Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024.

RATIONALE: Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods. OBJECTIVES: The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians. PANEL DESIGN: The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting. METHODS: We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research. RESULTS: This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available. CONCLUSIONS: The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.

Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study From the National Emergency Airway for Children Registry (2015-2019).

OBJECTIVES: To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019. DESIGN/SETTING: Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia. SUBJECTS: Critically ill children requiring TI in a PICU or pediatric cardiac ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021). CONCLUSIONS: TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.

Development and clinical feasibility of a reduced-dose radiograph in children for feeding tube placement.

BACKGROUND: Temporary feeding tubes are commonly used but may lead to complications if malpositioned. Radiographs are the gold standard for assessing tube position, but clinician concern over radiation risks may curtail their use. OBJECTIVE: We describe development and use of a reduced dose feeding tube radiograph (RDFTR) targeted for evaluation of feeding tube position. MATERIALS AND METHODS: Age-based abdominal radiograph was adapted to use the lowest mAs setting of 0.32 mAs with field of view between carina and iliac crests. The protocol was tested in DIGI-13 line-pair plates and anthropomorphic phantoms. Retrospective review of initial clinical use compared dose area product (DAP) for RDFTR and routine abdomen, chest, or infant chest and abdomen. Review of RDFTR reports assessed tube visibility, malpositioning, and incidental critical findings. RESULTS: Testing through a line-pair phantom showed loss of spatial resolution from 2.2 line pairs to 0.6 line pairs but preserved visibility of feeding tube tip in RDFTR protocol. DAP comparisons across 23,789 exams showed RDFTR reduced median DAP 72-93% compared to abdomen, 55-78% compared to chest, and 76-79% compared to infant chest and abdomen (p<0.001). Review of 3286 reports showed tube was visible in 3256 (99.1%), malpositioned in airway 8 times (0.2%) and in the esophagus 74 times (2.3%). The tip was not visualized in 30 (0.9%). Pneumothorax or pneumoperitoneum was noted seven times (0.2%) but was expected or spurious in five of these cases. CONCLUSION: RDFTR significantly reduces radiation dose in children with temporary feeding tubes while maintaining visibility of tube tip.

Predictors of the inability to achieve full oral feeding in postoperative infants with CHD.

OBJECTIVES: Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass. STUDY DESIGN: A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system. RESULTS: 58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding. CONCLUSIONS: Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.

A scoping review of the role of policy in mitigating childhood obesity in underserved populations using the RE-AIM framework.

BACKGROUND: Childhood obesity is an escalating crisis in the United States. Health policy may impact this epidemic which disproportionally affects underserved populations. AIM: The aim was to use the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to assess health policy impact on preventing or treating school-aged children (5 > 18 years) with obesity in underserved populations. METHODS: A scoping review of 842 articles was conducted. Twenty-four articles met the inclusion criteria and underwent data extraction. RESULTS: Twelve studies included subgroup analysis, with four suggesting an impact of policy on at-risk groups. None of the 24 studies fully applied the RE-AIM framework. Policies positively impacted childhood obesity in 12 studies across the sample. LINKING EVIDENCE TO ACTION: Our review revealed inconsistent evidence for the effectiveness of policy on childhood obesity, perhaps due to the lack of focus on the social determinants of health. In addition, many studies did not evaluate the outcomes for underserved populations. Therefore, we propose more attention to social determinants in future legislation and evaluation of policy effectiveness on underserved populations. Findings identify an urgent need for the design, implementation, and evaluation of policies specifically directed to address the inequities of racism, social injustices, and social determinants of health that impact childhood obesity in the United States. Future work needs to identify who was reached by the policy, who benefitted from the policy, and how policies were implemented to address obesity-related health disparities. Nurses should advocate for the evaluation of childhood obesity policies, particularly in underserved populations, to determine effectiveness. Nurses, particularly those trained in population and community health and research, should advocate for policy research that considers inequities rather than controls for these variables. Multi-layered interventions can then be tailored to sub-populations and evaluated more effectively.

Oral feeding dysfunction in post-operative infants with CHDs: a scoping review.

Post-operative oral feeding difficulties in neonates and infants with CHD is common. While pre-operative oral feeding may be normal, oral feeding challenges manifest in the post-operative period without a clearly defined aetiology. The objective of this scoping review was to examine post-operative oral feeding in full-term neonates and infants with a CHD. Electronic databases query (1 January 1975-31 May 2021), hand-search of the reference lists of included studies, contact with experts, and review of relevant conferences were performed to identify quantitative studies evaluating post-operative oral feeding in full-term neonates and infants with a CHD. Associations with additional quantitative variables in these studies were also examined. Twenty-five studies met inclusion criteria. Eighty per cent were cohort studies that utilised retrospective chart review from a single institution. The primary variable of interest in all studies was oral feeding status upon discharge from neonatal hospitalisation. The most common risk factors evaluated with poor feeding at time of discharge were birth weight (36% of included studies), gestational age (44%), duration of post-operative intubation (48%), cardiac diagnosis (40%), and presence of genetic syndrome or chromosomal anomaly (36%). The most common health-related outcomes evaluated were length of hospital stay (40%) and length of ICU stay (16%). Only the health-related outcomes of length of hospital stay and length of ICU stay were consistently significantly associated with poor post-operative oral feeding across studies in this review. A clear aetiology of poor post-operative oral feeding remains unknown.

The Prevalence, Intensity, Assessment, and Management of Acute Pain in Hospitalized Children in Botswana.

BACKGROUND: There is very limited clinical and observational data on acute pain experienced by children in sub-Saharan Africa. AIMS: To report the prevalence and intensity of acute pain, pain management practices, and describe associations between acute pain outcomes, children's and parents or guardian's demographics in hospitalized children aged 2 months to 13 years in Botswana. DESIGN: A descriptive correlational prospective observational study using five repeated cross-sectional samples. SETTINGS: Two referral hospitals in Botswana. PARTICIPANTS: The sample size included 308 children and 226 parents or guardians. Data were collected between November 2018 and February 2019 from children, their parents or guardians (<7 years child), and the health record for pain documentation and treatment. MEASURES: Pain was measured using Faces Pain Scale-Revised for children ≥7 years, revised Face, Legs, Activity, Cry, Consolability scale for children <7 years and numeric rating scale for parents or guardians. RESULTS: There are 1,290 data points for children of which 1,000 were children <7 years and 999 data points for parents or guardians of children <7 years were used in analysis. Fifty percent of children <7 years were in pain using the revised Face, Legs, Activity, Cry, Consolability scale, whereas parents indicated 46% to be in pain. The pain prevalence for children ≥7 years was estimated at 54%. Pain was documentated at a rate of 54 % on the health records. Acetaminophen was most common analgesic across all age groups. Univariate associations of child <7 years pain intensity was statistically significant (p ≤ .05) for weight, diagnosis, residence, and parent relationship. Parents reported pain intensity was statistically significant (p ≤ .05) for child sex, weight, diagnosis, residence, surgery, parent or guardian age and education. Only age and surgery were significant for children ≥7 years. CONCLUSIONS: Acute pain prevalence and intensity among hospitalized children in Botswana is low.

The perceptions and practices of parents and children on acute pain management among hospitalized children in two Botswana referral hospitals.

BACKGROUND: Perceptions and practices of parties in pediatric pain are critical in children's access to adequate acute pain management. The personal factors of the child and parents have been shown to be central to pediatric pain management by the Symptom Management Theory. AIM: To describe children and parents/guardians' perceptions (knowledge, attitudes and beliefs) and practices regarding pediatric acute pain management and explain the influence of socio-cultural and environmental factors on those perceptions and practices. METHODS: Descriptive cross-sectional survey using modified versions of the American Pain Society Patient Outcome Questionnaire-Revised among parents/guardians and children. RESULTS: A convenience sample of 275 parents/guardians and 42 children aged 8 to 13 years admitted between date November 2018 and February 2019 to two Botswana tertiary hospitals completed the surveys. Forty-seven percent (n = 129) of parents/guardians reported the child to be in moderate-severe pain, while 38% (n = 16) of children reported pain as moderate-severe at the time of the survey. The children mean scores for cm-APS-POQ-R were 113(33) while parents/guardian's guardians for m-APS-POQ-R were 123(26). The subscales except for the parents/'guardians' pain interference (p = .96) were statistically significant (p = .000), showing adequate knowledge, positive attitudes and high pain intensity for both parents/guardians and children. CONCLUSION: Parent/guardians and children reported a high incidence of acute pain, were content with pain management services, and showed adequate knowledge of pediatric pain and its management. The incongruence between the intensity of pain, satisfaction on the adequacy of pain management and knowledge and attitudes demonstrated in this study need further inquiry.

Lower serum selenium concentration associated with anxiety in children.

PURPOSE: Few studies have examined the role of selenium in anxiety. This study aimed to evaluate the association between serum selenium concentrations and anxiety disorders and symptoms in children. DESIGN AND METHODS: This study utilized data from 831 children participating in the China Jintan Child Cohort Study (mean age = 12.67 years; 46.1% female). Serum selenium samples were collected and anxiety was assessed using the Chinese version of the Screen for Child Anxiety Related Disorders. Six types of anxiety scores were calculated, including total anxiety, panic/somatic, generalized anxiety, separation anxiety, social anxiety, and school phobia. RESULTS: Controlling for covariates, children with lower serum selenium concentrations were more likely to meet clinical cutoffs for total anxiety (OR = 0.992, p < 0.01), panic/somatic disorder (OR = 0.993, p < 0.05), generalized anxiety disorder (OR = 0.990, p < 0.05), social anxiety disorder (OR = 0.991, p < 0.01), and school phobia (OR = 0.989, p < 0.01), but not separation anxiety (OR = 1.000, p > 0.05). Controlling for covariates, lower serum selenium concentrations were also associated with higher continuous total anxiety, generalized anxiety, and school phobia scores (p < 0.05). CONCLUSIONS: Lower serum selenium concentrations were associated with higher anxiety. To our knowledge, this was the first study to examine the relationship between serum selenium and anxiety disorders in a sample of children. Results indicate an association between children's micronutrient levels and anxiety disorders. PRACTICE IMPLICATIONS: Improving child nutrition may be a promising strategy to help reduce childhood anxiety.

Standardized Feeding Approach Mitigates Weight Loss in Infants with Congenital Heart Disease.

OBJECTIVE: To evaluate the effect of a standardized feeding approach using a clinical nutrition pathway on weight-for-age Z score (WAZ) over hospital length of stay (HLOS) for infants with congenital heart disease (CHD). STUDY DESIGN: A 10-year retrospective cohort study examined eligible infants who underwent neonatal cardiac surgery between July 2009 and December 2018 (n = 987). Eligibility criteria included infants born at least 37 weeks of gestation and a minimum birth weight of 2 kg who underwent cardiac surgery for CHD within the first 30 days of life. Using the best linear unbiased predictions from a linear mixed effects model, WAZ change over HLOS was estimated before and after January 2013, when the standardized feeding approach was initiated. The best linear unbiased predictions model included adjustment for patient characteristics including sex, race, HLOS, and class of cardiac defect. RESULTS: The change in WAZ over HLOS was significantly higher from 2013 to 2018 than from 2009 to 2012 (ß = 0.16; SE = 0.02; P < .001), after controlling for sex, race, HLOS, and CHD category, indicating that infants experienced a decreased WAZ loss over HLOS after the standardized feeding approach was initiated. Additionally, differences were found in WAZ loss over HLOS between infants with single ventricle CHD (ß = 0.26; SE = 0.04; P < .001) and 2 ventricle CHD (ß = 0.04; SE = 0.02; P = .04). CONCLUSIONS: These data suggest that an organized, focused approach for nutrition therapy using a standardized pathway improves weight change outcomes before hospital discharge for infants with single and 2 ventricle CHD who require neonatal cardiac surgery.

Serum micronutrient status, sleep quality and neurobehavioural function among early adolescents.

OBJECTIVE: To examine associations between serum micronutrients and neurobehavioural function and the mediating role of sleep quality in early adolescents. DESIGN: In this cross-sectional study, peripheral blood samples were analysed for Fe and Zn levels. The Pittsburgh Sleep Quality Index and Penn Computerized Neurocognitive Battery were used to assess sleep quality and neurobehavioural function, respectively. The logistic/linear regressions and generalised structural equation modelling were performed to estimate the associations. SETTING: Jintan, China. PARTICIPANTS: In total, 226 adolescents (106 females) from the Jintan Child Cohort study. RESULTS: Adolescents with low Fe (<75 µg/dl) (OR = 1·29, P = 0·04) and low Zn (<70 µg/dl) (OR = 1·58, P < 0·001) were associated with increased odds for poor sleep quality. Adolescents with low Fe and Zn were associated with fast (Fe: ß = -1353·71, P = 0·002, Zn: ß = -2262·01, P = 0·02) but less-accurate (Fe: ß = -0·97, P = 0·04; Zn: ß = -1·76, P = 0·04) performance on non-verbal reasoning task and poor sleep quality partially mediated the associations between low Fe/Zn and non-verbal reasoning (P < 0·05). Additionally, low Fe was associated with a slower reaction on spatial processing task (ß = 276·94, P = 0·04), and low Zn was associated with fast (ß = -1781·83, P = 0·03), but error-prone performance (ß = -1·79, P = 0·04) on spatial processing ability and slower reaction speed (ß = 12·82, P = 0·03) on the attention task. We observed similar trends using a cut-off point of 75 µg/dl for low serum Zn, except for the association with attention task speed (P > 0·05). CONCLUSION: Fe and Zn deficiencies may possibly be associated with poor sleep and neurobehavioural function among early adolescents. Poor sleep may partially mediate the relationship between micronutrients and neurobehavioural function.

Parental Decision-Making in the Pediatric Intensive Care Unit: An Integrative Review.

Parents are commonly responsible for making health care decisions for their seriously ill children in the pediatric intensive care unit (PICU); however, the factors influencing their decisions may vary. This integrative review examined the empirical literature between 2013 and 2018 to understand factors pertaining to parents' decision-making about serious illness care of their children in the PICU. Seventeen studies met the inclusion criteria with three key findings. First, parent-clinician communication in the PICU is critical; second, most parents want to be the final decision-maker for their critically ill child; and third, parents' emotions, support systems, and the child's clinical status impact decision-making. Parental perspectives are important to consider when discussing serious illness care decisions for critically ill children. Further inquiry is needed into how the parent-clinician encounter impacts the decision-making process and subsequent outcomes in this population.

Early Enteral Nutrition Is Associated With Improved Clinical Outcomes in Critically Ill Children: A Secondary Analysis of Nutrition Support in the Heart and Lung Failure-Pediatric Insulin Titration Trial.

OBJECTIVES: The impact of early enteral nutrition on clinical outcomes in critically ill children has not been adequately described. We hypothesized that early enteral nutrition is associated with improved clinical outcomes in critically ill children. DESIGN: Secondary analysis of the Heart and Lung Failure-Pediatric Insulin Titration randomized controlled trial. SETTING: Thirty-five PICUs. PATIENTS: Critically ill children with hyperglycemia requiring inotropic support and/or invasive mechanical ventilation who were enrolled for at least 48 hours with complete nutrition data. INTERVENTIONS: Subjects received nutrition via guidelines that emphasized enteral nutrition and were classified into early enteral nutrition (enteral nutrition within 48 hr of study randomization) and no early enteral nutrition (enteral nutrition after 48 hr of study randomization, or no enteral nutrition at any time). MEASUREMENTS AND MAIN RESULTS: Of 608 eligible subjects, 331 (54%) received early enteral nutrition. Both early enteral nutrition and no early enteral nutrition groups had similar daily caloric intake over the first 8 study days (median, 36 vs 36 kcal/kg/d; p = 0.93). After controlling for age, body mass index z scores, primary reason for ICU admission, severity of illness, and mean Vasopressor-Inotrope Score at the time of randomization, and adjusting for site, early enteral nutrition was associated with lower 90-day hospital mortality (8% vs 17%; p = 0.007), more ICU-free days (median, 20 vs 17 d; p = 0.02), more hospital-free days (median, 8 vs 0 d; p = 0.003), more ventilator-free days (median, 21 vs 19 d; p = 0.003), and less organ dysfunction (median maximum Pediatric Logistic Organ Dysfunction, 11 vs 12; p < 0.001). CONCLUSIONS: In critically ill children with hyperglycemia requiring inotropic support and/or mechanical ventilation, early enteral nutrition was independently associated with better clinical outcomes.

Incorporating the latest pediatric nutrition support guidelines into clinical practice.

Optimal nutrition support in critically ill children is associated with improved outcomes and decreased mortality. Nutrition provision often competes with other care priorities in critically ill patients. The 2017 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient supplement clinician knowledge and inform best practices for nutrition therapy in this vulnerable patient population.

The Association of Nutrition Status Expressed as Body Mass Index z Score With Outcomes in Children With Severe Sepsis: A Secondary Analysis From the Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study.

OBJECTIVES: The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the association of nutrition status (expressed as body mass index z score) with outcomes in pediatric severe sepsis. DESIGN: Secondary analysis of the Sepsis Prevalence, Outcomes, and Therapies study. Patient characteristics, ICU interventions, and outcomes were compared across nutrition status categories (expressed as age- and sex-adjusted body mass index z scores using World Health Organization standards). Multivariable regression models were developed to determine adjusted differences in all-cause ICU mortality and ICU length of stay by nutrition status. SETTING: One-hundred twenty-eight PICUs across 26 countries. PATIENTS: Children less than 18 years with severe sepsis enrolled in the Sepsis Prevalence, Outcomes, and Therapies study (n = 567). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nutrition status data were available for 417 patients. Severe undernutrition was seen in Europe (25%), Asia (20%), South Africa (17%), and South America (10%), with severe overnutrition seen in Australia/New Zealand (17%) and North America (14%). Severe undernutrition was independently associated with all-cause ICU mortality (adjusted odds ratio, 3.0; 95% CI, 1.2-7.7; p = 0.02), whereas severe overnutrition in survivors was independently associated with longer ICU length of stay (1.6 d; p = 0.01). CONCLUSIONS: There is considerable variation in nutrition status for children with severe sepsis treated across this selected network of PICUs from different geographic regions. Severe undernutrition was independently associated with higher all-cause ICU mortality in children with severe sepsis. Severe overnutrition was independently associated with greater ICU length of stay in childhood survivors of severe sepsis.

A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness.

OBJECTIVES: To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness. DATA SOURCES: For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017. STUDY SELECTION: Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment. DATA EXTRACTION: Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale. DATA SYNTHESIS: Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications. CONCLUSIONS: Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.

The state of the science in paediatric pain management practices in low-middle income countries: An integrative review.

AIM: Examine the state of the science for pain management in children living in low-middle income countries (LMIC). BACKGROUND: Significant challenges exist in pain management for children living in LMIC. METHODS: An integrative review was conducted using PRISMA guidelines for quality of reporting. Literature searches were completed using Medline, PubMed, Scopus, and CINAHL databases for publications between January 2006 and August 2016 using MeSH and primary search terms pain and LMIC. Full text publications were evaluated using GRADE criterion and methodology specific evaluation tools. RESULTS: Of 1510 publications identified, 31 met the criteria for inclusion. Data were categorized into three broad themes: (1) magnitude of the pain problem with subthemes describing the burden of and resources for paediatric pain management; (2) perceptions, experience, and practices for managing pain in children residing in LMIC with subthemes addressing health care providers, parent/caregiver and children, respectively; and (3) pain management practices with pain assessment and treatment strategies as subthemes. CONCLUSION: Current data on paediatric pain management in LMIC are limited with respect to describing the burden of pain, children's pain perceptions and experiences, and pain management practices. Rigorous investigations are needed to expand knowledge and address the pervasive problem of pain for children in LMIC.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.

This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

The prevalence and effects of aspiration among neonates at the time of discharge.

BACKGROUND: Neonates undergoing heart surgery for CHD are at risk for postoperative gastrointestinal complications and aspiration events. There are limited data regarding the prevalence of aspiration after neonatal cardiothoracic surgery; thus, the effects of aspiration events on this patient population are not well understood. This retrospective chart review examined the prevalence and effects of aspiration among neonates who had undergone cardiac surgery at the time of their discharge. Introduction This study examined the prevalence of aspiration among neonates who had undergone cardiac surgery. Demographic data regarding these patients were analysed in order to determine risk factors for postoperative aspiration. Post-discharge feeding routes and therapeutic interventions were extracted to examine the time spent using alternate feeding routes because of aspiration risk or poor caloric intake. Modified barium swallow study results were used to evaluate the effectiveness of the test as a diagnostic tool. Materials and methods A retrospective study was undertaken of neonates who had undergone heart surgery from July, 2013 to January, 2014. Data describing patient demographics, feeding methods, and follow-up visits were recorded and compared using a χ2 test for goodness of fit and a Kaplan-Meier graph. RESULTS: The patient population included 62 infants - 36 of whom were male, and 10 who were born with single-ventricle circulation. The median age at surgery was 6 days (interquartile range=4 to 10 days). Modified barium swallow study results showed that 46% of patients (n=29) aspirated or were at risk for aspiration, as indicated by laryngeal penetration. In addition, 48% (n=10) of subjects with a negative barium swallow or no swallow study demonstrated clinical aspiration events. Tube feedings were required by 66% (n=41) of the participants. The median time spent on tube feeds, whether in combination with oral feeds or exclusive use of a nasogastric or gastric tube, was 54 days; 44% (n=27) of patients received tube feedings for more than 120 days. Premature infants were significantly more likely to have aspiration events than infants delivered at full gestational age (OR p=0.002). Infants with single-ventricle circulation spent a longer time on tube feeds (median=95 days) than infants with two-ventricle defects (median=44 days); the type of cardiac defect was independent of prevalence of an aspiration event. CONCLUSIONS: Aspiration is common following neonatal cardiac surgery. The modified barium swallow study is often used to identify aspiration events and to determine an infant's risk for aspirating. This leads to a high proportion of infants who require tube feedings following neonatal cardiac surgery.