BackgroundEarly introduction of enteral nutrition (EN) in postoperative infants improves intestinal adaptation, reducing the risk of intestinal failure–associated liver disease (IFALD). Our objective was to determine whether guideline use reduces feeding variability and improves outcomes in the neonatal intensive care unit (NICU).MethodsIn a cohort study, surgical infants at risk for IFALD were evaluated pre and post implementation of feeding guidelines at 2 NICUs. A total of 167 guideline infants (2013–2018) were compared with 242 historical controls (2007–2013). Adherence was measured with timing and volume of initial postoperative feed. Primary outcomes were IFALD incidence and time to reach 50% and 100% of energy from EN. Secondary outcomes were parenteral nutrition (PN) days, postoperative necrotizing enterocolitis (NEC), central line–associated bloodstream infection (CLABSI), and length of stay (LOS).ResultsModerate IFALD decreased from 32% to 20% (P = .005) in the guideline group. Time to achieve 50% and 100% energy from EN was decreased from medians of 8 to 5 and 28 to 21 days, respectively (P < .001). There was an overall decrease in PN use from 41 to 29 days (P = .002), CLABSI incidence from 25% to 5% (P < .001), and LOS from 70 to 53 days (P = .030). Once stratified by diagnosis, infants with NEC showed greatest improvement and reduction in IFALD from 67% to 42% (P = .045). With no difference in postoperative NEC (P = .464).ConclusionEarly standardized postoperative EN guidelines in intestinal‐surgery infants was associated with improved outcomes, including faster achievement of feeding goals and reduced IFALD severity, especially in infants with NEC.
Background Systemic corticosteroids are vital to critical asthma management. While intravenous methylprednisolone is routinely used in the pediatric intensive care unit (PICU) setting, recent data supports dexamethasone as an alternative. Using the Pediatric Health Information System (PHIS) registry, we assessed trends and variation in corticosteroid prescribing among children hospitalized for critical asthma. Methods We performed a multicenter retrospective cohort study using PHIS data among children 3-17 years of age admitted for critical asthma from 2011 through 2019. Primary outcomes were corticosteroid prescribing rates by year and participating sites. Exploratory outcomes were corticosteroid-related adverse effects, rates of adjunctive pharmaceutical and respiratory interventions, mortality and length of stay. Results Of the 49 children's hospitals assessed, 26 907 encounters were included for study. Mean dexamethasone exposure rates were 18.1 ± 2.4% where 2.4 ± 1.2% represented dexamethasone-alone prescribing. Dexamethasone alone prescribing exhibited a linear trend (annual increase of 0.5 ± 0.1% annually R2 = 0.845) without correlation to cumulative site critical asthma admission rates. Compared to encounters prescribed solely methylprednisolone or a combination of dexamethasone and methylprednisolone, subjects provided dexamethasone alone had reduced asthma severity indices, length of stay, and exposure rates to adjunctive asthma interventions. Adverse events were rare and the dexamethasone-alone group less frequently experienced gastritis and hyperglycemia. Conclusions In this multicenter retrospective study from 49 children's hospitals, dexamethasone prescribing rates appear increasing for pediatric critical asthma. Observed variability in corticosteroid prescribing implies a continued need for controlled prospective comparative analyses to define ideal corticosteroid regimens for pediatric critical asthma.
Repurposing biological samples collected for required diagnostic purposes into suitable biobanking projects is a particularly useful method for enabling research in vulnerable populations. This approach is especially appropriate for the neonate in the neonatal intensive care unit (NICU), where blood volume reductions can quickly increase beyond minimal risk for adverse events, such as iatrogenic anemia, and proxy consent provided by parents or guardians is required. The method described in this study provides a framework to prospectively collect and store blood-derived clinical samples after all clinical and regulatory requirements are fulfilled. The consent approach incorporated a 30-day window to allow parents and guardians ample consideration time with follow-up involvement with NICU embedded study team members. The study enrolled 875 participants over a 3-year period. This established a critically needed biobank to support investigator-initiated research with explicit study aims requiring samples at defined day of life frequencies within the NICU and created a normative control reference bank for case comparisons for premature and full-term neonates with brain injury.
BACKGROUND: Cerebral sinovenous thrombosis (CSVT) is a rare but serious disease process among all patients, with a slightly higher prevalence in pediatric patients. Despite its low frequency, CSVT represents the second most common type of venous thromboembolism (VTE) in children, next to deep vein thrombosis (DVT) of the limbs. Current literature lacks robust evidence on risk factors for CSVT, especially in the pediatric population. We sought to determine risk factors of CSVT in pediatric patients, via a single-institutional case-control study. METHODS: A case-control study was conducted at Johns Hopkins All Children's Hospital from patients admitted between March 31st 2006 and April 1st 2018. Cases were identified based on ICD-9 and ICD-10 codes and confirmed via electronic medical record (EMR) review and neuroradiologist confirmation of radiologic testing. Two controls were then randomly selected for each CSVT case, matched by month and year of admission. Clinical and demographic parameters were collected via abstraction from the EMR, including: age at admission, prior history of VTE, previous hospitalization within 30 days, head/neck surgery, other major surgery, congenital or acquired heart disease, dehydration, cancer, serious infection (included meningitis, sepsis, pneumonia, osteomyelitis, fungemia, pyelonephritis, head/neck infection, abscess involving anatomic sites other than skin or head/neck), prematurity, mechanical ventilation, chronic inflammatory disease, cystic fibrosis, nephrotic syndrome, obesity, and head/neck trauma. Associations between CSVT and putative risk factors were evaluated via logistic regression, using odds ratios (ORs) and 95% confidence intervals (95%CIs). Those risk factors with P-values <0.1 in univariate logistic regression were included in adjusted (multivariate) logistic regression modeling; results of the latter employed a threshold of P<0.05 for statistical significance. RESULTS: A total of 60 CSVT cases and 120 controls were identified. Median (and interquartile range in) age was 4.79 years (0.02-13.56 years) for cases and 5.58 years (1.16-10.78 years) for controls. Factors putatively associated with CSVT in unadjusted analyses were: presence of central venous catheter; serious infection; mechanical ventilation; chronic inflammatory disease; and head/neck trauma. In the multivariate model, mechanical ventilation (OR=9.01, 95%CI=2.19-37.02) and head/neck trauma (OR=11.52, 95% CI=2.63-50.41) remained independent, statistically-significant risk factors for CSVT. CONCLUSIONS: This single-institutional case-control study reveals that mechanical ventilation and head/neck trauma are independent risk factors for pediatric CSVT. These findings will be further investigated via the multicenter Children's Hospital-Acquired Thrombosis (CHAT) registry dataset, by which a risk model for CSVT in children will be further developed and validated, in order to inform future preventive strategies in pediatric patients at heightened risk of CSVT. Table Disclosures Goldenberg: NIH: Other: research support and salary support.
Background: Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma. Methods: A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5−17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/ dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions)and safety (i.e., corticosteroid-related adverse events).Results: Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001).Conclusions: Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.
Purpose: Moyamoya disease/syndrome (MMD) is a progressive steno-occlusive disease involving the intracranial arterial circulation. Long term stenosis/hypoperfusion can lead to intellectual disability and cognitive impairment even in the absence of documented infarct. We aim investigate any underlying network abnormalities in MMD patients with no apparent ischemic injury. Materials and Methods: We retrospectively reviewed children with MMD with normal appearing parenchyma on conventional MRI. Control patients were selected from our existing database. Clinical, surgical and demographic data, including degree of stenosis as measured semi-quantitatively on MRA, were collected. Patients with documented infarcts, low quality DTI, and NF1 were excluded from the analysis. Group and correlational connectometry with degree of stenosis were performed. Results: A total of 28 patients were reviewed with 16 patients included in the study. Median (and interquartile range) age was 10.5 (8.5 - 13.5). Between group connectometry analysis identified infratentorial and supratentorial decreased connectivity in patients compared to controls, specifically in: middle cerebellar peduncle, corpus callosum, right parietopontine tract, superior cerebellar peduncle, left inferior fronto-occipital fasciculus. (Figure 1) In addition, we found negative correlation between the degree of stenosis and structural connectivity of multiple white matter pathways. Conclusion: Our findings reveal abnormal structural connectivity in children with MMD in the absence of infarcts on conventional MRI. Connectomics offers a unique opportunity to study the effect of long-term stenosis/hypoperfusion on cerebellar-cerebral networks and provide new insights into the mechanism of the structural plasticity/reorganization in these patients before bypass surgery. Future research is needed to determine longitudinal network changes before and after surgery.
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