Background Childhood migraines are a common source of morbidity. Purpose To assess the comparative effectiveness and side effects of migraine prophylactic medications in children. Data Sources PUBMED, EMBASE, Cochrane Trial Registry, bibliography of retrieved articles through 25 April 2012. Study Selection Randomized trials of children with migraine headaches. Data Extraction Extracted independently in duplicate, including quality (JADAD, Cochrane Risk of Bias). We pooled headache frequency per month using random effects methods. Data Synthesis Among 21 included trials, there were 13 placebo controlled and 11 comparative effectiveness trials (3 included placebo arms. Drugs more effective than placebo for episodic migraines (<15 headaches/month) included topiramate (−0.71 headaches/month, 95 % CI: −1.19 to −0.24, Q= 1.58, df=1, I2=0.0%) and trazodone (−0.60 headache/month, 95% CI: −1.09 to −0.11, 1 study, Figure 2). Ineffective drugs included clonidine, flunarizine, pizotifen, propranolol and valproate. A single trial of fluoxetine for chronic daily headaches found it ineffective. Patients given placebo experienced a significant (p=0.027) decline in headaches from 5.6 (95% CI: 4.52–6.77 Q=8.14, df=8, I2=1.7%) to 2.9 headaches/month (95% CI: 1.66–4.08, Q-4.72, df=10, I2=0.0%). Among the 10 comparative effectiveness trials, flunarizine was more effective than piracetam (−2.2 headaches/month, 9 CI: −3.93 to −0.47), but no better than aspirin, dihydroergotamine, and propranolol. Propranolol was compared to valproate as well as behavioral treatment and two studies compared different doses of topiramate; none of these trials showed a significant difference. Limitations Few trials, lack of patient level data, changing definitions of migraine over time, few comparative effectiveness trials. Conclusion Topiramate and trazodone have limited evidence supporting efficacy for episodic migraines. Placebo was effective in reducing headaches. Other commonly used drugs have no evidence supporting their use in children. Research in pediatric headaches is needed.

OBJECTIVE The pharmacokinetics of beta-lactam antibiotics favor administration via an extended infusion. Although literature supporting extended infusion beta-lactams exists in adults, few data are available to guide the practice in pediatrics. The purpose of this study was to compare clinical outcomes between extended and standard infusions in children. METHODS This retrospective chart analysis included hospitalized patients 0 to 18 years old who received at least 72 hours of cefepime, piperacillin-tazobactam, or meropenem between October 1, 2017, and March 31, 2019. Clinical outcomes of care included hospital length of stay, readmission within 30 days, and all-cause mortality. RESULTS A total of 551 patients (258 extended infusion, 293 standard infusion) met criteria for evaluation. Clinical outcomes among the entire population were similar. A subanalysis of select populations demonstrated decreased mortality in critical care patients (2.1% vs 19.6%, p = 0.006) and decreased 30-day readmission rates in bone marrow transplant patients (0% vs 50%, p = 0.012) who received the extended infusion compared with a standard infusion. CONCLUSIONS Outcomes were similar between extended and standard infusions in children. Subgroup analyses suggest a possible mortality benefit in the critically ill and decreased readmission rate in bone marrow transplant patients.

Background The prevalence of respiratory‐technology dependent children is increasing although for most children the goal is liberation from technology. Liberation from home mechanical ventilation (HMV) and decannulation strategies vary due to the lack of clinical practice standards. The primary objective of this study was to describe our practice utilizing a polysomnography (PSG) in the liberation from respiratory‐technology process. Methods Retrospective study of tracheostomized children with and without HMV who underwent an evaluation for decannulation between January 2006 and June 2016. Patient demographics, indication for tracheostomy, indication for PSG, PSG results and interventions performed after the PSG were collected. Results We identified 153 decannulation attempts in 148 children. Ninety‐nine children had a tracheostomy only and 49 children had a tracheostomy with HMV. There were 190 PSGs performed. Almost two‐thirds of the children (N = 92) had at least one PSG, 37 children (25%) had two and 19 children (13%) had more than 2 PSGs. Children with tracheostomy and HMV had more PSGs compared to children with tracheostomy only. PSGs were performed at four points: (1) prior to tracheostomy placement (N = 23); (2) to titrate HMV (N = 19); (3) off‐HMV support (N = 43); and with a capped tracheostomy (N = 101). Most of the off‐HMV PSGs (N = 39) were favorable for discontinuing HMV. About two‐thirds of the capped PSGs (N = 73) were favorable for decannulation; of the unfavorable capped PSGs (N = 28), thirteen required airway surgeries following the unfavorable PSG. Conclusion : Overnight PSG provides useful information to the liberation process, particularly when determining readiness for discontinuing HMV and decannulation.

Objectives: The use and outcomes of nasotracheal intubation in pediatric patients requiring mechanical ventilation have not been quantified. Our goal is to identify prevalence of use, associated factors, and outcomes of nasotracheal versus orotracheal intubation in patients requiring mechanical ventilation. Design: Retrospective cohort study using deidentified data from the Virtual Pediatric Systems database. Data from PICU admissions from January 1, 2015, to December 31, 2016 were analyzed. Setting: One hundred twenty-one PICUs located within the United States. Patients: PICU admissions requiring an endotracheal tube—either nasotracheal or orotracheal—were included. Those with a tracheostomy tube present at admission were excluded from the study. Interventions: Not applicable. Measurements and Main Results: Among the 121 PICUs included in the study, 64 PICUs (53%) had zero nasotracheal intubations during the reviewed time period. There were 12,088 endotracheal intubations analyzed, and 680 of them (5.6%) were nasotracheal. Of those patients nasotracheally intubated, most were under 2 years old (88.1%), and 82.2% of them were classified as a cardiac patient. Among these young cardiac patients, the rate of unplanned extubation was 0% in the nasotracheal intubated versus 2.1% in the orotracheal intubated group (p < 0.001) Conclusions: Nasotracheal intubation is used in a minority of U.S. PICUs and mainly among young cardiac patients. Nasotracheal intubation is associated with a lower rate of unplanned extubations in this patient population. Future prospective studies analyzing the benefits and complications of nasotracheal versus orotracheal intubation in pediatric patients requiring mechanical ventilation are indicated.