Search

Sepsis is a worldwide public health problem due to its high incidence and accompanying mortality, morbidity, and financial burden. It is a major cause of admission to paediatric intensive care units; despite advances in the diagnosis and treatment, both incidence and mortality are high in low-income and middle-income countries. There are several barriers in addressing the enormous burden of paediatric sepsis in these countries, which include: lack of data of incidence and mortality; unfamiliarity of sepsis by the lay public, leading to failure to seek care early, and by health professionals, leading to failure to treat emergently; and insufficient government funding for sepsis care programmes leading to inadequate staffing, material, and financial resources, and therefore, poor health systems. Socioeconomic inequalities, such as inequity and marked variation in income and education, high rates of malnutrition, high percentage of young population, and health systems that do not meet the population's demands also represent barriers in the care of children with sepsis in Latin America. In this Viewpoint, we draw attention to the problem of paediatric sepsis in Latin America and call for action to reduce the disease burden by proposing some solutions.

This article reviews the many factors that have to be taken into account as we consider the advancement of pediatric critical care (PCC) in multiple settings across the world. The extent of PCC and the range of patients who are cared for in this environment are considered. Along with a review of the ongoing treatment and technology advances in the PCC setting, the structures and systems required to support these services are also considered. Finally the question of how PCC can be made sustainable in a volatile world with the impacts of global crises such as climate change is addressed.

BackgroundStrong social distancing measures were quickly implemented in Chile during the SARS-CoV-2 outbreak. One of the aims of non-pharmaceutical interventions (NPI) mandates was to decrease overcrowding, thus is usually measured as mobility changes.Methodswe gather data from national health statistics for pediatric emergency (PED) visits for acute respiratory infection (ARI) in children younger than 15. We defined a historical cohort, including data from 2016 to 2019, and compared them with 2020 and 2021 pandemic years. Also, Chile’s national mobility reports from the online google database were downloaded. We tested the correlation between changes in mobility and relative reduction in PED-ARI by Spearman’s Rank Test.ResultsHistorical data showed a mean of 46863 ± 3071 PED-ARI weekly visits with a high seasonal variation, with two peaks in weeks 20 and 28 and weeks 32 to 36. This transient drop was temporally associated with the mid-winter 2-week holiday of schools. The usual PED visits peaks did not occur in 2020 and 2021. Mobility declined from week 9, reaching lower than historical data from week 12 and a minimum of 43% in week 15 of 2020 (Figure 1).The correlation between mobility and PED-ARI visits showed a strong monotonic relationship (quadratic) with a Spearman’s rho of 0.80 (95% CI 0.75 to 0.86) (Figure 2).ConclusionNPI resulting in a decrease in mobility should be considered a robust public health measure to relieve the winter’s collapse of the national health system, decreasing morbimortality in children due to PED-ARI.WHAT’S KNOWN ON THIS SUBJECTA remarkable decrease in pediatric respiratory infections has been described during the pandemic, although the causes are still poorly understood.WHAT THIS STUDY ADDSIn a historical cohort before the pandemic, we observed a temporal association between mid-winter holidays and the gap between the two peaks of acute pediatric respiratory infections. We found a strong correlation between national mobility changes due to non-pharmaceutical interventions and acute pediatric respiratory infections during the pandemic. Therefore, timely implementation of non-pharmaceutical interventions might be considered as a robust public health measure to attenuate the seasonal epidemic of non-COVID viral acute respiratory infections. With these data, we wonder if the time has come to implement non-pharmaceutical interventions to mitigate the stress, and frequently collapse, of national health systems due to the increase in pediatric acute respiratory infection, placing children as a priority, and provide the best care to this vulnerable population.

La sepsis es una causa importante de morbilidad y mortalidad pediátrica, especialmente en países de bajos recursos. Los datos sobre la prevalencia regional, las tendencias de mortalidad y su relación con variables socioeconómicas son escasos. Objetivo: determinar la prevalencia regional, mortalidad y situación sociodemográfica en pacientes con diagnóstico de sepsis severa (SS) y shock séptico (ShS) ingresados a Unidades de Cuidado Intensivo Pediátrico (UCIPs). Pacientes y Método:Se incluyeron pacientes de 1 a 216 meses de edad ingresados en 47 UCIPs participantes con diagnóstico de SS o ShS entre el 1 de enero de 2010 y el 31 de diciembre de 2018. Se efectuó análisis secundario de la base de datos del Programa de Benchmarking de Calidad de la Sociedad Argentina de Terapia Intensiva (SATI-Q) para SS y ShS, y revisión de los informes anuales del Ministerio de Salud de Argentina y del Instituto Nacional de Estadística y Censos para los índices sociodemográficos de los años correspon- dientes. Resultados: Se registraron 45.480 ingresos en 47 UCIPs, 3.777 con diagnóstico de SS y ShS. La prevalencia combinada de SS y ShS disminuyó del 9,9% en 2010 al 6,6% en 2018. La mortalidad combinada disminuyó del 34,5% al 23,5%. El análisis multivariado mostró que el Odds ratio (OR) de la asociación entre la mortalidad del SS y el ShS fue de 1,88 (IC 95%: 1,46-2,32) y 2,4 (IC 95%: 2,16- 2,66) respectivamente, ajustada por enfermedad maligna, PIM2 y ventilación mecánica. La prevalen- cia de SS y ShS en diferentes regiones sanitarias (RS) se asoció con el porcentaje de pobreza y la tasa de mortalidad infantil (p < 0,001). Sin embargo, no hubo asociación entre la mortalidad por sepsis y la RS ajustada por PIM2. Conclusiones: La prevalencia y la mortalidad por SS y ShS han disminuido con el tiempo en las UCIP participantes. Las condiciones socioeconómicas más bajas se asociaron con una mayor prevalencia pero con resultados similares de la sepsis.

To understand critical paediatric coronavirus disease 2019 (COVID-19) and evaluate factors associated with mortality in children from high and low-middle income countries.Prospective, observational study of critically ill children hospitalised for COVID-19 in 18 countries throughout North America, Latin America, and Europe between April 1 and December 31, 2020. Associations with mortality were evaluated using logistic regression.557 patients (median age, 8 years; 24%2 years) were enrolled from 55 sites (63% Latin American). Half had comorbidities. Invasive (41%) or non-invasive (20%) ventilation and vasopressors (56%) were the most common support modalities. Hospital mortality was 10% and higher in children2 years old (15%; odds ratio 1·94, 95%CI 1·08-3·49). Most who died had pulmonary disease. When adjusted for age, sex, region, and illness severity, mortality-associated factors included cardiac (aOR 2·89; 95%CI 1·2-6·94) or pulmonary comorbidities (aOR 4·43; 95%CI 1·70-11·5), admission hypoxemia (aOR 2·44; 95%CI 1·30-4·57), and lower respiratory symptoms (aOR 2·96; 95%CI 1·57-5·59). MIS-C (aOR 0·25; 95%CI 0·1-0·61) and receiving methylprednisolone (aOR 0·5; 95%CI 0·25-0·99), IVIG (aOR 0·32; 95%CI 0·16-0·62), or anticoagulation (aOR 0·49; 95%CI 0·25-0·95) were associated with lower mortality although these associations might be limited to children2 years old.We identified factors associated with COVID-19 mortality in critically ill children from both high and low-middle income countries, including higher mortality with younger age and COVID-related pulmonary disease but lower mortality in MIS-C. Further research is needed on optimal treatments for younger children and respiratory failure in paediatric COVID-19.None.

Las Guías Internacionales de la Campaña Sobreviviendo a la Sepsis para el Manejo del Shock Séptico y la Disfunción de Órganos Asociada a la Sepsis en Niños, fueron publicadas en 2020 y están desti- nadas a ser utilizadas en todos los lugares que atienden a niños. Sin embargo, los profesionales que atienden a los niños con sepsis en entornos con recursos limitados se enfrentan a una serie de desafíos y perfiles de enfermedad distintos a los que se encuentran en entornos ricos en recursos. Basándonos en nuestra experiencia colectiva en entornos con recursos limitados, nos propusimos reflexionar so- bre las dificultades de aplicar las directrices internacionales. Creemos que hay una necesidad urgente de más evidencia de entornos con recursos limitados en enfoques factibles y eficaces para el trata- miento de la sepsis y el shock séptico que podrían incluirse en las futuras directrices para situaciones y contextos específicos.