Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study.

OBJECTIVES: To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations. DESIGN: The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding. SETTING: Four-one PICUs in 13 LA countries. PATIENTS: Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively. CONCLUSIONS: The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.

Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary.

Objective: The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.

The Latin American and Spanish Survey on Nutrition in Pediatric Intensive Care (ELAN-CIP2).

OBJECTIVE: To characterize the practices of nutritional support in Latin American and Spanish PICUs. DESIGN: Survey with a questionnaire sent to Latin American Society of Pediatric Intensive Care members. SETTING: PICUs of participant hospitals. PATIENTS: Critically ill children between 1 month and 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-seven surveys from 17 countries were analyzed. Sixty-seven percent of PICUs were from university-affiliated hospitals, with a median of 380 admissions/yr. Sixty-eight percent and 48.9% had a nutritional support team and nutritional support protocol, respectively. Seventy-five percent completed nutritional evaluations, with 34.2% at admission. PICUs with high-volume admissions were likely to have a nutritional support team (p < 0.005), and university-affiliated hospitals showed a trend of having a nutritional support team (p = 0.056). Measured, estimated, and ideal weights were used in 75%, 14.6%, and 10.4%, respectively. Energy requirements were calculated using Holliday & Segar and Schofield equations in 90% of the PICUs; 43% used correction factors. Only three PICUs had indirect calorimetry. At day 3 of initiation of nutritional support, 57.3% of PICUs provided at least 50% of the calculated energy requirement, and 91.5% at day 5. Protein needs were estimated according to American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism/European Society for Paediatric Gastroenterology Hepatology and Nutrition guidelines in 55.3% and 40.4%, respectively. Enteral nutrition was the preferred feeding method, initiated in 97.7% at 48 hours. The feeding route was gastric (82.9%), by bolus (42.5%) or continuous (57.4%). Monitoring methods included gastric residual measurement in 55.3%. Enteral nutrition was discontinued in 82.8% when gastric residual was 50% of the volume. Prokinetics were used in 68%. More than half of PICUs used parenteral nutrition, with 95.8% of them within 72 hours. Parenteral nutrition was administered by central vein in 93.6%. Undernourished children received parenteral nutrition sooner, whether or not enteral nutrition intolerance was present. When enteral nutrition was not tolerated beyond 72 hours, parenteral nutrition was started in 57.4%. Parenteral nutrition was initiated when enteral nutrition delivered less than 50% in 97%. CONCLUSIONS: Nutritional practices are heterogeneous in Latin American PICUs, but the majority use nutritional support strategies consistent with international guidelines.

Severe Pediatric Neurological Manifestations With SARS-CoV-2 or MIS-C Hospitalization and New Morbidity.

Importance: Neurological manifestations during acute SARS-CoV-2-related multisystem inflammatory syndrome in children (MIS-C) are common in hospitalized patients younger than 18 years and may increase risk of new neurocognitive or functional morbidity. Objective: To assess the association of severe neurological manifestations during a SARS-CoV-2-related hospital admission with new neurocognitive or functional morbidities at discharge. Design, Setting, and Participants: This prospective cohort study from 46 centers in 10 countries included patients younger than 18 years who were hospitalized for acute SARS-CoV-2 or MIS-C between January 2, 2020, and July 31, 2021. Exposure: Severe neurological manifestations, which included acute encephalopathy, seizures or status epilepticus, meningitis or encephalitis, sympathetic storming or dysautonomia, cardiac arrest, coma, delirium, and stroke. Main Outcomes and Measures: The primary outcome was new neurocognitive (based on the Pediatric Cerebral Performance Category scale) and/or functional (based on the Functional Status Scale) morbidity at hospital discharge. Multivariable logistic regression analyses were performed to examine the association of severe neurological manifestations with new morbidity in each SARS-CoV-2-related condition. Results: Overall, 3568 patients younger than 18 years (median age, 8 years [IQR, 1-14 years]; 54.3% male) were included in this study. Most (2980 [83.5%]) had acute SARS-CoV-2; the remainder (588 [16.5%]) had MIS-C. Among the patients with acute SARS-CoV-2, 536 (18.0%) had a severe neurological manifestation during hospitalization, as did 146 patients with MIS-C (24.8%). Among survivors with acute SARS-CoV-2, those with severe neurological manifestations were more likely to have new neurocognitive or functional morbidity at hospital discharge compared with those without severe neurological manifestations (27.7% [n = 142] vs 14.6% [n = 356]; P < .001). For survivors with MIS-C, 28.0% (n = 39) with severe neurological manifestations had new neurocognitive and/or functional morbidity at hospital discharge compared with 15.5% (n = 68) of those without severe neurological manifestations (P = .002). When adjusting for risk factors in those with severe neurological manifestations, both patients with acute SARS-CoV-2 (odds ratio, 1.85 [95% CI, 1.27-2.70]; P = .001) and those with MIS-C (odds ratio, 2.18 [95% CI, 1.22-3.89]; P = .009) had higher odds of having new neurocognitive and/or functional morbidity at hospital discharge. Conclusions and Relevance: The results of this study suggest that children and adolescents with acute SARS-CoV-2 or MIS-C and severe neurological manifestations may be at high risk for long-term impairment and may benefit from screening and early intervention to assist recovery.

Prevalence and Risk Factors of Neurologic Manifestations in Hospitalized Children Diagnosed with Acute SARS-CoV-2 or MIS-C.

BACKGROUND: Our objective was to characterize the frequency, early impact, and risk factors for neurological manifestations in hospitalized children with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or multisystem inflammatory syndrome in children (MIS-C). METHODS: Multicenter, cross-sectional study of neurological manifestations in children aged <18 years hospitalized with positive SARS-CoV-2 test or clinical diagnosis of a SARS-CoV-2-related condition between January 2020 and April 2021. Multivariable logistic regression to identify risk factors for neurological manifestations was performed. RESULTS: Of 1493 children, 1278 (86%) were diagnosed with acute SARS-CoV-2 and 215 (14%) with MIS-C. Overall, 44% of the cohort (40% acute SARS-CoV-2 and 66% MIS-C) had at least one neurological manifestation. The most common neurological findings in children with acute SARS-CoV-2 and MIS-C diagnosis were headache (16% and 47%) and acute encephalopathy (15% and 22%), both P < 0.05. Children with neurological manifestations were more likely to require intensive care unit (ICU) care (51% vs 22%), P < 0.001. In multivariable logistic regression, children with neurological manifestations were older (odds ratio [OR] 1.1 and 95% confidence interval [CI] 1.07 to 1.13) and more likely to have MIS-C versus acute SARS-CoV-2 (OR 2.16, 95% CI 1.45 to 3.24), pre-existing neurological and metabolic conditions (OR 3.48, 95% CI 2.37 to 5.15; and OR 1.65, 95% CI 1.04 to 2.66, respectively), and pharyngeal (OR 1.74, 95% CI 1.16 to 2.64) or abdominal pain (OR 1.43, 95% CI 1.03 to 2.00); all P < 0.05. CONCLUSIONS: In this multicenter study, 44% of children hospitalized with SARS-CoV-2-related conditions experienced neurological manifestations, which were associated with ICU admission and pre-existing neurological condition. Posthospital assessment for, and support of, functional impairment and neuroprotective strategies are vitally needed.

[Latin American Consensus on Pediatric Cardiopulmonary Resuscitation. An Executive Summary from the CPR Committee, Latin American Society of Pediatric Intensive Care (SLACIP)]. / Consenso de Reanimación Cardiopulmonar Pediátrica del Comité de RCP de la Sociedad Latinoamericana de Cuidados Intensivos Pediátricos (SLACIP). Resumen Ejecutivo.

Cardiopulmonary Resuscitation (CPR) is a critical procedure with potential consequences over futu re vitality and functionality in survivors. In this document, we present a pragmatic and regional point of view on diagnosis, management, and prognostication in pediatric CPR developed by the Com mittee on CPR of the Latin American Society of Pediatric Intensive Care (SLACIP). We have chosen the main CPR topics with the aim of contribute for a better prevention and management of CPR, standardize the management of the post-cardiac arrest syndrome and neuro-prognostication, and identify opportunities for regional research. We have followed the Executive Summary published in 2020 by the International Liaison Committee on Resuscitation, ILCOR, adapted it to our reality, and developed this narrative review of pediatric CPR with the contribution of Latin American experts.

Challenges of implementing the Paediatric Surviving Sepsis Campaign International Guidelines 2020 in resource-limited settings: A real-world view beyond the academia.

The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children was released in 2020 and is intended for use in all global settings that care for children with sepsis. However, practitioners managing children with sep sis in resource-limited settings (RLS) face several challenges and disease patterns not experienced by those in resource-rich settings. Based upon our collective experience from RLS, we aimed to reflect on the difficulties of implementing the international guidelines. We believe there is an urgent need for more evidence from RLS on feasible, efficacious approaches to the management of sepsis and septic shock that could be included in future context-specific guidelines.

Fluidoterapia y electrolitos parenterales en pediatría / Fluid therapy and electrolytes in pediatrics

RESUMEN La administración de líquidos y electrolitos parenterales es una terapia fundamental de soporte en niños agudamente enfermos si la vía oral no permite la administración de la cantidad o composición requeridas de fluidos, por ejemplo en enfermedades de tipo gastrointestinal, respiratorio, neurológico, o en el período transoperatorio. Al momento de planificar la administración de líquidos y electrolitos parenterales en niños a partir del mes de edad, se debe considerar componentes relacionados con la cantidad de líquidos a infundir considerando los requerimientos secundarios a pérdidas hídricas habituales o requerimientos para reacciones metabólicas, evaluar el grado de deshidratación para la administración de líquidos que complementen el déficit, corregir las pérdidas que se han producido secundarios a una noxa externa (enfermedad, procedimiento quirúrgico, trauma, etc.) y finalmente aportar la cantidad adecuada de fluido que permita re-establecer la perfusión tisular. Es necesario conocer los cambios instaurados basados en la evidencia actual con la finalidad de incorporar a el manejo frecuente de los pacientes considerando también la toxicidad ya sean cualitativos o cuantitativos de esta terapéutica tan necesaria en el manejo del paciente pediátrico

ABSTRACT The administration of parenteral fluids and electrolytes is a fundamental support therapy in acutely ill children if the oral route does not allow the ad-ministration of the required amount or composition of fluids, for example in gastrointestinal, respiratory, neurological, or transoperative diseas-es. When planning the administration of parenteral fluids and electrolytes in children from one month of age onwards, components related to the amount of fluids to be infused should be considered, taking into account the requirements secondary to habitual water loss or requirements for meta-bolic reactions, evaluating the degree of dehydration for the administration of fluids to supplement the deficit, correcting the losses that have oc-curred secondary to an external noxa (illness, surgical procedure, trauma, etc.) and finally providing the adequate amount of fluid to allow re-es-tablishment of tissue perfusion. It is necessary to know the changes established based on current evidence in order to incorporate to the frequent management of patients, also considering the toxicity, either qualitative or quantitative, of this therapy, so necessary in the management of the pediatric patient.