Background There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar. Objective This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent’s procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure. Methods We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children’s hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure. Results A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t63.64=2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t75=−2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t59.98=−4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t68.51=1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure. Conclusions This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use.

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A growing number of children with life-limiting conditions (LLCs) are being cared for in paediatric critical care (PCC) settings. Children with LLCs admitted to PCC are at a high risk of developing complications and many die after prolonged admissions. Relatively few of these patients and their parents or carers have had documented discussions about their wishes for care in the event of a serious clinical deterioration before admission to PCC. There is a need for improved understanding of (1) how parents arrive at decisions regarding what is best for their child at times of critical illness and (2) the role of parallel planning and advance care plans in that process. This review examines the complexities of decision-making in children with LLCs who are admitted to PCC settings.

Sir: The pathogenesis of necrotising enterocolitis (NEC) is still unknown. Proposed risk factors include prematurity, the presence of bacteria within the lumen of the gut [3], and enteral feeding [2]. We hypothesised that alteration in the splanchnic oxygen delivery may be the ®nal common pathway which links these diverse risk factors.Near infrared spectroscopy (NIRS) can determine changes in concentration of oxyhaemoglobin (HbO 2 ), deoxyhaemoglobin (Hb) and regional blood volume (Hbvol) and has an established role in continuous, non-invasive, in-vivo monitoring of cerebral oxygenation [1].This study was approved by the local research ethics committee. Simultaneous measurements were made of peripheral oxygen saturation (SpO 2 ), heart rate, abdominal HbO 2 , Hb and Hbvol. Infrared light was emitted and received from small optodes (Niro 500, Hamamatsu Photonics, Japan) placed 23 mm apart upon the abdomen just above the umbilicus and protected from light. We report three neonates with apnoea. Case 1, an infant of 28 weeks gestation weighing 0.975 kg required ileal resection for intestinal perforation. Four days after tracheal extubation, at 2 weeks of age, she developed frequent episodes of apnoea and bradycardia having up to 20 self-limiting desaturations per day. The lowest SpO 2 was 65%. She subsequently developed extensive NEC and died. Case 2, an infant of 33 weeks gestation, weighing 3.3 kg, was referred at 8 weeks of age because of up to 10 apnoeic episodes per day. Investigation revealed gastro-oesophageal re¯ux and aspiration, necessitating surgical treatment. Case 3, an infant of 37 weeks gestation, weighing 1.8 kg, was monitored during weaning from mechanical ventilation. Two attempts to wean supplemental oxygen to room air failed. After settling he was given his routine feed while still being monitored.In all three cases, a fall in SpO 2 coincided with a fall in gastrointestinal HbO 2 signal and rise in gastro-intestinal Hb. Although episodes of systemic desaturation recovered within 2 min, recovery of HbO 2 and Hb was delayed and took an extra 3 min. Such rapid changes in gastro-intestinal oxygen delivery observed with NIRS have not been previously reported. Case 3 also demonstrates that after an enteral feed both the gastro-intestinal blood volume and oxygen delivery increased. Repeated episodes of apnoea and hypoxia causing systemic desaturation may result in chronic ischaemia of the gut due to delayed re-oxygenation even though there is rapid recovery in SpO 2 . Thus, although hypoxia is considered to be a minor risk factor in NEC, signi®cant splanchnic hypoxia apparently occurs during periods of desaturation and lasts longer than has until now been appreciated. References1. Edwards AD, Wyatt JS, Richardson C, Delpy DT, Cope M, Reynolds EO (1988) Cotside measurement of cerebral blood ow in ill newborn infants by near infrared spectroscopy. Lancet 2:770±771 2. Kanto EP, Hunter JE, Stoll BJ (1994) Recognition and medical management of necrotizing enterocolitis. Clin Perinatol 21:335± 336 3. Szylit O,...

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