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Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.

Nutrition status plays a critical role in pressure injury (PI) healing and yet the available literature, especially in pediatric patients, is limited. Critically ill pediatric patients are at an increased risk of skin integrity compromise and PI development. Adequate nutritional intake can often be challenging to achieve in this population and immobility and illness present additional obstacles to maintaining skin integrity in this vulnerable population. Despite the unique nutritional challenges and needs of this group, there is no standardized approach to macro- and micronutrient management and monitoring. Here, several key vitamins and minerals believed to play a role in PI healing are discussed and an approach to nutritional management and monitoring for PI healing in pediatric patients is proposed. Registered dietitians (RD) are essential to assess individual patient macro and micronutrient requirements, to identify gaps and make recommendations to optimize nutritional therapy that may exist and impact wound healing. We used a scoping review to focus on the interplay of nutrition and PI healing and inform a multidisciplinary approach to PI identification and management. Through this review, we propose a strategy for the nutritional management of pediatric patients

Objectives The impact of early enteral nutrition on clinical outcomes in critically ill children has not been adequately described. We hypothesized that early enteral nutrition is associated with improved clinical outcomes in critically ill children. Design Secondary analysis of the Heart and Lung Failure-Pediatric Insulin Titration randomized controlled trial. Setting Thirty-five PICUs. Patients Critically ill children with hyperglycemia requiring inotropic support and/or invasive mechanical ventilation who were enrolled for at least 48 hours with complete nutrition data. Interventions Subjects received nutrition via guidelines that emphasized enteral nutrition and were classified into early enteral nutrition (enteral nutrition within 48 hr of study randomization) and no early enteral nutrition (enteral nutrition after 48 hr of study randomization, or no enteral nutrition at any time). Measurements and main results Of 608 eligible subjects, 331 (54%) received early enteral nutrition. Both early enteral nutrition and no early enteral nutrition groups had similar daily caloric intake over the first 8 study days (median, 36 vs 36 kcal/kg/d; p = 0.93). After controlling for age, body mass index z scores, primary reason for ICU admission, severity of illness, and mean Vasopressor-Inotrope Score at the time of randomization, and adjusting for site, early enteral nutrition was associated with lower 90-day hospital mortality (8% vs 17%; p = 0.007), more ICU-free days (median, 20 vs 17 d; p = 0.02), more hospital-free days (median, 8 vs 0 d; p = 0.003), more ventilator-free days (median, 21 vs 19 d; p = 0.003), and less organ dysfunction (median maximum Pediatric Logistic Organ Dysfunction, 11 vs 12; p Conclusions In critically ill children with hyperglycemia requiring inotropic support and/or mechanical ventilation, early enteral nutrition was independently associated with better clinical outcomes.

Post-operative oral feeding difficulties in neonates and infants with CHD is common. While pre-operative oral feeding may be normal, oral feeding challenges manifest in the post-operative period without a clearly defined aetiology. The objective of this scoping review was to examine post-operative oral feeding in full-term neonates and infants with a CHD. Electronic databases query (1 January 1975–31 May 2021), hand-search of the reference lists of included studies, contact with experts, and review of relevant conferences were performed to identify quantitative studies evaluating post-operative oral feeding in full-term neonates and infants with a CHD. Associations with additional quantitative variables in these studies were also examined. Twenty-five studies met inclusion criteria. Eighty per cent were cohort studies that utilised retrospective chart review from a single institution. The primary variable of interest in all studies was oral feeding status upon discharge from neonatal hospitalisation. The most common risk factors evaluated with poor feeding at time of discharge were birth weight (36% of included studies), gestational age (44%), duration of post-operative intubation (48%), cardiac diagnosis (40%), and presence of genetic syndrome or chromosomal anomaly (36%). The most common health-related outcomes evaluated were length of hospital stay (40%) and length of ICU stay (16%). Only the health-related outcomes of length of hospital stay and length of ICU stay were consistently significantly associated with poor post-operative oral feeding across studies in this review. A clear aetiology of poor post-operative oral feeding remains unknown.

Background: Infants with congenital heart disease (CHD) often have poor growth and altered body composition (fat and muscle accretion). Aim: Describe growth patterns in infants with CHD using interval weight, length, head circumference (HC), triceps (TSF), subscapular skinfolds (SSSF), and mid-upper arm circumference (MUAC) measurements. Subjects and Methods: A total of 120 infants enrolled: 48% healthy and 58% with CHD (45% single ventricle [SV]; 55% two ventricle [2V] physiology). Weight, length, HC, TSF, SSSF, and MUAC measured at 3-, 6-, 9-, and 12-months of age. Results: CHD infants had lower weight, length, and HC z-scores at 3-, 6-, and 9-months. At 9-months, infants with SV physiology had larger TSF and SSSF z-scores over 2V and healthy infants. Overall MUAC z-scores were smaller at 3- and 6-months in infants with CHD. Conclusison: Infants with CHD have a complex pattern of growth. Longitudinal growth and body composition measurements provide information to better understand this pattern.

Despite decades of research and a multitude of prevention and treatment efforts, childhood obesity in the United States continues to affect nearly 1 in 5 (19.3%) children, with significantly higher rates among Black, Indigenous, and People of Colour communities. This narrative review presents social foundations of structural racism that exacerbate inequity and disparity in the context of childhood obesity. The National Institute of Minority Health and Health Disparities' Research Framework guides the explication of structurally racist mechanisms that influence health disparities and contribute to childhood obesity: biologic and genetic, health behaviours, chronic toxic stress, the built environment, race and cultural identity, and the health care system. Strategies and interventions to combat structural racism and its effects on children and their families are reviewed along with strategies for research and implications for policy change. From our critical review and reflection, the subtle and overt effects of societal structures sustained from years of racism and the impact on the development and resistant nature of childhood obesity compel concerted action.

Perceptions and practices of parties in pediatric pain are critical in children's access to adequate acute pain management. The personal factors of the child and parents have been shown to be central to pediatric pain management by the Symptom Management Theory.To describe children and parents/guardians' perceptions (knowledge, attitudes and beliefs) and practices regarding pediatric acute pain management and explain the influence of socio-cultural and environmental factors on those perceptions and practices.Descriptive cross-sectional survey using modified versions of the American Pain Society Patient Outcome Questionnaire-Revised among parents/guardians and children.A convenience sample of 275 parents/guardians and 42 children aged 8 to 13 years admitted between date November 2018 and February 2019 to two Botswana tertiary hospitals completed the surveys. Forty-seven percent (n = 129) of parents/guardians reported the child to be in moderate-severe pain, while 38% (n = 16) of children reported pain as moderate-severe at the time of the survey. The children mean scores for cm-APS-POQ-R were 113(33) while parents/guardian's guardians for m-APS-POQ-R were 123(26). The subscales except for the parents/'guardians' pain interference (p = .96) were statistically significant (p = .000), showing adequate knowledge, positive attitudes and high pain intensity for both parents/guardians and children.Parent/guardians and children reported a high incidence of acute pain, were content with pain management services, and showed adequate knowledge of pediatric pain and its management. The incongruence between the intensity of pain, satisfaction on the adequacy of pain management and knowledge and attitudes demonstrated in this study need further inquiry.

Comparison of bolus gastric feeding (BGF) vs continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated (MV) pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered.Multicenter, prospective, randomized comparative effectiveness trial conducted in seven pediatric intensive care units (PICUs). Eligibility criteria included patients aged 1 month to 12 years who were intubated within 24 h of PICU admission, with expected duration of ventilation at least 48 h, and who were eligible to begin enteral nutrition within 48 h. Exclusion criteria included patients with acute or chronic gastrointestinal pathology or acute surgery.We enrolled 158 MV children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). Children in the BGF group were slightly older than those in the CGF; otherwise, the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group who achieved goal feeds. Time to goal feeds was shorter in the BGF group (hazard ratio 1.5 [CI 1.02-2.33]; P = 0.0387). Median percentage of target kilocalories (median kcal 0.78 vs 0.59; P ≤ 0.0001) and median percentage of protein delivered (median protein 0.77 vs 0.59; P ≤ 0.0001) was higher for BGF patients. There was no difference in serial oxygen saturation index between groups.Our study demonstrated shorter time to achieve goal nutrition via BGF compared with CGF in MV pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations.

Background Nutrition guidelines recommend enteral nutrition in the form of gastric feedings for critically ill children and acknowledge a lack of evidence describing an optimal method for providing these feedings. Objective To determine the state of the science regarding the efficacy of bolus (intermittent) or continuous gastric feedings to improve nutrition delivery in critically ill children receiving mechanical ventilation. Methods Five hundred seventy-nine abstracts met the inclusion criteria and were screened by 2 reviewers according to prespecified criteria. Full-text reviews were performed on 28 articles; 11 studies were selected for detailed analysis. Because of the small number of eligible studies, broader searches were conducted. Results Only 5 studies with a collective enrollment of fewer than 200 children closely addressed the specific research question. These 5 studies did not report any similarity in feeding regimens, nor did they report nutritional outcomes. Two of the articles described findings from the same study population. Although 4 of the 5 studies randomized children to bolus versus continuous feedings, only 3 studies described attainment of nutrient delivery goals in both the intervention and the control groups; the remaining study did not report this outcome. The heterogeneity in methodology and outcomes among the 5 studies did not allow for a meta-analysis. Conclusions The dearth of evidence regarding best practices and outcomes related to bolus versus continuous gastric feedings in critically ill children receiving mechanical ventilation requires additional rigorous investigation.

Objective:To examine associations between serum micronutrients and neurobehavioural function and the mediating role of sleep quality in early adolescents.Design:In this cross-sectional study, peripheral blood samples were analysed for Fe and Zn levels. The Pittsburgh Sleep Quality Index and Penn Computerized Neurocognitive Battery were used to assess sleep quality and neurobehavioural function, respectively. The logistic/linear regressions and generalised structural equation modelling were performed to estimate the associations.Setting:Jintan, ChinaParticipants:In total, 226 adolescents (106 females) from the Jintan Child Cohort study.Results:Adolescents with low Fe (P= 0·04) and low Zn (P< 0·001) were associated with increased odds for poor sleep quality. Adolescents with low Fe and Zn were associated with fast (Fe:β= –1353·71,P= 0·002, Zn:β= –2262·01,P= 0·02) but less-accurate (Fe:β= –0·97,P= 0·04; Zn:β= –1·76,P= 0·04) performance on non-verbal reasoning task and poor sleep quality partially mediated the associations between low Fe/Zn and non-verbal reasoning (P< 0·05). Additionally, low Fe was associated with a slower reaction on spatial processing task (β= 276·94,P= 0·04), and low Zn was associated with fast (β= –1781·83,P= 0·03), but error-prone performance (β= –1·79,P= 0·04) on spatial processing ability and slower reaction speed (β= 12·82,P= 0·03) on the attention task. We observed similar trends using a cut-off point of 75 μg/dl for low serum Zn, except for the association with attention task speed (P> 0·05).Conclusion:Fe and Zn deficiencies may possibly be associated with poor sleep and neurobehavioural function among early adolescents. Poor sleep may partially mediate the relationship between micronutrients and neurobehavioural function.

There is very limited clinical and observational data on acute pain experienced by children in sub-Saharan Africa.To report the prevalence and intensity of acute pain, pain management practices, and describe associations between acute pain outcomes, children's and parents or guardian's demographics in hospitalized children aged 2 months to 13 years in Botswana.A descriptive correlational prospective observational study using five repeated cross-sectional samples.Two referral hospitals in Botswana.The sample size included 308 children and 226 parents or guardians. Data were collected between November 2018 and February 2019 from children, their parents or guardians (7 years child), and the health record for pain documentation and treatment.Pain was measured using Faces Pain Scale-Revised for children ≥7 years, revised Face, Legs, Activity, Cry, Consolability scale for children7 years and numeric rating scale for parents or guardians.There are 1,290 data points for children of which 1,000 were children7 years and 999 data points for parents or guardians of children7 years were used in analysis. Fifty percent of children7 years were in pain using the revised Face, Legs, Activity, Cry, Consolability scale, whereas parents indicated 46% to be in pain. The pain prevalence for children ≥7 years was estimated at 54%. Pain was documentated at a rate of 54 % on the health records. Acetaminophen was most common analgesic across all age groups. Univariate associations of child7 years pain intensity was statistically significant (p ≤ .05) for weight, diagnosis, residence, and parent relationship. Parents reported pain intensity was statistically significant (p ≤ .05) for child sex, weight, diagnosis, residence, surgery, parent or guardian age and education. Only age and surgery were significant for children ≥7 years.Acute pain prevalence and intensity among hospitalized children in Botswana is low.

Few studies have examined the role of selenium in anxiety. This study aimed to evaluate the association between serum selenium concentrations and anxiety disorders and symptoms in children.This study utilized data from 831 children participating in the China Jintan Child Cohort Study (mean age = 12.67 years; 46.1% female). Serum selenium samples were collected and anxiety was assessed using the Chinese version of the Screen for Child Anxiety Related Disorders. Six types of anxiety scores were calculated, including total anxiety, panic/somatic, generalized anxiety, separation anxiety, social anxiety, and school phobia.Controlling for covariates, children with lower serum selenium concentrations were more likely to meet clinical cutoffs for total anxiety (OR = 0.992, p 0.01), panic/somatic disorder (OR = 0.993, p 0.05), generalized anxiety disorder (OR = 0.990, p 0.05), social anxiety disorder (OR = 0.991, p 0.01), and school phobia (OR = 0.989, p 0.01), but not separation anxiety (OR = 1.000, p 0.05). Controlling for covariates, lower serum selenium concentrations were also associated with higher continuous total anxiety, generalized anxiety, and school phobia scores (p 0.05).Lower serum selenium concentrations were associated with higher anxiety. To our knowledge, this was the first study to examine the relationship between serum selenium and anxiety disorders in a sample of children. Results indicate an association between children's micronutrient levels and anxiety disorders.Improving child nutrition may be a promising strategy to help reduce childhood anxiety.

Parents are commonly responsible for making health care decisions for their seriously ill children in the pediatric intensive care unit (PICU); however, the factors influencing their decisions may vary. This integrative review examined the empirical literature between 2013 and 2018 to understand factors pertaining to parents’ decision-making about serious illness care of their children in the PICU. Seventeen studies met the inclusion criteria with three key findings. First, parent–clinician communication in the PICU is critical; second, most parents want to be the final decision-maker for their critically ill child; and third, parents’ emotions, support systems, and the child’s clinical status impact decision-making. Parental perspectives are important to consider when discussing serious illness care decisions for critically ill children. Further inquiry is needed into how the parent–clinician encounter impacts the decision-making process and subsequent outcomes in this population.

OBJECTIVE: To evaluate the effect of a standardized feeding approach using a clinical nutrition pathway on weight-for-age Z score (WAZ) over hospital length of stay (HLOS) for infants with congenital heart disease (CHD). STUDY DESIGN: A ten-year retrospective cohort study examined eligible infants who underwent neonatal cardiac surgery between July 2009 through December 2018 (n=987). Eligibility criteria included infants born at least 37 weeks gestation and a minimum birth weight of 2 kilograms who underwent cardiac surgery for CHD within the first 30 days of life. Using the best linear unbiased predictions (BLUP) from a linear mixed effects model, WAZ change over HLOS was estimated before and after January 2013, when the standardized feeding approach was initiated. BLUP model included adjustment for patient characteristics including sex, race, HLOS, and class of cardiac defect. RESULTS: Change in WAZ over HLOS was significantly higher during the period 2013–2018 than during the period 2009–2012 (β(SE)=0.16 (0.02), P < .001), after controlling for sex, race, HLOS, and CHD category, indicating that infants experienced decreased WAZ loss over HLOS after the standardized feeding approach was initiated. Additionally, differences were found in WAZ loss over HLOS between infants with single ventricle CHD (β(SE)=0.26 (0.04), p

Optimal nutrition support in critically ill children is associated with improved outcomes and decreased mortality. Nutrition provision often competes with other care priorities in critically ill patients. The 2017 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient supplement clinician knowledge and inform best practices for nutrition therapy in this vulnerable patient population.

Optimal nutrition support in critically ill children is associated with improved outcomes and decreased mortality. Nutrition provision often competes with other care priorities in critically ill patients. The pediatric critical care nutrition support guidelines supplement clinician knowledg

The placement of a nasogastric tube (NGT) in a pediatric patient is a common practice that is generally perceived as a benign bedside procedure. There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient safety, increasing the risk for serious and even fatal complications. There is no standardized method for verification of the initial NGT placement or reverification assessment of NGT location prior to use. Measurement of the acidity or pH of the gastric aspirate is the most frequently used evidence-based method to verify NGT placement. The radiograph, when properly obtained and interpreted, is considered the gold standard to verify NGT location. However, the uncertainty regarding cumulative radiation exposure related to radiographs in pediatric patients is a concern. To minimize risk and improve patient safety, there is a need to identify best practice and to standardize care for initial and ongoing NGT location verification. This article provides consensus recommendations for best practice related to NGT location verification in pediatric patients. These consensus recommendations are not intended as absolute policy statements; instead, they are intended to supplement but not replace professional training and judgment. These consensus recommendations have been approved by the American Society for Parental and Enteral Nutrition (ASPEN) Board of Directors.

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Enteral feeding tubes are used in pediatric patients to deliver nutrition, fluids or medications. The literature related to short-term feeding tube (nasogastric [NG], hereafter known as NGT, or orogastric [OGT],) use in pediatric homecare patients is sparse. This descriptive study sought to gather baseline information about these children and how their feeding tubes are managed at home. Specifically, we sought to better understand how the tubes are placed and the method(s) used for tube placement verification. Two surveys were distributed: one to parents and one to homecare providers who have direct patient contact. Results Responses were obtained from 144 parents and 66 homecare providers. Over half of the children were 12 months of age or younger and had a 6 Fr feeding tube. Over 75% (108) had an NGT for 1 year or less. Predominantly parents replaced the NGT but a few children self-inserted their tubes. Feeding tube placement was verified by auscultation (44%) or measurement of gastric pH (25%) in the parent's survey. Twenty-six percent of parents indicated they had misplaced an NGT at least once and 35 parents described symptoms of pulmonary misplacement. The homecare provider data indicated auscultation (39%) and pH measurement of gastric contents (28%) to verify NG tube placement location. Study results confirms a need for consistency of practice among health care professionals and in parent education for those children who require NGTs at home. It is troubling that auscultation is still widely used for NGT location confirmation despite practice alerts that warn against its use.

Summary Gastrointestinal physiology involves an intricate network of mechanical, hormonal, and motility functions, including enzymatic secretions, and acid production that work in concert to ensure the breakdown of ingested food for utilization by the body. In critical illness, this delicate interplay is disrupted with marked alterations in absorptive physiology and energy metabolism. This combination of changes necessitates a careful and nuanced approach to nutritional therapy for critically ill patients. The preillness nutrition status of the patient determines their ability to withstand and survive the critical illness state. Nutrition assessment is essential to characterize and define the nutrition status of the patient, determine appropriate nutrient intake goals, and identify the best mode for nutrient delivery. This chapter describes the current state of knowledge and evidence for the provision of nutritional therapy in the ICU patient and explains the nutritional relevance of selected diseases common to adult and pediatric ICU patients.

OBJECTIVES: Research has documented that frequent breakfast consumption is associated with better cognition. However, the relationship between breakfast type and cognitive functioning is lesser known. In this study, we examined both breakfast type and consumption frequency in relation to IQ and academic achievement in a sample of 12-year-old Chinese schoolchildren. METHODS: Participants included 835 12-year-old children from the China Jintan Cohort Study. Breakfast habits, food types, and intake frequency were assessed through self-administered nutrition questionnaires. The types of foods measured included fruits/vegetables, grain/rice, meat/egg, dairy products, and soy products. IQ was measured with the Chinese version of the Wechsler Intelligence Scale for Children. Standardized academic achievement was collected through school reports. Multivariate general linear modeling was implemented for data analysis. RESULTS: More frequent breakfast consumption of grain/rice and meat/egg (6–7 days per week) was significantly associated with higher verbal, performance, and full scale IQs, by 3.562, 3.687, and 4.559 points, respectively (all P

BackgroundNeonates undergoing heart surgery for CHD are at risk for postoperative gastrointestinal complications and aspiration events. There are limited data regarding the prevalence of aspiration after neonatal cardiothoracic surgery; thus, the effects of aspiration events on this patient population are not well understood. This retrospective chart review examined the prevalence and effects of aspiration among neonates who had undergone cardiac surgery at the time of their discharge.IntroductionThis study examined the prevalence of aspiration among neonates who had undergone cardiac surgery. Demographic data regarding these patients were analysed in order to determine risk factors for postoperative aspiration. Post-discharge feeding routes and therapeutic interventions were extracted to examine the time spent using alternate feeding routes because of aspiration risk or poor caloric intake. Modified barium swallow study results were used to evaluate the effectiveness of the test as a diagnostic tool.Materials and methodsA retrospective study was undertaken of neonates who had undergone heart surgery from July, 2013 to January, 2014. Data describing patient demographics, feeding methods, and follow-up visits were recorded and compared using a χ2 test for goodness of fit and a Kaplan–Meier graph.ResultsThe patient population included 62 infants – 36 of whom were male, and 10 who were born with single-ventricle circulation. The median age at surgery was 6 days (interquartile range=4 to 10 days). Modified barium swallow study results showed that 46% of patients (n=29) aspirated or were at risk for aspiration, as indicated by laryngeal penetration. In addition, 48% (n=10) of subjects with a negative barium swallow or no swallow study demonstrated clinical aspiration events. Tube feedings were required by 66% (n=41) of the participants. The median time spent on tube feeds, whether in combination with oral feeds or exclusive use of a nasogastric or gastric tube, was 54 days; 44% (n=27) of patients received tube feedings for more than 120 days. Premature infants were significantly more likely to have aspiration events than infants delivered at full gestational age (OR p=0.002). Infants with single-ventricle circulation spent a longer time on tube feeds (median=95 days) than infants with two-ventricle defects (median=44 days); the type of cardiac defect was independent of prevalence of an aspiration event.ConclusionsAspiration is common following neonatal cardiac surgery. The modified barium swallow study is often used to identify aspiration events and to determine an infant’s risk for aspirating. This leads to a high proportion of infants who require tube feedings following neonatal cardiac surgery.

The placement of a nasogastric tube (NGT) in a pediatric patient is a common practice that is generally perceived as a benign bedside procedure. There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient safety, increasing the risk for serious and even fatal complications. There is no standardized method for verification of the initial NGT placement or reverification assessment of NGT location prior to use. Measurement of the acidity or pH of the gastric aspirate is the most frequently used evidence-based method to verify NGT placement. The radiograph, when properly obtained and interpreted, is considered the gold standard to verify NGT location. However, the uncertainty regarding cumulative radiation exposure related to radiographs in pediatric patients is a concern. To minimize risk and improve patient safety, there is a need to identify best practice and to standardize care for initial and ongoing NGT location verification. This article provides consensus recommendations for best practice related to NGT location verification in pediatric patients. These consensus recommendations are not intended as absolute policy statements; instead, they are intended to supplement but not replace professional training and judgment. These consensus recommendations have been approved by the American Society for Parental and Enteral Nutrition (ASPEN) Board of Directors.

Examine the state of the science for pain management in children living in low-middle income countries (LMIC).Significant challenges exist in pain management for children living in LMIC.An integrative review was conducted using PRISMA guidelines for quality of reporting. Literature searches were completed using Medline, PubMed, Scopus, and CINAHL databases for publications between January 2006 and August 2016 using MeSH and primary search terms pain and LMIC. Full text publications were evaluated using GRADE criterion and methodology specific evaluation tools.Of 1510 publications identified, 31 met the criteria for inclusion. Data were categorized into three broad themes: (1) magnitude of the pain problem with subthemes describing the burden of and resources for paediatric pain management; (2) perceptions, experience, and practices for managing pain in children residing in LMIC with subthemes addressing health care providers, parent/caregiver and children, respectively; and (3) pain management practices with pain assessment and treatment strategies as subthemes.Current data on paediatric pain management in LMIC are limited with respect to describing the burden of pain, children's pain perceptions and experiences, and pain management practices. Rigorous investigations are needed to expand knowledge and address the pervasive problem of pain for children in LMIC.

Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.

Growth failure is often observed in infants with congenital heart disease (CHD); it is unclear, however, whether growth failure is due to increased total energy expenditure (TEE). An observational study of infants with CHD and surgical intervention within the first 30 days of life and healthy infants of similar age was undertaken. TEE was measured using the doubly labeled water method in 3-month-old infants (n = 15 CHD, 12 healthy) and 12-month-old infants (n = 11 CHD, 12 healthy). Multiple linear regression models were fit to examine the association between health status (CHD vs. healthy) and TEE. The accuracy of equations for calculating TEE was also determined. TEE for CHD infants was not significantly different from healthy infants at 3 and 12 months; TEE in CHD infants was 36.4 kcal/day higher (95 % CI -46.3, 119.2; p = 0.37) and 31.7 kcal/day higher, (95 % CI -71.5, 134.8; p = 0.53) at 3 and 12 months, respectively, compared to healthy infants. The 2002 Dietary Reference Intake (DRI) equation and the 1989 Recommended Dietary Allowance equation over-estimated measured TEE to a lesser extent than CHD specific equations; the 2002 DRI yielded the smallest mean difference between calculated versus measured TEE (difference 79 kcal/day). During the first year of life, TEE of infants with CHD and interventional surgery within the first month of life was not different than age-matched healthy infants. When calculating TEE of ≤12-month-old infants with CHD who have undergone surgical intervention, the 2002 DRI equation may be used as a starting point for estimating initial clinical energy intake goals.

To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness.For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017.Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment.Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale.Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications.Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.

Contains fulltext : 200437.pdf (Publisher’s version ) (Closed access) OBJECTIVES: The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the association of nutrition status (expressed as body mass index z score) with outcomes in pediatric severe sepsis. DESIGN: Secondary analysis of the Sepsis Prevalence, Outcomes, and Therapies study. Patient characteristics, ICU interventions, and outcomes were compared across nutrition status categories (expressed as age- and sex-adjusted body mass index z scores using World Health Organization standards). Multivariable regression models were developed to determine adjusted differences in all-cause ICU mortality and ICU length of stay by nutrition status. SETTING: One-hundred twenty-eight PICUs across 26 countries. PATIENTS: Children less than 18 years with severe sepsis enrolled in the Sepsis Prevalence, Outcomes, and Therapies study (n = 567). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nutrition status data were available for 417 patients. Severe undernutrition was seen in Europe (25%), Asia (20%), South Africa (17%), and South America (10%), with severe overnutrition seen in Australia/New Zealand (17%) and North America (14%). Severe undernutrition was independently associated with all-cause ICU mortality (adjusted odds ratio, 3.0; 95% CI, 1.2-7.7; p = 0.02), whereas severe overnutrition in survivors was independently associated with longer ICU length of stay (1.6 d; p = 0.01). CONCLUSIONS: There is considerable variation in nutrition status for children with severe sepsis treated across this selected network of PICUs from different geographic regions. Severe undernutrition was independently associated with higher all-cause ICU mortality in children with severe sepsis. Severe overnutrition was independently associated with greater ICU length of stay in childhood survivors of severe sepsis.

Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy.This was a multicenter 1-day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement.Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X-ray (n = 6).The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.

Objective Infants with Congenital Heart Disease (CHD) often exhibit growth failure. This can affect anthropometric and neurodevelopmental outcomes well into childhood. To determine the resting energy expenditure (REE), body composition, and growth in infants with CHD at 3 months of age, with the secondary aim to identify predictors of REE as compared with healthy infants. Design and Methods. This descriptive study is a subanalysis of a prospective study investigating predictors of growth in postoperative infants with CHD compared with healthy infants. Growth measurements, REE, and body composition were obtained in all infants. Analysis included chi-square for association between categorical variables, t-tests, ANOVA and ANCOVA. Outcome measures included the REE as determined by indirect calorimetry, anthropometric z-scores and body composition at 3 months of age. Setting. Participants were recruited from the Cardiac Intensive Care Unit of a large, urban, pediatric cardiac center and pediatric primary care practices. Results. The analysis included 93 infants, 44 (47%) with CHD. Of the infants with CHD, 39% had single ventricle (SV) physiology. There was no difference in REE related to cardiac physiology between infants with CHD and healthy infants or between infants with SV and biventricular (BV) physiology. Anthropometric z-scores for weight (−1.1 ± 1.1, P < 0.001), length (−0.7 ± 1.1, P < 0.05), and head circumference (−0.6 ± 1.2, P < 0.001) were lower in infants with CHD at 3 months of age. The percentage of body fat (%FAT) in postoperative infants with SV (24% ± 6, P = 0.02) and BV (23% ± 5, P < 0.001) physiology were lower than in healthy infants (27% ± 5), with no difference in REE. Conclusion. At 3 months of age, there was no difference in REE between postsurgical infants with CHD and healthy infants. Infants with CHD had lower growth z-scores and %FAT. These data demonstrate decreased %FAT contributed to growth failure in the infants with CHD.

BackgroundAdequate nutritional support is essential for normal infant growth and development. Infants with congenital cardiac disease are known to be at risk for growth failure. We sought to describe perioperative growth in infants undergoing surgical repair of two-ventricle congenital cardiac disease and assess for predictors of their pattern of growth.Materials and methodsFull-term infants who underwent surgical repair of two-ventricle congenital cardiac disease at a single institution were enrolled in a retrospective cohort study performed following a larger prospective study. Infants with facial, gastrointestinal, or neurologic anomalies, trisomy chromosomal abnormality, birth weight less than 2500 grams, or those transferred to another institution before discharge home were excluded. The primary outcome was change in weight-for-age z score from surgery to discharge. Our secondary outcome variable was post-operative hospital length of stay.ResultsA total of 76 infants met the inclusion criteria. Medain age at surgery was 5 days with a range from 1 to 44. The median weight-for-age z score at surgery was −0.2 with a range from −2.9 to 2.8 and by discharge had dropped to −1.2 with a range from −3.4 to 1.8. The median change in weight-for-age z score from surgery to discharge was −1.0 with a range from −2.3 to 0.2. Delayed post-operative nutrition (p < 0.001) and reintubation following initial post-operative extubation (p = 0.001) were associated with decrease in weight-for-age z score.ConclusionsInfants undergoing repair of two-ventricle congenital cardiac disease had poor growth in the post-operative period. This may be mitigated by early initiation of post-operative nutrition.

Aim Examine the state of the science for pain management in children living in low-middle income countries (LMIC). Background Significant challenges exist in pain management for children living in LMIC. Methods An integrative review was conducted using PRISMA guidelines for quality of reporting. Literature searches were completed using Medline, PubMed, Scopus, and CINAHL databases for publications between January 2006 and August 2016 using MeSH and primary search terms pain and LMIC. Full text publications were evaluated using GRADE criterion and methodology specific evaluation tools. Results Of 1510 publications identified, 31 met the criteria for inclusion. Data were categorized into three broad themes: (1) magnitude of the pain problem with subthemes describing the burden of and resources for paediatric pain management; (2) perceptions, experience, and practices for managing pain in children residing in LMIC with subthemes addressing health care providers, parent/caregiver and children, respectively; and (3) pain management practices with pain assessment and treatment strategies as subthemes. Conclusion Current data on paediatric pain management in LMIC are limited with respect to describing the burden of pain, children's pain perceptions and experiences, and pain management practices. Rigorous investigations are needed to expand knowledge and address the pervasive problem of pain for children in LMIC.

BACKGROUND Anthropometric measurements are vital for safe care in pediatric intensive care units. OBJECTIVE To identify barriers to anthropometric measurements and determine if perceptions of barriers differ between ordering providers and nurses. METHODS A 21-item survey to elicit perceptions of barriers to obtaining anthropometric measurements was distributed via e-mail to societies with members who provide care in pediatric intensive care units. RESULTS Most of the 258 eligible respondents (46% ordering providers) were from North America (90%). Although 84% agreed that anthropometric measurements are important, only 3% knew if these measurements were obtained upon admission to their unit. Estimates of patients' measurements by parents or caregivers were commonly used (72%) when actual measurements were not obtained. Leading barriers were presence of medical devices (57%), use of extracorporeal life support (54%), and unstable hemodynamic status (52%). More ordering providers than nurses considered osteopenia/fragile bones as a barrier to weight measurement (46% vs 29%; P = .007) and traumatic brain injury a barrier to measurement of head circumference (42% vs 24%; P = .002). More nurses than ordering providers perceived dialysis (21% vs 9%; P = .01) and obesity (26% vs 15%; P = .04) as barriers to measurement of stature. Ordering providers more than nurses perceived nurses' workload (51% vs 33%; P < .001) and lack of importance (43% vs 20%; P < .001) as barriers. CONCLUSIONS Barriers to obtaining anthropometric measurements exist in pediatric intensive care units; ordering providers and nurses have different perceptions of what constitutes a barrier.

Background: Growth failure is common in infants with congenital heart disease (CHD), however it is unclear if it is due to increased total energy expenditure (TEE). Objectives: To determine if TEE of infants with CHD post-surgical intervention differs from healthy infants, and evaluate the accuracy of equations used to calculate TEE. Design: Infants with CHD and surgical intervention within 30 days of life, and healthy 3- and 12-month old infants, were enrolled. TEE was measured via doubly labeled water at 3-months (n=15 CHD, 12 healthy) and 12-months (n=11 CHD, 12 healthy). Multiple linear regression models were fit to examine the association between health status (CHD vs. healthy) and TEE. Regression/summary statistics were used to assess accuracy of equations for calculating TEE. Results: 3-month TEE did not differ significantly between CHD vs. healthy infants; TEE was 36.4 kcal/day higher for CHD vs. healthy (95% CI: -46.3, 119.2 kcal/day; p=0.37). 12-month TEE was also not significantly different, wi...

Introduction Obtaining anthropometry measurements in critically ill children is challenging. Our objective was to improve the process of obtaining anthropometry measurements in the pediatric intensive care unit (PICU; even if previously obtained) using a dedicated PICU nutrition support team (NST). Methods PICU staff were trained to perform anthropometry measurements through online education, skills training, and just-in-time bedside teaching by the PICU NST. Equipment was upgraded and standardized throughout the PICU along with implementation of preselected orders in the electronic medical record. Data were collected before and immediately after intervention and at monthly intervals from 12 to 36 months to test sustainability of practice change. PICU staff were surveyed on barriers to anthropometry measurements at 36 months after initial intervention. Results Compared with baseline, the intervention resulted in more patients with orders for weight, stature, and head circumference (all P 7 days), compliance improved with measurements of serial weights (P = 0.002), stature (P < 0.001), and head circumference (P = 0.02). Between 12 and 36 months after the intervention, there was a noticeable trend to increases in weight measurements at PICU admission, and to a lesser extent, of stature and head circumference. Competing clinical priorities were a key barrier to anthropometry measurements. Conclusions Performance of anthropometry measurements in the PICU can be improved by a dedicated PICU NST; however, sustaining these improvements is challenging due to competing clinical priorities.

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all health care professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana.HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation.Of 214 HCP trained, 40% resuscitate ≥ 1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p0.01; adult 28% vs. 48%, p0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p0.01) and 6 months (38% vs. 67%, p0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p=0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance.HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.

This study aimed to identify and compare differences in temperament and maternal stress between infants with complex congenital heart disease and healthy controls at 3 months of age.Study sample was drawn from an existing longitudinal study examining growth in infants with congenital heart disease when compared with healthy controls. Infant temperament and parental stress were measured in 129 mother-infant dyads. Inclusion criteria for infants with congenital heart disease wereor = 36-week postmenstrual age,or = 2500 g at birth, surgery in first 6 weeks of life, and no major congenital anomalies or genetic syndromes. The Early Infancy Temperament Questionnaire and Parent Stress Index were the assessment tools used.Infants with single ventricular (SV) physiology were more negative in mood (F = 7.14, p.001) and less distractible (F = 5.00, p.008) than the biventricular physiology or Control (C) infant groups. The demands of care for infants with congenital heart disease were a source of stress when compared with Control infants (p.05). Five of 6 subscales of the Child Domain were significant sources of stress in the SV group compared with biventricle and Control groups. Negative mood and difficulty to soothe were predictors for Child Domain and Total Life Stress in SV infants.The demands of parenting an irritable infant with SV physiology put these mothers at risk for high levels of stress. Results suggest the need for predischarge anticipatory guidance for parents to better understand and respond to the behavioral style of their infants, in particular, infants with SV physiology.

Nursing care provided to patients and their families should be based on strong scientific evidence. In the quantitative research paradigm, the highest level of evidence is derived from conclusive randomized controlled clinical trials. Multicenter clinical research allows the accrual of sufficient numbers of diverse participants in a shorter period of time and improves the generalizability of the study findings. Clinical research is inherently complex; the complexity exponentially increases when conducting multicenter clinical trials. Investigators are challenged to maintain the internal validity of the study and the sustained commitment and collaboration of numerous disciplines over the study period. This article presents 10 essential points to consider when conducting multicenter clinical research.

To assess the association between early anthropometric measurements, device-assisted feeding, and early neurodevelopment in infants with complex congenital heart diseases (CHDs).Bayley Scales of Infant Development II were used to assess cognitive and motor skills in 72 infants with CHD at 6 and 12 months of age. Linear regression models were used to assess the association between mode of feeding and anthropometric measurements with neurodevelopment at 6 and 12 months of age.Of the 72 infants enrolled in the study, 34 (47%) had single-ventricle physiology. The mean Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) scores at 6 months of age were 92 ± 10 and 81 ± 14, respectively. At 12 months of age, the mean MDI and PDI scores were 94 ± 12 and 80 ± 16, respectively. Lower length-for-age z score (P.01) and head circumference-for-age z score (P.05) were independently associated with lower MDI at 6 months, and both increased hospital length of stay (P.01) and lower length-for-age z score (P = .04) were associated independently with lower MDI at 12 months. Device-assisted feeding at 3 months (P = .04) and lower length-for-age z score (P.05) were independently associated with lower PDI at 6 months. Both lower weight-for-age z score (P = .04) and lower length-for-age z score (P = .04) were associated independently with PDI at 12 months.Neonates with complex CHD who required device-assisted feeding and those with lower weight and length and head circumference z scores at 3 months were at risk for neurodevelopmental delay at 6 and 12 months of age.