Respiratory Rate Oxygenation (ROX) index as predictor of high flow nasal cannula in pediatric patients in pediatric intensive care unit.

BACKGROUND: High-flow nasal cannula (HFNC) is often used in pediatric populations with respiratory distress. In adults, the respiratory-rate oxygenation (ROX) index is used as a predictor of HFNC therapy; however, children have age-associated differences in respiratory rate, thus may not be applicable to children. This study aims to find the reliability of ROX index and modified P-ROX index as predictors of HFNC therapy failure in pediatric patients. METHODS: Subjects in this analytical cross-sectional study were taken from January 2023 until November 2023 in Cipto Mangunkusumo Hospital. Inclusion criteria are children aged 1 month to 18 years with respiratory distress and got HFNC therapy. Receiver operating characteristics (ROC) analysis was used to find mP-ROX index cutoff value as a predictor of HFNC failure. The area under curve (AUC) score of mP-ROX index was assessed at different time point. RESULTS: A total of 102 patients, with 70% of the population with pneumonia, were included in this study. There are significant differences in the ROX index between the successful and failed HFNC group therapy (p < 0.05). This study suggests that mP-ROX index is not useful as predictor of HFNC therapy in pediatrics. While ROX index < 5.52 at 60 min and < 5.68 at 90 min after HFNC initiation have a sensitivity of 90% and specificity of 71%, sensitivity of 78% and specificity of 76%, respectively. CONCLUSION: mP-ROX index is not useful as a predictor of HFNC therapy in pediatrics. Meanwhile, ROX index at 60 min and 90 min after initiation of HFNC is useful as a predictor of HFNC failure.

Clinical characteristics and outcome of critically ill children referred to a tertiary hospital in Indonesia: a prospective observational study.

BACKGROUND: The clinical characteristics of pediatric critically ill patients who need referral to a tertiary hospital is often unknown in resource limited settings where constraints in diagnosis capacity, resources, and infrastructures are common. There is a need to increase insight in the characteristics of these patients for capacity building strengthening and appropriate resource allocation. The aim of this study was to describe the clinical characteristics and outcomes of critically ill children who are referred to a tertiary referral teaching hospital in Yogyakarta. METHODS: A prospective observasional study was carried out from July 1st, 2022 -January 31st, 2023 which included all critically ill pediatric patients who were referred through the Integrated Referral System (SISRUTE) to the Pediatric Intensive Care Unit (PICU) of dr. Sardjito hospital. We excluded patients who were referred with a request for admission to the PICU, but were not admitted to the PICU due to their stable condition and lack of the need for intensive care. RESULT: During the study period, we received 1046 emergency referral requests for pediatric patients via SISRUTE, of those, 562 (53.7%) patients were critically ill. The reasons of PICU referral request were the need of solely intensive care 504 (89.7%), the need of multidisciplinary team care, including intensive care 57 (10.1%) and parents request 1 (0.3%). The pre-referral emergency diagnosis was shock 226 (40.3%), respiratory distress/failure 151 (26.7%), central nervous system (CNS) dysfunction 135 (24.1%), trauma 33 (5.9%) and sepsis 17 (3%). Of the 562 critically ill PICU referral requests, 473 (84.2%) requests were accepted. One hundred and eighty-one (58.7%) patients were finally admitted to the PICU, 125 (40.3%) admitted to our regular ward due to stable condition, 4 (1.3%) patients died in Emergency Departement (ED). The remaining accepted patients on request did not arrive in our facility due to various reasons. The mean (SD) response time was 9.1 (27.6) minutes. The mean (SD) transfer time was 6.45 (4.73) hours. Mean (SD) PICU and hospital length of stay was 6.7 (8.3) days and 10.2 (9.2) days respectively. PICU and hospital mortality was 24.3% and 29.7%, respectively. CONCLUSION: The mortality rate for critically ill pediatric patients referred to a tertiary PICU still high, with shock being the most common pre-referral emergency diagnosis. There is a discrepancy between the referring hospital's and the referral hospital's indication for PICU admission. The time required to reach the referral hospital is quite lengthy.

Pediatric sepsis profile in a tertiary-care hospital in Indonesia: a 4-year retrospective study.

AIM: This study aimed to explore the factors contributing to mortality and its management among pediatric sepsis patients at a single center in Indonesia. METHOD: We conducted a retrospective study of children admitted due to sepsis from January 2015 to December 2019 in an Indonesian tertiary hospital. RESULTS: The mortality rate of pediatric sepsis in our study was 76.1% among 176 records with outcome identified. Mortality was significantly associated with septic shock at triage, number of organ failure, intensive care unit admission, inotropic use, septic shock and severe sepsis during hospitalization. Timing of antibiotic use did not affect mortality. Death within the first 24 h occurred in 41.8% of subjects, mostly due to septic shock. CONCLUSION: This study illuminates the current state of pediatric sepsis management in our Indonesian hospital, revealing it as inadequate. Findings highlight the need for improved pre-hospital systems and sepsis recognition tools, and wider use of mechanical ventilators and advanced monitoring due to limited pediatric intensive care unit beds. Future research should focus on hospital-specific sepsis protocols to reduce pediatric sepsis mortality rates.

Clinical Features of Multisystem Inflammatory Syndrome in Children Associated with COVID-19 in Indonesia.

BACKGROUND: While the number of cases of multisystem inflammatory syndrome in children (MIS-C) is increasing, reported cases in Asian countries are still low, particularly in Indonesia. This study aimed to describe the characteristics of patients with MIS-C in a tertiary referral hospital in Indonesia. METHODS: This is a cross-sectional study with collected data of patients with MIS-C admitted to Dr. Cipto Mangunkusumo from March 2020 to April 2021. RESULTS: The first case of MIS-C was detected 5 months after the first reported coronavirus disease 2019 case in Indonesia. Thirteen patients out of 158 positive admitted patients for COVID-19 were diagnosed with MIS-C during the study period. Of these 13 patients, 2 patients (15%) had a fatal outcome. Subjects were predominantly male, and the median age was 7.58 years (IQR 12.3) years. Most patients required mechanical ventilation (7 out of 13 patients) and intubation (8 out of 13 patients). Patients who needed intubation usually needed mechanical ventilation. All inflammatory markers, white blood cells, neutrophil counts, and all coagulation factor parameters (except for normal prothrombin time and activated partial prothrombin time) were elevated. The median time to MIS-C diagnosis was 2 days in the survivor group (n = 11) compared to 8.5 days in the non-survivor group (n = 2). Compared to the non-survivor group, those who survived spent more days in the hospital, received vasopressors earlier, and did not require mechanical ventilation as early as the non-survivors. CONCLUSIONS: Our work highlights the differences in MIS-C clinical course, treatment, and clinical outcomes between the two groups.

Diabetic Ketoacidosis in Adolescents and Children: A Prospective Study of Blood versus Urine Ketones in Monitoring Therapeutic Response.

BACKGROUND: diabetic ketoacidosis (DKA) is a potentially lethal complication of diabetes mellitus (DM). There is no study in Indonesia that compares the much-preferred capillary beta hydroxybutirate (ß-OHB) measurement to urine acetoacetate in monitoring therapeutic response of DKA in adolescents. METHODS: a prospective study of 37 adolescents and children with DKA in Cipto Mangunkusumo Hospital was done between June 2006 and March 2011. The patients were followed until the time of DKA resolution. Hourly measurement of random blood glucose, capillary ß-OHB concentration, and urine ketones were done, while blood gas analysis and electrolyte were measured every four hours. RESULTS: median time to resolution was 21 (9-52) hours. Compared to urine ketones, capillary ß-OHB concentration showed stronger correlation with pH (r= -0,52, p= 0,003 vs r= -0,49, p= 0,005) and bicarbonate level (r=-0,60, p=0.000 vs r= -0.48, p=0.007) during the median time of DKA resolution. All capillary ß-OHB measurement yielded negative results at median time of DKA resolution, while urine ketones were still detected up to 9 hours after resolution. CONCLUSION: blood ketone concentration showed better correlation with pH and bicarbonate level, as a tool to monitor therapeutic response in DKA in adolescent, compared to traditional urine ketones test in adolescents.

Integration of Artificial Intelligence in Pediatric Education: Perspectives from Pediatric Medical Educators and Residents.

OBJECTIVES: The use of technology has rapidly increased in the past century. Artificial intelligence (AI) and information technology (IT) are now applied in healthcare and medical education. The purpose of this study was to assess the readiness of Indonesian teaching staff and pediatric residents for AI integration into the curriculum. METHODS: An anonymous online survey was distributed among teaching staff and pediatric residents from 15 national universities. The questionnaire consisted of two sections: demographic information and questions regarding the use of IT and AI in child health education. Responses were collected using a 5-point Likert scale: strongly disagree, disagree, neutral, agree, and highly agree. RESULTS: A total of 728 pediatric residents and 196 teaching staff from 15 national universities participated in the survey. Over half of the respondents were familiar with the terms IT and AI. The majority agreed that IT and AI have simplified the process of learning theories and skills. All participants were in favor of sharing data to facilitate the development of AI and expressed readiness to incorporate IT and AI into their teaching tools. CONCLUSIONS: The findings of our study indicate that pediatric residents and teaching staff are ready to implement AI in medical education.

Diagnostic challenges of hypoganglionosis based on immunohistochemical method.

Background: Hypoganglionosis resembles Hirschsprung's disease as in both diseases, patients may present with severe constipation or pseudo-obstruction. To date, diagnosis of hypoganglionosis is still difficult to be established due to lack of international consensus regarding diagnostic criteria. This study aims to evaluate the use of immunohistochemistry to provide objective support for our initial subjective impression of hypoganglionosis as well as to describe the morphological features of this study. Methods: This is a cross-sectional study. Three resected intestinal samples from patients with hypoganglionosis at Kyushu University Hospital, Fukuoka, Japan were included in this study. One healthy intestinal sample was used as control. All specimens were immunohistochemically stained with anti-S-100 protein, anti-α-smooth muscle actin (α-SMA), and anti-c-kit protein antibodies. Results: (I) S-100 immunostaining: hypoplasia of the myenteric ganglia and marked reduction of intramuscular nerve fibers were observed in several segments of the intestine. (II) α-SMA immunostaining: the pattern of the muscular layers was almost normal in all segments; however, some areas showed hypotrophy of the circular muscle (CM) layers and hypertrophy of the longitudinal muscle (LM) layers. (III) C-kit immunostaining: a decreased in the number of interstitial cells of Cajal (ICCs) was observed in almost all segments of the resected intestine, even around the myenteric plexus. Conclusions: Each segment of intestine in hypoganglionosis had different numbers of ICCs, sizes, and distributions of ganglions, as well as patterns of musculature, which may range from severely abnormal to nearly normal. Further investigations regarding the definition, etiology, diagnosis, and treatment of this disease should be performed to improve the prognosis of this disease.

The Role of Pretransplant Infections in Pediatric Receiving LDLT in Indonesia: A 7-y Retrospective Study.

Liver transplantation is the definitive treatment for pediatric end-stage liver disease. Infections posttransplantation might significantly affect the outcome of the surgery. This study aimed to identify the role of pretransplant infection among children who underwent living donor liver transplantation (LDLT) in Indonesia. Methods: This is an observational, retrospective cohort study. A total of 56 children were recruited between April 2015 and May 2022. Patients were categorized into 2 according to the presence of pretransplantation infections requiring hospitalization before the surgery. Diagnosis of posttransplantation infection was observed for up to 1 y based on the clinical features and laboratory parameters. Results: The most common indication for LDLT was biliary atresia (82.1%). Fifteen of 56 patients (26.7%) had a pretransplant infection, whereas 73.2% of patients were diagnosed with a posttransplant infection. There was no significant association between pretransplant and posttransplant infection in all 3-time points (≤1 mo, 2-6 mo, and 6-12 mo). The most common organ involvement posttransplantation was respiratory infections (50%). The pretransplant infection did not significantly affect posttransplant bacteremia, length of stay, duration of mechanical ventilation, initiation of enteral feeding, hospitalization cost, and graft rejection. Conclusions: Our data showed that pretransplant infections did not significantly affect clinical outcomes in post-LDLT procedures. A prompt and sufficient diagnosis and treatment before and after the LDLT procedure is the best way to obtain an optimal outcome.

The Comparison of Cerebral Oxygenation among Mechanically Ventilated Children Receiving Protocolized Sedation and Analgesia versus Clinician's Decision in Pediatric Intensive Care Unit.

Introduction: Adequate sedation and analgesia are two crucial factors affecting recovery of intensive care patients. Improper use of sedation and analgesia in intensive care patients may adversely lead to brain oxygen desaturation. This study aims to determine cerebral oxygenation as measured by near-infrared spectroscopy (NIRS) and inotropic interventions received among mechanically ventilated children in the pediatric intensive care unit (PICU). Methods: This study is a nested case - control study in the PICU of Indonesian tertiary hospital. Children aged 1 month to 17 years on mechanical ventilation and were given sedation and analgesia were included in the study. Subjects were divided into two groups according to the protocol of the main study (Clinical Trial ID NCT04788589). Cerebral oxygenation was measured by NIRS at five time points (before sedation, 5-min, 1, 6, and 12 h after sedation). Results: Thirty-nine of the 69 subjects were categorized into the protocol group and the rest were in the control group. A decrease of >20% NIRS values was found among subjects in the protocol group at 5-min (6.7%), 1-h (11.1%), 6-h (26.3%), and 12-h (23.8%) time-point. The mean NIRS value was lower and the inotropic intervention was more common in the control group (without protocol), although not statistically significant. Conclusion: This study found that mechanically ventilated children who received sedation and analgesia based on the protocol had a greater decrease of >20% NIRS values compared to the other group. The use of sedation and analgesia protocols must be applied in selected patients after careful consideration.

The role of passive leg raising to predict fluid responsiveness in pediatric intensive care unit patients.

OBJECTIVE: Fluid challenge is often used to predict fluid responsiveness in critically ill patients. Inappropriate fluid expansion can lead to some unwanted side effects; therefore, we need a noninvasive predictive parameter to assess fluid responsiveness. We want to assess the hemodynamic parameter changes after passive leg raising, which can mimic fluid expansion, to predict fluid responsiveness in pediatric intensive care unit patients and to get a cutoff value of cardiac index in predicting fluid responsiveness in pediatric patients. DESIGN: Nonrandomized experimental study. SETTING: Tertiary academic pediatric intensive care. PATIENTS: Children admitted to pediatric intensive care. INTERVENTION: Hemodynamic parameters were assessed at baseline, after passive leg raising, at second baseline, and after volume expansion (10 mL/kg normal saline infusion over 15 mins). MEASUREMENTS AND MAIN RESULTS: We measured the heart rate, systolic blood pressure, and stroke volume and cardiac index using Doppler echocardiography. The hemodynamic parameter changes induced by passive leg raising were monitored. Among 40 patients included in the study, 20 patients had a cardiac index increase of ≥10% after volume expansion (responders). Changes in heart rate, systolic blood pressure, and stroke volume after passive leg raising did not significantly relate to the response to volume expansion. There was significant relation between changes in cardiac index to predict fluid responsiveness (p = .012, r(2) = .22, 95% confidence interval 1.529 to 31.37). A cardiac index increase by ≥10% induced by passive leg raising predicted preload-dependent status with sensitivity of 55% and specificity of 85% (area under the curve 0.71 ± 0.084, 95% confidence interval 0.546-0.874). CONCLUSION: The concomitant measurements in cardiac index changes after the passive leg raising maneuver can be helpful in predicting who might have an increase in cardiac index with subsequent fluid resuscitation.

Characteristics of hemodynamic parameters after fluid resuscitation and vasoactive drugs administration in pediatric shock: A prospective observational study.

Background: Prior studies have shown that septic shock survivors had a normal cardiac index (CI) and systemic vascular resistance index (SVRI). However, this feature seems to be questionable in other-caused shock, since several factors are associated with the hemodynamic profile. This study aims to describe hemodynamic profiles (preload, inotropy, afterload, stroke volume, and cardiac output) after fluid resuscitation and vasoactive therapy in children with shock. Methods: Children aged 1 month to 18 years old with shock conditions were included in this study. Fluid resuscitation was administered following the American College of Critical Care Medicine (ACCM) protocol. Hemodynamic profiles were assessed at 1 and 6 h from the start of fluid resuscitation. Grouping of the subjects was determined by the USCOM examination in 1st hour until the end of the study and we divided into 3 groups. Results: At 1 h, group 1 (low CI) was 14% (CI:2.5[1.2-3.2]L/min/m2), group 2 (normal CI) was 66% (CI:4.2[3.4-5.8]L/min/m2), and group 3 (high CI) was 20% (CI:7.1[6.1-9.4]L/min/m2). SVRI was higher in groups 1 and 2 compared to group 3 (p < 0.05). Group 1 and 2 revealed fluid-refractory shock (SVV:25[12-34]% and 29(13-58)%, respectively), lower Smith-Madigan Inotropy Index (SMII) and higher Potential to Kinetic Ratio (PKR) compared to group 3 (p < 0.05). Group 3 revealed fluid-responsive shock (Stroke Volume Variation (SVV):32[18-158]%), higher SMII and lower PKR. At 6th hour, CI in all groups were normal (group 1:3.5[1.2-7.5]; group 2:4.0[1.7-6.1]; group 3:6.0[3.1-6.2]). However, 71.4% and 54.5% of subjects in groups 1 and 2, respectively, still revealed low inotropy. Group 3 revealed a significant increase in SVRI and PKR (p < 0.01). Conclusions: Most pediatric shock patients were hypodynamic. Even when the CI was normal, the preload, inotropy, and afterload may still be abnormal. It represented the inotropy as a key to hemodynamic.

The Correlations of Human Atrial Natriuretic Peptide on Cardiac Function and Hemodynamics in Pediatric Septic Shock.

Purpose: We aimed to determine the correlations of human Atrial Natriuretic Peptide (ANP) on cardiac function and hemodynamics in pediatric septic shock. Patients and Methods: We conducted an observational and prospective study on 30 children with septic shock. Measurement of the level of human atrial natriuretic peptide was determined in the serum of patients. Cardiac power (CP) is a cardiac function parameter measured with cardiac output (cardiovascular flow) and mean arterial (intravascular) pressure. Cardiac output and mean arterial pressure were monitored using pressure recording analytical methods (PRAM). Hemodynamic status was represented by a vasoactive inotropic score. Results: Thirty pediatric septic shock patients fulfilled the eligibility criteria. The human ANP level was not significantly different in pediatric septic shock on three days of examination. Cardiac power was significantly different in pediatric septic shock on three days of examination. There was a correlation between human ANP and cardiac power on day 3 and human ANP and VIS on day 2. Conclusion: There was a significant correlation between human ANP level and cardiac power on day 3 and ANP level and VIS on day 2. The cardiac power on day 3 and VIS on 48 hours can be alternatives to evaluate the hemodynamic status and cardiac function concerning human ANP in pediatric septic shock.

Correlation between syndecan-1 level and PELOD-2 score and mortality in pediatric sepsis. / Correlação entre níveis de sindecano 1, escore PELOD-2 e mortalidade em sepse pediátrica.

OBJECTIVE: To analyze the correlation between glycocalyx disruption measured via the serum syndecan-1 level and organ dysfunctions assessed by the PELOD-2 score and to evaluate its association with mortality in pediatric sepsis. METHODS: We performed a prospective observational study in a tertiary public hospital. Sixty-eight pediatric patients diagnosed with sepsis according to International Pediatric Sepsis Consensus Conference criteria were consecutively recruited. We performed measurements of day 1 and day 5 serum syndecan-1 levels and PELOD-2 score components. Patients were followed up to 28 days following sepsis diagnosis. RESULTS: Overall, the syndecan-1 level was increased in all subjects, with a significantly higher level among septic shock patients (p = 0.01). The day 1 syndecan-1 level was positively correlated with the day 1 PELOD-2 score with a correlation coefficient of 0.35 (p = 0.003). Changes in syndecan-1 were positively correlated with changes in the PELOD-2 score, with a correlation coefficient of 0.499 (p < 0.001) during the first five days. Using the cutoff point of day 1 syndecan-1 ≥ 430ng/mL, organ dysfunction (PELOD-2 score of ≥ 8) could be predicted with an AUC of 74.3%, sensitivity of 78.6%, and specificity of 68.5% (p = 0.001). CONCLUSION: The day 1 syndecan-1 level was correlated with the day 1 PELOD-2 score but not 28-day mortality. Organ dysfunction (PELOD-2 ≥ 8) could be predicted by the syndecan-1 level in the first 24 hours of sepsis, suggesting its significant pathophysiological involvement in sepsis-associated organ dysfunction.

OBJETIVO: Analisar a correlação entre a lesão do glicocálix medida pelo nível sérico de sindecano 1 e as disfunções de órgãos avaliadas com o escore PELOD-2, assim como avaliar sua associação com a mortalidade em sepse pediátrica. MÉTODOS: Realizou-se um estudo prospectivo observacional em um hospital terciário público. Sessenta e oito pacientes pediátricos, com diagnóstico de sepse segundo os critérios da International Pediatric Sepsis Consensus Conference, foram consecutivamente recrutados. Nos dias 1 e 5, realizaram-se dosagens dos níveis séricos de sindecano 1 e avaliação dos componentes do escore PELOD-2. Os pacientes foram seguidos por até 28 dias após o diagnóstico de sepse. RESULTADOS: Em geral, o nível de sindecano 1 estava aumentado em todos os participantes, com nível significantemente mais elevado nos pacientes em choque (p = 0,01). O nível de sindecano 1 no dia 1 teve correlação positiva com o escore PELOD-2 no dia 1 e coeficiente de correlação de 0,35 (p = 0,003). Nos primeiros 5 dias após o diagnóstico de sepse, as alterações nos níveis de sindecano 1 tiveram correlação positiva com modificações no escore PELOD-2, com coeficiente de correlação de 0,499 (p < 0,001). Com utilização de um ponto de corte dos níveis de sindecano 1 no dia 1 ≥ 430ng/mL, a disfunção de órgãos (escore PELOD-2 ≥ 8) pôde ser predita com área sob a curva de 74,3%, sensibilidade de 78,6% e especificidade de 68,5% (p = 0,001). CONCLUSÃO: O nível de sindecano 1 no dia 1 teve correlação com o escore PELOD-2 no dia 1, porém não se associou com a mortalidade aos 28 dias. A disfunção de órgãos (PELOD-2 ≥ 8) pôde ser predita pelo nível de sindecano 1 nas primeiras 24 horas de sepse, sugerindo seu significante envolvimento na fisiopatologia da disfunção de órgãos associada à sepse.

Resuscitation of hemorrhagic shock using normal saline does not damage the glycocalyx in the immediate resuscitation phase.

OBJECTIVES: The objectives were to study the effect of aggressive resuscitation using normal saline on hemodynamics, serum atrial natriuretic peptide (ANP), syndecan-1 (marker of endothelial glycocalyx shedding), and extravascular lung water index (ELWI) following hemorrhagic shock. METHODS: Eleven male piglets (Sus scrofa) underwent blood drawing to create 20% drop in mean arterial pressure (MAP). Two-phase resuscitation was performed: Phase 1 using normal saline of an equal volume of blood drawn to create shock and Phase 2 using 40 ml/kg BW of normal saline to simulate hypervolemia and hemodilution. Heart rate, MAP, cardiac index (CI), systemic vascular resistance index, oxygen delivery (DO2), global end-diastolic volume index, ELWI, hemoglobin (Hb), lactate, ANP, and syndecan-1 at each phase and up to 60 min following Phase 2 resuscitation were recorded. RESULTS: Phase 2 resuscitation significantly decreased Hb concentration (P = 0.006), however, DO2 was maintained (P = 1.000). CI increased from shock to Phase 1 (P = 0.029) and further increase in Phase 2 resuscitation (P = 0.001). Overall, there was a transient increase of ANP following Phase 1 resuscitation, from 85.20 ± 40.86 ng/L at baseline to 106.42 ± 33.71 ng/L (P = 0.260). Serum syndecan-1 and ELWI change at all phases were not significant. CONCLUSIONS: We demonstrate compensatory protective mechanism despite overzealous fluid resuscitation. Compensatory increased CI despite decreased Hb maintained DO2. In the absence of inflammation, serum ANP did not increase significantly, no glycocalyx shedding occurred, subsequently no change in ELWI. We show that factors other than volume overload are more dominant in causing glycocalyx shedding.

Parents' Perspectives Toward School Reopening During COVID-19 Pandemic in Indonesia-A National Survey.

Background: All sectors are affected due to COVID-19 pandemic occurring worldwide, including the education industry. School closure had been taking place for more than a year in Indonesia. Despite the controversies, Indonesian government had decided to begin school reopening. Objectives: This study aims to assess parental readiness for school reopening, and factors affecting parental attitude toward school reopening. Methods: A cross-sectional study using online questionnaire distributed via official Indonesian Pediatric Society (IPS) official social media account collected between March and April 2021. The questionnaire contained the general characteristics of study participants, parents' knowledge, and perspectives on COVID-19, and health protocols for school reopening. Results: A total of 17,562 responses were collected, of which 55.7% parents were ready to send their children to school should school reopens. Factors significantly contribute to parental decision to keep their child at home were: presence of vulnerable population at home [OR = 1.18 (1.10-1.27), p < 0.001], children with comorbidities [OR = 2.56 (2.29-2.87), p < 0.001], perception of COVID-19 as a dangerous disease [OR = 28.87 (14.29-58.33), p < 0.001], experience with COVID-19 positive cases in the community [OR = 1.75 (1.61-1.90), p < 0.001], COVID-19 related death in the community [OR = 2.05 (1.90-2.21), P < 0.001], approval for adult COVID-19 vaccination [OR = 1.69 (1.53-1.87), p < 0.001], and ownership of private transportation [OR = 1.46 (1.30-1.66), p <0.001]. Conclusion: We identified several factors affecting parental perception on school reopening during COVID-19 pandemic that should be addressed. This study can be used for policy-maker to make further recommendations and health educations prior to school reopening in Indonesia.

Corrigendum on: Pediatric COVID-19: Report from Indonesian pediatric society data registry.

[This corrects the article DOI: 10.3389/fped.2021.716898.].

Inferior Vena Cava/Abdominal Aorta Ratio as a Guide for Fluid Resuscitation.

INTRODUCTION: The fluid therapy is crucial in the treatment of critically ill children. Inadequate or excessive fluid resuscitation leads to increased mortality and morbidity, thus necessitating an accurate parameter for predicting fluid responsiveness when conducting fluid resuscitation. The inferior vena cava/abdominal aorta (IVC/Ao) ratio is suggested as a good guide for fluid resuscitation. However, the cutoff value for predicting fluid responsiveness in children has not been established. Is IVC/Ao ratio can be used to predict fluid responsiveness? METHODS: The objective was to determine the accuracy and a cutoff value of IVC/Ao in predicting fluid responsiveness. A prospective cross-sectional study was conducted in the emergency room and the pediatric intensive care unit of the tertiary hospital from March to August 2017. We consecutively enrolled all critically ill children aged 1 month to 18 years' old who were hemodynamically unstable (shock). Measurements of IVC/Ao with ultrasound and stroke volume with ultrasound cardiac output monitor were obtained before and after fluid challenge. RESULTS: Of 167 subjects enrolled in this study, only 58 subjects were included, most of whom were male (58.6%) and ranging in age from 1 to 11 months (32.8%). The mean IVC/Ao ratio before the fluid challenge in the fluid responsive group was 0.70 ± 0.053. The best cutoff of the IVC/Ao ratio is 0.675 with area under the curve 70.8% (95% confidence interval of 54.6%-87%), 75.7% sensitivity, and 61.9% specificity for predicting significant fluid responsiveness. CONCLUSION: The measurement of IVC/Ao is an accurate, sensitive, and specific parameter to predict fluid responsiveness. The best cut-off for the IVC/Ao ratio is 0.675.

Serum NT-Pro-BNP versus Noninvasive Bedside Inotropic Index in Paediatric Shock: A Contest of Myocardial Performance in Response to Fluid Loading.

BACKGROUND: Mild elevation of serum amino-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is associated with myocardial dysfunction. A significantly lower Smith-Madigan inotropic index (SMII) has been shown to accurately represent cardiac contractility among heart failure subjects. We aim to monitor the effect of fluid resuscitation on cardiac function among paediatric patients by measuring serum NT-pro-BNP and SMII. METHODS: This is an observational study on 70 paediatric shock patients. NT-pro-BNP and noninvasive bedside haemodynamic monitoring were done by using an ultrasonic cardiac output monitor (USCOM, USCOM, Sydney, Australia). The presence of cardiac diseases was excluded. SMII was obtained from the USCOM. An increase in the stroke volume index (SVI) of ≥15% indicates fluid responders. Measurements were taken before and after fluid loading. RESULTS: Preloading NT-pro-BNP and SMII category were significantly different between the fluid responsiveness group, p=0.001 and p=0.004, respectively. Higher median NT-pro-BNP (preloading NT-pro-BNP of 1175.00 (254.50-9965.00) ng/mL vs. 196.00 (65.00-509.00) ng/mL, p=0.002) was associated with fluid nonresponders (subjects >12 months old). Preloading NT-pro-BNP <242.5 ng/mL was associated with fluid responders (AUC: 0.768 (0.615-0.921), p=0.003), 82.1% sensitivity, and 68.7% specificity for subjects >12 years old. Delta NT-pro-BNP in fluid responders (15.00 (-16.00-950.00) ng/mL) did not differ from fluid nonresponders (505.00 (-797.00-1600.00) ng/mL), p=0.456. Postloading SMII >1.25 W·m-2 was associated with fluid responders (AUC: 0.683 (0.553-0.813), p = 0.011), 61.9% sensitivity, and 66.7% specificity, but not preloading SMII. Fluid responders had a higher mean postloading SMII compared to nonresponders (1.36 ± 0.38 vs. 1.10 ± 0.34, p=0.006). CONCLUSION: Higher NT-pro-BNP and lower SMII in the absence of cardiac diseases were associated with poor response to fluid loading. The SMII is affected by low preload conditions.

Echovirus-7 Infection in Children with Unusual Severe Manifestation: A Case Report.

We report a rare laboratory-confirmed, clinical case of Echovirus-7 infection in an immuno-competent child with central nervous system and systemic manifestation. Echovirus infection is usually mild, however in this case we identified echovirus-7 infection with 91% homology with the Echovirus-7 strain previously isolated in neighbouring country with severe manifestation.

Validation of the vasoactive-inotropic score in predicting pediatric septic shock mortality: A retrospective cohort study.

INTRODUCTION: Mortality in pediatric septic shock remains very high. Vasoactive-inotropic score (VIS) is widely used to predict prognosis in patients with heart disease. It is a simple method that was initially used as a predictor of morbidity and mortality in postoperative patients with congenital heart diseases. Previous reports showed that high VIS score was associated with high mortality in pediatric sepsis. However, its discriminative value remains unclear. We aim to explore the discriminative value of VIS in predicting mortality in pediatric septic shock patients. METHODS: We conducted a retrospective cohort study on medical records of septic shock patients who received care in the pediatric intensive care unit (PICU). We screened medical records of pediatric patients which were diagnosed with septic shock and admitted to the PICU and received vasoactive/inotropic score for more than 8 h. Other supporting examination results were recorded, such as organ function evaluation for calculation of Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score. The outcome of patients was recorded. The receiver operating curve was constructed to calculate the area under the curve (AUC), sensitivity, and specificity of each cutoff point. RESULTS: We obtained the optimum cutoff point of VIS > 11 with 78.87% sensitivity and 72.22% specificity. AUC positive was 0.779 (P < 0.001); predictive value and negative predictive value were 91.80% and 46.43%, respectively. CONCLUSION: VIS > 11 has a good ability to predict mortality in children with septic shock.