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ObjectiveTo evaluate the barriers and facilitators to implementing Alberta Family Integrated Care (AB-FICare [2019 Benzies]), a model of care for integrating parents into level II neonatal intensive care units (NICUs) care teams, from the perspective of healthcare providers (HCP) and hospital administrators.DesignQualitative process evaluation substudy.SettingTen level II NICUs in six cities across Alberta, Canada.ParticipantsHCP and hospital administrators (n=32) who were involved in the cluster-randomised controlled trial of AB-FICare in level II NICUs.MethodsPost-implementation semi-structured interviews were conducted via phone or in-person. The Consolidated Framework for Implementation Research was used to develop interview guides, code transcripts and analyse data.ResultsKey facilitators to implementation of AB-FICare included (1) a receptive implementation climate, (2) compatibility of the intervention with individual and organisational practices, (3) available resources and access to knowledge and information for HCP and hospital administrators, (4) engagement of key stakeholders across the organisation, (5) engagement of and outcomes for intervention participants, and (6) reflecting and evaluating on implementation progress and patient and family outcomes. Barriers were (1) design quality and packaging of the intervention, (2) relative priority of AB-FICare in relation to other initiatives, and (3) learning climate within the organisation. Mixed influences on implementation depending on contextual factors were coded to eight constructs: intervention source, cost, peer pressure, external policy and incentives, staff needs and resources, structural characteristics, organisational incentives and rewards, and knowledge, beliefs and attitudes.ConclusionsThe characteristics of an organisation and the implementation process had largely positive influences, which can be leveraged for implementation of AB-FICare in the NICU. We recommend site-specific consultations to mitigate barriers and assess how swing factors might impact implementation given the local context, with the goal that strategies can be put in place to manage their influence on implementation.Trial registration numberNCT02879799.

IntroductionRelatively limited data are available regarding paediatric COVID-19. Although most children appear to have mild or asymptomatic infections, infants and those with comorbidities are at increased risk of experiencing more severe illness and requiring hospitalisation due to COVID-19. The recent but uncommon association of SARS-CoV-2 infection with development of a multisystem inflammatory syndrome has heightened the importance of understanding paediatric SARS-CoV-2 infection.Methods and analysisThe Paediatric Emergency Research Network-COVID-19 cohort study is a rapid, global, prospective cohort study enrolling 12 500 children who are tested for acute SARS-CoV-2 infection. 47 emergency departments across 12 countries on four continents will participate. At enrolment, regardless of SARS-CoV-2 test results, all children will have the same information collected, including clinical, epidemiological, laboratory, imaging and outcome data. Interventions and outcome data will be collected for hospitalised children. For all children, follow-up at 14 and 90 days will collect information on further medical care received, and long-term sequelae, respectively. Statistical models will be designed to identify risk factors for infection and severe outcomes.Ethics and disseminationSites will seek ethical approval locally, and informed consent will be obtained. There is no direct risk or benefit of study participation. Weekly interim analysis will allow for real-time data sharing with regional, national, and international policy makers. Harmonisation and sharing of investigation materials with WHO, will contribute to synergising global efforts for the clinical characterisation of paediatric COVID-19. Our findings will enable the implementation of countermeasures to reduce viral transmission and severe COVID-19 outcomes in children.Trial registration numberNCT04330261.

Objectives: To compare complications in neonates who had umbilical venous catheter (UVC) versus peripherally inserted central catheter (PICC), percentage of non-elective removal of central catheters, and to compare complications of PICC in the upper limb compared with the lower limb., Design: A prospective cross-sectional cohort study., Setting: Neonatal intensive care unit (NICU) in Prince Sultan Military Medical City in Riyadh, Saudi Arabia., Participants: All infants who are admitted to the unit requiring central catheter insertion were included in the study., Primary Outcome Measure: Complications of central catheters in infants admitted to the NICU., Results: A total of 415 central catheters were involved in this study (206 UVCs and 209 PICCs (85 in the lower limb, 99 in the upper limb and 25 in the head and neck). The median birth weight of the neonates was 1470 grams (1000-2215). Low birth weight was the most common reason for central catheter insertion, which accounted for 59.8%. Neonatologists were the main insertor for the majority of the cases. The median dwell days for the study sample were 11.00 (7.00-16.50) days. Complications were more common across PICC cases compared with UVC cases (p=0.001). There was non-elective removal of PICC (32.1%) compared with UVC (22.8%) (p=0.035). Phlebitis, occlusion, local infiltrate and leakage were more common in PICC compared with UVC (p<0.05). However, malposition was more commonly associated with the use of UVC (mainly to the liver) (p<0.01). Central line-associated bloodstream infection (CLABSI) rate in 1000.00 dwell days was higher in the upper limb 4.6 compared with the lower limb 2.72 but was not statistically significant (p=0.63), and there was no statistically significant difference in the proportion of other complications between the upper limb and the lower limb (p>0.05)., Conclusion: Close monitoring during extended dwell times is crucial. Our findings underscore the importance of raising awareness of CLABSI risk factors and adhering to best practices for central catheter maintenance. Healthcare professionals should be vigilant about the differences in complication rates between PICC and UVC, tailoring their approach accordingly., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to assess fathers' knowledge of neonatal danger signs and their associated factors in Northwest Ethiopia., Design: Community-based cross-sectional study., Setting: Enarji and Enawga Woreda, Northwest Ethiopia., Participants: The study was conducted on 613 participants in Enarji and Enawga Woreda from 13 May to 13 June 2022. Participants were selected using stratified simple random sampling. Participants with serious illnesses who were unable to respond to the questions were excluded from the study. A total of 602 participants completed the questionnaire. Data were collected through face-to-face interviews conducted by four well-trained data collectors. To assess participants' knowledge, 10 structured and standardised questions were adopted from WHO and the Ethiopian Federal Ministry of Health. The data were analysed using SPSS V.26. A logistic regression model was fitted to identify factors associated with knowledge about neonatal danger signs. An adjusted OR (AOR) with a 95% CI and a p value <0.05 was used to declare factors as significantly associated., Result: Less than a quarter (23.26%) of fathers had good knowledge of neonatal danger signs (95% CI 19.9, 26.8). The study also found that several factors were significant predictors of good knowledge, including: secondary education (AOR 2.98, 95% CI 1.08, 8.24), college education or higher (AOR 3.45, 95% CI 1.09, 10.85), number of children (AOR 3.68, 95% CI 1.62, 8.34), history of sickness in the index baby (AOR 2.18, 95% CI 1.18, 4.01), fathers' attendance on postnatal care visits (AOR 4.32, 95% CI 2.06, 9.08), history of neonatal death (AOR 3.94, 95% CI 1.80, 8.64), receiving information on neonatal danger signs (AOR 2.71, 95% CI 1.30, 5.64) and health professionals as a source of information (AOR 3.27, 95% CI 1.52, 7.04). These factors were all significantly associated with good knowledge of neonatal danger signs., Conclusion: Fathers' knowledge of neonatal danger signs was found to be low. Therefore, substantial efforts are needed to enhance their knowledge. It is essential to develop strategies that actively involve fathers in the continuum of postnatal care for both mothers and newborns. Additionally, providing targeted information on neonatal danger signs through health professionals can significantly improve fathers' knowledge., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Identifying high-risk paediatric patients with a poor prognosis and providing timely and adequate treatment are critical. This study aimed to evaluate the effects of different types of cardiac enzyme spectrum within 24 hours of admission on the short-term prognosis of patients in paediatric intensive care units., Design: A retrospective study., Setting: A single-centre, tertiary care hospital in China, with patient data from 2010 to 2018., Participants: A total of 4343 critically ill children were enrolled., Intervention: None., Primary and Secondary Outcome Measures: The main outcome measure was in-hospital mortality, which was defined as death from any cause during hospitalisation. The secondary outcome was 30-day mortality, intensive care unit (ICU) length of stay (LOS) and total LOS., Results: Using the local polynomial regression fitting method, an approximately linear increase in in-hospital mortality was detected for creatine kinase (CK), creatine kinase MB (CK-MB), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH). Among the different types of cardiac enzyme spectrum, LDH had the highest area under the curve value (0.729), followed by AST (0.701), CK-MB (0.613) and CK (0.557). The Kaplan‒Meier analysis showed that the patients in the high LDH group had higher 30-day mortality. The multivariate logistic regression revealed that high LDH was independently associated with in-hospital mortality (OR 2.45, 95% CI 1.84 to 3.24). After propensity score matching (PSM) and sensitivity analysis, the results remained consistent., Conclusions: LDH is a reliable outcome predictor in critically ill children, including those with various comorbidities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

ObjectivesPneumonia is the largest infectious cause of death in children under 5 years globally, and limited resource settings bear an overwhelming proportion of this disease burden. Bubble continuous positive airway pressure (bCPAP), an accepted supportive therapy, is often thought of as cost-prohibitive in these settings. We hypothesise that bCPAP is a cost-effective intervention in a limited resource setting and this study aims to determine the cost-effectiveness of bCPAP, using Malawi as an example.DesignCost-effectiveness analysis.SettingDistrict and central hospitals in Malawi.ParticipantsChildren aged 1 month-5 years with severe pneumonia, as defined by WHO criteria.InterventionsUsing a decision tree analysis, we compared standard of care (including low-flow oxygen and antibiotics) to standard of care plus bCPAP.Primary and secondary outcome measuresFor each treatment arm, we determined the costs, clinical outcomes and averted disability-adjusted life years (DALYs). We assigned input values from a review of the literature, including applicable clinical trials, and calculated an incremental cost-effectiveness ratio (ICER).ResultsIn the base case analysis, the cost of bCPAP per patient was $15 per day and $41 per hospitalisation, with an incremental net cost of $64 per pneumonia episode. bCPAP averts 5.0 DALYs per child treated, with an ICER of $12.88 per DALY averted compared with standard of care. In one-way sensitivity analyses, the most influential uncertainties were case fatality rates (ICER range $9-32 per DALY averted). In a multi-way sensitivity analysis, the median ICER was $12.97 per DALY averted (90% CI, $12.77 to $12.99).ConclusionbCPAP is a cost-effective intervention for severe paediatric pneumonia in Malawi. These results may be used to inform policy decisions, including support for widespread use of bCPAP in similar settings.

Introduction: Surgical repair is the standard of care for most infants and children with congenital heart disease. Cardiopulmonary bypass (CPB) is required to facilitate these operations but elicits a systemic inflammatory response, leading to postoperative organ dysfunction, morbidity and prolonged recovery after the surgery. Subzero-balance ultrafiltration (SBUF) has been shown to extract proinflammatory cytokines continuously throughout the CPB exposure. We hypothesize that a high-exchange SBUF (H-SBUF) will have a clinically relevant anti-inflammatory effect compared with a low-exchange SBUF (L-SBUF)., Methods and Analysis: The ULTrafiltration to enhance Recovery After paediatric cardiac surgery (ULTRA) trial is a randomised, double-blind, parallel-group randomised trial conducted in a single paediatric cardiac surgery centre. Ninety-six patients less than 15 kg undergoing cardiac surgery with CPB will be randomly assigned to H-SBUF during CPB or L-SBUF during CPB in a 1:1 ratio with stratification by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) score 1 and STAT score 2-5. The primary outcome is peak postoperative vasoactive-ventilation-renal score. Time series and peak values of vasoactive-ventilation renal score, vasoactive-inotrope score, ventilation index and oxygenation index will be collected. Secondary clinical outcomes include acute kidney injury, ventilator-free days, inotrope-free days, low cardiac output syndrome, mechanical circulatory support, intensive care unit length of stay and operative mortality. Secondary biomarker data include cytokine, chemokine and complement factor concentrations at baseline before CPB, at the end of CPB exposure and 24 hours following CPB. Analyses will be conducted on an intention-to-treat principle., Ethics and Dissemination: The study has ethics approval (#1024932 dated August 31, 2021) and enrolment commenced in September 2021. The primary manuscript and any subsequent analyses will be submitted for peer-reviewed publication., Trial Registration Number: NCT04920643., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Understanding the epidemiological patterns of febrile infants can offer valuable insights for optimising management strategies and developing quality improvement initiatives, aiming to improve healthcare delivery in high-volume, low-resource emergency departments (EDs)., Objectives: To characterise the epidemiology of febrile infants presenting to the paediatric ED of a tertiary care hospital., Methods: A retrospective chart review of medical records was performed for febrile infants ≤1 year old, at paediatric ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan (1 January 2020-31 December 2020)., Results: There were a total of 2311 patients in the study, with a male-to-female ratio of 1.4:1. The mean age of presentation was 4.9±2.7 months. Cough (n=1002, 43.2%) was the most frequent presenting symptom. The most common provisional ED diagnosis in ≤1 month of age was sepsis (n=98, 51%), bronchopneumonia (n=138, 28.6%) in 1.1-3 and 3.1-6 months (n=176, 36.45%); and upper respiratory tract illness (n=206, 47.4%) in 6.1-12 months of age. Age was significantly associated with provisional ED diagnosis and outcomes (p<0.001). Of 175 ED admissions (n=47, 26.8%), patients were discharged with a hospital diagnosis of bronchopneumonia and (n=27, 15.4) of sepsis. The infant mortality rate was 3/1000 live births., Conclusions: This study is the first of its kind to explore the epidemiology of febrile infants in Pakistan, highlighting the burden and severity of respiratory illnesses and sepsis. It underscores the challenges of resource-limited settings, failing to meet the need for admission of febrile infants presenting to ED, IHHN. Moreover, it has highlighted the necessity to optimise the existing triage systems to effectively allocate resources and manage high patient volumes in low-resource EDs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Febrile convulsion (FC) among children is a common emergency concern received in hospitals and clinics. However, in Ghana, FC is commonly perceived as a non-hospital disease and usually managed at home. There is limited research on the home management of FC. This study, therefore, explored the home management of FC., Methods: The study design was a descriptive and interpretive phenomenology. Data sources were triangulated among 42 participants across 5 communities within 2 km distance from regional hospitals in the Cape Coast Metropolis. Participants were purposively selected and interviewed face to face in their homes and treatment centres using semistructured interview guides. Interviews were transcribed and thematically analysed with QSR NVivo V.14., Results: Three themes were identified from the inductive analysis. These themes were treatment, prevention and case referral. Subthemes on treatment were tepid sponging with lukewarm water, the use of herbal medicine and spiritual approaches. FC was referred to as 'asram suro'. The 'asram' literally means the moon, and 'suro' connotes the skies, indicating possibly that the condition emanates from a god of the moon. Caregivers prevented FC through behavioural approaches, herbal medicine, and mystical approaches including making scarification and tying amulets and beads particularly on the child's face and wrists respectively. FC cases were referred for clinical attention after home care resulted in undesirable treatment outcomes. A conceptual framework depicting the decision-making and practices towards FC management is presented., Conclusion: FC is commonly managed at home independent of orthodox care availability. Caregivers employed herbal and ad hoc treatment regimens, usually unwarranted, visually frightening and spiritual approaches which were not the best home management approaches. These findings call for the need to educate caregivers about the best home management of FC., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: It is well evidenced that healthcare professionals working in paediatric critical care experience high levels of burn-out, compassion fatigue and moral distress. This worsened during the COVID-19 pandemic. This work examines the nature of challenges to workplace well-being and explores what well-being means to staff. This evidence will inform the development of staff interventions to improve and maintain staff well-being., Design: Qualitative study., Setting: Paediatric critical care units in the UK., Participants: 30 nurses and allied health professionals took part in online interviews and were asked about well-being and challenges to well-being. Lived experiences of well-being were analysed using interpretative phenomenological analysis., Results: Themes generated were as follows: perception of self and identity; relationships and team morale; importance of control and balance and consequences of COVID-19. They focused on the impact of poor well-being on participants' sense of self; the significance of how or whether they feel able to relate well with their team and senior colleagues; the challenges associated with switching off, feeling unable to separate work from home life and the idealised goal of being able to do just that; and lessons learnt from working through the pandemic, in particular associated with redeployment to adult intensive care., Conclusions: Our findings align closely with the self-determination theory which stipulates autonomy, belonging and competence are required for well-being. Participants' accounts supported existing literature demonstrating the importance of empowering individuals to become self-aware, to be skilled in self-reflection and to be proactive in managing one's own well-being. Change at the individual and staff group level may be possible with relatively low-intensity intervention, but significant change requires systemic shifts towards the genuine prioritisation of staff well-being as a prerequisite for high-quality patient care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: In children, respiratory distress due to upper airway obstruction (UAO) is a common complication of extubation. The quantitative cuff-leak test (qtCLT) is a simple, rapid and non-invasive test that has not been extensively studied in children. The objective of the ongoing study whose protocol is reported here is to investigate how well the qtCLT predicts UAO-related postextubation respiratory distress in paediatric intensive care unit (PICU) patients., Methods and Analysis: Air Leak Test in the Paediatric Intensive Care Unit is a multicentre, prospective, observational study that will recruit 900 patients who are aged 2 days post-term to 17 years and ventilated through a cuffed endotracheal tube for at least 24 hours in any of 19 French PICUs. Within an hour of planned extubation, the qtCLT will be performed as a sequence of six measurements of the tidal volume with the cuff inflated then deflated. The primary outcome is the occurrence within 48 hours after extubation of severe UAO defined as combining a requirement for intravenous corticosteroid therapy and/or ventilator support by high-flow nasal cannula and/or by non-invasive ventilation or repeat invasive mechanical ventilation with a Westley score ≥4 with at least one point for stridor at each initiation. The results of the study are expected to identify risk factors for UAO-related postextubation respiratory distress and extubation failure, thereby identifying patient subgroups most likely to require preventive interventions. It will also determine whether qtCLT appears to be a reliable method to predict an increased risk for postextubation adverse events as severe UAO., Ethics and Dissemination: The study was approved by the Robert Debré University Hospital institutional review board (IRB) on September 2021 (approval #2021578). The report of Robert Debré University Hospital IRB is valid for all sites, given the nature of the study with respect to the French law. The results will be submitted for publication in a peer-reviewed journal., Trial Registration Number: NCT05328206., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In trials of acute severe infections or inflammations frequent administration of non-randomised treatment (ie, intercurrent event) in response to clinical events is expected. These events may affect the interpretation of trial findings. Swissped-RECOVERY was set up as one of the first randomised controlled trials worldwide, investigating the comparative effectiveness of anti-inflammatory treatment with intravenous methylprednisolone or intravenous immunoglobulins in children and adolescents with Paediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS). We present one approach towards improving the interpretation of non-randomised treatment in a randomised controlled trial., Design: This is a pre-planned ancillary analysis of the Swissped-RECOVERY trial, a randomised multicentre open-label two-arm trial., Setting: 10 Swiss paediatric hospitals (secondary and tertiary care) participated., Participants: Paediatric patients hospitalised with PIMS-TS., Interventions: All patient-first intercurrent events, if applicable, were presented to an independent adjudication committee consisting of four international paediatric COVID-19 experts to provide independent clinical adjudication to a set of standardised questions relating to whether additional non-randomised treatments were clinically indicated and disease classification at the time of the intercurrent event., Results: Of 41 treatments in 75 participants (24/41 (59%) and 17/41 (41%) in the intravenous methylprednisolone and immunoglobulin arms of the trial, respectively), two-thirds were considered indicated. The most common treatment (oral glucocorticoids, 14/41, 35%) was mostly considered not indicated (11/14, 79%), although in line with local guidelines. Intercurrent events among patients with Shock-like PIMS-TS at baseline were mostly considered indicated. A significant proportion of patients with undifferentiated PIMS-TS at baseline were not attributed to the same group at the time of the intercurrent event (6/12 unchanged, 4/12 Kawasaki disease-like, 2/12 Shock-like)., Conclusion: The masked adjudication of intercurrent events contributes to the interpretation of results in open-label trials and should be incorporated in the future., Trial Registration Numbers: SNCTP000004720 and NCT04826588., Competing Interests: Competing interests: JAB received grant support paid to the institution from the European and Developing Countries Clinical Trials Partnership (PediCaP, RIA2017MC-2023), Horizon 2020 (NeoIPC, grant 965328), the Swiss National Science Foundation (KIDS-STEP, grant 173532), National Institute for Health Research (CAP-IT, project 13/88/11), Innosuisse (SPEARHEAD flagship grant), the Swiss Personalised Health Network (Secretariat for Education Research and Innovation) (SwissPedHealth, award NDS-2021-911), in the past 36 months; consulting fees paid to the institution from Shionogi, Sandoz, Basilea, and GSK; payments to the institution for presentations, lectures, speakers bureaus, manuscript writing or educational events in the past 36 months from Pfizer, Sandoz and Bayer; participated at independent data monitoring committee boards of Avenir trial (member, expenses), Lakana trial (member, unfunded), CURLY trial (Chair, unfunded) in the past 36 months; is the vice president of the SwissPedNet (unpaid) and leadership of Severe Bacterial Infection and Antimicrobial Resistance working group of the Penta Foundation (unpaid). TW gave presentations for Novartis (payment to the institution) in the past 36 months. AB had received fixed-term consultancy fees from Gilead. KW is supported by the Crick African Network (CAN). The CAN receives its funding from the UK’s Global Challenges Research Fund (MR/P028071/1), the Francis Crick Institute which receives its core funding from Cancer Research UK (FC1001647), the UK Medical Research Council (FC1001647) and the Wellcome Trust (FC1001647). KW is also supported by the South African Medical Research Council with funds received from the National Treasury. PR received grant support from ViiV and consulting fees from MSD. AT received grant support paid to the institution/UCSD from the National Institute of Health and consulted Janssen Pharmaceuticals and Kiniksa with no payment received. All other authors declared no conflicts of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Prematurity presents a significant challenge to the global community due to the rapid increase in its incidence and its disproportionate contribution to increased infant mortality rates., Objective: To assess the survival status and predictors of mortality among preterm neonates., Design: A multicentre prospective follow-up study was used., Setting: 625 preterm neonates were admitted to hospitals for secondary level of care. The study covers the Bench Maji Zone, Keffa Zone, Sheka Zone, nearby woredas and portions of the Gambella area in Southwest Ethiopia., Participants: 614 preterm neonates with gestational age less than 37 weeks were entered for follow-up and 400 neonates were censored. Neonates with severe fetal malformations and neonates who need urgent referral were excluded from the study., Results: Overall, 200 (32.57%) participants died with an incidence rate of 61.69 deaths per 1000 person-day observations (95% CI: 53.71 to 70.86). Poor kangaroo mother care (KMC) services (adjusted HR (AHR)=0.19, 95% CI: 0.12 to 0.29), sex (AHR=0.66, 95%, CI: 0.47 to 0.94), not initiating breast feeding (HR=2.78, 95% CI: 1.8 to 4.28), hypothermia (AHR=0.63, 95% CI: 0.44 to 0.92), anaemia (AHR=6.2, 95% CI: 2.34 to 16.43) and gestational age less than 28 weeks (AHR=9.28, 95% CI: 1.78 to 48.42) were independent predictors., Conclusion and Recommendation: The rate of preterm neonatal mortality was high compared with the Ethiopia Demographic and Health Survey report nationally. Healthcare workers should encourage KMC services and breastfeeding initiation and prevent preterm neonates from being anaemic to increase their chances of survival., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To evaluate the knowledge, attitudes and practices towards diagnosing and managing paediatric sepsis among paediatric physicians and nurses., Design: A cross-sectional, questionnaire-based study., Setting: 21 hospitals in Hubei Province between February 2023 and March 2023., Participants: Paediatric physicians and nurses., Interventions: None., Primary and Secondary Outcome Measures: The questionnaire contained 35 items across four dimensions (demographic information, knowledge, attitude and practice)., Results: The study included 295 participants (173 women). The average knowledge, attitude and practice scores were 10.93±2.61 points (possible range, 0-20 points), 32.22±2.65 points (possible range, 7-35 points) and 36.54±5.24 points (possible range, 9-45 points), respectively. Knowledge had a direct influence on both attitude (β=0.240, 95% CI 0.136 to 0.365, p=0.009) and practice (β=0.278, 95% CI 0.084 to 0.513, p=0.010), which also indirectly influenced practice through attitude (β=0.162, 95% CI 0.078 to 0.290, p=0.007). Attitude directly influenced practice (β=0.677, 95% CI 0.384 to 0.902, p=0.025). A higher attitude score was associated with good practice (OR=1.392; 95% CI 1.231 to 1.576; p<0.001), while not working in a tertiary hospital reduced the odds of good practice (OR=0.443; 95% CI 0.2390.821; p=0.010)., Conclusions: The knowledge regarding paediatric sepsis, especially knowledge about sepsis management, is poor among paediatric physicians and nurses in Hubei Province. The findings of this study may facilitate the development and implementation of training programmes to improve the diagnosis and management of paediatric sepsis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: As paediatric intensive care unit (PICU) mortality declines, there is growing recognition of the morbidity experienced by children surviving critical illness and their families. A comprehensive understanding of the adverse physical, cognitive, emotional and social sequelae common to PICU survivors is limited, however, and the trajectory of recovery and risk factors for morbidity remain unknown., Methods and Analysis: The Post-Intensive Care Syndrome - paediatrics Longitudinal Cohort Study will evaluate child and family outcomes over 2 years following PICU discharge and identify child and clinical factors associated with impaired outcomes. We will enrol 750 children from 30 US PICUs during their first PICU hospitalisation, including 500 case participants experiencing ≥3 days of intensive care that include critical care therapies (eg, mechanical ventilation, vasoactive infusions) and 250 age-matched, sex-matched and medical complexity-matched control participants experiencing a single night in the PICU with no intensive care therapies. Children, parents and siblings will complete surveys about health-related quality of life, physical function, cognitive status, emotional health and peer and family relationships at multiple time points from baseline recall through 2 years post-PICU discharge. We will compare outcomes and recovery trajectories of case participants to control participants, identify risk factors associated with poor outcomes and determine the emotional and social health consequences of paediatric critical illness on parents and siblings., Ethics and Dissemination: This study has received ethical approval from the University of Pennsylvania Institutional Review Board (protocol #843844). Our overall objective is to characterise the ongoing impact of paediatric critical illness to guide development of interventions that optimise outcomes among children surviving critical illness and their families. Findings will be presented at key disciplinary meetings and in peer-reviewed publications at fixed data points. Published manuscripts will be added to our public study website to ensure findings are available to families, clinicians and researchers., Trials Registration Number: NCT04967365., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In critically ill children, pain management is complex owing to cognitive development and the nature of hospitalisation in paediatric intensive therapy units. Although there are many protocols and guidelines for pain control via pharmacological interventions, non-pharmacological practices should also be explored and disseminated for their potential benefit., Methods and Analysis: A systematic literature search will be performed using the following databases: Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica Database, Virtual Health Library, Medical Literature Analysis and Retrieval System Online, ScienceDirect, Scopus, Web of Science Core Collection, Theses from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior , Dart Europe, Open Access Theses and Dissertations and grey literature from Google Scholar. The research will consider quantitative and qualitative studies, mixed-method studies, systematic reviews, text articles, opinion articles, letters to editors and editorials in any language and from any database. The following will be eligible for inclusion: (1) newborns, infants, children and adolescents; and (2) non-pharmacological therapies used for pain in paediatric intensive care., Ethics and Dissemination: This study does not require ethical approval. The results of this research will be disseminated through social media channels and podcasts about pain in children., Trial Registration Number: This protocol has been registered with the Open Science Framework (DOI 10.17605/OSF.IO/DZHKT)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support., Methods and Analysis: This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management., Ethics and Dissemination: Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Antimicrobial resistance (AMR) is a major global health problem. Efforts to mitigate AMR prioritise antimicrobial stewardship (AMS) interventions. These interventions typically focus on deficiencies in practice and providing negative or normative feedback. This approach may miss opportunities to learn from success. We aimed to identify factors that enable success in AMS practices in the paediatric intensive care unit (PICU) by analysing the data obtained from interviews with staff members who had achieved success in AMS., Design: Qualitative study design using thematic analysis of appreciative inquiry interviews with healthcare staff., Setting: 31-bedded PICU in the UK between January 2017 and January 2018., Participants: 71 staff who had achieved success in AMS in the PICU., Results: Six themes were identified: (1) cultural factors including psychological safety, leadership and positive attitude are important enablers for delivering good clinical care; (2) ergonomic design of the physical environment and ready availability of tools and resources are key elements to support good practice and decision-making; (3) expertise and support from members of the multidisciplinary team contribute to good care delivery; (4) clarity of verbal and written communication is important for sharing mental models and aims of care within the clinical team; (5) a range of intrinsic factors influences the performance of individual HCPs, including organisation skill, fear of failure, response to positive reinforcement and empathetic considerations towards peers; (6) good clinical care is underpinned by a sound domain knowledge, which can be acquired through training, mentorship and experience., Conclusion: The insights gained in this study originate from frontline staff who were interviewed about successful work-as-done. This strengths-based approach is an understudied area of healthcare, and therefore offers authentic intelligence which may be leveraged to effect tangible improvement changes. The methodology is not limited to AMS and could be applied to a wide range of healthcare settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to determine the time to death and predictors of mortality among asphyxiated neonates admitted to public hospitals in the southwest region of Ethiopia., Design: An institution-based prospective cohort study was conducted., Setting: Public hospitals in southwest Ethiopia., Participants: A total of 144 asphyxiated neonates, who were admitted to the neonatal intensive care unit, and their mothers participated from March 2022 to 30 September 2022. Data were entered into EpiData V.4.4.2.1 and exported to STATA V.16 for analysis. The Cox proportional hazards model using bivariate (p<0.25) and multivariate (p<0.05) analyses was used to identify the predictors of mortality. The median survival time was estimated using Kaplan-Meier survival estimates., Primary Outcome: Time to death from asphyxia and its predictors in neonates., Results: The mortality incidence rate of asphyxiated neonates was 9.1 deaths per 1000 person-days of observation (95% CI: 7.11 to 11.52) with a median survival time of 8 days, and 45.83% (95% CI: 37.81% to 54.08%) of asphyxiated neonates died. Being male (adjusted HR (AHR) 0.32 (95% CI: 0.14 to 0.76)), neonatal sepsis (AHR 0.321 (95% CI: 0.13 to 0.77)), not receiving kangaroo mother care (AHR 0.16 (95% CI: 0. 07 to 0.39)) and vaginal delivery (AHR 0.39 (95% CI: 0.16 to 0.95)) were independent predictors of mortality of asphyxiated neonates., Conclusions: In this study, asphyxiated neonates had a higher incidence of mortality with a median survival time of only 8 days. Being male, vaginal delivery, not receiving kangaroo mother care and comorbidities such as neonatal sepsis were independent predictors of mortality among asphyxiated neonates. Therefore, healthcare providers and other stakeholders should provide timely initiation of advanced diagnosis and appropriate therapeutic interventions for neonates with asphyxia to reduce neonatal mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The Bronchiolitis Endotracheal Surfactant Study (BESS) is a randomised controlled trial to determine the efficacy of endo-tracheal surfactant therapy for critically ill infants with bronchiolitis. To explore acceptability of BESS, including approach to consent within a limited time frame, we explored parent and staff experiences of trial involvement in the first two bronchiolitis seasons to inform subsequent trial conduct., Design: A mixed-method embedded study involving a site staff survey, questionnaires and interviews with parents approached about BESS., Setting: Fourteen UK paediatric intensive care units., Participants: Of the 179 parents of children approached to take part in BESS, 75 parents (of 69 children) took part in the embedded study. Of these, 55/69 (78%) completed a questionnaire, and 15/69 (21%) were interviewed. Thirty-eight staff completed a questionnaire., Results: Parents and staff found the trial acceptable. All constructs of the Adapted Theoretical Framework of Acceptability were met. Parents viewed surfactant as being low risk and hoped their child's participation would help others in the future. Although parents supported research without prior consent in studies of time critical interventions, they believed there was sufficient time to consider this trial. Parents recommended that prospective informed consent should continue to be sought for BESS. Many felt that the time between the consent process and intervention being administered took too long and should be 'streamlined' to avoid delays in administration of trial interventions. Staff described how the training and trial processes worked well, yet patients were missed due to lack of staff to deliver the intervention, particularly at weekends., Conclusion: Parents and staff supported BESS trial and highlighted aspects of the protocol, which should be refined, including a streamlined informed consent process. Findings will be useful to inform proportionate approaches to consent in future paediatric trials where there is a short timeframe for consent discussions., Trial Registration Number: ISRCTN11746266., Competing Interests: Competing interests: MGS: Independent external and non-remunerated member of Pfizer’s External Data Monitoring Committee for their mRNA vaccine program(s); HMG UK Scientific Advisory Group for Emergencies (SAGE), COVID-19 Response, Non-remunerated independent member March 2020 to March 2022. HMG UK New Emerging Respiratory Virus Threats Advisory Group (NERVTAG), Non-remunerated independent member since 2014; Integrum Scientific LLC, Greensboro, NC, USA, Chair of Infectious Disease Scientific Advisory Board; MedEx Solutions Ltd, Director; Integrum Scientific LLC, Greensboro, NC, USA, Minority Owner: MedEx Solutions Ltd, Majority Owner., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Extracorporeal membrane oxygenation (ECMO) is an intervention used in critically ill patients with severe cardiopulmonary failure that is expensive and resource intensive and requires specialised care. There remains a significant practice variation in its application. This systematic review will assess the evidence for key performance indicators (KPIs) in ECMO., Methods and Analysis: We will search Ovid MEDLINE, Ovid EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and databases from the National Information Center of Health Services Research and Health Care Technology, for studies involving KPIs in ECMO. We will rate methodological quality using the Newcastle-Ottawa Quality Assessment Scale. Randomized controlled trials (RCTs) will be evaluated with the Cochrane Risk of Bias tool, and qualitative studies will be evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN checklist). Grey literature sources will be searched for technical reports, practice guidelines and conference proceedings. We will identify relevant organisations, industry leaders and non-profit organisations that represent key opinion leads in the use of ECMO. We will search the Agency of Healthcare Research and Quality National Quality Measures Clearinghouse for ECMO-related KPIs. Studies will be included if they contain quality measures that occur in critically ill patients and are associated with ECMO. The analysis will be primarily descriptive. Each KPI will be evaluated for importance, scientific acceptability, utility and feasibility using the four criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, KPIs will be evaluated for their potential operational characteristics, their potential to be integrated into electronic medical records and their affordability, if applicable., Ethics and Dissemination: Ethical approval is not required as no primary data will be collected. Findings will be published in a peer-reviewed journal and presented at academic., Prospero Registration Number: 9 August 2022. CRD42022349910., Competing Interests: Competing interests: EF has consulted and received honoraria from ALung Technologies, Baxter, Inspira, Vasomune, Aerogen and GE Healthcare., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Intravenous fluid therapy is the most common intervention in critically ill children. There is an increasing body of evidence questioning the safety of high-volume intravenous fluid administration in these patients. To date, the optimal fluid management strategy remains unclear. We aimed to test the feasibility of a pragmatic randomised controlled trial comparing a restrictive with a standard (liberal) fluid management strategy in critically ill children., Methods and Analysis: Multicentre, binational pilot, randomised, controlled, open-label, pragmatic trial. Patients <18 years admitted to paediatric intensive care unit and mechanically ventilated at the time of screening are eligible. Patients with tumour lysis syndrome, diabetic ketoacidosis or postorgan transplant are excluded., Interventions: 1:1 random assignment of 154 individual patients into two groups-restrictive versus standard, liberal, fluid strategy-stratified by primary diagnosis (cardiac/non-cardiac). The intervention consists of a restrictive fluid bundle, including lower maintenance fluid allowance, limiting fluid boluses, reducing volumes of drug delivery and initiating diuretics or peritoneal dialysis earlier. The intervention is applied for 48 hours postrandomisation or until discharge (whichever is earlier)., Endpoints: The number of patients recruited per month and proportion of recruited to eligible patients are feasibility endpoints. New-onset acute kidney injury and the incidence of clinically relevant central venous thrombosis are safety endpoints. Fluid balance at 48 hours after randomisation is the efficacy endpoint. Survival free of paediatric intensive care censored at 28 days is the clinical endpoint., Ethics and Dissemination: Ethics approval was gained from the Children's Health Queensland Human Research Ethics Committee (HREC/21/QCHQ/77514, date: 1 September 2021), and University of Zurich (2021-02447, date: 17 March 2023). The trial is registered with the Australia New Zealand Clinical Trials Registry (ACTRN12621001311842). Open-access publication in high impact peer-reviewed journals will be sought. Modern information dissemination strategies will also be used including social media to disseminate the outcomes of the study., Trial Registration Number: ACTRN12621001311842., Protocol Version/date: V5/23 May 2023., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Paediatric intensive care units (PICUs) survivors and their families often experience widespread morbidity and psychosocial consequences after discharge, known as post-intensive care syndrome in paediatrics (PICS-p). In Switzerland, more than 5000 children are admitted to PICUs each year, and despite the high survival rate, there are no data on post-PICU recovery. This study aims to investigate PICS in children and families and identify its associated factors., Methods and Analysis: This is a national, multicentre, longitudinal, observational study that includes PICU survivors, main family caregivers and siblings (n=1300) recruited from the eight Swiss accredited PICUs with follow-up at discharge, 1, 3 and 6 months after discharge from the PICU. Data will be collected on the domains of physical, emotional, social and cognitive health, as well as factors affecting the outcome related to demographics, clinical specification, PICU and family environment, as well as community and social resources. Structural equation models and growth mixture models will analyse the outcomes, and the heterogeneity of recovery that shed light on the diverse recovery experiences of children and their families. The study identifies risk and protective factors with a focus on the influence of social and familial resources. It will also explore the mutual impact of the child's recovery and parent/sibling psychosocial health., Ethics and Dissemination: The protocol is approved by the CER-VD ethics committee. Participants will be provided with verbal and written explanations of the study, and their privacy and anonymity will be protected throughout the process. The results will be presented at local and international conferences., Approval Number: Swiss ethics committees ID: 2022-02128, representing the eight cantons for both French and German-speaking parts of Switzerland., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to explore paediatric hospitalisation related to medication administration errors (MAEs) of non-opioid analgesics, antipyretics and antirheumatics in England and Wales., Design: An ecological study., Setting: A population-based study on hospitalised patients in England and Wales. Hospital admission data were extracted from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales for the period between April 1999 and April 2020. Admissions cause was confirmed using the diagnostic codes T39.0-T39.9., Participants: Paediatric patients aged 15 years and below who were hospitalised at all National Health Service (NHS) trusts and any independent sector funded by NHS trusts., Primary Outcome Measure: Hospitalisation rates related to MAEs of non-opioid analgesics, antipyretics and antirheumatics., Results: The yearly number of admissions for MAEs associated with non-opioid analgesics, antipyretics and antirheumatics experienced a notable growth of 21.7% over the span of two decades, rising from 4574 cases in 1999 to 5568 cases in 2020. The observed increase demonstrates a significant upward trend in hospital admissions rate, with a 12.3% growth from 46.16 per 100 000 individuals in 1999 to 51.83 per 100 000 individuals in 2020 (95% CIs 44.83 to 47.50 and 50.47 to53.19, respectively, trend test, p<0.05). The therapeutic categories that exhibited the highest frequency of MAEs were '4-aminophenol derivatives' and 'other non-steroidal anti-inflammatory drugs', accounting for 79.3% and 16.0% of cases, respectively. It is worth noting that there was a significant increase of 28.9% in hospitalisations linked to MAEs specifically associated with '4-aminophenol derivatives.', Conclusion: The research revealed a notable rise in the overall yearly number of hospital admissions associated with MAEs within the paediatric population. This study emphasises the necessity for additional research aimed at mitigating the potential hazards associated with the ingestion of these medications, particularly within susceptible demographics, such as young children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Hypocalcaemia forms part of the 'diamond of death' in major trauma, alongside hypothermia, acidosis and coagulopathy. In adults, admission hypocalcaemia prior to transfusion is associated with increased mortality, increased blood transfusion requirements and coagulopathy. Data on paediatric major trauma patients are limited. This systematic review and meta-analysis aims to describe and synthesise the available evidence relevant to paediatric trauma, admission hypocalcaemia and outcome., Methods and Analysis: The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines will be used to construct this review. A planned literature search for articles in the English language will be conducted from inception to the date of searches using MEDLINE on the EBSCO platform, CINAHL on the EBSCO platform and Embase on the Ovid platform. The grey literature will also be searched. Both title and abstract screening and full-text screening will be done by two reviewers, with an adjudicating third reviewer. Heterogeneity will be assessed using the I 2 test, and the risk of bias will be assessed using the ROBINS-I tool. A meta-analysis will be undertaken using ratio measures (OR) and mean differences for measures of effect. When possible, the estimate of effect will be presented along with a CI and a p value., Ethical Review and Dissemination: Ethical review is not required, as no original data will be collected. Results will be disseminated through peer-reviewed publications and at academic conferences., Prospero Registration Number: CRD42023425172., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Intrauterine growth restriction (IUGR) is a pregnancy condition, which is associated with poor perinatal outcomes and long-term neurodevelopmental impairment. Several studies also investigated the impact of IUGR on child behaviour (eg, internalising and externalising behaviour, social competencies). However, so far, no systematic review or meta-analysis has been conducted that summarises these effects while considering relevant third variables such as type of IUGR diagnosis and control group, or concurrent cognitive abilities. The objective of this study is to summarise the current evidence regarding the relationship between IUGR and behavioural outcomes from early childhood to young adulthood. Additionally, to explore how third variables such as type of control group, or cognitive abilities, relate to this association., Methods: Search strategy: The following electronic databases will be searched-Web of Science, Medline Ovid, PsycInfo, Cochrane Library, Scopus and Embase., Inclusion Criteria: observational (eg, cohort studies and case-control studies) and intervention studies (if standard care is used and norm values are reported for the control group) will be included if they quantitatively compare children with and without IUGR from the age of 2 to 18 years. The main outcomes are internalising and externalising behaviour, and social competencies., Ethics and Dissemination: No ethics approval was necessary for this protocol. Dissemination of findings will be done by publishing the results in peer-reviewed journals. The results of this systematic review will provide guidance for practice and counselling for clinicians and therapists facing patients affected by IUGR and their families., Prospero Registration Number: CRD42022347467., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Delirium is one of the most common forms of acute cerebral dysfunction in critically ill children leading to increased morbidity and mortality. Prevention, identification and management of delirium is an important part of paediatric and neonatological intensive care. This scoping review aims to identify and map evidence on non-pharmacological interventions for paediatric delirium prevention and management in paediatric and neonatal intensive care settings., Methods and Analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches will be performed in the databases Medline (via PubMed), CINAHL, Cochrane Library, Ovid (Journals), EMBASE and Web of Science (01/2000-current). Two reviewers will independently review retrieved studies, and relevant information will be extracted using data extraction forms. The results will be presented in tabular format and accompanied by a narrative summary., Inclusion Criteria: The review will include references that describe or evaluate non-pharmacological interventions to prevent or manage paediatric delirium. Conference abstracts, editorials, opinion papers and grey literature will be excluded., Ethics and Dissemination: Due to the nature of research involving humans or unpublished secondary data, approval of an ethics committee are not required. The dissemination of findings is planned via professional networks and publication in an open-access scientific journal., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite growing awareness of neurodevelopmental impairments in children with congenital heart disease (CHD), there is a lack of large, longitudinal, population-based cohorts. Little is known about the contemporary neurodevelopmental profile and the emergence of specific impairments in children with CHD entering school. The performance of standardised screening tools to predict neurodevelopmental outcomes at school age in this high-risk population remains poorly understood. The NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial randomised 1371 children <2 years of age, investigating the effect of gaseous nitric oxide applied into the cardiopulmonary bypass oxygenator during heart surgery. The NITRIC follow-up study will follow this cohort annually until 5 years of age to assess outcomes related to cognition and socioemotional behaviour at school entry, identify risk factors for adverse outcomes and evaluate the performance of screening tools., Methods and Analysis: Approximately 1150 children from the NITRIC trial across five sites in Australia and New Zealand will be eligible. Follow-up assessments will occur in two stages: (1) annual online screening of global neurodevelopment, socioemotional and executive functioning, health-related quality of life and parenting stress at ages 2-5 years; and (2) face-to-face assessment at age 5 years assessing intellectual ability, attention, memory and processing speed; fine motor skills; language and communication; and socioemotional outcomes. Cognitive and socioemotional outcomes and trajectories of neurodevelopment will be described and demographic, clinical, genetic and environmental predictors of these outcomes will be explored., Ethics and Dissemination: Ethical approval has been obtained from the Children's Health Queensland (HREC/20/QCHQ/70626) and New Zealand Health and Disability (21/NTA/83) Research Ethics Committees. The findings will inform the development of clinical decision tools and improve preventative and intervention strategies in children with CHD. Dissemination of the outcomes of the study is expected via publications in peer-reviewed journals, presentation at conferences, via social media, podcast presentations and medical education resources, and through CHD family partners., Trial Registration Number: The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as 'Gene Expression to Predict Long-Term Neurodevelopmental Outcome in Infants from the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) Study - A Multicentre Prospective Trial'., Trial Registration: ACTRN12621000904875., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research., Design: Scoping review., Methods: This study used Arksey and O'Malley's six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate., Results: 47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges., Conclusion: COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The aim of this retrospective cross-sectional study was to assess the performance of paediatric organ donation in intensive care units following neurological determinants of death in Saudi Arabia., Design: Retrospective cross-sectional study., Setting: Paediatric intensive care units at three tertiary centres over 5 years., Participants: 423 paediatric deaths (<14 years) from January 2017 to December 2021., Primary Outcome: Patients were identified as either possible, potential, eligible, approached, consented or actual donors based on organ donation definitions from the WHO, Transplantation Society and UK potential donor audit., Secondary Outcome: Secondary outcome was causative mechanisms of brain injury in possible donors. Demographics of the study cohort (age, sex, hospital length of stay (LOS), paediatric intensive care unit LOS, pre-existing comorbidities, admission type and diagnosis category) were compared between possible and non-possible donors. Demographics were also compared between patients who underwent neurological determination of death and patients who did not., Results: Among the 423 paediatric deaths, 125 (29.6%) were identified as possible donors by neurological criteria (devastating brain insult with likelihood of brain death, Glasgow Coma Score of 3 and ≥2 absent brainstem reflexes). Of them, 41 (32.8%) patients were identified as potential donors (neurological determination of death examinations initiated by the treating team), while only two became actual donors. The eligible death conversion rate was 6.9%. The reporting rate to organ procurement organisation was 70.7% with a consent rate of 8.3%. The most common causes of brain insult causing death were cardiac arrest (44 of 125 patients, 35.2%), followed by traumatic brain injury and drowning (31 of 125 patients, 24.8%), and intracranial bleeding (13 of 125 patients, 11.4%)., Conclusion: Major contributors to low actual donation rate were consent, donor identification and donor referral., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: As routine genomic testing expands, so too does the opportunity to look for additional health information unrelated to the original reason for testing, termed additional findings (AF). Analysis for many different types of AF may be available, particularly to families undergoing trio genomic testing. The optimal model for service delivery remains to be determined, especially when the original test occurs in the acute care setting., Methods and Analysis: Families enrolled in a national study providing ultrarapid genomic testing to critically ill children will be offered analysis for three types of AF on their stored genomic data: paediatric-onset conditions in the child, adult-onset conditions in each parent and reproductive carrier screening for the parents as a couple. The offer will be made 3-6 months after diagnostic testing. Parents will have access to a modified version of the Genetics Adviser web-based decision support tool before attending a genetic counselling appointment to discuss consent for AF. Parental experiences will be evaluated using qualitative and quantitative methods on data collected through surveys, appointment recordings and interviews at multiple time points. Evaluation will focus on parental preferences, uptake, decision support use and understanding of AF. Genetic health professionals' perspectives on acceptability and feasibility of AF will also be captured through surveys and interviews., Ethics and Dissemination: This project received ethics approval from the Melbourne Health Human Research Ethics Committee as part of the Australian Genomics Health Alliance protocol: HREC/16/MH/251. Findings will be disseminated through peer-review journal articles and at conferences nationally and internationally., Competing Interests: Competing interests: The authors declare no competing interests. YB and MC are co-Founders of Genetics Adviser, Inc., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: To explore doctors' experiences of referring and admitting patients to the intensive care unit (ICU) at two tertiary hospitals in Malawi., Design: This was a qualitative study that used face-to-face interviews. The interviews were audiotaped and transcribed verbatim into English. The data were analysed manually through conventional content analysis., Setting: Two public tertiary hospitals in the central and southern regions of Malawi. Interviews were conducted from January to June 2021., Participants: Sixteen doctors who were involved in the referral and admission of patients to the ICU., Results: Four themes were identified namely, lack of clear admission criteria, ICU admission requires a complex chain of consultations, shortage of ICU resources, and lack of an ethical and legal framework for discontinuing treatment of critically ill patients who were too sick to benefit from ICU., Conclusion: Despite the acute disease burden and increased demand for ICU care, the two hospitals lack clear processes for referring and admitting patients to the ICU. Given the limited bed space in ICUs, hospitals in low-income countries, including Malawi, need to improve or develop admission criteria, severity scoring systems, ongoing professional development activities, and legislation for discontinuing intensive care treatments and end-of-life care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In the early stage of sepsis, identifying high-risk paediatric patients with a poor prognosis and providing timely and adequate treatment are critical. This study aimed to evaluate the effect of average body temperature within 24 hours of admission on the short-term prognosis of paediatric patients with sepsis., Design: A retrospective cohort study., Setting: A single-centre, tertiary care hospital in China, containing patient data from 2010 to 2018., Participants: 1144 patients with sepsis were included., Intervention: None., Primary and Secondary Outcome Measures: The main outcome measure was in-hospital mortality, which was defined as death from any cause during hospitalisation. The secondary outcome was the length of hospital stay., Results: The LOWESS method showed a roughly 'U'-shaped relationship between body temperature on the first day and in-hospital mortality. Multivariate logistic regression showed that severe hypothermia (OR 14.72, 95% CI 4.84 to 44.75), mild hypothermia (OR 3.71, 95% CI 1.26 to 10.90), mild hyperthermia (OR 3.41, 95% CI 1.17 to 9.90) and severe hyperthermia (OR 5.15, 95% CI 1.84 to 14.43) were independent risk factors for in-hospital mortality. Compared with other variables, the Wald χ 2 value of temperature on the first day minus the degree of freedom was the highest., Conclusions: Whether hypothermic or hyperthermic, the more abnormal the temperature on the first day is, the higher the risk of in-hospital death in children with sepsis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Failure to secure an airway during general anaesthesia is a major cause of adverse events (AEs) in children. The safety of paediatric anaesthesia may be improved by identifying the incidence of AEs and their attributed risk factors. The aim of the current study is to obtain real-world data on the incidence of adverse peri-intubation events and assess their association with patient characteristics (including the prevalence of difficult airway features) and choice of anaesthesia management. These data can be used to develop a targeted education programme for anaesthesia providers towards quality improvement activities., Methods and Analysis: This prospective, multicentre, registry-based, cross-sectional study will be conducted in four tertiary care hospitals in Japan from June 2022 to May 2025. Children <18 years of age undergoing surgical and/or diagnostic test procedures under general anaesthesia or sedation by anaesthesiologists will be enrolled in this study. Data on patient characteristics, discipline of anaesthesia providers and methodology of airway management will be collected through a standardised verification system. The exposure of interest is the presence of difficult airway features defined based on the craniofacial appearance. The primary and secondary endpoints are all AEs associated with airway management and reduced peripheral capillary oxygen saturation values. Potential confounders are related to the failure to secure the airway and variations in the anaesthesia providers' levels, adjusted using hierarchical multivariable regression models with mixed effects. The sample size was calculated to be approximately 16 000 assuming a 99% probability of obtaining a 95% Wilson CI with±0.3% of the half-width for the 2.0% of the incidence of critical AEs., Ethics and Dissemination: The study protocol was approved by the Institutional Review Board at Aichi Children's Health and Medical Center (2021051). The results will be reported in a peer-reviewed journal and a relevant academic conference., Trial Registration Number: UMIN000047351., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Diarrhoea is one of the leading causes of under-5 childhood mortality and accounts for 8% of 5.4 million global under-5 deaths. In severely malnourished children, diarrhoea progresses to shock, where the risk of mortality is even higher. At icddr,b Dhaka Hospital, the fatality rate is as high as 69% in children with severe malnutrition and fluid refractory septic shock. To date, no study has evaluated systematically the effects of inotrope or vasopressor or blood transfusion in children with dehydrating diarrhoea (eg, in cholera) and severe acute malnutrition (SAM) or severe underweight who are in shock and unresponsive to WHO-recommended fluid therapy. To reduce the mortality of severely malnourished children presenting with diarrhoea and fluid refractory shock, we aim to compare the efficacy of blood transfusion, dopamine and epinephrine in fluid refractory shock in children who do not respond to WHO-recommended fluid resuscitation., Methods and Analysis: In this randomised, three-arm, controlled, non-masked clinical trial in children 1-59 months old with SAM or severe underweight and fluid refractory shock, we will compare the efficacy of dopamine or epinephrine administration versus blood transfusion in children who failed to respond to WHO-recommended fluid resuscitation. The primary outcome variable is the case fatality rate. The effect of the intervention will be assessed by performing an intention-to-treat analysis. Recruitment and data collection began in July 2021 and are now ongoing. Results are expected by May 2023., Ethics and Dissemination: This study has been approved by the icddr,b Institutional Review Board. We adhere to the 'Declaration of Helsinki' (2000), guidelines for Good Clinical Practice. Before enrolment, we collect signed informed consent from the parents or caregivers of the children. We will publish the results in a peer-reviewed journal and will arrange a dissemination seminar., Trial Registration Number: NCT04750070., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Sub-Saharan Africa has the highest rate of unintentional paediatric injury deaths. The Pediatric Resuscitation and Trauma Outcome (PRESTO) model predicts mortality using patient variables available in low-resource settings: age, systolic blood pressure (SBP), heart rate (HR), oxygen saturation, need for supplemental oxygen (SO) and neurologic status (Alert Verbal Painful Unresponsive (AVPU)). We sought to validate and assess the prognostic performance of PRESTO for paediatric injury patients at a tertiary referral hospital in Northern Tanzania., Methods: This is a cross-sectional study from a prospective trauma registry from November 2020 to April 2022. We performed exploratory analysis of sociodemographic variables and developed a logistic regression model to predict mortality using R (V.4.1). The logistic regression model was evaluated using area under the receiver operating curve (AUC)., Results: 499 patients were enrolled with a median age of 7 years (IQR 3.41-11.18). 65% were boys, and in-hospital mortality was 7.1%. Most were classified as alert on AVPU Scale (n=326, 86%) and had normal SBP (n=351, 98%). Median HR was 107 (IQR 88.5-124). The logistic regression model based on the original PRESTO model revealed that AVPU, HR and SO were statistically significant to predict in-hospital mortality. The model fit to our population revealed AUC=0.81, sensitivity=0.71 and specificity=0.79., Conclusion: This is the first validation of a model to predict mortality for paediatric injury patients in Tanzania. Despite the low number of participants, our results show good predictive potential. Further research with a larger injury population should be done to improve the model for our population, such as through calibration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The ProSPoNS trial is a multicentre, double-blind, placebo-controlled trial to evaluate the role of probiotics in prevention of neonatal sepsis. The present protocol describes the data and methodology for the cost utility of the probiotic intervention alongside the controlled trial., Methods and Analysis: A societal perspective will be adopted in the economic evaluation. Direct medical and non-medical costs associated with neonatal sepsis and its treatment would be ascertained in both the intervention and the control arm. Intervention costs will be facilitated through primary data collection and programme budgetary records. Treatment cost for neonatal sepsis and associated conditions will be accessed from Indian national costing database estimating healthcare system costs. A cost-utility design will be employed with outcome as incremental cost per disability-adjusted life year averted. Considering a time-horizon of 6 months, trial estimates will be extrapolated to model the cost and consequences among high-risk neonatal population in India. A discount rate of 3% will be used. Impact of uncertainties present in analysis will be addressed through both deterministic and probabilistic sensitivity analysis., Ethics and Dissemination: Has been obtained from EC of the six participating sites (MGIMS Wardha, KEM Pune, JIPMER Puducherry, AIPH, Bhubaneswar, LHMC New Delhi, SMC Meerut) as well as from the ERC of LSTM, UK. A peer-reviewed article will be published after completion of the study. Findings will be disseminated to the community of the study sites, with academic bodies and policymakers., Registration: The protocol has been approved by the regulatory authority (Central Drugs Standards Control Organisation; CDSCO) in India (CT-NOC No. CT/NOC/17/2019 dated 1 March 2019). The ProSPoNS trial is registered at the Clinical Trial Registry of India (CTRI). Registered on 16 May 2019., Trial Registration Number: CTRI/2019/05/019197; Clinical Trial Registry., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Early recognition and appropriate management of paediatric sepsis are known to improve outcomes. A previous system's biology investigation of the systemic immune response in neonates to sepsis identified immune and metabolic markers that showed high accuracy for detecting bacterial infection. Further gene expression markers have also been reported previously in the paediatric age group for discriminating sepsis from control cases. More recently, specific gene signatures were identified to discriminate between COVID-19 and its associated inflammatory sequelae. Through the current prospective cohort study, we aim to evaluate immune and metabolic blood markers which discriminate between sepses (including COVID-19) from other acute illnesses in critically unwell children and young persons, up to 18 years of age., Methods and Analysis: We describe a prospective cohort study for comparing the immune and metabolic whole-blood markers in patients with sepsis, COVID-19 and other illnesses. Clinical phenotyping and blood culture test results will provide a reference standard to evaluate the performance of blood markers from the research sample analysis. Serial sampling of whole blood (50 μL each) will be collected from children admitted to intensive care and with an acute illness to follow time dependent changes in biomarkers. An integrated lipidomics and RNASeq transcriptomics analyses will be conducted to evaluate immune-metabolic networks that discriminate sepsis and COVID-19 from other acute illnesses. This study received approval for deferred consent., Ethics and Dissemination: The study has received research ethics committee approval from the Yorkshire and Humber Leeds West Research Ethics Committee 2 (reference 20/YH/0214; IRAS reference 250612). Submission of study results for publication will involve making available all anonymised primary and processed data on public repository sites., Trial Registration Number: NCT04904523., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)