal suctioning (ETS) in children and adults with severe traumatic brain injury (TBI). BACKGROUND: TBI is the leading cause of death in children worldwide and continues to result in widespread mortality and morbidity. In intensive care, ETS is an essential nursing procedure that is undertaken but is known to produce some adverse effects in children. METHOD: A comprehensive literature search was undertaken using a Parahoo and quality of reporting of meta-analyses (QUOROM) approach. A range of databases was searched to identify published papers with key search terms. The databases searched included Cochrane Library, Medline, PubMed Central, CINAHL, Proquest and Science Direct. FINDINGS: This review is based on 21 papers (with 433 patients in total), but specific papers in paediatric head injury children were extremely limited, and the evidence was largely dated and inconclusive. Although the majority of papers demonstrate an increase in intracranial pressure (ICP) with ETS, there are contradictory results with regard to recovery times. CONCLUSIONS: Further research is needed specifically into the effect of ETS on ICP and cerebral perfusion pressure of children with severe TBI, taking into account all the known confounding variables. [ABSTRACT FROM AUTHOR]

Research in adult patients, in the last decade, has highlighted suboptimal care and failures in the recognition of sick adults in ward areas. In addition, many of these patients (at least 50%) demonstrated documented evidence, on observation charts, of clinical deterioration in the 24-48 h preceding cardiopulmonary arrest or emergency intensive care unit admission. However, there is little published data on whether these findings apply to children (0-17 years). The aim of the study was to examine the extent of inpatient deterioration and critical care unit admission within a children's hospital based in the North West of England, during a 4-month period. The design included a prospective chart review of clinical observations. As noted in adult patients, there is considerable documented evidence (in terms of abnormal vital signs) of physiological deterioration in the 24 h preceding intensive care or high-dependency unit admission. The use of a Paediatric Early Warning (PEW) tool could potentially have identified 87% of these children of being 'at risk' of deterioration. It is recommended that a PEW tool be incorporated into the routine paediatric ward observation charts and practice to identify children 'at risk' of deterioration. [ABSTRACT FROM AUTHOR]

Although data about vital signs is needed to develop early warning tools for use with children in paediatric wards, the validity and reliability of nurses' recordings must be considered, as Lyvonne Tume and Ian Bullock explain. [ABSTRACT FROM AUTHOR]

The author argues that the paediatric intensive care unit workforce should move beyond the traditional model of physician only service delivery to a more flexible team approach. She mentions that the new model should be responsive to the needs of patients and families in a time of ICU service deficits and budget cuts. She notes that the ICU nursing workforce should include assistant critical care practitioners in the team.

Background: The timeline of the 3 Pediatric International Nutrition Studies (PINS) coincided with the publication of 2 major guidelines for the timing of parenteral nutrition (PN) and recommended energy and protein delivery dose., Objective: The study's main objective was to describe changes in the nutrition delivery practice recorded in PINS1 and PINS2 (PINS1-2) (conducted in 2009 and 2011, preexposure epoch) vs PINS3 (conducted in 2018, postexposure epoch), in relation to the published practice guidelines., Design: This study is a secondary analysis of data from a multicenter prospective cohort study., Participants/setting: Data from 3650 participants, aged 1 month to 18 years, admitted to 100 unique hospitals that participated in 3 PINS was used for this study., Main Outcome Measures: The time in days from pediatric intensive care unit admission to the initiation of PN and enteral nutrition delivery were the primary outcomes. Prescribed energy and protein goals were the secondary outcomes., Statistical Analyses Performed: A frailty model with a random intercept per hospital with stratified baseline hazard function by region for the primary outcomes and a mixed-effects negative binomial regression with random intercept per hospital for the secondary outcomes., Results: The proportion of patients receiving enteral nutrition (88.3% vs 80.6%; P < .001) was higher, and those receiving PN (20.6% vs 28.8%; P < .001) was lower in the PINS3 cohort compared with PINS1-2. In the PINS3 cohort, the odds of initiating PN during the first 10 days of pediatric intensive care unit admission were lower, compared with the PINS1-2 cohort (hazard ratio 0.8, 95% CI 0.67 to 0.95; P = .013); and prescribed energy goal was lower compared with the PINS1-2 cohort (incident rate ratio 0.918, 95% CI 0.874 to 0.965; P = .001)., Conclusions: The likelihood of initiation of PN delivery significantly decreased during the first 10 days after admission in the PINS3 cohort compared with PINS1-2. Energy goal prescription in children receiving mechanical ventilation significantly decreased in the postguidelines epoch compared with the preguidelines epoch., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections., Objective: The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions., Methods: A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models., Results: Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use., Conclusions: Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections., Competing Interests: Conflict of interest The authors have no conflicts of interest to disclose., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Prolonged mechanical ventilation increases the risk of mortality and morbidity. Optimising sedation and early testing for possible liberation from invasive mechanical ventilation (IMV) has been shown to reduce time on the ventilator. Alongside a multicentre trial of sedation and ventilation weaning, we conducted a mixed method process evaluation to understand how the intervention content and delivery was linked to trial outcomes., Methods: 10,495 children admitted to 18 paediatric intensive care units (ICUs) in the United Kingdom participated in a stepped-wedge, cluster randomised controlled trial, with 1955 clinical staff trained to deliver the intervention. The intervention comprised assessment and optimisation of sedation levels, and bedside screening of respiratory parameters to indicate readiness for a spontaneous breathing trial prior to liberation from ventilation. 193 clinical staff were interviewed towards the end of the trial. Interview data were thematically analysed, and quantitative adherence data were analysed using descriptive statistics., Results: The intervention led to a reduced duration of IMV (adjusted median difference- 7.1 hours, 95% CI -9.6 to -5.3, p = 0.01). Overall intervention adherence was 75% (range 59-85%). Ease and flexibility of the intervention promoted it use; designated responsibilities, explicit pathways of decision-making and a shared language for communication fostered proactivity and consistency towards extubation. Delivery of the intervention was hindered by established hospital and unit organisational and patient care routines, clinician preference and absence of clinical leadership., Conclusions: The SANDWICH trial showed a significant, although small, reduction in duration of IMV. Findings suggest that greater direction in decision-making pathways, robust embedment of new practice in unit routine, and capitalising on the skills of Advanced Nurse Practitioners and physiotherapists would have contributed to greater intervention effect., Trial Registration: isrctn.org Identifier: ISRCTN16998143., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Jordan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients., Methods: An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data., Results: A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated., Conclusion: This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter., (© 2023 The Authors. Nutrition in Clinical Practice published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.)

Paediatric early warning systems (PEWS) to reduce in-hospital mortality have been a laudable endeavour. Evaluation of their impact has rarely examined the internal validity of the components of PEWS in achieving desired outcomes. We highlight the assumptions made regarding the mode of action of PEWS and, as PEWS become more commonplace, this paper asks whether we really understand their function, process and outcome., Competing Interests: Competing interests: DR and GS are involved in the NHS England National Inpatient PEWS programme., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background/objective: Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations., Methods: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation., Results: Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances., Conclusion: Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients., Methods: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness., Conclusions: The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Paediatric mortality rates in the United Kingdom are amongst the highest in Europe. Clinically missed deterioration is a contributory factor. Evidence to support any single intervention to address this problem is limited, but a cumulative body of research highlights the need for a systems approach., Methods: An evidence-based, theoretically informed, paediatric early warning system improvement programme (PUMA Programme) was developed and implemented in two general hospitals (no onsite Paediatric Intensive Care Unit) and two tertiary hospitals (with onsite Paediatric Intensive Care Unit) in the United Kingdom. Designed to harness local expertise to implement contextually appropriate improvement initiatives, the PUMA Programme includes a propositional model of a paediatric early warning system, system assessment tools, guidance to support improvement initiatives and structured facilitation and support. Each hospital was evaluated using interrupted time series and qualitative case studies. The primary quantitative outcome was a composite metric (adverse events), representing the number of children monthly that experienced one of the following: mortality, cardiac arrest, respiratory arrest, unplanned admission to Paediatric Intensive Care Unit, or unplanned admission to Higher Dependency Unit. System changes were assessed qualitatively through observations of clinical practice and interviews with staff and parents. A qualitative evaluation of implementation processes was undertaken., Results: All sites assessed their paediatric early warning systems and identified areas for improvement. All made contextually appropriate system changes, despite implementation challenges. There was a decline in the adverse event rate trend in three sites; in one site where system wide changes were organisationally supported, the decline was significant (ß = -0.09 (95% CI: - 0.15, - 0.05); p = < 0.001). Changes in trends coincided with implementation of site-specific changes., Conclusions: System level change to improve paediatric early warning systems can bring about positive impacts on clinical outcomes, but in paediatric practice, where the patient population is smaller and clinical outcomes event rates are low, alternative outcome measures are required to support research and quality improvement beyond large specialist centres, and methodological work on rare events is indicated. With investment in the development of alternative outcome measures and methodologies, programmes like PUMA could improve mortality and morbidity in paediatrics and other patient populations., (© 2021. The Author(s).)

Background: Routine measurement of gastric residual volume to guide feeding is widespread in neonatal units but not supported by high-quality evidence. Outcome selection is critical to trial design., Objective: To determine optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care., Design: A focused literature review, parent interviews, modified two-round Delphi survey and stakeholder consensus meeting., Participants: Sixty-one neonatal healthcare professionals participated in an eDelphi survey; 17 parents were interviewed. 19 parents and neonatal healthcare professionals took part in the consensus meeting., Results: Literature review generated 14 outcomes, and parent interviews contributed eight additional outcomes; these 22 outcomes were then ranked by 74 healthcare professionals in the first Delphi round where four further outcomes were proposed; 26 outcomes were ranked in the second round by 61 healthcare professionals. Five outcomes were categorised as 'consensus in', and no outcomes were voted 'consensus out'. 'No consensus' outcomes were discussed and voted on in a face-to-face meeting by 19 participants, where four were voted 'consensus in'. The final nine consensus outcomes were: mortality, necrotising enterocolitis, time to full enteral feeds, duration of parenteral nutrition, time feeds stopped per 24 hours, healthcare-associated infection; catheter-associated bloodstream infection, change in weight between birth and neonatal discharge and pneumonia due to milk aspiration., Conclusions and Relevance: We have identified outcomes for a trial of no routine measurement of gastric residual volume to guide feeding in neonatal care. This outcome set will ensure outcomes are important to healthcare professionals and parents., Competing Interests: Competing interests: CG reports grants from Medical Research Council and the NIHR during the conduct of the study; grants from NIHR, Mason Medical Research Foundation, Rosetrees Foundation and from Canadian Institute for Health Research outside the submitted work. He reports grants and personal fees from Chiesi Pharmaceuticals outside of the submitted work; the grant is for a research study, and the personal fee was to support attendance at an educational meeting. CG is vice-chair of the NIHR Research for Patient Benefit London Regional Assessment Panel and has sat on the panel since 2016. JD reports grants from NIHR, during the conduct of the study for the study; grants from NIHR, and grants from Nutrinia, outside the submitted work. The grant from Nutrinia in 2018 was for part of his salary to work as an expert advisor on a trial. JD was a member of the NIHR HTA General Board (from 2017 to 2018) and the NIHR HTA Maternity, Newborn and Child Health Panel (from 2013 to 2018). FV reports personal fees from BAXTER, personal fees from NUTRICIA, outside the submitted work. LT is an NIHR HTA panel member., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

There are reports of children COVID-19 or COVID-19 like symptoms with hyperinflammatory multisystem syndrome, ARDS, gastrointestinal and atypical Kawasaki disease presenting to PICU worldwide temporally associated with COVID-19, for which there are important nutrition support considerations. As a result, the European Society of Pediatric and Neonatal Intensive Care - Metabolism, Endocrine and Nutrition group (ESPNIC-MEN) and paediatric nutritionists working in PICUs are being consulted regarding nutrition management of critically ill children with COVID-19 or COVID-19 like symptoms. Therefore, the aim of this short report is to provide a summary of nutrition support recommendations for critically ill children with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 and surviving sepsis recommendations from February 2020., Competing Interests: Conflict of interest None to declare., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Critically ill patients receiving invasive ventilation are at risk of sputum retention. Mechanical insufflation-exsufflation (MI-E) is a technique used to mobilise sputum and optimise airway clearance. Recently, interest has increased in the use of mechanical insufflation-exsufflation for invasively ventilated critically ill adults, but evidence for the feasibility, safety and efficacy of this treatment is sparse. The aim of this scoping review is to map current and emerging evidence on the feasibility, safety and efficacy of MI-E for invasively ventilated adult patients with the aim of highlighting knowledge gaps and identifying areas for future research. Specific research questions aim to identify information informing indications and contraindications to the use of MI-E in the invasively ventilated adult, MI-E settings used, outcome measures reported within studies, adverse effects reported and perceived barriers and facilitators to using MI-E reported., Methods: We will search electronic databases MEDLINE, EMBASE, CINAHL using the OVID platform, PROSPERO, The Cochrane Library, ISI Web of Science and the International Clinical Trials Registry Platform. Two authors will independently screen citations, extract data and evaluate risk of bias using the Mixed Methods Appraisal Tool. Studies included will present original data and describe MI-E in invasively ventilated adult patients from 1990 onwards. Our exclusion criteria are studies in a paediatric population, editorial pieces or letters and animal or bench studies. Search results will be presented in a PRISMA study flow diagram. Descriptive statistics will be used to summarise quantitative data. For qualitative data relating to barriers and facilitators, we will use content analysis and the Theoretical Domains Framework (TDF) as a conceptual framework. Additional tables and relevant figures will present data addressing our research questions., Discussion: Our findings will enable us to map current and emerging evidence on the feasibility, safety and efficacy of MI-E for invasively ventilated critically ill adult patients. These data will provide description of how the technique is currently used, support healthcare professionals in their clinical decision making and highlight areas for future research in this important clinical area., Systematic Review Registration: Open Science Framework submitted on 9 July 2020.  https://osf.io/mpksq/ .

Purpose: In the United Kingdom, critically ill adolescents are treated in either adult or pediatric intensive care units (AICUs or PICUs). This study explores staff perspectives on where and how best to care for this distinct group., Materials and Methods: Semistructured interviews were conducted with 12 members of staff (3 medical, 6 nursing, and 3 allied health professionals) working in 4 ICUs; 2 general hospital AICUs and 2 tertiary centre-based PICUs in England. Interviews were audio-recorded, transcribed, and analyzed using framework analysis., Findings: One overarching theme was identified, reflecting staff understanding of the term "adolescent," and this was linked to 2 further themes, each of which had several subthemes. "Needs of the critically ill adolescent" included medical needs, dignity and privacy, issues around consent, and the impact of intensive care admission. "Implications for staff" included managing parental presence and lack of familiarity, and emotional impact, of dealing with this patient group. Some of these factors are currently better accommodated in adult settings., Conclusions: Decision-making about the place of care should take into account the individual circumstances of the patient (e.g., nature of their medical condition and previous experiences, maturity, family preference) and not be based only on age at admission. We should work across disciplines to ensure we can discover, and consistently deliver, best practice to meet the needs of critically ill adolescents.

Introduction: Despite potential benefits, it is not known how widely physiotherapists use mechanical insufflation-exsufflation devices on UK adult intensive care units. This survey aimed to describe mechanical insufflation-exsufflation use in UK adult intensive care units., Methods: Cross-sectional electronic survey of physiotherapists working in a permanent post on adult intensive care units., Results: One hundred and sixty-six complete surveys were available for analysis, reflecting a diverse geographical spread. Nearly all (98%; 163/166) clinicians had access to mechanical insufflation-exsufflation. The estimated frequency of use varied, with the majority reporting weekly or monthly use (52/163, 32%; 50/163, 31%, respectively). Nearly all clinicians (99%) used mechanical insufflation-exsufflation with extubated patients. In contrast, around half of respondents (86/163, 53%) used mechanical insufflation-exsufflation with intubated patients, with a range of perceived barriers reported., Conclusions: Mechanical insufflation-exsufflation devices are widely available on UK adult intensive care units, with use more common in extubated patients. Barriers to mechanical insufflation-exsufflation use in the intubated population warrant further investigation., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2019.)

Objective: Despite little evidence, the practice of routine gastric residual volume (GRV) measurement to guide enteral feeding in neonatal units is widespread. Due to increased interest in this practice, and to examine trial feasibility, we aimed to determine enteral feeding and GRV measurement practices in British neonatal units., Design and Setting: An online survey was distributed via email to all neonatal units and networks in England, Scotland and Wales. A clinical nurse, senior doctor and dietitian were invited to collaboratively complete the survey and submit a copy of relevant guidelines., Results: 95/184 (51.6%) approached units completed the survey, 81/95 (85.3%) reported having feeding guidelines and 28 guidelines were submitted for review. The majority of units used intermittent (90/95) gastric feeds as their primary feeding method. 42/95 units reported specific guidance for measuring and interpreting GRV. 20/90 units measured GRV before every feed, 39/90 at regular time intervals (most commonly four to six hourly 35/39) and 26/90 when felt to be clinically indicated. Most units reported uncertainty on the utility of aspirate volume for guiding feeding decisions; 13/90 reported that aspirate volume affected decisions 'very much'. In contrast, aspirate colour was reported to affect decisions 'very much' by 37/90 of responding units. Almost half, 44/90, routinely returned aspirates to the stomach., Conclusions: Routine GRV measurement is part of standard practice in British neonatal units, although there was inconsistency in how frequently to measure or how to interpret the aspirate. Volume was considered less important than colour of the aspirate., Competing Interests: Competing interests: JD reports grants from National Institute for Health Research (NIHR), during the conduct of the study; grants from NIHR, grants from Nutrinia, outside the submitted work. LT reports grant from NIHR, during the conduct of the study. ED reports grants from NIHR Health Technology Assessment (HTA) programme during the conduct of the study. HE reports grants from NIHR HTA during the conduct of the study. HH reports this grant from NIHR HTA, during the conduct of the study. MB reports grants from NIHR HTA during the conduct of the study. CG reports grants from NIHR, during the conduct of the study; grants from NIHR, grants from Medical Research Foundation, grants from Mason Medical Research Foundation, grants and personal fees from Chiesi Pharmaceuticals, grants from Rosetrees Foundation, grants from Canadian Institute for Health Research, outside the submitted work. FV reports personal fees from Baxter, personal fees from Nutricia, outside the submitted work. LT reports grants from NIHR during the conduct of the study., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective: To identify parents' prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection., Design: Qualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection., Participants: n=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved., Results: In addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that parents' prioritisation of outcomes was influenced by their experience of their child's illness, survival and the point at which they are asked about outcomes of importance in the course of their child's illness., Conclusions: Findings provide insight into parent prioritised outcomes to inform the design of future trials investigating treatments for paediatric suspected or proven severe infection as well as core outcome set development work., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Malnutrition and faltering growth at PICU admission have been related to suboptimal outcomes. However, little is known about nutritional status deterioration during PICU stay, as critical illness is characterized by a profound and complex metabolism shift, which affects energy requirements and protein turnover. We aim to describe faltering growth occurrence during PICU stay., Design: Single-center prospective observational study., Setting: Twenty-three-bed general PICU, Lyon, France., Patients: All critically ill children 0-18 years old with length of stay longer than 5 days were included (September 2013-December 2015)., Interventions: Weight and height/length were measured at admission, and weight was monitored during PICU stay, in order to calculate body mass index for age z score. Faltering growth was defined as body mass index z score decline over PICU stay. Children admitted during the first year of the study and who presented with faltering growth were followed after PICU discharge for 3 months., Measurements and Main Results: We analyzed 579 admissions. Of them, 10.2% presented a body mass index z score decline greater than 1 SD and 27.8% greater than 0.5. Admission severity risk scores and prolonged PICU stay accounted for 4% of the variability in nutritional status deterioration. Follow-up of post-PICU discharge nutritional status showed recovery within 3 months in most patients., Conclusions: Nutritional deterioration is frequent and often intense in critically ill children with length of stay greater than 5 days. Future research should focus on how targeted nutritional therapies can minimize PICU faltering growth and improve post-PICU rehabilitation.

Background: Fever improves pathogen control at a significant metabolic cost. No randomized clinical trials (RCT) have compared fever treatment thresholds in critically ill children. We performed a pilot RCT to determine whether a definitive trial of a permissive approach to fever in comparison to current restrictive practice is feasible in critically ill children with suspected infection., Methods: An open, parallel-group pilot RCT with embedded mixed methods perspectives study in four UK paediatric intensive care units (PICUs) and associated retrieval services. Participants were emergency PICU admissions aged > 28 days to < 16 years receiving respiratory support and supplemental oxygen. Subjects were randomly assigned to permissive (antipyretic interventions only at ≥ 39.5 °C) or restrictive groups (antipyretic interventions at ≥ 37.5 °C) whilst on respiratory support. Parents were invited to complete a questionnaire or take part in an interview. Focus groups were conducted with staff at each unit. Outcomes were measures of feasibility: recruitment rate, protocol adherence and acceptability, between group separation of temperature and safety., Results: One hundred thirty-eight children met eligibility criteria of whom 100 (72%) were randomized (11.1 patients per month per site) without prior consent (RWPC). Consent to continue in the trial was obtained in 87 cases (87%). The mean maximum temperature (95% confidence interval) over the first 48 h was 38.4 °C (38.2-38.6) in the restrictive group and 38.8 °C (38.6-39.1) in the permissive group, a mean difference of 0.5 °C (0.2-0.8). Protocol deviations were observed in 6.8% (99/1438) of 6-h time periods and largely related to patient comfort in the recovery phase. Length of stay, duration of organ support and mortality were similar between groups. No pre-specified serious adverse events occurred. Staff (n = 48) and parents (n = 60) were supportive of the trial, including RWPC. Suggestions were made to only include invasively ventilated children for the duration of intubation., Conclusion: Uncertainty around the optimal fever threshold for antipyretic intervention is relevant to many emergency PICU admissions. A more permissive approach was associated with a modest increase in mean maximum temperature. A definitive trial should focus on the most seriously ill cases in whom antipyretics are rarely used for their analgesic effects alone., Trial Registration: ISRCTN16022198 . Registered on 14 August 2017.

Withdrawal assessment in critically ill children is complicated by the reliance on non-specific behaviours and compounded when the child's typical behaviours are unknown. The existing approach to withdrawal assessment assumes that nurses elicit the parents' view of the child's behaviours., Objective and Research Methodology: This qualitative study explored parents' perspectives of their child's withdrawal and preferences for involvement and participation in withdrawal assessment. Parents of eleven children were interviewed after their child had completed sedation weaning during recovery from critical illness. Data were analysed using thematic analysis., Setting: A large children's hospital in the Northwest of England., Findings: Parents experienced varying degrees of partnership in the context of withdrawal assessment and identified information deficits which contributed to their distress of parenting a child with withdrawal syndrome. Most parents were eager to participate in withdrawal assessment and reported instances where their knowledge enabled a personalised interpretation of their child's behaviours. Reflecting on the reciprocal nature of the information deficits resulted in the development of a model for nurse-parent collaboration in withdrawal assessment., Conclusion: Facilitating nurse-parent collaboration in withdrawal assessment may have reciprocal benefits by moderating parental stress and aiding the assessment and management of withdrawal syndrome., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Fever accelerates host immune system control of pathogens but at a high metabolic cost. The optimal approach to fever management and the optimal temperature thresholds used for treatment in critically ill children are unknown., Objectives: To determine the feasibility of conducting a definitive randomised controlled trial (RCT) to evaluate the clinical effectiveness and cost-effectiveness of different temperature thresholds for antipyretic management., Design: A mixed-methods feasibility study comprising three linked studies - (1) a qualitative study exploring parent and clinician views, (2) an observational study of the epidemiology of fever in children with infection in paediatric intensive care units (PICUs) and (3) a pilot RCT with an integrated-perspectives study., Setting: Participants were recruited from (1) four hospitals in England via social media (for the FEVER qualitative study), (2) 22 PICUs in the UK (for the FEVER observational study) and (3) four PICUs in England (for the FEVER pilot RCT)., Participants: (1) Parents of children with relevant experience were recruited to the FEVER qualitative study, (2) patients who were unplanned admissions to PICUs were recruited to the FEVER observational study and (3) children admitted with infection requiring mechanical ventilation were recruited to the FEVER pilot RCT. Parents of children and clinicians involved in the pilot RCT., Interventions: The FEVER qualitative study and the FEVER observational study had no interventions. In the FEVER pilot RCT, children were randomly allocated (1 : 1) using research without prior consent (RWPC) to permissive (39.5 °C) or restrictive (37.5 °C) temperature thresholds for antipyretics during their PICU stay while mechanically ventilated., Main Outcome Measures: (1) The acceptability of FEVER, RWPC and potential outcomes (in the FEVER qualitative study), (2) the size of the potentially eligible population and the temperature thresholds used (in the FEVER observational study) and (3) recruitment and retention rates, protocol adherence and separation between groups and distribution of potential outcomes (in the FEVER pilot RCT)., Results: In the FEVER qualitative study, 25 parents were interviewed and 56 clinicians took part in focus groups. Both the parents and the clinicians found the study acceptable. Clinicians raised concerns regarding temperature thresholds and not using paracetamol for pain/discomfort. In the FEVER observational study, 1853 children with unplanned admissions and infection were admitted to 22 PICUs between March and August 2017. The recruitment rate was 10.9 per site per month. The majority of critically ill children with a maximum temperature of > 37.5 °C received antipyretics. In the FEVER pilot RCT, 100 eligible patients were randomised between September and December 2017 at a recruitment rate of 11.1 per site per month. Consent was provided for 49 out of 51 participants in the restrictive temperature group, but only for 38 out of 49 participants in the permissive temperature group. A separation of 0.5 °C (95% confidence interval 0.2 °C to 0.8 °C) between groups was achieved. A high completeness of outcome measures was achieved. Sixty parents of 57 children took part in interviews and/or completed questionnaires and 98 clinicians took part in focus groups or completed a survey. Parents and clinicians found the pilot RCT and RWPC acceptable. Concerns about children being in pain/discomfort were cited as reasons for withdrawal and non-consent by parents and non-adherence to the protocol by clinicians., Limitations: Different recruitment periods for observational and pilot studies may not fully reflect the population that is eligible for a definitive RCT., Conclusions: The results identified barriers to delivering the definitive FEVER RCT, including acceptability of the permissive temperature threshold. The findings also provided insight into how these barriers may be overcome, such as by limiting the patient inclusion criteria to invasive ventilation only and by improved site training. A definitive FEVER RCT using a modified protocol should be conducted, but further work is required to agree important outcome measures for clinical trials among critically ill children., Trial Registration: The FEVER observational study is registered as NCT03028818 and the FEVER pilot RCT is registered as Current Controlled Trials ISRCTN16022198., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 23, No. 5. See the NIHR Journals Library website for further project information., Competing Interests: Mark J Peters is a member of the National Institute for Health Research (NIHR) Health Technology Assessment General Board. Kathryn M Rowan is a member of the NIHR Health Services and Delivery Research Board.

Background: In hospital, staff need to routinely monitor patients to identify those who are seriously ill, so that they receive timely treatment to improve their condition. A Paediatric Early Warning System is a multi-faceted socio-technical system to detect deterioration in children, which may or may not include a track and trigger tool. It functions to monitor, detect and prompt an urgent response to signs of deterioration, with the aim of preventing morbidity and mortality. The purpose of this study is to develop an evidence-based improvement programme to optimise the effectiveness of Paediatric Early Warning Systems in different inpatient contexts, and to evaluate the feasibility and potential effectiveness of the programme in predicting deterioration and triggering timely interventions., Methods: This study will be conducted in two district and two specialist children's hospitals. It deploys an Interrupted Time Series (ITS) design in conjunction with ethnographic cases studies with embedded process evaluation. Informed by Translational Mobilisation Theory and Normalisation Process Theory, the study is underpinned by a functions based approach to improvement. Workstream (1) will develop an evidence-based improvement programme to optimise Paediatric Early Warning System based on systematic reviews. Workstream (2) consists of observation and recording outcomes in current practice in the four sites, implementation of the improvement programme and concurrent process evaluation, and evaluation of the impact of the programme. Outcomes will be mortality and critical events, unplanned admission to Paediatric Intensive Care (PICU) or Paediatric High Dependency Unit (PHDU), cardiac arrest, respiratory arrest, medical emergencies requiring immediate assistance, reviews by PICU staff, and critical deterioration, with qualitative evidence of the impact of the intervention on Paediatric Early Warning System and learning from the implementation process., Discussion: This paper presents the background, rationale and design for this mixed methods study. This will be the most comprehensive study of Paediatric Early Warning Systems and the first to deploy a functions-based approach to improvement in the UK with the aim to improve paediatric patient safety and reduce mortality. Our findings will inform recommendations about the safety processes for every hospital treating paediatric in-patients across the NHS., Trial Registration: Sponsor: Cardiff University, 30-36 Newport Road, Cardiff, CF24 0DE Sponsor ref.: SPON1362-14. Funder: National Institute for Health Research, Health Services & Delivery Research Programme (NIHR HS&DR) Funder reference: 12/178/17. Research Ethics Committee reference: 15/SW/0084 [13/04/2015]. PROSPERO reference: CRD42015015326 [23/01/2015]., Isrctn: 94228292 https://doi.org/10.1186/ISRCTN94228292 [date of application 13/05/2015; date of registration: 18/08/2015]. Prospective registration prior to data collection and participant consent commencing in September 2014.

Background: This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain-related distress (adequacy of sedation, iatrogenic withdrawal syndrome and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient., Methods: A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain-related distress in critically ill and nonverbal children, and searched the PubMed/Medline, CINAHL and Embase databases for studies describing the psychometric properties of assessment instruments. Furthermore, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added on the basis of the level of evidence., Results: An ESPNIC position statement was drafted which provides clinical recommendations on assessment of pain (n = 5), distress and/or level of sedation (n = 4), iatrogenic withdrawal syndrome (n = 3) and delirium (n = 3). These recommendations were based on the available evidence and consensus amongst the experts and other members of ESPNIC., Conclusions: This multidisciplinary ESPNIC position statement guides professionals in the assessment and reassessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium.

Objectives: Malnutrition in critically ill children contributes to morbidity and mortality. The French-speaking pediatric intensive care nutrition group (NutriSIP) aims to promote optimal nutrition through education and research., Methods: The NutriSIP-designed NutriRéa-Ped study included a cross-sectional survey. This 62-item survey was sent to the nursing teams of all of the French-speaking pediatric intensive care units (PICUs) to evaluate nurses' nutrition knowledge and practices. One nurse per PICU was asked to answer and describe the practices of their team., Results: Of 44 PICUs, 40 responded in Algeria, Belgium, Canada, France, Lebanon, Luxemburg, and Switzerland. The majority considered nutrition as a priority care but only 12 of the 40 (30%) had a nutrition support team, 26 of the 40 (65%) had written nutrition protocols, and 19 of 39 (49%) nursing teams felt confident with the nutrition goals. Nursing staff generally did not know how to determine nutritional requirements or to interpret malnutrition indices. They were also unaware of reduced preoperative fasting times and fast-track concepts. In 17 of 35 (49%) PICUs, the target start time for enteral feeding was within the first 24 hours; however, frequent interruptions occurred because of neuromuscular blockade, fasting for extubation or surgery, and high gastric residual volumes. Combined pediatric neonatal intensive care units were less likely to perform systematic nutritional assessment and to start enteral nutrition rapidly., Conclusions: We found a large variation in nursing practices around nutrition, exacerbated by the lack of nutritional guidelines but also because of the inadequate nursing knowledge around nutritional factors. These findings encourage the NutriSIP to improve nutrition through focused education programs and research.

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention., Methods: Using a fieldwork approach, we describe PICU context, 'usual' practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff., Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9% and 4% of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39% of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9% of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74%) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision., Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.

Currently there appears to be few opportunities and little evidence of physically disabled children and young people (C&YP) participating in mainstream social activities. A qualitative review was undertaken to examine the factors affecting physically disabled C&YP (8-15 years) in the United Kingdom participating in out-of-school activities. Views and experiences were explored from the perspective of the service users and providers to assess current provision and to determine the need for future research into factors that may affect participation. Searches were conducted across eight databases, the references of the included studies were checked and the websites were searched. Studies that used a qualitative design that examined the views relating to out-of-school activities were included. Nine papers were identified, which included three peer-reviewed papers and six pieces of grey literature and pertinent government documents to include views and experiences of out-of-school activity provision. The main themes emerging from the review were the need for social inclusion, out-of-school activities run by volunteers and accessibility, with threads throughout, which require further research including parental influence, provision, training and attitudes. This review highlights the absence of the service user's voice and sheds light on the limited provision and barriers affecting participation in out-of-school activities., (© The Author(s) 2013.)

The aim of the present study was to describe the present knowledge of healthcare professionals and the practices surrounding enteral feeding in the UK and Irish paediatric intensive care unit (PICU) and propose recommendations for practice and research. A cross-sectional (thirty-four item) survey was sent to all PICU listed in the Paediatric Intensive Care Audit Network (PICANET) database (http://www.picanet.org.uk) in November 2010. The overall PICU response rate was 90 % (27/30 PICU; 108 individual responses in total). The overall breakdown of the professional groups was 59 % nursing staff (most were children's nurses), 27 % medical staff, 13 % dietitians and 1 % physician assistants. Most units (96 %) had some written guidance (although brief and generic) on enteral nutrition (EN); 85 % of staff, across all professional groups (P= 0.672), thought that guidelines helped to improve energy delivery in the PICU. Factors contributing to reduced energy delivery included: fluid-restrictive policies (60 %), the child just being 'too ill' to feed (17 %), surgical post-operative orders (16 %), nursing staff being too slow in starting feeds (7 %), frequent procedures requiring fasting (7 %) and haemodynamic instability (7 %). What constituted an 'acceptable' level of gastric residual volume (GRV) varied markedly across respondents, but GRV featured prominently in the decision to both stop EN and to determine feed tolerance and was similar for all professional groups. There was considerable variation across respondents about which procedures required fasting and the duration of this fasting. The present survey has highlighted the variability of the present enteral feeding practices across the UK and Ireland, particularly with regard to the use of GRV and fasting for procedures. The present study highlights a number of recommendations for both practice and research.

The aims of this study were to determine the contents of cadmium (Cd), copper (Cu), lead (Pb), zinc (Zn), aluminium (Al), and iron (Fe) (aqua regia-extractable) in 27 soil plots (54 samples) from Manresa, NE Spain, and to establish relationships between heavy metals and some soil properties. The main soil types were surveyed and the median concentrations (mg kg(-1)) obtained were Cd 0.28, Cu 20.3, Pb 18.6, Zn 67.4, Al 22,572, and Fe 21,551. Element concentrations for these soils were lower than the published values for the Valencia region (Spain) and Torrelles and Sant Climent municipal districts (Catalonia, Spain). In terms of soil properties, the results of this study suggest that, in Manresa soils, both trace element adsorption and retention are influenced by several properties such as clay minerals, carbonates, organic matter, and pH. All element contents were positively correlated with clay content. Pb and Zn were negatively correlated with pH and CaCO(3).

Concentrations of Cd, Cr, Ni, Pb, and Zn in the top-(0-10 cm) and sub-surface (10-20 cm) soils of the Talcahuano urban area were measured. The main soil properties (organic matter, CaCO3, pH, particle sizes) were determined for a network of representative sampling sites. The mean Cr, Ni, Pb, and Zn contents in the urban topsoil samples from Talcahuano (37.8, 22.6, 35.2, 333 mg kg(-1), respectively) were compared with mean concentrations for other cities around the world. The results revealed higher concentrations of heavy metals in topsoil samples than in sub-surface samples. The samples from IS1, IS2, and IS3, located in the Talcahuano industrial park, had higher Cr, Ni, Pb, and Zn contents than did samples from the other sites. This was probably due to local pollution by industrial (metallurgical) dust, although other diffuse pollution throughout the entire port region (shipyards, metallurgy, the dismantling of old ships), and contributions from the wind from adjacent industrial, storage, and vessel areas clearly played a role. Heavy metals were lowest in the sample taken on school grounds (SG).