Risk factors and development of a predictive score model for tumor lysis syndrome in childhood leukemia: a 10-year experience from a single tertiary hospital in Thailand.

Tumor lysis syndrome (TLS) in childhood leukemia was assessed retrospectively in 252 patients in a single tertiary center in Thailand during 2009-2019. Fifty-one (20.2%) developed TLS during their induction chemotherapy; 60.7% (31/51) were spontaneous TLS and 47% (24/51) developed clinical TLS. The predictive score model consisted of white blood cell (WBC) count more than 50,000 cells/mm3, glomerular filtration rate less than 90, and aspartate transaminase more than 44 units/L. The TLS development rates were 11.1%, 46.2%, and 78.5% in the low, intermediate, and high-risk groups, respectively. Death during the first induction phase in patients with TLS was significantly higher than in the patients without TLS. However, the 5-year overall survival rates for the children with and without TLS were not significantly different.

Development and Evaluation of a Prototype Mobile Application for Intravenous Drug Dose Calculation in Overweight and Obese Thai Children: Precision Dosing in Practice.

Background: Medication dosing in overweight and obese children often involves complex weight-based calculations, leading to higher dosing errors, particularly with intravenous drugs. Currently, tools to aid in dosage calculations are lacking for these patients, especially in Thai population. Objective: This study aimed to develop a mobile application with the intent of utilizing it as a tool to enhance the efficiency and accuracy of dosing calculations required for obese and overweight Thai children. Methods: The performance of the application was assessed in 3 key aspects using a sample of 30 healthcare professionals. These key aspects included: 1) the accuracy of dosage calculations, assessed through pre- and posttests comparing manual calculations to app-based calculations using a 10-item questionnaire, 2) the time taken for calculations before and after app usage, 3) user satisfaction, which was measured through a questionnaire. Results: The integration of applications into the calculation demonstrated a significant improvement when compared to the manual calculation in both accuracy (6.10 vs 9.33 out of 10, P < .001) and efficiency (10.40 vs 8.53 minutes per 10 questions, P = .008). Also, the application elicited high levels of satisfaction among users, as reflected by an overall mean satisfaction score of 4.57 on a 5-point scale. Conclusion: The integration of this application to assist in dosage calculations for overweight and obese pediatric Thai patients has yielded favorable outcomes concerning accuracy, efficiency, and user satisfaction. Further development should be pursued within a larger cohort, with an emphasis on real-world implementation in clinical settings.

Effectiveness of a Telephone Counseling Intervention in Reducing Passive Smoking Among Children.

Legislative smoking bans that prohibit smoking in public places have successfully reduced passive smoking in public areas. However, smokers only partially adhere to smoking restrictions in their homes. Young children are particularly vulnerable to exposure to tobacco smoke because they spend more time at home. In this study, we designed an intervention program based on an empowerment theory to reduce passive smoking among children. The priority participants were nonsmoking mothers living with smokers who smoke in the presence of children. The aim of this randomized control trial study was to examine the effectiveness of this intervention in reducing children's exposure to tobacco smoke at home. The intervention group received tailored educational brochures and two follow-up counseling telephone calls at 2 and 8 weeks, which provided resources to support the mothers to increase their knowledge, skill, and self-confidence in promoting behavior shaping of smokers. The control group received only tailored educational brochures. We found the intervention group demonstrated a higher rate of maternal actions to reduce their children's exposure to smoke and a higher rate than the control group of attempts to avoid smoking in the presence of children at the 16-week follow-up. These results suggest that the intervention helped reduce passive smoking among children. These findings highlight the need to empower and train mothers to help them develop rules for smoking at home. These interventions could be applied in the home of children who live with smokers who are unable or unwilling to quit smoking.

A Longitudinal Study of a Selected Pediatric Asthmatic Population with Normal and Abnormal Spirometry at Baseline: An Emphasis on Treatment Outcomes.

Purpose: It is still unclear whether considering abnormal spirometry as a marker for disease control can help physicians adjust asthma controllers in children because of the scarcity of pediatric studies. We aimed to investigate the prevalence of abnormal spirometry in a selected pediatric asthmatic population and its effect on longitudinal outcomes. Patients and Methods: This retrospective cohort study was conducted at the Songklanagarind Hospital, Thailand. Children with asthma aged <18 years were recruited for review if they attended the clinic and underwent acceptable spirometry with bronchodilator responsiveness (BDR) tests after receiving asthma treatment for at least 3 months between January 2011 and June 2022. Differences in baseline characteristics, atopic factors, asthma treatment, and outcomes were analyzed between the normal and abnormal spirometry groups over a 12-month post-spirometry period. Results: The mean age of the 203 enrolled patients was 10.9 ± 2.6 years. Abnormal spirometry, defined as airflow limitation or the presence of BDR, was observed in 58.1% of patients. No significant differences were observed in baseline characteristics, atopic factors, asthma treatment, or outcomes between the normal and abnormal spirometry groups. Further analysis of 107 patients with abnormal spirometry with symptom control revealed that physicians adjusted the asthma controller based on spirometry and symptoms in 84 and 23 patients, respectively. There was no significant difference in the loss of disease control over the 12-month post-spirometry period between the two groups. Conclusion: Abnormal spirometry was found in 58.1% of treated school-aged patients with asthma. Abnormal spirometry results were not associated with poor asthma outcomes during the 12-month follow-up. Both symptom-based and spirometry-based adjustments of asthma controllers resulted in comparable symptom control over a 12-month follow-up period in the selected population.

Sepsis-related pediatric acute respiratory distress syndrome: A multicenter prospective cohort study.

OBJECTIVES: This study aimed to compare the risk factors and outcomes for organ dysfunction between sepsis-related Pediatric acute respiratory distress syndrome (PARDS) and nonsepsis PARDS. METHODS: We prospective cohort recruited intubated patients with PARDS at four tertiary care centers in Thailand. The baseline characteristics, mechanical ventilation, fluid balance, and clinical outcomes were collected. The primary outcome was organ dysfunction. RESULTS: One hundred and thirty-two mechanically ventilated children with PARDS were included in the study. The median age was 29 months and 53.8% were male. The mortality rate was 22.7% and organ dysfunction was 45.4%. There were 26 (19.7%) and 106 (80.3%) patients who were classified into sepsis-related PARDS and nonsepsis PARDS, respectively. Sepsis-related PARDS patients had a significantly higher incidence of acute kidney injury (30.8% vs. 13.2%, P = 0.041), septic shock (88.5% vs. 32.1%, P < 0.001), organ dysfunction (84.6% vs. 35.8%, P < 0.001), and death (42.3% vs. 17.9%, P = 0.016) than nonsepsis PARDS group. Multivariate analysis adjusted for clinical variables showed that sepsis-related PARDS and percentage of fluid overload were significantly associated with organ dysfunction (odds ratio [OR] 11.414; 95% confidence interval [CI] 1.40892.557, P = 0.023 and OR 1.169; 95% CI 1.0121.352, P = 0.034). CONCLUSIONS: Sepsis-related PARDS patients had more severe illness, organ dysfunction, and mortality than nonsepsis PARDS patients. The higher percentage of fluid overload and presentation of sepsis was the independent risk factor of organ dysfunction in PARDS patients.

Predictive parameters and model for extubation outcome in pediatric patients.

Background: Prolonged mechanical ventilation is associated with significant morbidity in critically ill pediatric patients. In addition, extubation failure and deteriorating respiratory status after extubation contribute to increased morbidity. Well-prepared weaning procedures and accurate identification of at-risk patients using multimodal ventilator parameters are warranted to improve patient outcomes. This study aimed to identify and assess the diagnostic accuracy of single parameters and to develop a model that can help predict extubation outcomes. Materials and methods: This prospective observational study was conducted at a university hospital between January 2021 and April 2022. Patients aged 1 month to 15 years who were intubated for more than 12 h and deemed clinically ready for extubation were enrolled. A weaning process with a spontaneous breathing trial (SBT), with or without minimal setting, was employed. The ventilator and patient parameters during the weaning period at 0, 30, and 120 min and right before extubation were recorded and analyzed. Results: A total of 188 eligible patients were extubated during the study. Of them, 45 (23.9%) patients required respiratory support escalation within 48 h. Of 45, 13 (6.9%) were reintubated. The predictors of respiratory support escalation consisted of a nonminimal-setting SBT [odds ratio (OR) 2.2 (1.1, 4.6), P = 0.03], >3 ventilator days [OR 2.4 (1.2, 4.9), P = 0.02], occlusion pressure (P0.1) at 30 min ≥0.9 cmH2O [OR 2.3 (1.1, 4.9), P = 0.03], and exhaled tidal volume per kg at 120 min ≤8 ml/kg [OR 2.2 (1.1, 4.6), P = 0.03]; all of these predictors had an area under the curve (AUC) of 0.72. A predictive scoring system to determine the probability of respiratory support escalation was developed using a nomogram. Conclusion: The proposed predictive model, which integrated both patient and ventilator parameters, showed a modest performance level (AUC 0.72); however, it could facilitate the process of patient care.

Unusual presentation of alveolar capillary dysplasia with misalignment of the pulmonary veins in a child with respiratory syncytial virus pneumonia: A case report.

Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACDMPV) is a rare congenital diffuse lung disorder, with a fatal course during the neonatal period. We describe an 18-month-old boy who presented with respiratory syncytial virus pneumonia and pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation. Exome sequencing revealed a FOXF1 frameshift variant, NM_001451.2:c.995_998delACTC, inherited from his asymptomatic mother. Genetic findings were compatible with histopathology findings from a lung biopsy. Based on the disease course, histopathology, and outcomes of this case, we believe ACDMPV should be considered a possibility in an infant presenting with hypoxemic respiratory failure, resistant pulmonary hypertension, and vasodilator-induced pulmonary edema. Genetic testing can contribute to the diagnostic process.

Probability of successful inhaled corticosteroids cessation in preschool wheezers: a predictive score.

Nearly all asthma predictive tools estimate the future risk of asthma development. However, there is no tool to predict the probability of successful ICS cessation at an early age. Therefore, we aimed to determine the predictors of successful ICS cessation in preschool wheezers, and developed a simple predictive tool for clinical practice. This was a retrospective cohort study involving preschool wheezers who had undergone an ICS therapeutic trial during 2015-2020 at the University Hospital, Southern, Thailand. A predictive scoring system was developed using a nomogram to estimate the probability of successful ICS cessation. We calculated area under ROC curve and used a calibration plot for assessing the tool's performance. A total of 131 medical records were eligible for analysis. Most of the participants were male (68.9%). More than half of the preschool wheezers had successful ICS cessation after an initial therapeutic trial regimen. The predictors of less successful ICS cessation were perinatal oxygen use [OR 0.10 (0.01, 0.70), P = 0.02], allergic rhinitis [OR 0.20 (0.08, 0.56), P = 0.002], blood eosinophil count > 500 cell/mm3 [OR 0.20 (0.06, 0.67), P = 0.008], and previous ICS use > 6 months [OR 0.30 (0.09, 0.72), P = 0.009]. CONCLUSIONS: Predictors of less successful ICS cessation were the following: perinatal oxygen use, allergic rhinitis, blood eosinophil count > 500 cell/mm3, and previous ICS use > 6 months. A simple predictive score developed in this study may help general practitioners to be more confident in making a decision regarding the discontinuation of ICS after initial therapeutic trials. WHAT IS KNOWN: • Early allergic sensitization is associated with reduced chances of inhaled corticosteroid cessation at school age. • Prolonged ICS is associated with the emergence of adverse effect and discontinuing too early can result in recurrence symptoms. WHAT IS NEW: • Requirement of oxygen support within 7 days after birth in term neonate is a postnatal factor associated with less successful ICS cessation. • We propose a simple predictive tool with easily available clinical parameters (perinatal oxygen use, allergic rhinitis, blood eosinophil count, parental asthma history, and duration of previous ICS use) to determine the timing of inhalational corticosteroid cessation in preschool wheezers.

Predictors of high-flow nasal cannula failure in pediatric patients with acute respiratory distress.

BACKGROUND: Heated humidified high-flow nasal cannula (HFNC) has gained popularity recently and is considered a standard respiratory support tool for pediatric patients with acute respiratory distress. However, data are limited on the bedside parameters that can predict HFNC failure in pediatric patients. PURPOSE: To evaluate the performance of SpO2/FiO2 (SF) ratio, pediatric respiratory rate-oxygenation (pROX) index, and clinical respiratory score (CRS), for predicting the HFNC outcomes. METHODS: This prospective observational study included 1- month to 15-year-old patients with acute respiratory distress who required HFNC support. The HFNC setting, vital signs, CRS, and treatment outcomes were recorded. Data were analyzed to determine the predictors of HFNC failure. RESULTS: Eighty-two children participated in the study, 16 of whom (19.5%) did not respond to HFNC treatment (failure group). Pneumonia was the main reason for intubation (62.5%). Predictors of HFNC failure at 12 hours were: SF index ≤166 (sensitivity, 62.5%; specificity, 87.8%; area under the curve [AUC], 0.75), pROX index <132 (sensitivity, 68.7%; specificity, 84.8%; AUC, 0.77), and CRS ≥6 (sensitivity, 87.5%; specificity, 96.9%; AUC, 0.92). CONCLUSION: The CRS was the most accurate predictor of HFNC failure in pediatric patients. A CRS ≥ 6 at 12 hours after HFNC initiation and pROX, a newly modified parameter, are helpful indicators of HFNC failure.

Treatment and outcomes of chylothorax in children: 20-year experience of a single institute.

Background: Chylothorax is an uncommon cause of pleural effusion in children. This study aimed to determine the characteristics, treatment strategies, and outcomes of chylothorax in children from a single institute. Methods: The 65 episodes of chylothorax in patients aged 0-15 years who were diagnosed and received treatment in Songklanagarind Hospital between January 2001 and December 2020 were retrospectively review and analyzed. Results: Of the 65 episodes, 80% were postoperative chylothorax, and were mostly related to cardiac surgery. The most common treatment strategy employed was dietary modification (64.6%). Octreotide was used as adjunctive therapy in 33.8%. Most cases of chylothorax were successfully treated by conservative treatment, while 10.7% required surgical therapy. The median time to resolution of chylothorax was 21 days [interquartile range (IQR): 8-33 days]. Young children aged <1 year were more likely to require mechanical ventilation and develop ventilator-associated pneumonia and catheter-related complications. The factors associated with death or prolonged hospitalization (>28 days) were non-postoperative chylothorax, use of total parental nutrition (TPN) >14 days, hypoalbuminemia, and ventilator-associated pneumonia. Conclusions: Most (89.2%) cases of chylothorax were successfully treated conservatively using dietary modification and octreotide therapy. The modifiable risk factors for death or prolonged hospitalization were use of TPN >14 days and hypoalbuminemia.

Persistent Asthma at School Age: Associated Factors in Preschool Children with Asthma.

Most patients with childhood asthma present their first symptoms at preschool age. Identifying modifiable risks and protective factors at an early age may help develop asthma prevention and control strategies. This study aimed to identify factors at preschool age that are associated with persistent asthma at school age. This retrospective observational study included preschool children with asthma from 2015 to 2020 at a university hospital in Southern Thailand. In total, 189 eligible participants (70.9% boys; median age, 7.6 [6.7, 8.5] years) were included. Wheeze characteristics included early transient wheeze, persistent wheeze, and late-onset wheeze that accounted for 55%, 27.5%, and 19.5% of the patients, respectively. Approximately 20% of the participants had persistent asthma. Breastfeeding was a protective factor (odds ratio [OR] 0.4 [0.2, 0.9], p = 0.04). The modifiable risk factors were siblings living in the same household (OR 2.6 [1.1, 6.2], p = 0.02) and residence in an industrial area (OR 3.8 [1.4, 10.5], p = 0.009). Additionally, presence of allergic rhinitis was associated with an increased risk of persistent asthma at school age (OR 3.6 [1.6, 8.2], p = 0.002). Early therapeutic interventions targeting modifiable factors provide a window of opportunity to prevent persistent asthma at school age.

Acquired tracheo-oesophageal fistula in a child with unrecognised tracheal foreign body.

We report the case of a 6-month-old girl who presented with recurrent pneumonia and growth failure. After full examination, she was diagnosed with long-standing, unrecognised tracheal foreign body, which was then successfully removed. However, her chronic respiratory symptoms did not improve, and she also had feeding intolerance. The persistence of symptoms indicated a second bronchoscopy and finally an acquired tracheo-oesophageal fistula was diagnosed. This case emphasises the challenges in diagnosis of an inhaled foreign body in young children. Late diagnosis of this condition can cause significant morbidities. A high index of suspicion and careful investigation are very important to prevent long-term complications.

Practice, self-confidence and understanding of pediatric obstructive sleep apnea survey among pediatricians.

BACKGROUND: Pediatricians play an important role in the screening, diagnosis and management of childhood obstructive sleep apnea (OSA). This study used a questionnaire to explore the knowledge, self-confidence and general practices of childhood OSA among Thai pediatricians. METHODS: This was a descriptive cross-sectional survey study, using a newly developed questionnaire; including: 21 knowledge items, 4 self-confidence items, questions regarding OSA screening, number of OSA cases per month and OSA management. RESULTS: A total of 307, convenient pediatricians; from different types of hospitals across all regions of Thailand, participated in this study. The median, total knowledge score was 19 (range 14‒21). Two-thirds of the respondents felt confident/extremely confident in their ability to identify and manage children with OSA. The average number of OSA cases reported by pediatricians was 5.9 cases per month. During a general medical check-up, 86.6% of the respondents did not routinely ask about OSA symptoms. Significant odds ratios (ORs) for the use of montelukast, as the first-line drug for OSA in young children, were observed in pediatric allergists and pulmonologists (adjusted OR 2.58, 95% CI 1.11-6.01 and adjusted OR 2.20, 95% CI 1.2-4.02) (P = 0.008), respectively, compared to general pediatricians and other sub-specialties. CONCLUSIONS: Pediatricians had a high level of overall OSA knowledge, and good self-confidence in identifying and managing children with OSA. However, a low recognition rate and unawareness of OSA screening were observed.

Effectiveness of Protocolized Sedation Utilizing the COMFORT-B Scale in Mechanically Ventilated Children in a Pediatric Intensive Care Unit.

Appropriate sedation in mechanically ventilated patients is important to facilitate adequate respiratory support and maintain patient safety. However, the optimal sedation protocol for children is unclear. This study assessed the effectiveness of a sedation protocol utilizing the COMFORT-B sedation scale in reducing the duration of mechanical ventilation in children. This was a nonrandomized prospective cohort study compared with a historical control. The prospective cohort study was conducted between November 2015 and August 2016 and included 58 mechanically ventilated patients admitted to the pediatric intensive care unit (PICU). All patients received protocolized sedation utilizing the COMFORT-B scale, which was assessed every 12 hours after intubation by a single assessor. The prospective data were compared with retrospective data of 58 mechanically ventilated patients who received sedation by usual care from November 2014 to August 2015. Fifty percent of 116 patients were male and the mean age was 22 months (interquartile range [IQR]: 6.6-68.4). Patients in the intervention group showed no difference in the duration of mechanical ventilation (median 4.5 [IQR: 2.2-10.5] vs. 5 [IQR: 3-8.8] days). Also, there were no significant differences in the PICU length of stay (LOS; median 7 vs. 7 days, p = 0.59) and hospital LOS (median 18 vs. 14 days, p = 0.14) between the intervention and control groups. The percentages of sedative drugs, including fentanyl, morphine, and midazolam, in each group were not statistically different. The COMFORT-B scale with protocolized sedation in mechanically ventilated pediatric patients in the PICU did not reduce the duration of mechanical ventilation compared with usual care.

Gastropleural fistula masquerading as chylothorax in a child with lymphoma.

We report the case of an 8-year-old boy with diffuse large B cell lymphoma who developed a right-sided spontaneous pneumothorax with pleural effusion after recovery from septic shock. The pleural fluid was thought to be malignancy-associated chylothorax concomitant with complicated pleural effusion due to a milky-like appearance, a high level of triglycerides and Gram-negative bacteria staining in the fluid. He was put on total parental nutrition and octreotide for 2 weeks, but did not improve. The laboratory results also showed a persistent bacterial infection in the pleural fluid despite appropriate antibiotics. Eventually, a CT scan revealed a fistulous tract between the right pleural cavity and the stomach. Fistula repair was successful by right open thoracotomy with decortication. Even though the gastropleural fistula is a very rare condition in paediatric patients, the physician should consider this diagnosis in a patient who has an unusual presentation or refractory chylothorax-like pleural effusion.

Severity and Mortality Predictors of Pediatric Acute Respiratory Distress Syndrome According to the Pediatric Acute Lung Injury Consensus Conference Definition.

OBJECTIVES: The objective of this study was to assess the prevalence, severity, and outcomes of pediatric acute respiratory distress syndrome in a resource-limited country. In addition, we sought to explore the predisposing factors that predicted the initial severity, a change from mild to moderate-severe severity, and mortality. DESIGN: Retrospective study. SETTING: PICU in Songklanagarind Hospital, Songkhla, Thailand. PATIENTS: Children 1 month to 15 years old with acute respiratory failure admitted to the PICU from January 2013 to December 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From a total of 1,738 patients admitted to PICU, 129 patients (prevalence 7.4%) were diagnosed as pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition. The patients were categorized by severity. Fifty-seven patients (44.2%) were mild, 35 (27.1%) were moderate, and 37 (28.1%) were severe. After multivariable analysis was performed, factors significantly associated with moderate to severe disease at the initial diagnosis were Pediatric Risk of Mortality III score (odds ratio, 1.08; 95% CI, 1.03-1.15; p = 0.004), underlying oncologic/hematologic disorder (odds ratio, 0.32; 95% CI, 0.12-0.77; p = 0.012), and serum albumin level (odds ratio, 0.46; 95% CI, 0.27-0.80; p = 0.006), whereas underlying oncologic/hematologic disorder (odds ratio, 5.33; 95% CI, 1.33-21.4) and hemoglobin (odds ratio, 0.63; 95% CI, 0.44-0.89) predicted the progression of this syndrome within 7 days. The 30-day all-cause mortality rate was 51.2% (66/129). The predictors of mortality were the Pediatric Risk of Mortality III score (odds ratio, 1.12; 95% CI, 1.02-1.24; p = 0.017), underlying oncologic/hematologic disorder (odds ratio, 7.81; 95% CI, 2.18-27.94; p = 0.002), receiving systemic steroids (odds ratio, 4.04; 95% CI, 1.25-13.03; p = 0.019), having air leak syndrome (odds ratio, 5.45; 95% CI, 1.57-18.96; p = 0.008), and presenting with multiple organ dysfunction (odds ratio, 7.41; 95% CI, 2.00-27.36; p = 0.003). CONCLUSIONS: The prevalence and mortality rate of pediatric acute respiratory distress syndrome in a developing country are high. The oncologic/hematologic comorbidity had a significant impact on the severity of progression and mortality.

Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial.

OBJECTIVES: To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children. DESIGN: Double-blind, placebo-controlled randomized clinical trial. SETTING: PICU in a tertiary referral center. PATIENTS: Children 1 month to 15 years old who underwent mechanical ventilation. INTERVENTIONS: Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor. MEASUREMENTS AND MAIN RESULTS: One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90-585] vs 60 [42-116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively). CONCLUSIONS: The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.