Dexmedetomidine for EEG sedation in children with behavioral disorders.

OBJECTIVE: To evaluate the efficacy and safety of sedation with dexmedetomidine, a highly selective α2-agonist with sedative effect, for EEG recording in children with behavioral disorders. MATERIAL AND METHODS: Prospective observational study on children with behavioral disorders undergoing EEG at the Pediatric Hospital in Padova, Italy. A 2 mcg/kg intravenous bolus of dexmedetomidine was administered, followed by a 1-2 mcg/kg/h infusion. If necessary, bolus was repeated up to 3 times to reach the target level of sedation, assessed by Pediatric Sedation State Scale. Patients were fully monitored before, during and after the procedure until complete recovery. EEG recording quality, and caregivers' satisfaction were collected. Any adverse effect was registered using SIVA score. RESULTS: For this preliminary study, 19 patients were enrolled. EEG was successfully completed in all of them. Mean total dose of dexmedetomidine was 3.7 ± 1.7 mcg/kg. Adequate sedation was achieved within 11.9 ± 8 minutes. Mean time to first awakening was 30.9 ± 36.9 minutes and time to complete recovery 113.3 ± 92.7 minutes. Adverse effects (hypotension, bradycardia) were reported in 10 patients, all classified as "minor." EEG recording quality was good or excellent. Parents' satisfaction was high in all the interviewed families. CONCLUSIONS: Intravenous dexmedetomidine as a single drug showed an excellent efficacy and good safety profile for EEG recording in children with behavioral disorders.

The rolling cyst: migrating intraventricular neurocysticercosis-a case-based update.

BACKGROUND: Neurocysticercosis is the most frequent parasitic disease of the central nervous system, and its incidence in the developed countries is increasing due to immigration and travels from endemic areas. The intraventricular location has been found to involve up to 61.3% of the patients; moreover, only 22 cases of migrating intraventricular cyst have been reported so far. Despite the rarity of the condition in western countries, its occurrence generates some concerns and the aim of this paper is to update the information concerning pathogenesis, clinical presentation, diagnosis and management of this entity. METHODS AND RESULTS: All the pertinent literature was analysed, focused on the cases of migrating intraventricular neurocysticercosis and its peculiar features. An illustrative case regarding a 14-year-old girl is also presented. CONCLUSIONS: Migrating intraventricular neurocysticercosis is a pathognomonic entity usually presenting with hydrocephalus, and its treatment is mainly surgical, preferring an endoscopic approach. When the resection of the intraventricular cyst is not performed, an accurate follow-up is mandatory to detect clinical changes due to a recurrent hydrocephalus or to the effect of the dying cyst on the surrounding area. In case of permanent shunt placement, the cysticidal and steroid treatment is recommended to reduce the risk of shunt failure.

The quality of life in extracorporeal life support survivors: single-center experience of a long-term follow-up.

OBJECTIVE: To evaluate the health-related quality of life on a very long-term follow-up in patients treated with extracorporeal membrane oxygenation (ECMO) during neonatal and pediatric age. DESIGN: Prospective follow-up study. SETTING: Pediatric Intensive Care Unit of a tertiary-care University-Hospital. PATIENTS: Out of 20 neonates and 21 children treated with ECMO in our center, 24 patients underwent short-term neurological follow-up. Twenty of them underwent long-term neurological follow-up. INTERVENTION: Short-term follow-up was performed at 18 months and consisted in clinical evaluation, electroencephalography, and neuroimaging. Long-term follow-up was performed in 2017, at the mean period 19.72 years from ECMO (median 20.75, range 11.50-24.08) and consisted in a standardized questionnaires self-evaluation (PedsQL 4.0 Generic Core Scale) of health-related quality of life and an interviewed about the presence of organ morbidity, school level, or work position. MEASUREMENTS AND MAIN RESULTS: Sixty-one percent (25/41) of the patients survived within 30 days after ECMO treatment. Short-term follow-up was performed in 24 patients (1 patient but died before the evaluation): 21 patients (87%) showed a normal neurological status, and 3 developed severe disability. Long-term follow-up was performed in 20 long-term survivors (3 patients were not possible to be contacted and considered lost to follow-up): mean age of patients at long-term follow-up was 21.23 (median 20.96, range 13.33-35.58) years; 90% (18/20) of them have no disability with a complete normal quality of life and 95% have no cognitive impairment. CONCLUSIONS: ECMO represents a life-saving treatment for infants and children with respiratory and/or heart failure; survivors show a good quality of life comparable to healthy peers.

The use of handheld near-infrared device (Infrascanner)for detecting intracranial haemorrhages in children with minor head injury.

OBJECTIVE: A handheld device using near-infrared technology(Infrascanner) has shown good accuracy for detection of traumatic intracranial haemorrhages in adults. This study aims to determine the feasibility of use of Infrascanner in children with minor head injury (MHI) in the Emergency Department(ED). Secondary aim was to assess its potential usefulness to reduce CT scan rate. METHODS: Prospective pilot study conducted in two paediatric EDs, including children at high or intermediate risk for clinically important traumatic brain injury (ciTBI) according to the adapted PECARN rule in use. Completion of Infrascanner measurements and time to completion were recorded. Decision on CT scan and CT scan reporting were performed independently and blinded to Infrascanner results. RESULTS: Completion of the Infrascanner measurement was successfully achieved in 103 (94 %) of 110 patients enrolled,after a mean of 4.4±2.9 min. A CT scan was performed in 18(17.5 %) children. Only one had an intracranial haemorrhage that was correctly identified by the Infrascanner. The exploratory analysis showed a specificity of 93 % (95 % CI, 86.5­96.6) and a negative predictive value of 100 % (95 % CI,81.6­100) for ciTBI. The use of Infrascanner would have led to avoid ten CT scan, reducing the CT scan rate by 58.8 %. CONCLUSIONS: Infrascanner seems an easy-to-use tool for children presenting to the ED following a MHI, given the high completion rate and short time to completion. Our preliminary results suggest that Infrascanner is worthy of further investigation as a potential tool to decrease the CT scan rate in children with MHI.

The use of handheld near-infrared device (Infrascanner) for detecting intracranial haemorrhages in children with minor head injury.

OBJECTIVE: A handheld device using near-infrared technology (Infrascanner) has shown good accuracy for detection of traumatic intracranial haemorrhages in adults. This study aims to determine the feasibility of use of Infrascanner in children with minor head injury (MHI) in the Emergency Department (ED). Secondary aim was to assess its potential usefulness to reduce CT scan rate. METHODS: Prospective pilot study conducted in two paediatric EDs, including children at high or intermediate risk for clinically important traumatic brain injury (ciTBI) according to the adapted PECARN rule in use. Completion of Infrascanner measurements and time to completion were recorded. Decision on CT scan and CT scan reporting were performed independently and blinded to Infrascanner results. RESULTS: Completion of the Infrascanner measurement was successfully achieved in 103 (94 %) of 110 patients enrolled, after a mean of 4.4 ± 2.9 min. A CT scan was performed in 18 (17.5 %) children. Only one had an intracranial haemorrhage that was correctly identified by the Infrascanner. The exploratory analysis showed a specificity of 93 % (95 % CI, 86.5-96.6) and a negative predictive value of 100 % (95 % CI, 81.6-100) for ciTBI. The use of Infrascanner would have led to avoid ten CT scan, reducing the CT scan rate by 58.8 %. CONCLUSIONS: Infrascanner seems an easy-to-use tool for children presenting to the ED following a MHI, given the high completion rate and short time to completion. Our preliminary results suggest that Infrascanner is worthy of further investigation as a potential tool to decrease the CT scan rate in children with MHI.

Adherence to guideline recommendations in the management of pediatric cardiac arrest: a multicentre observational simulation-based study.

BACKGROUND AND IMPORTANCE: Pediatric cardiac arrest is a rare emergency with associated high mortality. Its management is challenging and deviations from guidelines can affect clinical outcomes. OBJECTIVES: To evaluate the adherence to guideline recommendations in the management of a pediatric cardiac arrest scenario by teams of pediatric residents. Secondarily, the association between the use of the Pediatric Advanced Life Support-2015 (PALS-2015) pocket card, and the teams' adherence to international guidelines, were explored. DESIGN, SETTINGS AND PARTICIPANTS: Multicentre observational simulation-based study at three Italian University Hospitals in 2018, including PALS-2015 certified pediatric residents in their 3rd-5th year of residency program, divided in teams of three. INTERVENTION OR EXPOSURE: Each team conducted a standard nonshockable pediatric cardiac arrest scenario and independently decided whether to use the PALS-2015 pocket card. OUTCOME MEASURE AND ANALYSIS: The primary outcome was the overall number and frequency of individual deviations from the PALS-2015 guidelines, measured by the novel c-DEV15plus score (range 0-15). Secondarily, the performance on the validated Clinical Performance Tool for asystole scenarios, the time to perform resuscitation tasks and cardiopulmonary resuscitation (CPR) quality metrics were compared between the teams that used and did not use the PALS-2015 pocket card. MAIN RESULTS: Twenty-seven teams (81 residents) were included. Overall, the median number of deviations per scenario was 7 out of 15 [interquartile range (IQR), 6-8]. The most frequent deviations were delays in positioning of a CPR board (92.6%), calling for adrenaline (92.6%), calling for help (88.9%) and incorrect/delayed administration of adrenaline (88.9%). The median Clinical Performance Tool score was 9 out of 13 (IQR, 7-10). The comparison between teams that used ( n = 13) and did not use ( n = 14) the PALS-2015 pocket card showed only significantly higher Clinical Performance Tool scores in the former group [9 (IQR 9-10) vs. 7 (IQR 6-8); P = 0.002]. CONCLUSIONS: Deviations from guidelines, although measured by means of a nonvalidated tool, were frequent in the management of a pediatric cardiac arrest scenario by pediatric residents. The use of the PALS-2015 pocket card was associated with better Clinical Performance Tool scores but was not associated with less deviations or shorter times to resuscitation tasks.

Multistep antimicrobial stewardship intervention on antibiotic prescriptions and treatment duration in children with pneumonia.

INTRODUCTION: The Italian antimicrobial prescription rate is one of the highest in Europe, and antibiotic resistance has become a serious problem with high costs and severe consequences, including prolonged illnesses, the increased period of hospitalization and mortality. Inadequate antibiotic prescriptions have been frequently reported, especially for lower respiratory tract infections (LRTI); many patients receive antibiotics for viral pneumonia or bronchiolitis or broad-spectrum antibiotics for not complicated community-acquired pneumonia. For this reason, healthcare organizations need to implement strategies to raise physicians' awareness about this kind of drug and their overall effect on the population. The implementation of antibiotic stewardship programs and the use of Clinical Pathways (CPs) are excellent solutions because they have proven to be effective tools at diagnostic and therapeutic levels. AIMS: This study evaluates the impact of CPs implementation in a Pediatric Emergency Department (PED), analyzing antibiotic prescriptions before and after the publication in 2015 and 2019. The CP developed in 2019 represents an update of the previous one with the introduction of serum procalcitonin. The study aims to evaluate the antibiotic prescriptions in patients with community-acquired pneumonia (CAP) before and after both CPs (2015 and 2019). METHODS: The periods analyzed are seven semesters (one before CP-2015 called PRE period, five post CP-2015 called POST 1-5 and 1 post CP-2019 called POST6). The patients have been split into two groups: (i) children admitted to the Pediatric Acute Care Unit (INPATIENTS), and (ii) patients evaluated in the PED and sent back home (OUTPATIENTS). We have analyzed all descriptive diagnosis of CAP (the assessment of episodes with a descriptive diagnosis were conducted independently by two pediatricians) and CAP with ICD9 classification. All antibiotic prescriptions for pediatric patients with CAP were analyzed. RESULTS: A drastic reduction of broad-spectrum antibiotics prescription for inpatients has been noticed; from 100.0% in the PRE-period to 66.7% in POST1, and up to 38.5% in POST6. Simultaneously, an increase in amoxicillin use from 33.3% in the PRE-period to 76.1% in POST1 (p-value 0.078 and 0.018) has been seen. The outpatients' group's broad-spectrum antibiotics prescriptions decreased from 54.6% PRE to 17.4% in POST6. Both for outpatients and inpatients, there was a decrease of macrolides. The inpatient group's antibiotic therapy duration decreased from 13.5 days (PRE-period) to 7.0 days in the POST6. Antibiotic therapy duration in the outpatient group decreased from 9.0 days (PRE) to 7.0 days (POST1), maintaining the same value in subsequent periods. Overlapping results were seen in the ICD9 group for both inpatients and outpatients. CONCLUSIONS: This study shows that CPs are effective tools for an antibiotic stewardship program. Indeed, broad-spectrum antibiotics usage has dropped and amoxicillin prescriptions have increased after implementing the CAP CP-2015 and the 2019 update.

Development and Usability of a Novel Interactive Tablet App (PediAppRREST) to Support the Management of Pediatric Cardiac Arrest: Pilot High-Fidelity Simulation-Based Study.

BACKGROUND: Pediatric cardiac arrest (PCA), although rare, is associated with high mortality. Deviations from international management guidelines are frequent and associated with poorer outcomes. Different strategies/devices have been developed to improve the management of cardiac arrest, including cognitive aids. However, there is very limited experience on the usefulness of interactive cognitive aids in the format of an app in PCA. No app has so far been tested for its usability and effectiveness in guiding the management of PCA. OBJECTIVE: To develop a new audiovisual interactive app for tablets, named PediAppRREST, to support the management of PCA and to test its usability in a high-fidelity simulation-based setting. METHODS: A research team at the University of Padova (Italy) and human-machine interface designers, as well as app developers, from an Italian company (RE:Lab S.r.l.) developed the app between March and October 2019, by applying an iterative design approach (ie, design-prototyping-evaluation iterative loops). In October-November 2019, a single-center nonrandomized controlled simulation-based pilot study was conducted including 48 pediatric residents divided into teams of 3. The same nonshockable PCA scenario was managed by 11 teams with and 5 without the app. The app user's experience and interaction patterns were documented through video recording of scenarios, debriefing sessions, and questionnaires. App usability was evaluated with the User Experience Questionnaire (UEQ) (scores range from -3 to +3 for each scale) and open-ended questions, whereas participants' workload was measured using the NASA Raw-Task Load Index (NASA RTLX). RESULTS: Users' difficulties in interacting with the app during the simulations were identified using a structured framework. The app usability, in terms of mean UEQ scores, was as follows: attractiveness 1.71 (SD 1.43), perspicuity 1.75 (SD 0.88), efficiency 1.93 (SD 0.93), dependability 1.57 (SD 1.10), stimulation 1.60 (SD 1.33), and novelty 2.21 (SD 0.74). Team leaders' perceived workload was comparable (P=.57) between the 2 groups; median NASA RTLX score was 67.5 (interquartile range [IQR] 65.0-81.7) for the control group and 66.7 (IQR 54.2-76.7) for the intervention group. A preliminary evaluation of the effectiveness of the app in reducing deviations from guidelines showed that median time to epinephrine administration was significantly longer in the group that used the app compared with the control group (254 seconds versus 165 seconds; P=.015). CONCLUSIONS: The PediAppRREST app received a good usability evaluation and did not appear to increase team leaders' workload. Based on the feedback collected from the participants and the preliminary results of the evaluation of its effects on the management of the simulated scenario, the app has been further refined. The effectiveness of the new version of the app in reducing deviations from guidelines recommendations in the management of PCA and its impact on time to critical actions will be evaluated in an upcoming multicenter simulation-based randomized controlled trial.

Immunotherapy for food allergies in children.

Food allergy is an increasingly prevalent problem all over the world and especially in westernized countries, and there is an unmet medical need for an effective form of therapy. During childhood natural tolerance development is frequent, but some children with cow's milk or hen's egg allergy and the majority of children with peanut allergy will remain allergic until adulthood, limiting not only the diet of patients but also their quality of life. Within the last several years, the usefulness of immunotherapy for food allergies has been investigated in food allergic patients. Several food immunotherapies are being developed; these involve oral, sublingual, epicutaneous, or subcutaneous administration of small amounts of native or modified allergens to induce immune tolerance. The approach generally follows the same principles as immunotherapy of other allergic disorders and involves administering small increasing doses of food during an induction phase followed by a maintenance phase with regular intake of a maximum tolerated amount of food. Oral immunotherapy seems to be a promising approach for food allergic patients based on results from small uncontrolled and controlled studies. Diet containing heated milk and egg may represent an alternative approach to oral immunomodulation for cow's milk and egg allergic subjects. However, oral food immunotherapy remains an investigational treatment to be further studied before advancing into clinical practice. Additional bigger, multicentric and hopefully randomized-controlled studies must answer multiple questions including optimal dose, ideal duration of immunotherapy, degree of protection, efficacy for different ages, severity and type of food allergy responsive to treatment.

Treatment of bronchiolitis: state of the art.

Bronchiolitis is a leading cause of acute illness and hospitalization for infants and young children worldwide. It is usually a mild disease, but the few children developing severe symptoms need to be hospitalized and some will need ventilatory support. To date, the mainstay of therapy has been supportive care, i.e. assisted feeding and hydration, minimal handling, nasal suctioning and oxygen therapy. In recent years the delivery of oxygen has been improved by using a high-flow nasal cannula. At the same time, the discovery of nebulized hypertonic saline enables better airway cleaning with a benefit for respiratory function. The possible role of any pharmacological approach is still debated: many pharmacological therapies tried in the past, ranging from bronchodilators to corticosteroids, were found to offer no benefit in this disease. More recently, nebulized adrenaline demonstrated a short-term benefit. Prophylaxis and prevention, especially in children at high risk of severe infection, such as prematurely born infants and children with bronchopulmonary dysplasia, have a fundamental role in dealing with this disease. In this review, we focus on current recommendations for the management and prevention of bronchiolitis, paying particular attention to the latest literature in search of answers to the questions that remain open.