Clinical Outcomes In Children Research Articles

Impact of the COVID-19 pandemic on the incidence and clinical outcomes of diabetic ketoacidosis among male and female children with type 1 diabetes: systematic review and meta-analysis

Background: Some studies suggest that the SARS-CoV-2 pandemic increased the incidence of type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA). However, the impact of this pandemic on pediatric T1DM is still mostly unknown. Therefore, we aimed to assess the effect of the COVID-19 pandemic on clinical outcomes in children with T1DM. Methods: We systematically searched for six databases up to 31 August 2022. We included 46 observational studies, 159,505 children of both sexes with T1DM, and 17,547 DKA events. Results: The COVID-19 pandemic significantly increased, in both sexes, the incidence of 1) DKA (OR 1.68; 95% CI 1.44–1.96), 2) severe DKA (OR 1.84; 95% CI 1.59–2.12), 3) DKA in newly diagnosed T1DM (OR 1.75; 95% CI 1.51–2.03), and 4) ICU admissions (OR 1.90; 95% CI 1.60–2.26). However, we did not find a significant association between this pandemic and 1) the incidence of T1DM, 2) the incidence of DKA in established T1DM, 3) the incidence of KDA complications, 4) the length of hospitalization stay, and 5) mortality. Subgroup analysis showed that the study design and the continent of origin accounted for the heterogeneity. Conclusions: The pandemic SARS-CoV-2 raised, in both sexes, the risk of DKA, severe DKA, DKA de novo, and ICU admissions.

Developing Consensus on Clinical Outcomes for Children with Mild Pneumonia: A Delphi Study.

The absence of consensus for outcomes in pediatric antibiotic trials is a major barrier to research harmonization and clinical translation. We sought to develop expert consensus on study outcomes for clinical trials of children with mild community-acquired pneumonia (CAP). Applying the Delphi method, a multispecialty expert panel ranked the importance of various components of clinical response and treatment failure outcomes in children with mild CAP for use in research. During Round 1, panelists suggested additional outcomes in open-ended responses that were added to subsequent rounds of consensus building. For Rounds 2 and 3, panelists were provided their own prior responses and summary statistics for each item in the previous round. The consensus was defined by >70% agreement. The expert panel determined that response to and failure of treatment should be addressed at a median of 3 days after initiation. Complete or substantial improvement in fever, work of breathing, dyspnea, tachypnea when afebrile, oral intake, and activity should be included as components of adequate clinical response outcomes. Clinical signs and symptoms including persistent or worsening fever, work of breathing, and reduced oral intake should be included in treatment failure outcomes. Interventions including receipt of parenteral fluids, supplemental oxygen, need for high-flow nasal cannula oxygen therapy, and change in prescription of antibiotics should also be considered in treatment failure outcomes. Clinical response and treatment failure outcomes determined by the consensus of this multidisciplinary expert panel can be used for pediatric CAP studies to provide objective data translatable to clinical practice.

Enhanced recovery after surgery in children undergoing abdominal surgery: meta-analysis.

Enhanced recovery after surgery (ERAS) is a multimodal approach that streamlines patient processes before, during, and after surgery. The goal is to reduce surgical stress responses and improve outcomes; however, the impact of ERAS programmes in paediatric abdominal surgery remains unclear. The authors aimed to review the effectiveness of ERAS on clinical outcomes in children undergoing abdominal surgery. CINAHL, CENTRAL, Embase, ProQuest, PubMed, and Scopus were searched for relevant studies published from inception until January 2021. The length of hospital stay (LOS), time to oral intake, time to stool, complication rates, and 30-day readmissions were measured. Meta-analyses and subgroup analyses were conducted using RevMan 5.4 with a random-effects model. Among 2371 records from the initial search, 111 articles were retrieved for full-text screening and 12 were included for analyses. The pooled mean difference (MD) demonstrated reduced LOS (MD -1.96; 95 per cent c.i. -2.75 to -1.17), time to oral intake (MD -3.37; 95 per cent c.i. -4.84 to -1.89), and time to stool (MD -4.19; 95 per cent c.i. -6.37 to -2.02). ERAS reduced postoperative complications by half and 30-day readmission by 36 per cent. Subgroup analyses for continuous outcomes suggested that ERAS was more effective in children than adolescents. ERAS was effective in improving clinical outcomes for paediatric patients undergoing abdominal surgery.

Effect of nutritional status on outcomes in children receiving umbilical cord blood stem cell transplantation.

The impacts of nutritional status on clinical outcomes in children receiving umbilical cord blood stem cell transplantation (UCBT) are not fully described. We evaluated the risk for malnutrition before transplantation admission and influence of weight loss during hospitalization on short-term clinical outcomes in children with UCBT. We conducted a retrospective study of pediatric patients up to age 18 years who received UCBT and were treated at the Children's Hospital of Fudan University between January 2019 and December 2020. The mean age of the 91 patients was 1.3 years, with 78 (85.7%) men and 13 (14.3%) women (p<0.001). UCBT was performed mostly for primary immunodeficiency disease (PID) (83, 91.2%). The weight loss differences among children with different primary diseases were statistically significant (p=0.003). Children with a large amount of weight loss during hospitalization (n = 24) had higher risks of skin graft-versus-host disease (GVHD) (multivariate OR=5.01, 95% CI: 1.35-18.65), intestinal GVHD (multivariate OR=7.27, 95% CI: 1.74-30.45), a longer median hospital stay (p=0.004), higher antibiotic costs (p=0.008) and higher total hospitalization costs (p=0.004). Malnutrition on admission was significantly positively correlated with longer parenteral nutrition (PN) time (p=0.008). Early nutritional intervention effects on clinical outcomes need further assessment. Underweight recipient child and excessive weight loss during transplantation increases the length and cost of hospital stay, and is associated with a high incidence of GVHD, which affects the prognosis of transplantation and medical resources consumption.

Radiologic Assessment of Lung Edema Score as a Predictor of Clinical Outcome in Children with Acute Respiratory Distress Syndrome.

The radiographic assessment of lung edema (RALE) score enables objective quantification of lung edema and is a valuable prognostic marker of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the validity of RALE score in children with ARDS. The RALE score was measured for its reliability and correlation to other ARDS severity indices. ARDS-specific mortality was defined as death from severe pulmonary dysfunction or the need for extracorporeal membrane oxygenation therapy. The C-index of the RALE score and other ARDS severity indices were compared via survival analyses. Among 296 children with ARDS, 88 did not survive, and there were 70 ARDS-specific non-survivors. The RALE score showed good reliability with an intraclass correlation coefficient of 0.809 [95% confidence interval (CI), 0.760-0.848]. In univariable analysis, the RALE score had a hazard ratio (HR) of 1.19 (95% CI, 1.18-3.11), and the significance was maintained in multivariable analysis adjusting with age, ARDS etiology, and comorbidity, with an HR of 1.77 (95% CI, 1.05-2.91). The RALE score was a good predictor of ARDS-specific mortality, with a C-index of 0.607 (95% CI, 0.519-0.695). The RALE score is a reliable measure for ARDS severity and a useful prognostic marker of mortality in children, especially for ARDS-specific mortality. This score provides information that clinicians can use to decide the proper time of aggressive therapy targeting severe lung injury and to appropriately manage the fluid balance of children with ARDS.

Evaluation of Clinical Outcomes in Children with Intrahepatic Cholestasis Postpartial External Biliary Diversion: A Single-Center Experience.

Severe pruritus caused by progressive familial intrahepatic cholestasis (PFIC) and Alagille syndrome (AGS) is refractory to medical treatment. Surgical interruption of the enterohepatic circulation is considered the mainstay of alleviating distressing symptoms and delaying cirrhosis. This study aims to evaluate the short-term effect of partial external biliary diversion (PEBD) on pruritus, liver disease progression, patient's growth, and quality of life. This prospective cohort study enrolled children with PFIC and AGS from July 2019 to July 2021, whose guardians consented to the PEBD procedure. A standard surgical approach was performed by a single surgeon. Outcomes were measured subjectively and objectively pre- and post-procedure using the pruritus 5-D itching score, Paediatric Quality of Life Inventory scale (PedsQL), growth parameters, bile acids level, and liver function tests. Patients' follow-up period ranged from 6 to 12 months. Seven patients had PEBD procedure; five with PFIC and two with AGS. A significant improvement was detected in the 5-D itching score (p-value < 0.001), PedsQL (p-value < 0.001), and bile acids level (p-value 0.013). The preexisting growth failure was ameliorated. The downward trend in the bilirubin level was not significant. No influential difference in the other liver function tests occurred. No intra-operative complications encountered. Only one case had a post-operative stoma prolapse which was managed surgically. PEBD procedure could be considered as an effective and safe treatment options for intractable pruritus in patients with PFIC or AGS, providing preserved synthetic liver functions.

Nutritional status and clinical outcome in children with acute pancreatitis

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Prevalence and Clinical Outcome of Inpatient Hyperglycemia in a Tertiary Care Medical Centre

Aim: To determine the association between hyperglycaemia and clinical outcome in children admitted to a tertiary care medical centre Methods: A retrospective observational study was carried out on pediatric patients admitted to a tertiary care medical centre. A total of 160 cases were included. The details were recorded and the prevalence of hyperglycaemia and its association with clinical outcome was analysed. Results: A total of 120 patients (75%) had an admission blood glucose ≤ 120 mg/dl [(mean 97 ± 1 mg/dl (± SEM)], 31 children (19.3%) had an admission blood glucose level between 121–179 mg/dl (mean 151 ± 2 mg/dl), and 9 patients (5.6%) had a blood glucose level ≥ 180 mg/dl (mean 270 ± 14 mg/dl). Children with hyperglycemia were more likely to be admitted to the ICU (p&lt;0.001) and had a longer length of ICU stay (p&lt;0.001), but admission hyperglycemia was not associated with longer hospital stay or higher hospital mortality. Conclusion: Hyperglycemia is present in one-fourth of children admitted to the hospital, most of them without a history of diabetes prior to admission. There was no in-hospital mortality but however there was a greater need for ICU care and longer ICU stay in hyperglycemic patients. Keywords: Hyperglycemia, children, paediatrics, mortality, hospital stay

727: LONGITUDINAL STUDY OF THYROID PROFILE IN CHILDREN DURING SEPTIC SHOCK AND ITS IMPACT ON OUTCOMES

Introduction: Non-thyroidal illness syndrome (NTIS) is common in septic shock. Data on thyroid profile in pediatric patients from low- and middle-income countries (LMICs) are scarce, where undernutrition is common. Longitudinal behaviour of thyroid hormones during initial 7 days of septic shock and its association with clinical outcome in children from LMICs was studied. Methods: This prospective observational study was conducted in pediatric emergency room and pediatric intensive care unit in a tertiary care centre of a low-middle income country. Sixty-two patients (age, 6mo-12yrs) with fluid refractory septic shock at admission or developing it within 24hrs of admission were enrolled. Exclusions were history of CPR, chronic illness, endocrine disorders, and recent radio-contrast study. Serum levels of Thyroid Stimulating Hormone (TSH), T4 and T3 were measured on Day 1, 3 and 7. Correlation between thyroid hormones and severity of organ dysfunctions, outcomes and nutritional status were analysed. Results: TSH was low in 20% patients, which remained unaltered during 7 days. T4 and T3 levels were low in the majority (Day 1: 84% and 72%; Day 7: 68% and 59% respectively). Non-Survivors (n=24) have significantly lower TSH and T4 levels during 7 days compared to survivors (n=38) (p=0.045 and p=0.004 respectively). Non-survivors had significantly lower T3 on day 1 (p< 0.001), however it increased significantly over 7 days (p=0.05) to become similar to that among survivors. TSH, T4 and T3 levels were negatively correlated with admission pSOFA, maximum pSOFA and PRISM-III scores (p< 0.05). Children with VIS >40 had significantly lower T3 levels on day 1 and 3 (p=0.008 and p=0.034 respectively). Time to shock reversal was negatively correlated with T3 levels on day 3 (rho=-0.43, p=0.008). Children requiring ventilation had lower thyroid hormones on day 1 and 3. Their levels were positively correlated with ventilator-free days and acute care area free days. Nutritional status did not affect thyroid profile. Conclusions: Children with more severe disease had lower levels of all thyroid hormones on day 1 and 3. Non-survivors had significantly lower thyroid hormones on day 1, which mostly failed to increase during initial 7 days as compare to survivors. Nutritional status did not affect thyroid profile.

1311. Associations Between Microbiological Diagnoses and Clinical Outcomes in Children with Acute Hematogenous Osteomyelitis: A Retrospective Cohort Study

Abstract Background Acute hematogenous osteomyelitis (AHO) affects about 2-13 children per 100,000 in developed countries each year. Staphylococcus aureus is the most common causative pathogen of AHO and, due to antibiotic resistant strains of this species, a microbial diagnosis is often desired. Blood and bone cultures may identify causative pathogens and determine antibiotic susceptibilities but obtaining bone cultures carries risks. The benefit to patients of having a pathogen identified is disputed and further research is required to address this question. The objectives of this study were to determine if length of stay differs between culture-negative and culture-positive patients and to determine if odds of receiving 3 or more unique antibiotics differs between culture-negative and culture-positive patients. Methods Data were retrospectively abstracted from medical records of pediatric patients with a clinician’s diagnosis of AHO admitted to Children’s National Hospital (CNH) between January 1, 2010 – June 30, 2020. Baseline characteristics, treatment, and outcomes were described. For culture-negative and culture-positive AHO patients, length of stay and odds of receiving 3 or more unique antibiotics were compared using multiple linear regression and multiple logistic regression, respectively. Results Of 367 included patients, 210 had a positive culture result about 83% of which were identified as S. aureus. Culture-negative patients were associated with a 6.45-day shorter length of stay compared to culture-positive patients, adjusting for age, peak C-reactive protein (CRP), and surgery (p = 0.02). Culture-negative patients had 0.196 times the odds of receiving 3 or more unique antibiotics than culture-positive patients, adjusting for age, peak CRP, and surgery (95% CI: 0.114, 0.336). Conclusion Among AHO patients admitted to CNH, being culture-negative was associated with shorter length of stay and lower odds of receiving 3 or more unique antibiotics. Disclosures All Authors: No reported disclosures.

1444. Pediatric Tuberculosis in Mexican Children: A Retrospective Analysis of 100 Patients

Abstract Background Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis complex, mainly by M. tuberculosis. Annually, 1 million children develop TB disease and many more present a latent form of infection. The objective of this study is to define the epidemiological trends of the different clinical presentations of TB in pediatric population. Methods A retrospective, cross-sectional study, carried out at a pediatric referral hospital in Mexico between 2012-2021. Pediatric patients diagnosed with TB were included. Descriptive statistics were performed in order to summarize the demographic, clinical and paraclinical characteristics of pediatric patients with TB. A Chi-squared univariate analysis was performed evaluate the association between several variables of interest with mortality. Diagnostic criteria for TB in children according to the Mexican Clinical Practice Guidelines Results A total of 100 patients were included in the study. Pulmonary TB was the most common presentation (51%), followed by ganglionic (21%), meningeal (14%), and milliary (7%). A male predominance was observed (54%). Mean age of presentation was 7.8 years ± 1.5, most lived in urban areas (79%) and had a positive COMBE (57%). Half of the patients had BCG vaccination. Fifty-two patients were successfully cured, 36 patients were receiving antituberculous treatment and fatality rate was 12%. Meningeal TB was the most fatal clinical presentation. Fever was the most common sign (65%), followed by cough (56%) and weight loss (37%). The most common sign of meningeal TB were generalized seizures (10/14), fever (10/14), and vomiting (7/14). Brain imaging was performed in all patients with meningeal TB: hydrocephalus (71.4%) and basal arachnoiditis (64.3%) were present. Cerebrospinal fluid analysis was also performed: 11 patients had pleocytosis, 10 had hyperproteinorrhachia, and 10 had hypoglycorrhachia. Clinical TB presentation (p=0.009) and immunodeficiency (p= 0.015) were significantly associated with mortality. Epidemiological Characteristics According to TB Clinical Presentation. Signs and symptoms in children according to their clinical presentation of TB. Clinical, radiological and cerebrospinal fluid characteristics in meningeal TB. Conclusion Pediatric TB cases in this referral hospital indicated an equivalent proportion of pulmonary and extrapulmonary TB. Most of the patients with milliary and meningeal TB were not vaccinated; however, BCG vaccination was not significantly associated with mortality. Patients with extrapulmonary forms of the disease and with immunodeficiency were associated with mortality. Clinical outcomes of children with TB according to their epidemiological characteristics Disclosures All Authors: No reported disclosures.

Antibiotic use in nonintubated children with bronchiolitis in the intensive care unit.

Antibiotic use may shorten mechanical ventilation duration and length of stay for patients with bronchiolitis that require intubation. The goals of this study were to describe antibiotic use in previously healthy children with bronchiolitis admitted to the intensive care unit (ICU) for noninvasive respiratory support and to describe associations of early antibiotic use with clinical outcomes. The Pediatric Health Information Systems database was queried for children <2 years of age without significant comorbidities admitted to the ICU for bronchiolitis. Children requiring mechanical ventilation on the first ICU day were excluded. Two groups were analyzed: those patients receiving antibiotics on the first day of their ICU stay (early antibiotics), and those receiving no antibiotics on their first ICU day (no antibiotics). Primary outcome was the length of ICU stay. A total of 11,029 admissions met criteria, 2522 (22.9%) in the early antibiotic group, and 8507 (77.1%) in the no antibiotic group. The use of early antibiotics varied by center from 10% to 54%. In multivariate analysis, the early antibiotic group had similar ICU length of stay compared to the no antibiotic group (relative risk,RR [95% confidence interval,CI] 1.01 [0.98-1.05]). For patients on noninvasive ventilation, the first ICU day early antibiotics did not impact ICU length of stay (RR [95% CI] 0.97 [0.92-1.02]) or need for intubation (RR [95% CI] 1.11 [0.77-1.58]). Early antibiotic use was common with significant variation between centers. Early antibiotic use was not associated with improved clinical outcomes in children admitted to the ICU for noninvasive respiratory support for bronchiolitis.

Impact of Penicillin Allergy Labels on Children Treated for Outpatient Respiratory Infections.

Penicillin allergy is the most common antibiotic allergy, yet most children labeled as allergic tolerate penicillin. The impact of inaccurate penicillin allergy labels (PALs) on pediatric outpatients is unknown. The objective of this study was to compare outcomes between children with and without a PAL after treatment for outpatient respiratory tract infections (RTI). A retrospective, longitudinal birth cohort study was performed in children who received care in 90 pediatric primary care practices in Philadelphia and Houston metropolitan areas. Prescribing and clinical outcomes of children with a PAL at the time of an RTI were compared to non-allergic children, adjusting for potential confounders. Antibiotics were prescribed for 663,473 non-recurrent RTIs among 200,977 children. Children with a PAL (5% of cohort) were more likely than non-allergic children to receive broad-spectrum antibiotics (adjusted relative risk (aRR) 3.24, 95% CI 3.22-3.26) and second-line antibiotics (aRR 4.87, 95% CI 4.83, 4.89). Compared to non-allergic children receiving first-line antibiotics, children with a PAL were more likely to return with adverse drug events (aRR 1.28, 95% CI 1.18-1.39). There was no difference in treatment failure between groups (aRR 0.95, 95% CI 0.90-1.00). PALs lead to higher rates of broad-spectrum and second-line antibiotic prescribing in children treated for RTIs in primary care and contribute to unnecessary healthcare utilization through increased adverse events. Given the frequency of PALs, efforts to prevent inappropriate penicillin allergy labeling and promote de-labeling of existing inaccurate allergy labels may improve care of children treated for common bacterial infections.

The financial burden of out-of-pocket healthcare expenses on caregivers of children with atopic dermatitis in the United States.

Atopic dermatitis (AD) is associated with elevated financial costs, including out-of-pocket (OOP) expenses. Yet, the full burden of OOP expenses in children with AD is poorly understood. We sought to characterise categories, impact, and associations of caregiver-reported OOP AD healthcare expenses for US children. An online survey was administered to National Eczema Association members (N=113502). Inclusion criteria (US resident; respondent age ≥18; self or caregiver report of AD diagnosis) was met by 77.3% (1118/1447) of those who completed the questionnaire. Caregivers of children (<18years) with AD reported increased healthcare provider (HCP) visits, comorbid food allergy, cutaneous infections, and topical antimicrobial use (p<0.005 for all), and increased OOP expenses for hospitalisation, emergency room visits, emollients, hygiene/bathing products, childcare, and specialised cleaning products, and clothing/bedding (p<0.05 for all) compared to adults with AD. Children with AD had increased median total yearly OOP expenditures ($860 vs. $500, p=0.002) and were more likely to spend ≥$1000 OOP per year (48.9% vs. 40.0%, p=0.03). In children, yearly OOP expenses ≥$1000 were associated with increased AD severity, flares, HCP visits, prescription polypharmacy, and step-up therapy use (p<0.005 for all) compared with adults. Predictors of harmful financial impact among children included black race (adjusted OR [95% confidence interval]: 3.86 [1.66-8.98] p=0.002) and ≥$1000 annual OOP expenditures (6.98 [3.46-14.08], p<0.0001). Children with AD have unique and increased OOP expenses that are associated with significant disease burden. Strategies are needed to reduce OOP costs and improve clinical outcomes in children with AD.

Changes in the Gut Microbial Diversity and Its Correlation with the Clinical Outcome in Children with Acute Myeloid Leukemia (AML) Receiving Induction Chemotherapy

Introduction Febrile neutropenia (FN) in patients with AML is associated with iatrogenic damage to the gut microbiota. Intensive chemotherapy also impairs gut barrier integrity, facilitating bacterial translocation and increasing the risk of bloodstream infection.Objectives: Our study aimed to describe the microbiological profile and microbiome changes in newly diagnosed AML children during the induction period and its impact on the clinical outcome. Patients and methods: This is a prospective study conducted at Children's cancer hospital in Egypt, studying 29 newly diagnosed AML patients aged 0-18 years during induction chemotherapy. The study was designated to compare the changes in gut microbiota at 3-time points: before induction chemotherapy D0, D7, and D21 from the beginning of induction chemotherapy. Two samples (rectal swabs or stool samples) were collected for each patient at three-time points; One swab was used for the microbiology analysis, and the other was stored at −20 °C for 16S rRNA sequencing. The Friedman test was used to assess for changes in alpha diversity from Day 0 to Day 7 to Day 21 samples. Microbial DNA was extracted from stool samples, and sequencing of the V4 region of the bacterial 16S rRNA genes was performed using an Illumina MiSeq platform. Alpha microbial diversity was measured by the Shannon Index. The Kruskal Wallis one-way variance test was performed to assess for changes in alpha diversity from baseline to day 7 to d21 samples. DESeq2 was used to identify differentially abundant bacteria at 3-time points. The samples were grouped into two groups, patients who did not acquire MDRO - and were treated as a control and patients who acquired MDRO during their hospital stay. MDRO biomarkers were identified using the online tool Galaxy lefse at the Genus level. Results Chemotherapy significantly decreases the Microbial richness of the Gut microbiome. Regarding relative abundance at phyla and genera level: Actinobacter is the most abundant before starting chemotherapy, Proteobacteria and Firmicutes are highly abundant on day 7 and on day 21. Verrucomicrobacteria increases on day 7 and disappears on day 21. Conclusion Gut microbial diversity declines in patients receiving intensive induction chemotherapy for AMLduring Induction Chemotherapy, even without antibacterial therapy. Additional study of the impact of the gut microbiome on outcomes in patients with AML is warranted to correlaate it with the clinical outcome. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Global Coinfections with Bacteria, Fungi, and Respiratory Viruses in Children with SARS-CoV-2: A Systematic Review and Meta-Analysis.

Background: Coinfection with bacteria, fungi, and respiratory viruses has been described as a factor associated with more severe clinical outcomes in children with COVID-19. Such coinfections in children with COVID-19 have been reported to increase morbidity and mortality. Objectives: To identify the type and proportion of coinfections with SARS-CoV-2 and bacteria, fungi, and/or respiratory viruses, and investigate the severity of COVID-19 in children. Methods: For this systematic review and meta-analysis, we searched ProQuest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus, and Nature through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies on the incidence of COVID-19 in children with bacterial, fungal, and/or respiratory coinfections, published from 1 December 2019 to 1 October 2022, with English language restriction. Results: Of the 169 papers that were identified, 130 articles were included in the systematic review (57 cohort, 52 case report, and 21 case series studies) and 34 articles (23 cohort, eight case series, and three case report studies) were included in the meta-analysis. Of the 17,588 COVID-19 children who were tested for co-pathogens, bacterial, fungal, and/or respiratory viral coinfections were reported (n = 1633, 9.3%). The median patient age ranged from 1.4 months to 144 months across studies. There was an increased male predominance in pediatric COVID-19 patients diagnosed with bacterial, fungal, and/or viral coinfections in most of the studies (male gender: n = 204, 59.1% compared to female gender: n = 141, 40.9%). The majority of the cases belonged to White (Caucasian) (n = 441, 53.3%), Asian (n = 205, 24.8%), Indian (n = 71, 8.6%), and Black (n = 51, 6.2%) ethnicities. The overall pooled proportions of children with laboratory-confirmed COVID-19 who had bacterial, fungal, and respiratory viral coinfections were 4.73% (95% CI 3.86 to 5.60, n = 445, 34 studies, I2 85%, p < 0.01), 0.98% (95% CI 0.13 to 1.83, n = 17, six studies, I2 49%, p < 0.08), and 5.41% (95% CI 4.48 to 6.34, n = 441, 32 studies, I2 87%, p < 0.01), respectively. Children with COVID-19 in the ICU had higher coinfections compared to ICU and non-ICU patients, as follows: respiratory viral (6.61%, 95% CI 5.06−8.17, I2 = 0% versus 5.31%, 95% CI 4.31−6.30, I2 = 88%) and fungal (1.72%, 95% CI 0.45−2.99, I2 = 0% versus 0.62%, 95% CI 0.00−1.55, I2 = 54%); however, COVID-19 children admitted to the ICU had a lower bacterial coinfection compared to the COVID-19 children in the ICU and non-ICU group (3.02%, 95% CI 1.70−4.34, I2 = 0% versus 4.91%, 95% CI 3.97−5.84, I2 = 87%). The most common identified virus and bacterium in children with COVID-19 were RSV (n = 342, 31.4%) and Mycoplasma pneumonia (n = 120, 23.1%). Conclusion: Children with COVID-19 seem to have distinctly lower rates of bacterial, fungal, and/or respiratory viral coinfections than adults. RSV and Mycoplasma pneumonia were the most common identified virus and bacterium in children infected with SARS-CoV-2. Knowledge of bacterial, fungal, and/or respiratory viral confections has potential diagnostic and treatment implications in COVID-19 children.

Laboratory Findings, Medical Imaging, and Clinical Outcome in Children with Cerebral Sinus Venous Thrombosis.

Cerebral sinus venous thrombosis (CSVT) is a rare disease, especially in children. Therefore, thrombophilia markers, risk factors, treatment strategy, and MRI, as well as clinical outcome need further investigation to support future diagnostic and therapeutic guidelines for children. We retrospectively identified all children with CSVT treated in our center between January 1, 2000, and December 31, 2015. Risk factors and laboratory findings were investigated. Furthermore, outcome and treatment satisfaction were evaluated using magnetic resonance imaging (MRI) analyses and a modified questionnaire. All 43 patients, who agreed to participate, were treated with therapeutic levels of heparin; 86% of children had an increased risk for thromboembolic events upon onset of CSVT (acute disease: 58.1%, perinatal risk factors: 9.3%, medical intervention/immobility: 14%, chronic disease: 16.3%). Thrombophilia markers showed positive results (e.g., reduced values for protein C/S, factor-V-Leiden mutation) in 58% of children at the time of CSVT diagnosis but dropping to 20.9% over the course of the disease. Forty-two of 43 patients received MRI follow-ups and the outcome showed complete recanalization in 69% of the patients and partial recanalization in 31%. At the onset of CSVT, 88% of patients reported restrictions in everyday life due to CSVT; at follow-up this percentage declined to 18%. Satisfaction with the outcome among parents/patients according to the questionnaire was high with 1.7 (German school grades from 1 to 6). All 42 children with MRI follow-up demonstrated complete or partial recanalization under anticoagulation. This positive result underlines the need for future studies on anticoagulation to optimize therapy regimens of pediatric CSVT.

Fluid Overload Mechanically Ventilated Days: A Novel Fluid Exposure Measure in Critically Ill Children With Acute Respiratory Failure.

We propose a novel metric evaluating the impact an exposure to a large positive fluid balance over time has on clinical outcomes in children with respiratory failure, termed "fluid overload mechanically ventilated" (FOMV) days. We performed a retrospective cohort study of mechanically ventilated children. Using multivariable regression analyses, each FOMV day was associated with a 5% decreased likelihood of having a ventilator-free day (adjusted incidence rate ratio [aIRR], 0.95; 95% CI, 0.95-0.96), a 5% increased likelihood of having an additional day of stay (aIRR, 1.05; 95% CI 1.05-1.06), and a 6% increased relative risk of death (aRR, 1.06; 95% CI, 1.01-1.11). FOMV is a novel exposure measure in children with acute respiratory failure associated with poor outcomes paralleling published data demonstrating dose-dependent exposure to a positive fluid balance is associated with worse outcomes. FOMV is a targetable exposure metric for future use in quality improvement initiatives and research studies that may help to determine the efficacy of interventions.

PSUN193 Comparing Long-Term Outcomes of Children Diagnosed with New-Onset Type 2 Diabetes in an Outpatient vs Inpatient Setting

Abstract Background Early identification and treatment of children and adolescents with Type 2 Diabetes (T2DM) is thought to improve long-term outcomes. However, it is unclear if severity of T2DM at presentation affects long-term clinical outcomes. Using the location of treatment initiation (inpatient compared to outpatient) as a proxy for severity of illness, we aimed to assess changes in dysglycemia and insulin requirements at diagnosis and after 3 years of follow-up. Methods We performed a retrospective chart review of children 8-18 years of age diagnosed with new onset type 2 diabetes and receiving diabetes care within a large tertiary care center between 1/1/2010 and 11/1/2021 for three consecutive years. Children were identified by ICD codes (ICD9 250.00, ICD10 E13.9 or E11.9). Charts were reviewed to confirm diagnosis. Exclusion criteria included medication induced diabetes, MODY, &amp;gt;1 positive diabetes autoantibody, BMI&amp;lt;85%, complicated medical history (genetic disorders, transplant, cancer, etc.), and &amp;lt; 3 visits in the study time frame. Chi-squared, t-tests, ANOVA, and linear regression were used for analyses. Results A total of 513 patients were identified by ICD code and, after exclusions, 116 were included in the analysis: 69 initially treated in an inpatient setting and 47 initially treated in an outpatient setting. The average A1C at presentation was higher in the inpatient group (11.02% ± 1.77) than the outpatient group (7.19% ± 0.72) (p&amp;lt;0.001). The BMI z-score at presentation was lower in the inpatient group (2.17%±0.58) than the outpatient group (2.41% ±0.35) (p=0.015), but at three years of follow-up the BMI z-score between the groups was not significantly different (2.05%±0.60) compared to (2.12% ±0.50) (p = 0.536). The average A1C remained higher in the inpatient group (9.58%±2.92) compared to the outpatient group (8.43% ±2.44) (p = 0.031). At treatment initiation the average total daily dose of insulin in the inpatient group (0.68±0.36 units/kg/day) was higher than the outpatient group (0.05±0.18 units/kg/day) (p&amp;lt;0.001). At three years of follow-up the average total daily dose of insulin remained higher in the inpatient group (0.50±0.46 units/kg/day) compared to the outpatient (0.29±0.36) (p=0.008 units/kg/day) group. Conclusion In conclusion, pediatric patients initially treated in the inpatient setting had poorer glycemic control and higher insulin requirements at baseline that persisted after three years of follow-up. These findings suggest that initial presentation may predict long-term clinical outcomes in children with T2DM. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Maintenance biofeedback therapy for dysfunctional voiding: Does every child need it?

The aim of the present study is to analyze the long-term clinical outcomes in children who were treated with biofeedback therapy (BF) for dysfunctional voiding (DV) and to determine the need for maintenance of BF due to clinical relapse. Files of children with DV who underwent BF between 2013 and 2020 were retrospectively reviewed. Patients with neurological or anatomical problems were excluded. A total of 64 patients (52 girls, 12 boys) with a mean age of 8.89 ± 2.48 years who completed the initial BF sessions were included in the study. The demographic and clinical data, dysfunctional voiding symptom scores (DVSS), and uroflowmetry parameters were recorded before and after the initial BF sessions. Clinical success was regarded as the cessation of electromyography activity as well as concurrent resolution of lower urinary tract symptoms and improvement in uroflowmetry parameters. After the initial BF sessions, children who had initial success showed DV relapse at any time during follow-up received the maintenance BF sessions. Therefore, the patients with successful initial BF were divided into two groups: the group that needed maintenance BF, and the group which required no maintenance BF. Clinical success was achieved in 48 (75.0%) of 64 children following a median of 6 sessions (range 2-8). At the follow-up, 10 (20.8%) out of 48 patients showed symptom relapse at a median of 8 months (range 2-24 months). After a median of 3.5 maintenance BF sessions (range 1-6), clinical success was observed in all patients. Both groups showed a significant DVSS decrease after initial BF, however, those who needed maintenance had significantly higher DVSS (6.80 ± 2.53 vs. 3.61 ± 1.12, p < 0.001). At admission, DVSS <17.5 (odds ratio [OR]: 4.31, p = 0.025) and post-voiding residual volume as a percentage of estimated bladder capacity for age <28.9 (OR: 5.00, p = 0.009) were found as the predictive factors for initial BF success. The need for maintenance BF was 2.56-fold higher with a DVSS above 5.5 after initial BF sessions. Our results show that despite a clinical success rate of 75% after the initial BF, relapse can be seen within 2 years in approximately 20% of the patients. Nevertheless, maintenance of BF may provide clinical success in all patients. Relatively higher DVSS after initial BF can be used as a predictor of the need for maintenance BF.