Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS): Prospective, national surveillance, United Kingdom and Ireland, 2020.

BACKGROUND: Paediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2 (PIMS-TS), first identified in April 2020, shares features of both Kawasaki disease (KD) and toxic shock syndrome (TSS). The surveillance describes the epidemiology and clinical characteristics of PIMS-TS in the United Kingdom and Ireland. METHODS: Public Health England initiated prospective national surveillance of PIMS-TS through the British Paediatric Surveillance Unit. Paediatricians were contacted monthly to report PIMS-TS, KD and TSS cases electronically and complete a detailed clinical questionnaire. Cases with symptom onset between 01 March and 15 June 2020 were included. FINDINGS: There were 216 cases with features of PIMS-TS alone, 13 with features of both PIMS-TS and KD, 28 with features of PIMS-TS and TSS and 11 with features of PIMS-TS, KD and TSS, with differences in age, ethnicity, clinical presentation and disease severity between the phenotypic groups. There was a strong geographical and temporal association between SARS-CoV-2 infection rates and PIMS-TS cases. Of those tested, 14.8% (39/264) children had a positive SARS-CoV-2 RT-PCR, and 63.6% (75/118) were positive for SARS-CoV-2 antibodies. In total 44·0% (118/268) required intensive care, which was more common in cases with a TSS phenotype. Three of five children with cardiac arrest had TSS phenotype. Three children (1·1%) died. INTERPRETATION: The strong association between SARS-CoV-2 infection and PIMS-TS emphasises the importance of maintaining low community infection rates to reduce the risk of this rare but severe complication in children and adolescents. Close follow-up will be important to monitor long-term complications in children with PIMS-TS. FUNDING: PHE.

The impact of transfers from neonatal intensive care to paediatric intensive care.

OBJECTIVES: Infants receiving care from neonatal intensive care unit (NICU) can develop chronic problems and be transferred to a paediatric intensive care unit (PICU) for on-going care. There is concern that such infants may take up a large amount of PICU resource, but this is not evidence based. We determined the impact of such transfers. METHODS: We reviewed 10 years of NICU admissions to two tertiary PICUs, which had approximately 12,000 admissions during that period. RESULTS: Sixty-seven infants, gestational age at birth 34.7 (IQR 27.1-38.8) weeks and postnatal age on transfer 81 (IQR 9-144) days were admitted from NICUs. The median (IQR) length of stay was 12 (4-41) days. The 19 infants born <28 weeks of gestation had a greater median length of stay (32, range IQR 10-93 days) than more mature born infants (7.5, IQR 4-26 days) (p=0.003). The median cost of PICU stay for NICU transfers was £23,800 (range 1,205-1,034,000) per baby. The total cost of care for infants transferred from NICUs was £6,457,955. CONCLUSIONS: Infants transferred from NICUs were a small proportion of PICU admissions but, particularly those born <28 weeks of gestation, had prolonged stays which needs to be considered when determining bed capacity.

Acute Kidney Injury in Pediatric Inflammatory Multisystem Syndrome Temporally Associated With Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Experience From PICUs Across United Kingdom.

OBJECTIVES: To study the prevalence, evolution, and clinical factors associated with acute kidney injury in children admitted to PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. DESIGN: Multicenter observational study. SETTING: Fifteen PICUs across the United Kingdom. PATIENTS: Patients admitted to United Kingdom PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 between March 14, 2020, and May 20, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deidentified data collected as part of routine clinical care were analyzed. All children were diagnosed and staged for acute kidney injury based on the level of serum creatinine above the upper limit of reference interval values according to published guidance. Severe acute kidney injury was defined as stage 2/3 acute kidney injury. Uni- and multivariable analyses were performed to study the association between demographic data, clinical features, markers of inflammation and cardiac injury, and severe acute kidney injury. Over the study period, 116 patients with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 were admitted to 15 United Kingdom PICUs. Any-stage acute kidney injury occurred in 48 of 116 patients (41.4%) and severe acute kidney injury in 32 of 116 (27.6%) patients, which was mostly evident at admission (24/32, 75%). In univariable analysis, body mass index, hyperferritinemia, high C-reactive protein, Pediatric Index of Mortality 3 score, vasoactive medication, and invasive mechanical ventilation were associated with severe acute kidney injury. In multivariable logistic regression, hyperferritinemia was associated with severe acute kidney injury (compared with nonsevere acute kidney injury; adjusted odds ratio 1.04; 95% CI, 1.01-1.08; p = 0.04). Severe acute kidney injury was associated with longer PICU stay (median 5 days [interquartile range, 4-7 d] vs 3 days [interquartile range, 1.5-5 d]; p < 0.001) and increased duration of invasive mechanical ventilation (median 4 days [interquartile range, 2-6 d] vs 2 days [interquartile range, 1-3 d]; p = 0.04). CONCLUSIONS: Severe acute kidney injury occurred in just over a quarter of children admitted to United Kingdom PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. Hyperferritinemia was significantly associated with severe acute kidney injury. Severe acute kidney injury was associated with increased duration of stay and ventilation. Although short-term outcomes for acute kidney injury in pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 appear good, long-term outcomes are unknown.

Estimating blood loss: comparative study of the accuracy of parents and health care professionals.

OBJECTIVE: Hematemesis and hematochezia are not uncommon presenting complaints in children. The amount of blood loss reported by the parent is likely to influence the pediatrician's decision regarding investigations and management. Currently, there are only very limited data regarding the ability of laypersons to estimate blood losses visually. This study investigated the accuracy of parents, in comparison to pediatric health care professionals, in estimating blood loss volumes. PATIENTS AND METHODS: We performed a prospective, single-blinded study including 227 participants, comprising 131 parents, 58 nurses, and 38 doctors. Participants visually estimated the volume of 1 randomly allocated sample from each of the 2 categories: (1) 1, 5, or 10 mL of artificial blood applied to a diaper (simulated hematochezia) and (2) 5, 10, or 50 mL placed in a kidney-dish (simulated hematemesis). An "error factor" (=, estimated volume/actual volume shown) was used to facilitate comparisons. RESULTS: Parents provided the most inaccurate estimates overall, although individual accuracy varied considerably. The largest overestimate (518 mL) and the highest error factor (23.4) were recorded in a parent; overall, 71% of the estimates provided by parents were overestimates. The highest proportion of accurate estimates (+/-50% of actual volume) was recorded by nurses (29%). Doctors had a tendency to underestimate volumes (62% of the estimates were less than half the actual volume). However, there was no statistically significant difference between the performance of nurses and doctors. Health care professionals tended to overestimate small volumes and underestimate large volumes. Professional experience had no relevant impact on accuracy, nor did parental gender or age. CONCLUSIONS: Visual estimation of blood losses is highly inaccurate, both by laypersons and by health care professionals. Physicians should, therefore, base management decisions primarily on clinical findings and not overly rely on the history provided, or their own estimates.