Clinical-Ultrasound Model to Predict the Clinical Course in Bronchiolitis.

BACKGROUND: The aim of the present study was to develop a clinical-ultrasound model for early detection of hospital admission, pediatric intensive care unit (PICU) admission, and oxygen requirement in children diagnosed with acute bronchiolitis (AB). Furthermore, the prognostic ability of models including sonographic data from antero-lateral, lateral-posterior, and posterior areas (eight zones) vs. antero-lateral and lateral-posterior areas (six zones) vs. only antero-lateral areas (four zones) was analyzed. METHODS: A prospective study was conducted on infants under 12 months with AB. A lung ultrasound (LUS) was performed within 24 h of hospital care and analyzed using the Lung Ultrasound Combined Score (LUCS) based on the ultrasound patterns and their extent. Regression models combining LUCS (using eight, six, or four lung areas) with age and clinical scale were created. RESULTS: A total of 90 patients were included (62 admitted to the ward, 15 to PICU), with a median age of 3.7 months. Clinical-ultrasound models with eight and six lung zones predicted hospital admission (AUC 0.89), need for oxygen therapy (AUC 0.88), and its duration (40% explanatory capacity). Models using four lung areas had lower prognostic yield. No model predicted PICU admission needs or duration. CONCLUSIONS: The ultrasound pattern and its extension combined with clinical information may be useful to predict hospital admission and oxygen requirement.

Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: a randomized controlled trial.

INTRODUCTION: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. METHODS: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7 g/dL), protein-enriched diet (2.7 g/dL) and high protein-enriched diet (5.1 g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3-5 days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. RESULTS: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3-5 days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. CONCLUSION: Enteral administration of higher amounts of protein improves serum protein levels in critically ill children. A protein intake of 2.2 g/kg/day is generally safe and well tolerated, whereas an intake of 3.4 g/kg/day may produce hyperuraemia in some patients.

Characteristics and management of patients with SARS-CoV2 infection admitted to pediatric intensive care units: Data analysis of the Spanish national multicenter registry.

INTRODUCTION: The purpose of this study is to describe the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) disease characteristics and management in children admitted to the pediatric intensive care units (PICU). METHODS: The present study was based on a national multicentric prospective registry including PICU patients with SARS-CoV2 infection or symptoms of multisystem inflammatory syndrome in children (MIS-C). RESULTS: A total of 298 patients were admitted to 41 different Spanish PICUs. A total of 76% of them were previously healthy. The most frequent manifestation was MIS-C (69.8%). On admission, 59.4% of patients did not have respiratory distress, and only 17.4% needed conventional mechanical ventilation (MV). The need for MV was associated with age (incidence rate ratios [IRR] 1.21, p < .012), pediatric sequential organ failure assessment score (p-SOFA) Score (IRR 1.12, p = .001), and need for transfusion (IRR 4.5, p < .004) in MIS-C patients, and with vasoactive drug use (IRR 2.73, p = .022) and the diagnosis of acute respiratory distress syndrome (IRR 2.83, p = .018) in patients admitted for other reasons. During the first day of admission, 56% of patients met shock criteria and 50.7% needed vasoactive drugs. In MIS-C patients, their use was associated with higher p-SOFA score (IRR 1.06, p < .001) and with the diagnosis of shock (IRR 5.78, p < .001). In patients without MIS-C, it was associated with higher p-SOFA score (IRR 1.05, p = .022). The mortality rate was 3%, being lower in MIS-C patients compared to patients admitted for other reasons (0.5% vs. 9.4%, p < .001). It was also lower in previously healthy patients compared to patients with previous comorbidities (0.9% vs. 9.7%, p < .001). CONCLUSIONS: Severe SARS-CoV2 infection is uncommon in the pediatric population. In our series, respiratory distress was rare, being MIS-C the most frequent cause of PICU admission related to SARS-CoV2. In most cases, the course of the disease was mild except in children with previous diseases.

A Dynamic Approach for Early Risk Prediction of Gram-Negative Bloodstream Infection and Systemic Inflammatory Response Syndrome in Febrile Pediatric Hemato-Oncology Patients.

Background: The aim of this study was to evaluate the usefulness of C-Reactive Protein (CRP), Procalcitonin (PCT), and Interleukine 6 (IL6) biomarkers in predicting the existence of high-risk episodes (HRE) during the first 24 h of fever in pediatric cancer patients. HRE were defined as the presence of Gram-negative bloodstream infections or Systemic Inflammatory Response Syndrome. Methods: The study included 103 consecutive fever episodes in 44 hemato-oncological pediatric patients, from whom samples for biomarkers were taken upon initial evaluation (CRP-1, PCT-1 and IL6-1) and then between 12 and 24 h afterward (CRP-2, PCT-2 and IL6-2). Results: An IL6-1 value higher than 164 pg/mL showed an area under the curve (AUC) of 0.890 (0.791−0.989) and OR of 48.68 (7.92−951.42, p < 0.001) to detect HRE in multivariate analysis. A PCT-1 higher than 0.32 ng/mL showed an AUC of 0.805 (0.700−0.910) and OR of 4.55 (0.90−27.84, p = 0.076). A PCT-2 higher than 0.94 ng/mL showed an AUC of 0.836 (0.725−0.947) and OR of 13.01 (1.82−149.13, p = 0.018), and an increase in CRP between the first and second sample (CRP-2vs1) higher than 291% also showed an AUC of 0.785 (0.655−0.915) and OR of 31.09 (4.87−355.33, p = 0.001). Conclusions: IL6-1, PCT-2, and CRP-2vs1 showed a strong and independent correlation with HREs in pediatric cancer patients. CRP variations over the first 24 h provide an improvement in predictive models that are especially useful if IL-6 and PCT are not available.

Multicenter randomized clinical trial comparing dexamethasone versus placebo in preventing upper airway obstruction after extubation in critically ill children.

To analyze the effectiveness of dexamethasone in preventing upper airway obstruction (UAO) symptoms after extubation and the need of reintubation in critically ill children. Multicenter, prospective, double-blind, randomized, phase IV clinical trial involving five pediatric intensive care units. Children between 1 month and 16 years-of-age intubated for more than 48 h were included. Patients were randomized to receive placebo or dexamethasone 0.25 mg/kg every 6 h, 6-to-12 h prior to extubation (four doses). 48 h follow-up was carried out after extubation. Severity of UAO symptoms (Taussig score, stridor) and reintubation requirement were compared. 147 patients were randomized (10 were excluded), 70 patients received dexamethasone and 67 placebo. No global differences were found in the presence of stridor or moderate-to-severe UAO symptoms (Taussig ≥ 5), but Taussig ≥ 5 was less frequent in patients less than 2 years-of-age treated with steroids (p = 0.014). Median Taussig score was lower in the dexamethasone group 1 h after extubation, p < 0.001. 27 patients required reintubation, 9 due to UAO: 3 (4.3%) in the dexamethasone group and 6 (8.9%) in the placebo group, p = 0.319. In those intubated > 5 days, reintubation due to UAO was higher in the placebo group (2.4% vs. 14.3, p = 0.052). Nebulized epinephrine and budesonide were required more frequently in the placebo group in the first 2 h (p = 0.041) and 1 h (p = 0.02) after extubation, respectively. No relevant side effects were observed. Dexamethasone prior to extubation did not significantly reduce moderate-severe UAO symptoms, except for patients under 2-years of age. Dexamethasone could decrease Taussig score and the need of rescue therapies, as well as reintubation rates in those intubated for more than 5 days.

Biomarkers and Fever in Children with Cancer: Kinetics and Levels According to Final Diagnosis.

We investigated the kinetics of CRP, PCT, IL-6 and MR-proADM in a cohort of consecutive febrile patients with cancer in order to test the hypothesis that higher plasma concentrations and the absence of a rapid decrease in peak values would be associated with disease severity. (1) Method: A prospective descriptive and analytical study of patients with cancer and fever (≤18 years of age) at a University Hospital was carried out between January 2018 and December 2019. Information collected: sex, age, diagnosis, date and symptoms at diagnosis and medical history. The episodes were classified into three groups: bacterial infection, non-bacterial infection and systemic inflammatory response syndrome (SIRS). (2) Results: One hundred and thirty-four episodes were included. Bacterial infection criteria were met in 38 episodes. Biomarkers were measured at four different points: baseline, at 12-24 h, at 25-48 h and at 49-72 h. All the biomarkers evaluated decreased after the peak level was reached. IL-6 and MR-proADM showed a trend towards higher levels in the SIRS group although this rise was statistically significant only for IL-6 (p < 0.005). Bacterial infections more frequently presented values of PCT above the cut-off point (>0.5 ng/mL) at 12-24 h. (3) Conclusion: In our experience, IL-6 kinetics is faster than PCT kinetics and both are faster than CRP in patients with fever and cancer who present a good outcome. Patients with a good evolution show a rapid increase and decrease of PCT and particularly of IL-6 levels.

Analysis of a sustained educational intervention to teach cardiopulmonaryresuscitation to schoolchildren. / Análisis de una experiencia perdurable de un proyecto educativo de reanimación cardiopulmonar en un centro escolar.

EN: This project analyzed the feasibility, effectiveness, and sustainability of an educational project to teach cardiopulmonary resuscitation (CPR). This project has been carried out in a publicly subsidized school in a town in Asturias, Spain (population, over 80 000 inhabitants). The enrollment included students in preschool and both primary and secondary education classes. The project had 3 phases: 1) health care experts trained the teachers in CPR and they designed the educational project together; 2) health care experts taught CPR to schoolchildren, and 3) teachers taught CPR to the children. All the children enrolled in preschool and primary school (aged 3 to 12 years) initially participated in the study. Training followed the 2005 guidelines of the International Liaison Committee on Resuscitation (ILCOR) in effect at the time of the study. In the first phase (2006), 19 teachers (79.2% of the faculty) were trained in basic CPR and collaborated with the health care professionals in designing the course, including setting its objectives and developing materials. In the second phase (2006-2011), the health care professionals trained 646 preschool and primary school children and accredited 13 teachers (54.2% of the faculty) in the use of an automated external defibrillator (AED) and to serve as CPR instructional monitors. In the third phase (2012-2014), 7 teachers trained 703 preschool and primary and secondary school students, and 17 teachers (70.8% of the faculty) received training to become CPR monitors and/or to update their knowledge of AED use. A total of 1349 students between the ages of 3 and 15 years received instruction in CPR. The school has had an AED on its premises since 2011. The teachers have made further improvements in the courses, incorporating new teaching materials, updating the objectives, and extending instruction to secondary school students. The implementation of an educational program to teach CPR in a school that enrolls preschool through secondary school students was feasible and sustainable. Teachers have improved the program, extended it to secondary school students, and made the project known in the local media and on the school's web site, thus contributing to the creation of a CPR culture that reached out to the community.

ES: Se analiza la experiencia de un proyecto educativo de reanimación cardiopulmonar básica (RCPB) en un centro escolar valorando si es viable, efectivo y perdurable en el tiempo. Se trata de un proyecto desarrollado en un centro de enseñanza concertada de educación infantil (EI), primaria (EP) y secundaria (ESO), ubicado en un concejo muy poblado de Asturias, de más de 80.000 habitantes, en tres fases: 1) formación de maestros por personal sanitario y diseño conjunto del proyecto; 2) formación de escolares por personal sanitario, y 3) formación de niños por sus profesores. Se incluyeron todos los alumnos matriculados en el colegio en EI y EP (3 a 12 años). La formación impartida siguió las recomendaciones ILCOR (International Liaison Committee on Resuscitation) 2005, vigentes en aquel momento. En la fase 1 (año 2006) 19 profesores (79,2% de la plantilla) recibieron formación en RCPB y diseñaron con el personal sanitario los objetivos y material a emplear para cada curso. En la fase 2 (2006-2011) el personal sanitario formó a 646 escolares de EI y EP, y acreditó a 13 maestros (54,2% de la plantilla) para utilizar un DEA y como monitores de RCPB. En la fase 3 (2012-2014) 7 maestros formaron a 703 alumnos de EI, EP y ESO; 17 profesores (70,8% de la plantilla) recibieron cursos de monitor de RCPB y reciclajes DEA. En total recibieron formación en RCPB 1.349 niños entre 3 y 15 años. Desde el año 2011, el colegio cuenta con un DEA. Los profesores han mejorado el proyecto incorporando nuevos materiales, adelantado objetivos y extendiéndolo a los alumnos de ESO. La implantación de un proyecto educativo en RCPB en un colegio de enseñanza concertada de EI, EP y ESO de Asturias fue viable y ha perdurado. El profesorado ha mejorado el proyecto y lo ha extendido a los alumnos de secundaria, difundiendo la RCPB en medios de comunicación locales y en su página web, creando una cultura de la RCPB y acercándola a toda la comunidad.

Efecto de tres dietas enterales con diferente contenido en proteínas sobre el metabolismo proteico en lactantes críticamente enfermos: un ensayo clínico aleatorizado / Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: A randomized controlled trial

Introducción: No se ha establecido cuál es el aporte óptimo para mejorar el metabolismo proteico sin producir efectos adversos en lactantes gravemente enfermos. Nuestro objetivo fue analizar si un mayor aporte proteico a través de la nutrición enteral se relaciona con una mejoría en el balance proteico en lactantes críticamente enfermos. Material y métodos: Se diseñó un estudio multicéntrico, prospectivo, aleatorizado y controlado (diciembre de 2016 a junio de 2019). Se incluyeron lactantes críticamente enfermos con nutrición enteral, asignándose aleatoriamente a tres dietas con diferente contenido proteico: estándar (1,7g/100ml), hiperproteica (2,7g/100ml) e hiperproteica suplementada (5,1g/100ml). Se realizaron análisis de sangre y orina y se calculó el balance nitrogenado en el momento basal y tras 3-5días de nutrición. Se analizó la variación del balance nitrogenado y de las proteínas séricas (proteínas totales, albúmina, transferrina, prealbúmina y proteína ligada al retinol) a lo largo del periodo de estudio. Resultados: Noventa y nueve lactantes (33 por grupo) completaron el estudio. No se encontraron diferencias entre grupos en características demográficas, puntuaciones de gravedad y otros tratamientos recibidos, salvo corticoides, administrados en una mayor proporción de pacientes del tercer grupo. Tuvo lugar un aumento significativo de los niveles de prealbúmina y proteína ligada al retinol en los grupos con nutrición hiperproteica e hiperproteica suplementada. El balance nitrogenado aumentó en todos los grupos, pero este incremento no fue significativo en el grupo de nutrición hiperproteica suplementada. No se encontraron diferencias en cuanto a tolerancia gastrointestinal. Los pacientes con nutrición hiperproteica suplementada presentaron niveles superiores de urea sérica y mayor incidencia de hiperuremia. (AU)

Introduction: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. Material and methods: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7g/dL), protein-enriched diet (2.7g/dL) and high protein-enriched diet (5.1g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3 to 5days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. Results: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3 to 5days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. (AU)

Admission, discharge and triage guidelines for paediatric intensive care units in Spain. / Guias de ingreso, alta y triage para las unidades de cuidados intensivos pediátricos en España.

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.

[Admission, discharge and triage guidelines for paediatric intensive care units in Spain]. / Guias de ingreso, alta y triage para las unidades de cuidados intensivos pediátricos en España.

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.

Formación en reanimación cardiopulmonar pediátrica en los grados de Medicina y Enfermería en las universidades españolas / Training in pediatric cardiopulmonary resuscitation in the Medicine and Nursing degrees in Spanish universities

Objetivos: Conocer la docencia en reanimación cardiopulmonar (RCP) pediátrica en las universidades españolas.Material y métodos.Se envió una encuesta a los responsables de pediatría de las universidades españolas.Resultados.Se recibieron 35 respuestas de Medicina y 18 de Enfermería. Existió una gran diversidad en la docencia de la RCP y su duración. En muchos casos, la duración de la formación en RCP es insuficiente.Conclusiones.Es necesario establecer unos requisitos de formación obligatoria en RCP pediátrica para los grados de Medicina y Enfermería. (AU)

Aims: To analyse the education in pediatric cardiopulmonary resuscitation (CPR) in the universities in Spain.Material and methods.A survey was sent to those responsible for Pediatrics at the Spanish universities.Results.35 responses from Medicine and 18 from Nursing were received). There was a great diversity in CPR teaching and duration. In many cases, the duration of the training is insufficient.Conclusions.It is necessary to establish mandatory training requirements in pediatric CPR for Medicine and Nursing degrees. (AU)

Informe anual de los editores de Anales de Pediatría / Annual report of Anales de Pediatría editors

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Anales de Pediatría: otra etapa cumplida / Anales de Pediatría: Another milestone achieved

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Infección por coronavirus (COVID-19) en Anales de Pediatría / Coronavirus infection (COVID-19) in Anales de Pediatría

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[Organ donation after brain death due to child abuse]. / Donación de órganos tras muerte encefálica debida a maltrato infantil.

More than 40 percent of deaths from child abuse occur among children younger than 5 years. The injury pattern in child abuse is block abuse head trauma which in the most severe cases produces brain death. Organ donation is uncommon in children younger than five years. We describe two cases of child abuse that caused brain death; subsequently they were subsidiary for organ donation. It is very important to establish a good coordination between health, social care and legal assistance teams to obtain organ donation.