Multisystem inflammatory syndrome in children (MISC): A systematic review.

OBJECTIVE: The aim of this systematic review was to analyse current literature and reported cases of multisystem inflammatory syndrome in children (MISC), concerning its clinical spectrum, complications associated, therapeutic strategies and distinguishing features of other clinical syndromes. METHODS: Extensive literature research was performed in MEDLINE (through PubMed), Scopus and Web of Science from December 2019 to December 2020. First analysis included all article titles and abstracts screening to identify relevant studies, and second analysis included a full-text screening of previously selected studies. Eligibility was assessed independently by two authors, and disagreements were resolved by discussion and consensus. Data were extracted on MISC definition, demographic data, clinical features, diagnostic tests, laboratory analysis and imaging, therapeutical approach and outcomes. RESULTS: Common symptoms included gastrointestinal (70%), rash (57%) and cardiovascular (52% with shock). Notable differences with Kawasaki disease were identified including age, clinical presentation and cardiac involvement. Thirty per cent presented positive severe acute respiratory syndrome coronavirus-2 reverse transcription polymerase chain reaction and 51% positive serologies. Sixty-two per cent received intravenous immunoglobulin and 42% glucocorticoids. Sixty-two per cent required intensive care and 21 children died (<2%). Severe presentations were associated with neurological symptoms, hepatitis and acute kidney injury. CONCLUSIONS: MISC raises concern on its severe cardiac involvement at presentation, with frequent intensive care and immunomodulatory therapy need. Short-term outcomes seem to be favourable, with cardiac dysfunction recovery and low mortality rates.

Non-pharmacological management of neonatal pain: a systematic review.

INTRODUCTION: Shortly after birth, neonates are exposed to several painful medical procedures, such as newborn metabolic screening, vaccination and venipuncture, without proper management of pain. Unpleasant experiences during the neonatal period are proven to be associated with negative long-term consequences. Non-pharmacological interventions have been studied, although rarely administered and seldom documented. The aim of this systematic review was to assess non-pharmacological approaches to neonatal pain during diagnostic and treatment procedures. EVIDENCE ACQUISITION: Extensive literature research to access randomized controlled trials on non-pharmacological pain management in neonates was performed in MEDLINE (through PubMed), Scopus and Web of Science from October 2011 to September 2021. First analysis included all article titles and abstracts screening to identify relevant studies, and second analysis included a full-text screening of previously selected studies. Eligibility was assessed independently by two authors, and disagreements were resolved by discussion and consensus. In the end, 19 published studies were included, representing a total of 1930 newborns. Main outcome, neonatal pain, was assessed by different neonatal pain evaluation scales. EVIDENCE SYNTHESIS: Non-pharmacological interventions including sucrose/glucose solutions, non-nutritive sucking, breastfeeding, olfactive stimulus, auditory stimulus and sensory stimulus (skin-to-skin care, kangaroo/maternal holding, heat, therapeutic massage, swaddling/facilitated tucking and acupressure) showed decreased behavioral and physiologic pain responses. CONCLUSIONS: Evidence suggests non-pharmacological approaches are safe, effective and can be easily applied in daily practice. There is the need for continued research on non-pharmacological interventions on neonatal pain to help healthcare providers build a tailored pain treatment plan for neonates submitted to procedural pain.

Predictors of poor neurodevelopmental outcomes of very preterm and very low birth weight infants.

BACKGROUND: Despite recent improvements, premature infants remain at high risk for long-term morbidity and poorer neurodevelopment, particularly very preterm (VP) and very low birth weight (VLBW). The aim of this study was to describe neurodevelopmental outcomes at two years and identify potential predictors of worse performance. METHODS: In a retrospective cohort, a two-years' neurodevelopmental evaluation was analyzed. Multivariable regressions were used to study the association of perinatal history with neurodevelopmental outcomes. Subjects included VP and/or VLBW born at a Portuguese III-level perinatal center between 2011-2017. Milestones outcomes were assessed using the Griffiths' Mental Development Scales. RESULTS: One hundred seventy-seven infants were included. Two-years milestones were not achieved in 18.6% in language domain and 7.3% in motor function, 4.5% wore glasses and 1.1% auditory prosthesis/cochlear implant. Almost 30% needed intervention, 18.6% occupational therapy, 16.4% physiotherapy and 13.6% speech therapy. Griffiths' Mental Development Scales was performed in 139, with a mean global quotient of 98.3 and hearing/speech as the least quoted scale. Global development delay (GDD) was present in 14.8% and cerebral palsy in 2.8%. Multivariate analysis by logistic regression adjusted to gestational age, birth weight and confounding variables, revealed a statistically significant association between GDD and hydrocephalus with shunt/reservoir (OR:19.01), retinopathy of prematurity stage ≥2 (OR:7.86) and neonatal sepsis (OR:3.34). CONCLUSIONS: Consistent with recent studies, preterm are at increased risk of neurodevelopmental impairment, mainly due to GDD and language delay, rather than cerebral palsy. In this population, hydrocephalus, retinopathy of prematurity and neonatal sepsis were strongly associated with poorer outcomes. Insight into these factors is essential to refer patients for specific early intervention programs.

Comparison Between Continuous Positive Airway Pressure and High-Flow Nasal Cannula as Postextubation Respiratory Support in Neonates: A Systematic Review and Meta-Analysis.

OBJECTIVE: The interest in noninvasive respiratory support has been increasing, including continuous positive airway pressure and recent respiratory methods, namely high-flow nasal cannula. It is discussed if high-flow nasal cannula can reduce continuous positive airway pressure or invasive ventilation use. This systematic review and meta-analysis aimed to compare continuous positive airway pressure and high-flow nasal cannula as postextubation respiratory support in neonates. MATERIALS AND METHODS: A literature search, based on Preferred Reporting of Items of Systematic Reviews and Meta-Analyses guidelines, was conducted across MEDLINE (through PubMed), Scopus, and Web of Science in 15 years (2006-2021) assessing randomized controlled trials that compared continuous positive airway pressure with high-flow nasal cannula as postextubation interventions in neonates. The primary outcome was extubation failure at 72 hours and/or at 7 days and the secondary outcomes included air leak syndrome, pneumothorax, bronchopulmonary dysplasia, nasal trauma, abdominal distension, and mortality. RESULTS: Seven studies were included, comprising 1044 neonates. No statistically significant differences were found between high-flow nasal cannula and continuous positive airway pressure in extubation failure (at 72 hours and 7 days), air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality. High-flow nasal cannula was associated with a lower incidence of nasal trauma (odds ratio = 0.21; 95% CI 0.08-0.52; P = .0008). Studies assessing extreme premature infants (<28 weeks) raised some efficacy and safety concerns. CONCLUSION: High-flow nasal cannula may be as effective and safe as continuous positive airway pressure, with similar extubation failure and risk of air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality with the advantage of less nasal trauma. High-flow nasal cannula should be considered as an alternative to continuous positive airway pressure in postextubation settings in neonates. Further studies are needed to establish efficacy and safety in lower gestational ages.

Chest pain in a pediatric emergency department: clinical assessment and management reality in a third-level Portuguese hospital.

Chest pain in children and adolescents is a common complaint in the emergency department (ED), being mostly benign. A thorough patient history and physical examination should be enough in most cases for its proper management. Regarding non-cardiac chest pain, anxiety plays an important role. Methods: Retrospective analysis of all admissions in a pediatric ED of a Portuguese third-level hospital with a chief complaint of chest pain between January and December 2018. Chi-square test was used to compare different etiologies, considering a significance level of 5%. Results: A total of 798 visits were included: 53.6% girls, 80.8% adolescents (mean age: 13years old). According to the Pediatric Canadian Triage and Acuity Scale, 77.7% was prioritized as level IV: less urgent; 65.3% reported associated symptoms including dyspnea (31.8%), cough (18.2%), and palpitations (16.1%). In physical examination, 45.5% had alterations: 62.8% with chest wall tenderness. Further investigation was done in 84% of patients: 62.4% electrocardiograms (altered in 14.7%), 52.6% chest radiographies (altered in 17.1%) and 8.9% cardiac biomarkers (altered in 12.7%). The 3 main causes of chest pain were musculoskeletal (33%), idiopathic (24.4%) and psychogenic (21.6%), with 1.1% of cardiac etiology. Less than 3% needed hospital admission and 18.9% were oriented to an outpatient consultation. 7.1% readmissions reported. When compared to other causes as a group, psychogenic chest pain presented a statistically significant association with female sex, adolescence, psychiatric antecedents, previous stressful event, and normal physical examination. Of these, <30% were oriented to a pedopsychiatry/psychology consultation. Conclusions: Opposing to the low priority level in triage, benign diagnosis found, and low hospital admissions, there was a high percentage of complementary diagnostic tests performed with few altered results. In psychogenic chest pain there was a low postdischarge referral. The authors highlight the importance of clinical algorithms to reduce unnecessary tests performed and readmissions and improve orientation and follow-up, particularly in psychogenic etiology.