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Objectives: To explore enteral feeding practices and the achievement of energy targets in children on noninvasive respiratory support, in four European PICUs. Design: A four-center retrospective cohort study. Setting: Four PICUs: Bristol, United Kingdom; Lyon, France; Madrid, Spain; and Rotterdam, The Netherlands. Patients: Children in PICU who required acute noninvasive respiratory support in the first 7 days. The primary outcome was achievement of standardized kcal/goal. Interventions: None. Measurements and Main Results: A total of 325 children were included (Bristol 104; Lyon 99; Madrid 72; and Rotterdam 50). The median (interquartile range) age and weight were 3 months (1-16 mo) and 5 kg (4-10 mo), respectively, with 66% admitted with respiratory failure. There were large between-center variations in practices. Overall, 190/325 (58.5%) received noninvasive respiratory support in order to prevent intubation and 41.5% after extubation. The main modes of noninvasive respiratory support used were high-flow nasal cannula 43.6%, bilevel positive airway pressure 33.2%, and continuous positive airway pressure 21.2%. Most children (77.8%) were fed gastrically (48.4% continuously) and the median time to the first feed after noninvasive respiratory support initiation was 4 hours (interquartile range, 1-9 hr). The median percentage of time a child was nil per oral while on noninvasive respiratory support was 4 hours (2-13 hr). Overall, children received a median of 56% (25-82%) of their energy goals compared with a standardized target of 0.85 of the recommended dietary allowance. Patients receiving step-up noninvasive respiratory support (p = < 0.001), those on bilevel positive airway pressure or continuous positive airway pressure (compared with high-flow nasal cannula) (p = < 0.001), and those on continuous feeds (p = < 0.001) achieved significantly more of their kcal goal. Gastrointestinal complications varied from 4.8 - 20%, with the most common reported being vomiting in 54/325 (16.6%), other complications occurred in 40/325 (12.3%) children, but pulmonary aspiration was rare 5/325 (1.5%). Conclusions: Children on noninvasive respiratory support tolerated feeding well, with relatively few complications, but prospective trials are now required to determine the optimal timing and feeding method for these children.

OBJECTIVES: In children, coronavirus disease 2019 is usually mild but can develop severe hypoxemic failure or a severe multisystem inflammatory syndrome, the latter considered to be a postinfectious syndrome, with cardiac involvement alone or together with a toxic shock like-presentation. Given the novelty of severe acute respiratory syndrome coronavirus 2, the causative agent of the recent coronavirus disease 2019 pandemic, little is known about the pathophysiology and phenotypic expressions of this new infectious disease nor the optimal treatment approach.STUDY SELECTION: From inception to July 10, 2020, repeated PubMed and open Web searches have been done by the scientific section collaborative group members of the European Society of Pediatric and Neonatal Intensive Care.DATA EXTRACTION: There is little in the way of clinical research in children affected by coronavirus disease 2019, apart from descriptive data and epidemiology.DATA SYNTHESIS: Even though basic treatment and organ support considerations seem not to differ much from other critical illness, such as pediatric septic shock and multiple organ failure, seen in PICUs, some specific issues must be considered when caring for children with severe coronavirus disease 2019 disease.CONCLUSIONS: In this clinical guidance article, we review the current clinical knowledge of coronavirus disease 2019 disease in critically ill children and discuss some specific treatment concepts based mainly on expert opinion based on limited experience and the lack of any completed controlled trials in children at this time.

Background: Critically ill patients frequently need blood transfusions. For safety, blood must be delivered via syringe infusion pumps, yet this can cause red cell damage and increase the rate of haemolysis. \ud Aims and objectives: To evaluate biochemical and haemolytic markers of red blood cells transfused in three different, common type of syringe infusion pumps with two different infusion rates (10 and 100 ml/h).\ud Methods: A lab-based study using aliquots of 16 red blood cells bags was undertaken. Haemolysis markers (total haemoglobin(g/dl), haematocrit(%), free haemoglobin(g/dl), potassium(mmol/L), lactate dehydrogenase(U/L), osmolality(mOsm/kg), pH, degree of haemolysis(%)) were measured before and after red blood cells infusion and exposure. Three different syringe infusion pumps brands (A, B and C) were compared with two different infusion rates (10 and 100 ml/h). \ud Results: The total haemoglobin fell significantly in all red blood cells units during manipulation (Pre-infusion: 26.44±5.74; Post-exposure: 22.62±4.00; p=0.026). The degree of haemolysis significantly increased by 40% after manipulation of the red blood cells. Syringe infusion pump A caused a threefold increase in potassium levels (3.78±6.10) when compared to B (-0.14±1.46) and C (1.63± 1.98) (p=0.015). This pump also produced the worst changes, with an increase in free haemoglobin (0.05±0.05; p=0.038) and more haemolysis (0.08±0.07; p=0.033). There were significant differences and an increase in the degree of haemolysis (p=0.004) in the infusion rate of 100 mL/h. \ud Conclusions: Syringe infusion pumps may cause significant red blood cell damage during infusion, with increases in free haemoglobin, potassium and the degree of haemolysis. Some pumps types, with a cassette mechanism, caused more damage.\ud Relevance to clinical practice: In many ICUs, bedside nurses are able to consider infusion pump choice and understanding the impact of different pump types on RBC during a transfusion provides the nurses with more information to enhance decision-making and improve the quality of the transfusion.

Background The FIRST-ABC trial comprises of two pragmatic, multicentre, parallel groups, non-inferiority randomised clinical trials designed to evaluate the clinical non-inferiority of first-line use of high flow nasal cannula (HFNC) to continuous positive airway pressure (CPAP) in critically ill children who require non-invasive respiratory support (NRS). Objectives To describe the pre-specified statistical and health economic analysis for the FIRST-ABC trial before completion of patient recruitment and data collection. Methods The statistical analysis plan was designed by the chief investigators and statisticians. We define the primary and secondary outcomes, summarise methods for data collection and safety monitoring, and present a detailed description of the planned statistical and health economic analysis. Results The primary clinical outcome is time to liberation from respiratory support. The primary effect estimate will be the adjusted hazard ratio, reported with a 95% confidence interval. As a sensitivity analysis, the primary analysis will be repeated using time to start weaning of NRS. Subgroup analyses will be performed to test for interactions between the effect of allocated treatment group and pre-specified baseline covariates. The health economic analysis will follow the intention-to-treat principle and report the mean (95% confidence interval) incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness up to 6 months. All analyses will be performed separately for each of the two trials, and any results will not be combined. Conclusion The FIRST-ABC trial will assess the non-inferiority of HFNC compared to CPAP in two parallel trials with shared infrastructure (step-up RCT and step-down RCT). We have developed a pre-specified statistical and health economics analysis plan for the FIRST-ABC study before trial completion to minimise analytical bias. Trial registration ISRCTN ISRCTN60048867. Registered on 19 June 2019.

Background\ud Choosing trial outcome measures is important. When outcomes are not clinically relevant or important to parents/patients, trial evidence is less likely to be implemented into practice. This study aimed to determine optimal outcome measures for a trial of no routine gastric residual volume measurement in critically ill children.\ud Methods: A mixed methods approach: a focused literature review, parent and clinician interviews, a modified two-round Delphi and a stakeholder consensus meeting.\ud Results: The review generated 13 outcomes. 14 Pediatric Intensive Care Unit (PICU) parents proposed 3 additional outcomes, these 16 were then rated by 28 clinicians in Delphi round 1. Six further outcomes were proposed, and 22 outcomes were rated in the second round. No items were voted ‘consensus out’. The 18 ‘no-consensus’ items were voted in a face-to-face meeting by 30 participants. The final 12 outcome measures were: Time to reach energy targets; ventilator associated pneumonia; vomiting; time enteral feeds withheld per 24 hour; necrotizing enterocolitis; length of invasive ventilation; PICU length of stay; mortality; change in weight and markers of feed intolerance: parenteral nutrition administered; feed formula altered and changing to post-pyloric feeds all secondary to feed intolerance.\ud Conclusion: We have identified 12 outcomes for a trial of no gastric residual volume measurement through a multi-stage process, seeking views of parents and clinicians.\ud Clinical Relevancy statement: Twelve relevant outcomes have been identified for a trial of no routine gastric residual volume measurement in critically ill children.

Background: Generating robust evidence within Pediatric Intensive Care (PIC) can be challenging because of low patient numbers and patient heterogeneity. Systematic reviews may overcome small study biases but are limited by lack of standardisation in outcome measures and their definition. Trials of nutritional interventions in PIC are increasing, thus we wanted to examine the outcome measures being used in these trials.\ud Objective: To systematically describe outcome measures used when a nutritional intervention has been evaluated in a PIC randomized controlled trial. \ud Methods: A systematic literature review of all studies involving a PIC trial of a nutritional intervention was undertaken from 1 January 1996 until 20 February 2018. \ud Results: Thirty-one trials met the criteria and were reviewed. They included a total of 3346 patients across all trials. Thirty-nine primary outcomes and 93 secondary outcomes were found. These were categorized into PIC-related outcomes (infection, intensive care dependency, organ dysfunction / long-term functional and mortality) and nutritional outcomes (energy targets, nutritional parameters and feeding tolerance). We found large variation in the outcome measures used. Outcome domains of energy targets, feeding tolerance and infection were not adequately defined. \ud Conclusions: Large variations in the outcome measures chosen and their definitions exist within PIC nutritional trials. Optimal nutritional outcomes for PIC must be agreed and defined, specifically domains of nutrition efficiency, nutrition tolerance and non-nutritional PIC outcomes. The next step is to conduct an International Delphi study to gain expert consensus and develop a core outcome set to be reported in future pediatric nutrition trials.

Objective\ud To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians and physicians) in delivering enteral nutrition (EN) to critically ill children across the world.\ud Design\ud Cross-sectional international online survey adapted for use in pediatric settings.\ud Setting and subjects\ud Pediatric Intensive Care physicians, nurses and dietitians across the world\ud Interventions\ud The 20-item adult intensive care ‘Barriers to delivery of enteral nutrition’ survey was modified for pediatric settings, tested and translated into ten languages. The survey was distributed online to pediatric intensive care nurses, physicians and dieticians via professional networks in March – June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of EN in their pediatric intensive care unit (PICUs) with a 7-point Likert scale from 0 ‘‘not at all a barrier’’ to 6 ‘‘an extreme amount’’. \ud Measurement and Main Results\ud 920 pediatric intensive care professionals responded from 57 countries; 477/920 (52%) nurses, 407/920 (44%) physicians and 36/920 (4%) dieticians. Sixty-two percent had more than five years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were: (1) enteral feeds being withheld in advance of procedures or operating department visits, (2) none or not enough dietitian coverage on weekends or evenings, (3) not enough time dedicated to education and training on how to optimally feed patients.\ud Conclusions\ud This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focussed nutrition education for all PICU professional groups.

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.

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

Background Endotracheal suction (ETS) is essential in intubated patients to prevent tube occlusion and is one of the most common nursing interventions performed in intensive care. Aims and objectives To explore how paediatric ETS practices reflect evidence-based practice (EBP) recommendations in paediatric intensive care units (PICU) worldwide. Study design and methods A cross-sectional electronic survey linked to a real patient suction episode. Nurses completed the survey following a recent ETS episode. Evidence-based practice (EBP) was defined based on four of the American Association for Respiratory Care (AARC) best evidence recommendations: pre-oxygenation before suction, use of a suction catheter no more than half the diameter of the tracheal tube, shallow depth of suction, and the continuous suction applied upon withdrawal of the catheter. Participants included PICU nurses who performed ETS in children (0-17 years) excluding preterm neonates. Results Four hundred forty-six complete surveys were received from 20 countries. Most nurses (80%, 367/446) reported that their units had local guidelines for ETS. The most common reason for suctioning (44%) was audible/visible secretions. Over half of ETS episodes (57%) used closed suction. When exploring the individual components of suction, 63% (282/446) of nurses pre-oxygenated their patient prior to suction, 71% (319/446) suctioned no further than 0.5 cm past end of the endotracheal tube (ETT), 59% (261/446) used a catheter no more than half the diameter of the ETT, and 78% (348/446) used continuous negative pressure. 24% of nurses gave patients an additional bolus of sedative, analgesic, and/or muscle-relaxant medication prior to suction; this decision was not related to the child's history of instability with suction, as there was no significant difference in those who reported patients had a history of being unstable with suction (P = .80). 26% (117/446) of nurses complied with all four EBP components in the reported suctioning episode. Conclusions Considerable variation in paediatric endotracheal suctioning practices exists internationally. Although most nurses applied single components of evidence-based recommendations during ETT suctioning, just a quarter applied all four elements. Relevance to clinical practice Nurses' need to consider and strive to apply EBP principles to common nursing interventions such as ETS.

ObjectiveTo explore parent and staff views on the acceptability of a randomised controlled trial investigating temperature thresholds for antipyretic intervention in critically ill children with fever and infection (the FEVER trial) during a multi-phase pilot study.DesignMixed methods study with data collected at three time points: (1) before, (2) during and (3) after a pilot trial.SettingEnglish, Paediatric Intensive Care Units (PICUs).Participants(1) Pre-pilot trial focus groups with pilot site staff (n=56) and interviews with parents (n=25) whose child had been admitted to PICU in the last 3 years with a fever and suspected infection, (2) Questionnaires with parents of randomised children following pilot trial recruitment (n=48 from 47 families) and (3) post-pilot trial interviews with parents (n=19), focus groups (n=50) and a survey (n=48) with site staff. Analysis drew on Sekhon et al’s theoretical framework of acceptability.ResultsThere was initial support for the trial, yet some held concerns regarding the proposed temperature thresholds and not using paracetamol for pain or discomfort. Pre-trial findings informed protocol changes and training, which influenced views on trial acceptability. Staff trained by the FEVER team found the trial more acceptable than those trained by colleagues. Parents and staff found the trial acceptable. Some concerns about pain or discomfort during weaning from ventilation remained.ConclusionsPre-trial findings and pilot trial experience influenced acceptability, providing insight into how challenges may be overcome. We present an adapted theoretical framework of acceptability to inform future trial feasibility studies.Trial registration numbersISRCTN16022198 and NCT03028818.

Background Routine measurement of gastric residual volume (GRV) to guide feeding in neonatal and paediatric intensive care is widespread. However, this practice is not evidence based and may cause harm. As part of a feasibility study, we explored parent and practitioner views on the acceptability of a trial comparing GRV measurement or no GRV measurement. Methods A mixed-methods study involving interviews and focus groups with practitioners and interviews with parents with experience of tube feeding in neonatal and/or paediatric intensive care. A voting system recorded closed question responses during practitioner data collection, enabling the collection of quantitative and qualitative data. Data were analysed using thematic analysis and descriptive statistics. Results We interviewed 31 parents and nine practitioners and ran five practitioner focus groups (n=42). Participants described how the research question was logical, and the intervention would not be invasive and potential benefits of not withholding the child’s feeds. However, both groups held concerns about the potential risk of not measuring GRV, including delayed diagnosis of infection and gut problems, increased risk of vomiting into lungs and causing discomfort or pain. Parent’s views on GRV measurement and consent decision making were influenced by their views on the importance of feeding in the ICU, their child’s prognosis and associated comorbidities or complications. Conclusions The majority of parents and practitioners viewed the proposed trial as acceptable. Potential concerns and preferences were identified that will need careful consideration to inform the development of the proposed trial protocol and staff training.

Objective: The Paediatric Intensive Care Society Study Group conducted a research prioritization exercise with the aim to identify and agree research priorities in Pediatric Critical Care in the United Kingdom (UK) both from a healthcare professional (HCP) and parent/caregiver perspective.\ud \ud Design: A modified three round e-Delphi survey, followed by a survey of parents of the top 20 HCP priorities \ud \ud Setting: UK PICUs\ud \ud Population: UK Pediatric Intensive Care Unit (PICU) HCP who are members of the professional society and parents and family members of children, with experience of a UK PICU admission \ud \ud Interventions: None\ud \ud Main outcome measures: A list of HCP and parent research priorities for PICU in the UK.\ud \ud Results: Forty-nine HCP submitted topics in round one, 98 participated in round two and 102 in round three. These topics were categorized into eight broad domain areas, and within these there were 73 specific topics in round two. At round three, 18 topics had a mean score < 5.5 and were removed, leaving 55 topics for ranking in round three. Ninety-five parents and family members completed the surveys from at least 17 UK PICUs. Both parents and HCP prioritized research topics associated with the PICU workforce. HCP research priorities reflected issues which impacted on day to day management and practice. Parents’ prioritized research addressing acute situations such as infection identification of and sepsis management, or research addressing long term outcomes for children and parents after critical illness. Parents prioritized research into longer term outcomes more than HCP. Parental responses showed clear support for the concept of research in PICU, but few novel research questions were proposed. \ud \ud Conclusion: This is the first research prioritization exercise within UK PICU setting to include parents and families’ perspectives and compare these to HCP. Results will guide both funders and future researchers.

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/.

Introduction: Many critically ill children can be fed orally at some point during their paediatric intensive care (PICU) stay, but reduced appetite and other factors may impact on their intake. At home, oral feeding is usually delivered by parents; so involving parents more actively during the mealtimes in PICU may contribute to improved patient/family satisfaction. We aimed to assess the impact of a new “room service” initiative involving parents on mealtime quality and on both family and healthcare professional (HCP) satisfaction.\ud Methods: A prospective, single centre, before and after intervention study was designed, as part of a PICU quality of care improvement program in 2013-2016. Two questionnaires assessing oral nutrition practices and family/HCP overall satisfaction were disseminated among the parents of critically ill children capable of oral feeding during their PICU admission and among the whole PICU healthcare professional team (nurses, nurse assistants, and medical doctors). Categorical variables were compared using the chi-square test and Likert scales were compared between groups with the Mann-Whitney-Wilcoxon test.\ud Results: the pre-intervention surveys were completed by 97/130 (75%) HCPs and 52 families, and the post-intervention surveys by 74/130 (57%) HCPs and 54 families. After the intervention, a marked improvement was shown for the overall quality of meal service rating by both HCPs and families (medians and IQR: 5 (5-7) to 7 (7-8) and 6 (6-8) to 8 (7-9) respectively; p

Background: Widespread variation exists in pediatric critical care nutrition practices, largely because of the scarcity of evidence to guide best practice recommendations. Objective: The objective of this paper was to develop a list of topics to be prioritized for nutrition research in pediatric critical care in the next 10 years. Methods: A modified 3-round Delphi process was undertaken by a newly established multidisciplinary group comprising 11 international researchers in the field of pediatric critical care nutrition. Items were ranked on a 5-point Likert scale. Results: Forty-five research topics (with a mean priority score >3(0-5) were identified within the following 10 domains: the pathophysiology and impact of malnutrition in critical illness; nutrition assessment: nutrition risk assessment and biomarkers; accurate assessment of energy requirements in all phases of critical illness; the role of protein intake; the role of pharmaco-nutrition; effective and safe delivery of enteral nutrition; enteral feeding intolerance: assessment and management; the role of parenteral nutrition; the impact of nutrition status and nutrition therapies on long-termpatient outcomes; and nutrition therapies for specific populations. Ten top research topics (that received a mean score >4(0-5) were identified as the highest priority for research. Conclusions: This paper has identified important consensus-derived priorities for clinical research in pediatric critical care nutrition. Future studies should determine topics that are a priority for patients and parents. Research funding should target these priority areas and promote an international collaborative approach to research in this field, with a focus on improving relevant patient outcomes.

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.

Critically ill children frequently fail to achieve adequate energy intake and some care practices, such as the measurement of gastric residual volume (GRV) may contribute to this problem. We compared outcomes in two similar European Pediatric Intensive Care Units (PICUs): one which routinely measures GRV (PICU-GRV) to one unit that does not (PICU-noGRV). An observational pilot comparison study was undertaken. 87 children were included in the study, 42 (PICU-GRV) and 45 (PICU-noGRV). There were no significant differences in the percentage of energy targets achieved in the first four days of PICU admission although PICU-noGRV showed more consistent delivery of median (and IQR) energy targets, and less under and over feeding for PICU-GRV and PICU-noGRV Day 1 37 (14-72) vs 44 (0-100); Day 2 97 (53-126) vs 100 (100-100), Day 3 84 (45-112) vs 100 (100-100) , Day 4 101 (63-124) vs 100 (100-100). The incidence of vomiting was higher in PICU-GRV. No necrotising enterocolitis was confirmed in either unit and ventilator acquired pneumonia rates were not significantly different (7.01 vs 12 5.31 per 1000 ventilator days; p=0.70) between PICU-GRV and PICU-noGRV units. Conclusions: The practice of routine gastric residual measurement did not significantly impair energy targets in the first four days of PICU admission. However, not measuring GRV did not increase vomiting, ventilator acquired pneumonia or necrotising enterocolitis, which is the main reason clinicians cite for measuring GRV. What is known? • The practice of routinely measuring gastric residual volume is widespread in critical care units • This practice is increasingly being questioned in critically ill patients, both as a practice that increases • the likelihood of delivering inadequate enteral nutrition amounts and as a tool to assess feeding tolerance What is new? • Not routinely measuring gastric residual volume did not increase adverse events of ventilator acquired pneumonia, necrotising enterocolitis or vomiting • In the first four days of PICU stay, energy target achievement was not significantly different, but the rates of under and over feeding were higher in the routine GRV measurement unit

Background Measuring gastric residual volume (GRV) to guide enteral feeding is a common nursing practice in intensive care units, yet little evidence supports this practice. In addition, this practice has been shown to potentially contribute to inadequate energy delivery in intensive care, which remains a problem in critically ill children. Aims We aimed to explore paediatric intensive care nurses' decision-making surrounding this practice. Methods This is a cross-sectional electronic survey in a single mixed general and cardiac surgical PICU in the UK. Results The response rate was 59% (91/154), and responding nurses were experienced, with a mean PICU experience of 10·5 years (SD 8·09). The three main reasons for stopping or withholding enteral feeds were: the volume of GRV obtained (67%), the appearance of this gastric aspirate (40%) and the overall clinical condition of the child (23%). Most nurses reported checking GRV primarily to determine ‘feed tolerance’ (97%) as well as confirming feeding tube position (94%). Nurses' perceived harms from high GRV were: the risk of pulmonary aspiration (44%), malabsorption of feeds (20%) and the risk of vomiting (19%). GRV was measured frequently in this PICU, with 58% measuring GRV before every feed, 27% measuring every 4 h and 17% measuring every 6 h. The majority of nurses (84%) stated they would be worried or very worried if they could not measure GRV routinely. Conclusions PICU nurses' decision-making surrounding initiating and withholding enteral feeds and determining ‘feed tolerance’ remains heavily based on GRV. PICU nurses' have significant fears around patient harm if they do not measure GRV routinely. Relevance to clinical practice This nursing practice is likely to be one of the factors that impair the delivery of enteral nutrition in critically ill children, and as such, its validity and usefulness needs to be challenged and studied in future research.

Objectives: This survey had three key objectives: 1) To describe responsibility for key ventilation and weaning decisions in European PICUs and explore variations across Europe; 2) To describe the use of protocols, spontaneous breathing trials, noninvasive ventilation, high-flow nasal cannula use, and automated weaning systems; and 3) To describe nurse-to-patient staffing ratios and perceived nursing autonomy and influence over ventilation decision making.Design: Cross-sectional electronic survey.Setting: European PICUs.Participants: Senior ICU nurse and physician from participating PICUs.Interventions: None.Measurements and Main Results: Response rate was 64% (65/102) representing 19 European countries. Determination of weaning failure was most commonly based on collaborative decision making (81% PICUs; 95% CI, 70-89%). Compared to this decision, selection of initial ventilator settings and weaning method was least likely to be collaborative (relative risk, 0.30; 95% CI, 0.20-0.47 and relative risk, 0.45; 95% CI, 0.32-0.45). Most PICUs (> 75%) enabled physicians in registrar (fellow) positions to have responsibility for key ventilation decisions. Availability of written guidelines/protocols for ventilation (31%), weaning (22%), and noninvasive ventilation (33%) was uncommon, whereas sedation protocols (66%) and sedation assessment tools (76%) were common. Availability of protocols was similar across European regions (all p > 0.05). High-flow nasal cannula (53%), noninvasive ventilation (52%) to avoid intubation, and spontaneous breathing trials (44%) were used in approximately half the PICUs greater than 50% of the time. A nurse-to-patient ratio of 1: 2 was most frequent for invasively (50%) and noninvasively (70%) ventilated patients. Perceived nursing autonomy (median [interquartile range], 4 [2-6]) and influence (median [interquartile range], 7 [5-8]) for ventilation and weaning decisions varied across Europe (p = 0.007 and p = 0.01, respectively) and were highest in Northern European countries.Conclusions: We found variability across European PICUs in interprofessional team involvement for ventilation decision making, nurse staffing, and perceived nursing autonomy and influence over decisions. Patterns of adoption of tools/adjuncts for weaning and sedation were similar.

Background Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions. Electronic supplementary material The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.

In 2001, the Surviving Sepsis Campaign (SSC) began to develop evidence-based guidelines and recommendations for the resuscitation and management of patients with sepsis. With the 2016 edition, the Society of Critical Care Medicine and European Society of Intensive Care Medicine recommended a separate task force be dedicated to guideline formulation for children. The objective of the “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children” is to provide guidance for the care of infants, children, and adolescents with septic shock and other sepsis-associated organ dysfunction. Recommendations are intended to guide “best practice” rather than to establish a treatment algorithm or to define standard of care and cannot replace the clinician's decision-making capability when presented with a patient's unique set of clinical variables.

Contains fulltext : 230013.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS: The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS: A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research. 01 februari 2020

IntroductionWeaning from ventilation is a complex process involving several stages that include recognition of patient readiness to begin the weaning process, steps to reduce ventilation while optimising sedation in order not to induce distress and removing the endotracheal tube. Delay at any stage can prolong the duration of mechanical ventilation. We developed a multicomponent intervention targeted at helping clinicians to safely expedite this process and minimise the harms associated with unnecessary mechanical ventilation.Methods and analysisThis is a 20-month cluster randomised stepped wedge clinical and cost-effectiveness trial with an internal pilot and a process evaluation. It is being conducted in 18 paediatric intensive care units in the UK to evaluate a protocol-based intervention for reducing the duration of invasive mechanical ventilation. Following an initial 8-week baseline data collection period in all sites, one site will be randomly chosen to transition to the intervention every 4 weeks and will start an 8-week training period after which it will continue the intervention for the remaining duration of the study. We aim to recruit approximately 10 000 patients. The primary analysis will compare data from before the training (control) with that from after the training (intervention) in each site. Full details of the analyses will be in the statistical analysis plan.Ethics and disseminationThis protocol was reviewed and approved by NRES Committee East Midlands—Nottingham 1 Research Ethics Committee (reference: 17/EM/0301). All sites started patient recruitment on 5 February 2018 before randomisation in April 2018. Results will be disseminated in 2020. The results will be presented at national and international conferences and published in peer-reviewed medical journals.Trial registration numberISRCTN16998143.

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. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made.

Background:Infants born with undiagnosed transposition of the great arteries continue to be born in district general hospitals despite the improvements made in antenatal scanning. Evidence indicates improved outcomes with early definitive treatment after birth, hence the recommendation of delivery in a tertiary centre. The role of specialist paediatric and neonatal transport teams, to advise, stabilise, and transport the infants to a tertiary centre in a timely manner, is critical for those infants born in a district general hospital. This pilot study aims to compare outcomes between infants born in district general hospitals and those who were born in a tertiary maternity unit in South West England and South Wales.Methods:This was a secondary data analysis of data collected from the local Paediatric Intensive Care Audit Network and the local transport database. Infants born with a confirmed diagnosis of transposition of the great arteries, that required an arterial switch operation as the definitive procedure between April, 2012 and March 2018 were included.Results:Forty-five infants with a confirmed diagnosis of transposition of the great arteries were included. Statistical analysis demonstrated there were no significant differences in the time to balloon atrial septostomy (p = 0.095), time to arterial switch operation (p = 0.461), length of paediatric ICU stay (p = 0.353), and hospital stay (p = 0.095) or mortality between the two groups.Conclusions:We found no significant differences in outcomes between infants delivered outside the specialist centre, who were transferred in by a specialist team.

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.

The role played by fever in the outcome of critical illness in children is unclear. This survey of medical and nursing staff in 35 paediatric intensive care units and transport teams in the United Kingdom and Ireland established attitudes towards the management of children with fever. Four hundred sixty-two medical and nursing staff responded to a web-based survey request. Respondents answered eight questions regarding thresholds for temperature control in usual clinical practice, indications for paracetamol use, and readiness to participate in a clinical trial of permissive temperature control. The median reported threshold for treating fever in clinical practice was 38 °C (IQR 38-38.5 °C). Paracetamol was reported to be used as an analgesic and antipyretic but also for non-specific comfort indications. There was a widespread support for a clinical trial of a permissive versus a conservative approach to fever in paediatric intensive care units. Within a trial, 58% of the respondents considered a temperature of 39 °C acceptable without treatment.Staff on paediatric intensive care units in the United Kingdom and Ireland tends to treat temperatures within the febrile range. There was a willingness to conduct a randomized controlled trial of treatment of fever. What is known: • The effect of fever on the outcome in paediatric critical illness is unknown. • Paediatricians have traditionally been reluctant to allow fever in sick children. What is new: • Paediatric intensive care staff report a tendency towards treating fever, with a median reported treatment threshold of 38 °C. • There is widespread support amongst PICU staff in the UK for a randomized controlled trial of temperature in critically ill children. • Within a trial setting, PICU staff attitudes to fever are more permissive than in clinical practice.

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.

Background Impaired nutritional status is adversely associated with suboptimal outcomes in critically ill children. Undernutrition at pediatric intensive care unit (PICU) admission ranges from 15 to 65%. A lack of knowledge of the nutritional status of children in French PICUs prevents us from specifically targeting education. This study aims to describe the nutritional status of children in French PICUs and to assess nutritional practices and physicians’ knowledge of nutrition, in order to focus NutriSIP (the French-speaking PICU nutrition group) future education programs. A prospective observational multicenter point prevalence study was conducted in French PICUs, recruiting all children admitted over three different weeks. Anthropometric measurements were taken (weight, height/length, mid-upper arm, and head circumferences), in order to calculate nutritional indices. Nutritional status was defined according to WHO Body Mass Index z-score and dynamic assessment based on growth faltering detection. Concurrently, PICU physicians and PICU nurses from seven French-speaking countries completed a survey to ascertain knowledge about local nutritional care practices and overall nutrition knowledge. PICU physicians’ responses were compared to PICU nurses’ responses (previously published). Results Four hundred and thirty-two children were included in the observational study from 27 French PICUs. Undernutrition was diagnosed in 18.5% of them, young age and underlying chronic condition being the two independent risk factors. Faltering growth was diagnosed in 4.8% and overweight in 7.4%. Subjective nutritional assessment was not accurate. Thirty-eight French-speaking PICUs completed the survey. These showed nutritional practices frequently did not comply with international guidelines, especially regarding nutritional goals, and the reasons for withholding enteral nutrition. Comparison between physicians’ and nurses’ responses to the survey showed large discrepancies. Conclusion Undernutrition is frequent at admission in French PICUs. Nutritional status should be assessed using a holistic approach, because of the potential impact on outcome. French-speaking PICU healthcare professionals need further nutrition education, in order to improve nutritional practices to comply with international recommendations. This study will serve as a baseline to focus NutriSIP teaching programs in the future. Electronic supplementary material The online version of this article (10.1186/s13613-019-0493-z) contains supplementary material, which is available to authorized users.

© 2018, Springer-Verlag GmbH Germany, part of Springer Nature. Feeding difficulties are common in young infants presenting with acute bronchiolitis, but limited data is available to guide clinicians adapting nutritional management. We aimed to assess paediatricians’ nutritional practices among Western Europe French speaking countries. A survey was disseminated to describe advice given to parents for at home nutritional support, in hospital nutritional management, and preferred methods for enteral nutrition and for intravenous fluid management. A documentary search of international guidelines was concomitantly conducted. Ninety-three (66%) contacted physicians responded. Feeding difficulties were a common indication for infants’ admission. Written protocols were rarely available. Enteral nutrition was favoured most of the time when oral nutrition was insufficient and might be withheld in case of severe dyspnoea to decrease respiratory workload. Half of physicians were aware of hyponatremia risk and pathophysiology, and isotonic intravenous solutions were used in less than 15% of centres. International guideline search (23 countries) showed a lack of detailed nutritional management recommendations in most of them. Conclusion: practices were inconsistent among physicians. Guidelines detailed nutritional management poorly. Awareness of hyponatremia risk in relation to intravenous hypotonic fluids and of the safety of enteral hydration and nutrition is insufficient. New guidelines including detailed nutritional management recommendations are urgently needed.What is Known?• Infants presenting with acute bronchiolitis face feeding difficulties.• Underfeeding may promote undernutrition, and intravenous hydration with hypotonic fluids may induce hyponatremia.What is New?• Physicians’ nutritional practices are inconsistent and awareness of hyponatremia risk and pathophysiology is insufficient among physicians.• Awareness of hyponatremia risk and pathophysiology is insufficient among physicians.• The reasons for enteral nutrition withholding in bronchiolitis infants are not evidence based, and national guidelines of acute bronchiolitis across the world are elusive regarding nutritional management.• National guidelines of acute bronchiolitis across the world are elusive regarding nutritional management.

Background: Despite potential benefits it is not known how widely mechanical insufflation-exsufflation (MI-E) is used by physiotherapists on UK intensive care units (ICU). Aim: To describe the use of MI-E in adult ICUs across the UK. Method: Physiotherapists working on UK, adult ICUs were invited to participate in an electronic survey. Ethical approval was granted by the Faculty Research Ethics Committee, University of the West of England, Bristol. Results: 166 complete surveys were returned, with good geographical UK representation. Over half (72% 119/166) respondents were band 7 and above, with a mean (±SD) of 13 (±7) years since qualification. Nearly all (98% 163/166) clinicians had access to MI-E on ICU, with a range of devices reported. Estimated frequency of use varied; the majority reporting weekly or monthly use (n=52/163, 32% and n=50/163, 31% respectively). Just over half of clinicians (n=86/163, 53%) stated they use MI-E with intubated patients. In contrast, 99% of clinicians stated MI-E use with extubated patients. Of those clinicians who did not use MI-E in intubated patients (n=74/163, 45%), a range of perceived barriers were reported (fig 1). Conclusions: MI-E is widely available on adult ICUs across the UK. Clinicians reported greater use with extubated patients. Barriers to MI-E use in the intubated population warrants further investigation. Figure 1: Perceived barriers to MI-E use in the intubated population

© 2018, The Author(s). Ensuring optimal nutrition is vital in critically ill children and enteral feeding is the main route of delivery in intensive care. Feeding intolerance is the most commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition, yet the definition for this remains inconsistent, nebulous, and entirely arbitrary. Not only does this pose problems clinically, but research in this field frequently uses feeding intolerance as an endpoint and the heterogeneity in this definition makes the comparison of studies difficult and meta-analysis impossible. We reviewed the use of, and definitions of, the term feed intolerance in pediatric intensive care research papers in the last 20years. Gastric residual volume remains the most common factor used to define feed intolerance, despite the lack of evidence for this. Healthcare professionals would benefit from further education to improve their awareness of the limitations of the markers to define feeding intolerance, and the international PICU community needs to agree a consistent definition of this phenomenon to improve consistency in both practice and research. Conclusion: This paper will provide a narrative review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children.What is Known?:• Feeding intolerance is a commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition.• There is no agreed definition for feeding intolerance in critically ill children.What is New?:• This paper provides an up to date review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children.• Despite no evidence, gastric residual volume continues to drive clinical bedside decisions about enteral feeding and feeding tolerance.

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.

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. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4344-1) contains supplementary material, which is available to authorized users.

Objectives: Despite the increasing use of near-infrared spectroscopy across pediatric cardiac ICUs, there is significant variability and equipoise with no universally accepted management algorithms. We aimed to explore the use of near-infrared spectroscopy in pediatric cardiac ICUs in the United Kingdom, Ireland, Italy, and Germany. Design: A cross-sectional multicenter, multinational electronic survey of one consultant in each pediatric cardiac ICU. Setting: Pediatric cardiac ICUs in the United Kingdom and Ireland (n = 13), Italy (n = 12), and Germany (n = 33). Interventions: Questionnaire targeted to establish use, targets, protocols/thresholds for intervention, and perceived usefulness of near-infrared spectroscopy monitoring. Results: Overall, 42 of 58 pediatric cardiac ICUs (72%) responded: United Kingdom and Ireland, 11 of 13 (84.6%); Italy, 12 of 12 (100%); and Germany, 19 of 33 (57%, included all major centers). Near-infrared spectroscopy usage varied with 35% (15/42) reporting that near-infrared spectroscopy was not used at all (7/42) or occasionally (8/42); near-infrared spectroscopy use was much less common in the United Kingdom (46%) when compared with 78% in Germany and all (100%) in Italy. Only four units had a near-infrared spectroscopy protocol, and 18 specifically used near-infrared spectroscopy in high-risk patients; 37 respondents believed that near-infrared spectroscopy added value to standard monitoring and 23 believed that it gave an earlier indication of deterioration, but only 19 would respond based on near-infrared spectroscopy data alone. Targets for absolute values and critical thresholds for intervention varied widely between units. The reasons cited for not or occasionally using near-infrared spectroscopy were expense (n = 6), limited evidence and uncertainty on how it guides management (n = 4), difficulty in interpretation, and unreliability of data (n = 3). Amongst the regular or occasional near-infrared spectroscopy users (n = 35), 28 (66%) agreed that a multicenter study is warranted to ascertain its use. Conclusions: Although most responding units used near-infrared spectroscopy for high-risk patients, the majority (31/35 [88%]) did not have any protocols or guidelines for intervention. Target thresholds and intervention algorithms are needed to support the use of near-infrared spectroscopy in pediatric cardiac ICUs; an international multicenter study is warranted. (Pediatr Crit Care Med 2016; 17:36–44)

Objectives: To describe enteral feeding practices in pre and post-operative infants with congenital heart disease(CHD) in European Pediatric Intensive Care Units (PICU). Design: Cross-sectional electronic survey Setting: European pediatric intensive care units that admit infants with congenital heart disease pre and post-operatively. Participants: One senior PICU physician or designated person per unit. Interventions: None Measurements and Main Results: Fifty nine PICUs from 18 European countries responded to the survey. PICU physicians were involved in the nutritional care of children with CHD in most (76%) PICUs, but less than 60% of units had a dedicated dietician. Infants with CHD were routinely fed pre-operatively in only 63% of the PICUs, due to ongoing concerns around prostaglandin (PGE1) infusion, the presence of umbilical venous and/or arterial catheters and the use of vasoactive drugs. In three quarters of the PICUs (76%) infants were routinely fed during the first 24 hours post-operatively. Units cited, the most common feeding method, both pre and post-operatively, was intermittent bolus feeds via the gastric route. Importantly, 69% of European PICUs still did not have written guidelines for feeding, but this varied for pre and post-operative patients. Conclusions: Wide variations in practices exist in the nutritional care between European PICUs, which reflects the absence of local protocols and scientific society-endorsed guidelines. This is likely to contribute to suboptimal energy delivery in this particularly vulnerable group.

Background \ud It is recognised that nurses’ failure to recognise and respond promptly to a deterioration in children’s physiological status can result in increased morbidity and mortality. \ud Aim \ud The aim of this study was to explore Saudi-educated newly qualified nurses, working in paediatric wards, ability to recognise children’s deterioration. \ud Methods \ud A pilot study was carried out to assess Nurses’ responses to three clinical vignettes (deteriorating child, improving child and ambiguous scenarios). The nurses’ ability to make a correct identification was captured using a ‘Think Aloud’ approach and quantified using a visual analogue scale. \ud Results \ud Twenty-seven nurses in two geographical regions in Saudi Arabia participated. Only half the nurses (51.8%) correctly identified the deteriorating child vignette. Of the ones who could not, 37% were unsure and 11% responded incorrectly. No nurses correctly identified all three vignettes, and four nurses (15%) responded incorrectly to all vignettes. \ud Relevance to clinical practice \ud Newly qualified nurses working in paediatric wards frequently find it difficult to identify the deteriorating child. \ud Conclusions: \ud The recognition of the deteriorating child is complex, and even in non-stressful simulated scenarios using vignettes, many newly qualified nurses working with children failed to recognise clear signs of the deteriorating child. A focused (culturally specific) educational intervention is being developed to target this, taking into account the Saudi nurses’ perceived education and training needs.

Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Objectives: To determine the hemodynamic effect of tracheal suction method in the first 36 hours after high-risk infant heart surgery on the PICU and to compare open and closed suctioning techniques. Design: Pilot randomized crossover study. Setting: Single PICU in United Kingdom. Participants: Infants undergoing surgical palliation with Norwood Sano, modified Blalock-Taussig shunt, or pulmonary artery banding in the first 36 hours postoperatively. Interventions: Infants were randomized to receive open or closed (in-line) tracheal suctioning either for their first or second study tracheal suction in the first 36 hours postoperatively. Measurements and Main Results: Twenty-four infants were enrolled over 18 months, 11 after modified Blalock-Taussig shunt, seven after Norwood Sano, and six after pulmonary artery banding. Thirteen patients received the open suction method first followed by the closed suction method second, and 11 patients received the closed suction method first followed by the open suction method second in the first 36 hours after their surgery. There were statistically significant larger changes in heart rate (p = 0.002), systolic blood pressure (p = 0.022), diastolic blood pressure (p = 0.009), mean blood pressure (p = 0.007), and arterial saturation (p = 0.040) using the open suction method, compared with closed suctioning, although none were clinically significant (defined as requiring any intervention). Conclusions: There were no clinically significant differences between closed and open tracheal suction methods; however, there were statistically significant greater changes in some hemodynamic variables with open tracheal suctioning, suggesting that closed technique may be safer in children with more precarious physiology.

Consulting with users is considered best practice and is highly recommended in designing new trials. As part of our feasibility work, we undertook a consultation exercise with parents, ex-patients and young people prior to designing a trial of protocol-based ventilator weaning. Our aims were to (1) ascertain views on the relevance and importance of the trial; (2) determine the important parent/patient outcome measures; and (3) ascertain views on informed consent in a cluster randomized controlled trial. We conducted audio-recorded face-to-face, telephone and focus group interviews with parents and young people. Data were content analysed to generate information to address our specific consultation objectives. The setting was the north-western region of England. A total of 16 participants were interviewed: 2 parents of paediatric intensive care unit (PICU) survivors; 1 PICU survivor; and 13 young people from the former Medicines for Children Research Network. The trial objectives were deemed important and relevant, and participants considered the most important outcome measure to be the length of time on ventilation. Parents and young people did not consider written informed consent to be a necessary requirement in the context of this trial, rather awareness of unit participation in the trial was important with the opportunity of opting out of data collection. This consultation provided useful, pragmatic insights to inform trial design. We encountered significant challenges in recruiting parents and young people for this consultation exercise, and novel recruitment methods need to be considered for future work in this field. Patient and public involvement is essential to ensure that future trials answer parent-relevant questions and have meaningful outcome measures, as well as involving parents and young people in the general development of health care services.