Pediatric Community Research Articles

Audit to Assess Melatonin Prescribing in Community CAMHS

AimsDisordered sleep is common, affecting 20–30%of children aged 1–5 years and often continues later into childhood. Neurodevelopmental disorders and psychiatric comorbidities pose a greater risk. The audit aimed to determine whether clinical prescribing practice of melatonin in Burlington House, Sefton CAMHS reflected current NICE recommendations. NICE suggest that first-line treatments for children with sleep problems include good sleep hygiene and behavioural therapy (including sleep diary).MethodsNice guideline CG170 provides guidance on Autism management. BNFC states that melatonin therapy should be reviewed every 6 months. Records of children currently prescribed modified release melatonin were checked to see if they met the inclusion criteria. Data were collected retrospectively from clinical case files and pharmacy records (December 2020- February 2021).ResultsThe results showed 18 young persons received melatonin for insomnia with ASD, 26 for insomnia without ASD, 3 for likely ASD and none for Smith Magenis syndrome. 36 received Specialist CAMHS review, 9 received Community Pediatrics review and 2 GP review. All patients received melatonin as per dose recommendations with 6 monthly reviews. Documentation on sleep hygiene was unclear.ConclusionWe concluded that Melatonin prescribing in community CAMHS tends to be high and discussion on sleep hygiene measures must be given importance.

It’s not Autism. It’s Your Parenting. An Autoethnographic Exploration of the Relationships Between Professionals and Parents of an Autistic Child in the UK

This paper is based on my own child who was diagnosed with Autism (aged 7 years and Autism and PDA aged 11). Using autoethnography, drawing on my own diaries, records and journals that I kept throughout this process, I document how our parenting was continually questioned and considered to be ineffective. This was the case even when our child had received his first diagnosis of autism. The extra stress and trauma that such continual questioning had impacted not only on us as parents, but also on our child with worsening behaviour. It seems that professionals continually questioned parenting styles, rather than focusing on the link between autism and behaviour, nor did they seem to understand the extreme stress and anxiety that parents and the autistic child themselves face. It was only when we started using strategies for Pathological Demand Avoidance (PDA) that our child’s behaviour improved although despite the casual remarks by the community paediatrician and other professionals that ‘it’s not PDA, it’s ineffectual parenting.’

International Perspective on a Revised Pediatric Sepsis Definition.

International Perspective on a Revised Pediatric Sepsis Definition.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Aug 2022This Month in Pediatric Urology Stacy T. Tanaka Stacy T. TanakaStacy T. Tanaka More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002760AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Pediatric Ureteroscopy Laser Outcomes The application of new medical technology in children commonly lags innovation in adult patients. Jaeger et al (page 426) at Boston Children’s Hospital in Boston, Massachusetts describe their early-adopter experience using a superpulse thulium fiber laser (SPTF) to treat upper tract stones in children.1 The group started using SPTF in September 2020. In a retrospective analysis, the authors compared stone-free rates in patients less than 21 years of age treated with either SPTF (23) or low-power Ho:YAG (holmium:yttrium-aluminum-garnet) laser (69). Stone-free rate, measured by primarily renal ultrasound within 90 days of the procedure, was higher in patients treated with SPTF (70% vs 59%). Because of concern about SPTF generating higher temperatures, the authors were careful to use continuous irrigation and low power settings. The SPTF was not associated with higher postoperative complications or an increase in operative time. The authors’ careful analysis addresses some of the limitations of the retrospective nature of this study. Nevertheless, their success with SPTF without increase in complication rate or operative time is very promising. Salvage Surgery Rates for Pediatric Testicular Torsion Hospital rating systems have weaknesses, but are there any strengths? Mandated reporting of hospital metrics can be a motivator to focus attention on specific aspects of care quality. In 2015, the US News & World Report introduced the quality metric of “time from ED/clinic to operating room” for testicular torsion in their Best Children’s Hospital Rankings. Using the Pediatric Health Information System database, which includes 52 children’s hospitals across the United States, Chun et al (page 441) from Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania compared testicular salvage rate before and after this metric was introduced.2 The authors found that the salvage rate improved. Of course, temporal association does not prove causation. However, it is suggestive that salvage rates did not change at hospitals that were receiving full score when the metric was introduced but did increase at hospitals not initially receiving the full score. From 2015 to 2019, the number of hospitals that received a full score for this question increased from 62% to 98%. Hospital rating systems are here to stay. Although it will take work, there is the potential for the pediatric urology community to replace flawed measures with meaningful ones that can nudge care quality. Dietary Risk Factors for Pediatric Kidney Stones Dietary counseling for children with stone disease is primarily based on adult data. Wang et al (page 434) from Boston Children’s Hospital in Boston, Massachusetts present one of the only studies to investigate the relationship between dietary nutrient intake and urolithiasis occurrence in children.3 At Boston Children’s, the primary care clinic was administering the Harvard Service Food Frequency Questionnaire at well child visits while the pediatric stone clinic was administering the Youth Adolescent Food Frequency Questionnaire to first-time stone formers within 6 months of diagnosis. The Harvard School of Public Health Nutrition Department has an analysis mechanism to translate data from both these validated surveys to standardized daily nutrition intake. The authors elegantly used this information to perform a case-control study in 57 stone patients and 228 controls. Unsurprisingly, they found that stone formers had higher sodium intake and lower potassium intake. Unexpectedly, they also found an association with increased calcium intake and increased beta-carotene intake. Although carrots are the most well-known dietary source of beta-carotene, high oxalate foods like spinach and kale also have beta-carotene; however, there did not appear to be an association with dietary oxalate intake. Unfortunately, the dietary surveys did not include data on water intake or specific diets (eg ketogenic diet). However, this novel exploratory study generates intriguing questions for future pediatric stone research.

Connected Care: Leveraging Virtual Solutions to Build Capacity from Hospital to Paediatric Home and Community Care

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Urinary biomarkers indicate pediatric renal injury among rural farming communities in Sri Lanka

Pediatric renal injury is an emerging health concern in communities affected by chronic kidney disease of uncertain etiology (CKDu). Early detection of susceptibilities through highly sensitive and specific biomarkers can lead to effective therapeutic and preventive interventions against renal diseases. Here, we aimed to investigate the utility of kidney injury molecule (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) in early detection of renal abnormalities in selected pediatric communities in Sri Lanka. The study areas were stratified as CKDu endemic, emerging, and non-endemic based on the prevalence of CKDu, and a total of 804 school students (10–18 years of age) participated in the study. The median (IQR) urinary KIM-1 levels of the participants were 0.193 (0.026–0.338), 0.082 (0.001–0.220) and 0.040 (0.003–0.242) ng/mgCr for CKDu endemic, emerging and non-endemic regions respectively. Participants from CKDu endemic regions reported elevated (p < 0.0001) urinary KIM-1 expression compared to those from the other regions. The median (IQR) NGAL levels in participants from CKDu endemic (2.969; 1.833–5.641), emerging (3.374; 1.766–6.103), and non-endemic (3.345; 1.742–5.128 ng/mgCr) regions showed no significant difference. Also, urinary albumin-creatinine ratio (UACR) showed no significant differences across gender or residency. The prevalence of albuminuria was 1–2% in the locations irrespective of CKDu burden. Albuminuric participants reported higher (p < 0.05) urinary KIM-1 levels in comparison to normoalbuminuric participants. Significantly elevated urinary KIM-1 expression in a pediatric population from CKDu affected regions, especially in the presence of albuminuria, may indicate low-grade early renal damage supporting the utility of KIM-1 as a quantifiable biomarker.

Faculty Support for Advocacy Is Key to Training the Next Generation of Pediatrician-Advocates.

We are pleased to see a focus on advocacy in the hospital setting described by Winthrop et al in the October 2021 Hospital Pediatrics perspectives article, “Training the Next Generation of Pediatrician-Advocates: A New Focus on the Inpatient Setting.” We agree that pediatric residency training would benefit from advocacy teaching in this setting. Such training can be modeled after the advocacy curricular resources developed for pediatric hospital medicine. These resources include: (1) competency-based goals and objectives for the advocacy rotation that map to pediatric subspecialty entrustable professional activities, developed by the curriculum committee of the Pediatric Hospital Medicine Fellowship Program Directors Council; and (2) specific knowledge, skills, and attitudes in advocacy as defined by the 2020 Pediatric Hospital Medicine Core Competencies.1However, faculty development in advocacy is necessary but not sufficient to allow for advocacy training and curricular development in the inpatient setting. Inpatient faculty must also be given the time, resources, and support to perform and teach advocacy. This can only happen if advocacy scholarship is congruent to traditional scholarship, including both research and medical education. We propose the following additional faculty needs to establish integration of advocacy in the hospital practice setting: Adoption of advocacy portfolios: Clinician-researchers generate scholarship to benefit patients and populations in the form of peer-reviewed grants and publications. Clinician-educators have gained support for scholarly activities and faculty promotion in medical education through the development and application of educator portfolios. Recognition of advocacy as a scholarly pursuit can only be achieved through the dissemination and widespread adoption of advocacy portfolios (APs).2 APs supplement the curriculum vitae to highlight how advocacy can be held to the same rigorous scholarly standards as traditional scholarship. Recognition of advocacy and APs in the academic promotion process will allow those interested in pursuing an advocacy scholarship to be successful in obtaining the time and resources necessary for practice. A national group of pediatrician-advocates has developed the first standardized AP template along with the American Academy of Pediatrics Community Pediatrics Training Initiative.3Advocacy recognition within the Pediatric Hospital Medicine Board certification process: The American Board of Pediatrics (ABP) has proposed a pediatric subspecialty entrustable professional activity focused on population health. Additionally, “advocacy and leadership” is a content domain for Pediatric Hospital Medicine Board certification. Despite this, the ABP has not recognized advocacy as a form of scholarship and “work product” allowable for pediatric subspecialty fellowship completion and subsequent board certification, even it if meets the Glassick criteria for scholarship.4 Lastly, allowing physicians to submit advocacy projects for maintenance of certification credit would greatly assist in recognizing the role of physician advocacy in improving population health.Advocacy will gain congruence in academics through a simultaneous bottom-up and top-down approach: faculty use of APs as developmental and promotional tools, along with recognition and support from medical school leadership and the ABP. Only if these criteria are met will faculty be recognized for scholarly advocacy activities, thereby supporting the time, resources, and funding necessary for teaching such practice to the next generation.

Providing optimal care for active youth in Canada

Sports are important activities for youth, with millions of children and adolescents participating in organized sports and recreational activities every year. Sports participation has many benefits but can also cause injuries, accounting for two-thirds of all injuries in Canadian adolescents and resulting in hundreds of thousands of medical visits annually. Despite the frequency of sports-related injuries in youth, many practising pediatricians are not comfortable managing these issues, citing a lack of teaching and clinical exposure during training. Many studies have found deficits in musculoskeletal (MSK) and sport and exercise medicine (SEM) training in residency programs in North America, including Canadian pediatric residency programs. To address this learning gap, Canadian pediatric residency programs should incorporate more MSK/SEM training and clinical exposure to these issues. A standardized national curriculum in MSK/SEM will help ensure that community pediatricians practicing in Canada are adequately prepared to care for active youth.

Arresting microbiome development limits immune system maturation and resistance to infection

Abstract The transition from milk to solid food is a critical period in post-natal human development. Weaning coincides with a dramatic and rapid maturation of both the microbiome and immune system. Whether these weaning induced changes in commensal communities shape immune system development and susceptibility to enteric infection remains unknown. Here we find maturation of the microbiome during weaning is required for proper immune system development and protection against enteric infection. To this end, we developed a stable gnotobiotic mouse model of the early-life microbiome composed of a representative nine-member consortium of phylogenetically diverse microbes found pre-weaning, designated as Pediatric Community (PedsCom). PedsCom efficiently colonized germfree adult mice and was vertically transmitted to offspring. Unexpectedly, the composition of PedsCom was unaffected by the transition from a milk-based to a fiber rich solid food diet. This permitted us to study adult mice with a pre-weaning intestinal microbiome. We find that arresting intestinal microbiome maturation in PedsCom mice limited immune system development. PedsCom mice displayed decreased both peripheral regulatory T cells accumulation and Immunoglobulin A production, hallmarks of microbiota-driven immune development. Consistent with defects in maturation, adult PedsCom mice retain high susceptibility to Salmonella infection characteristic of young mice and humans. Altogether, our work illustrates how the post-weaning transition in intestinal microbiome composition is essential for normal immune maturation, and protection from enteric infection. Supported by 1R21AI146629-01A1

An Ounce of Prevention Is Worth a Pound of Cur(i)e.

The following material is in this sense a “preventative” topic, in the spirit of early and anticipatory efforts rather than greater investments once situations arise. The axiom is from The Philadelphia Gazette in 1734 and under the pseudonym of A.A. but attributed to Benjamin Franklin [ 1 Franklin B. On protection of towns from fire. Pennsylvania Gazette; 1734. https://founders.archives.gov/documents/Franklin/01-02-02-0002Date accessed: March 24, 2022 Google Scholar ]. Unlike the common current application of this saying to general medical care, Franklin was in fact addressing local fire safety. Although the juxtaposition of the words “fire” and “radiation” in generalizing this axiom is alarming (the only intended pun), the early investment and longer-term benefits are relevant to both. The “pound of cure” can be represented by many of the current efforts at radiation safety including technical improvements in equipment, protocol modifications, adherence to appropriateness, advances in measures and benchmarks for radiation dose estimates, and enhanced understanding through education and awareness. Examples of this last effort include the Image Gently® and Image Wisely® organizations as recognized promoters among many global professional societies and organizations. And although the success of such efforts is difficult to determine beyond attribution [ 2 Frush D.P. Sorantin E. Radiation use in diagnostic imaging in children: approaching the value of the pediatric radiology community. Pediatr Radiol. 2021; 51: 532-543 Crossref PubMed Scopus (6) Google Scholar ], the “ounce of prevention” of early exposure, namely early medical education, on the informed use of medical imaging, especially regarding radiation doses, risks, and associated risk dialogues, embraces the conviction that the benefits down the line will be evident and amplified.

Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma.

Introduction:The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment.Methods:Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year.Results:After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months.Conclusions:Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.

To sim or not to sim-choosing wisely for procedural skills training in paediatrics.

Simulation is a commonly used modality to teach paediatric procedural skills, however, it is resource intensive. Which paediatric skills are best taught using simulation is not known. This study aims to examine what skills to simulate, allowing for the best use of resources in ever expanding curricula. We administered a questionnaire to community and hospitalist general paediatricians in Canada asking them to rate the importance of maintaining competency in each paediatric procedural skill and the frequency with which they perform the skill in their practice. Skills that were rated as highly important and also high frequency were: bag-mask ventilation (BMV), lumbar puncture, neonatal cardiopulmonary resuscitation (CPR), specimen procurement for infectious diseases, immunization, and ear curettage. Skills that were rated as highly important but low frequency were: paediatric CPR, intraosseous needle insertion, neonatal intubation, defibrillation, gathering specimens for evidence of child maltreatment, paediatric intubation, cervical spine immobilization, and oral/nasogastric tube placement. Paediatric procedural skills are rated variably in terms of importance and frequency of use in general paediatric practice. Eight skills of high importance are infrequently performed and should be targeted for teaching via simulation.

Normothermic Machine Perfusion in pediatric liver transplantation: A survey of attitudes and barriers.

NMP provides a superior strategy for the assessment and preservation of marginal donor livers and has demonstrated increased utilization and enhances organ quality when used in adult liver transplantation. We aimed to evaluate the interest of incorporating the use of NMP in pediatric liver transplantation. An anonymous online survey was distributed to pediatric transplant surgeons and hepatologists across the United States. Respondent demographic information, attitudes toward NMP in pediatric liver transplantation, and barriers to utilization were examined. Thirty-two providers (18 transplant surgeons and 14 hepatologists) completed the survey, yielding a response rate of 64%. Half (50%) of respondents indicated prior exposure to NMP. Overall, 96% of respondents believed there was benefit to using NMP in pediatric liver transplantation. DCD (68%) and post-cross-clamp (75%) grafts were the greatest opportunity for NMP use. A role in splitting livers ex vivo (71%) was also seen as a potential major opportunity. Cost was perceived as a barrier to implementation (36%), followed by institutional factors (32%). Cost tolerance was significantly greater in respondents residing in OPTN regions with greater than median wait times (63% vs. 11% in OPTN regions with greater vs. shorter wait times, p=.010). There is significant interest within the pediatric liver transplant community for NMP to expand the donor pool. Interest appears particularly strong in regions where wait times for suitable pediatric donors are prolonged.

Supporting Children on the Autism Spectrum as They Experience the Challenges of COVID-19.

The response to the COVID-19 pandemic has amplified stress and social isolation for many children, but those children living with a diagnosis of autism spectrum disorder (ASD) have been disproportionately affected. Prior to the pandemic, children with ASD often faced social isolation due to struggles with their social communication and social development. Planning for children with ASD to return to community experiences, including school, appointments, and even recreational activities, will require an understanding of the impact of COVID-19 on the child and their family. As the child and family are working to adjust to changes like new routines, sleep patterns, and sensory issues as a result of the pandemic, the pediatric nursing community should be knowledgeable and prepared to develop creative opportunities to meet the needs of this vulnerable population.

Caring for children with cancer evacuated from Ukraine

Since the war in Ukraine started on Feb 24, 2022, thousands of children and civilians have been killed, and the resulting humanitarian crisis is one of the worst that Europe has experienced in recent times. Among the 2 million child refugees who fled Ukraine, children and adolescents with cancer are facing particular challenges as their treatment is interrupted by the war. The international paediatric oncology community has been trying to find ways and resources to deal with a new emergency—to continue care provision for these patients.

Magnesium Orotate and the Microbiome-Gut-Brain Axis Modulation: New Approaches in Psychological Comorbidities of Gastrointestinal Functional Disorders.

Magnesium orotate has been cited in the medical literature for the past three years as a possible adjuvant in some pediatric and adult gastroenterological disorders associated with dysbiosis. Studies also focus on the possibility of adding magnesium orotate in psychiatric disorders’ treatment, such as major depression and anxiety. The most relevant element in these studies is the efficiency of magnesium orotate therapy in cases with both gastroenterological and psychiatric symptoms. This article proposes a literature review, focused on the studies published in the last three years, targeting magnesium orotate treatment and probiotic supplementation in patients with both digestive and psychiatric symptoms. Moreover, this review will compare the efficiency of magnesium orotate and probiotics within both the pediatric and adult communities, focusing on the possibility of gut–brain axis modulation and its involvement in the clinical evolution of these patients.

Community paediatricians’ experience of joint working with child and adolescent mental health services: findings from a British national survey

ObjectivesChildren and young people (CYP) presenting to paediatric or child and adolescent mental health services (CAMHS) often have needs spanning medical and psychiatric diagnoses. However, joint working between paediatrics and...

Primary care provider diagnosed eczema within electronic medical records from seven canadian provinces.

Most epidemiological research on eczema has largely relied on patient survey data. With the increasing use of electronic medical records (EMR) in primary care, there has been a shift in epidemiological research towards the use of validated case definitions to study disease. Apply a validated case definition for eczema to EMR data from primary care providers participating in the Canadian Primary Care Sentential Surveillance Network (CPCSSN) to determine the prevalence of diagnosed eczema in Canada and describe patient's characteristics including risk factors and comorbidities. Cross-sectional study. EMR data from 1,574 primary care providers in seven Canadian provinces. Patient records were examined for those with at least one encounter with a family physician, nurse practitioner or community pediatrician participating in CPCSSN between January 1, 2017, and December 31, 2019 (N= 689,301 patients). Primary outcome was lifetime prevalence of eczema. Secondary outcomes were demographics of eczema patients and the association between eczema and various comorbidities. Descriptive statistics revealed a lifetime prevalence of documented eczema of 11.6% overall, 15.1% in those <19 years, and 11.5% in those >19 years. Patients with eczema were more likely to be smokers. Using the Material and Social Deprivation Index we found eczema was more prevalent among the least materially and socially deprived quintiles. In logistic regression, female patients (OR, 1.29; 95% CI, 1.27-1.32) and patients <19 years (OR, 1.27; 95% CI, 1.19-1.35) had higher odds of eczema compared to male patients and patients aged >19 years. Patients with comorbidities such as rhinitis (OR, 2.11; 95% CI, 2.06-2.17), asthma (OR, 1.4; 95% CI, 1.37-1.43), any allergy (OR, 1.09, 95% CI 1.06-1.11), COPD (OR, 1.1; 95% CI, 1.06-1.14) and anxiety (OR, 1.66; 95% CI, 1.63-1.69) had higher odds of eczema compared to patients without these comorbidities. Depression (OR, 0.96; 95% CI, 0.94-0.98) and obesity (OR, 0.96; 95% CI, 0.94-0.98) were negatively associated with a diagnosis of eczema. This is the first study in Canada to determine the prevalence of primary care provider documented eczema using EMR data. This study can inform and improve disease surveillance as well as future studies exploring burden of illness, trends or interventions related to eczema care in Canada.

Vitamin B 12 deficiency….The predominant cause of macrocytic anemia in pediatric population visiting Children hospital Lahore

Objectives: The purpose of this scrutiny was to note the part played by folic acid and vitamin B 12 inadequacies resulting in macrocytic anemia in pediatric community visiting our institute. Study Design: Retrospective cross sectional study Place and duration: Department of Hematology and Transfusion Medicine, The Children Hospital, University of Child Health Sciences, Lahore from Jan 2021 to Dec 2021. Methodology: Medical data of 294 children demonstrating features of megaloblastic anemia were scrutinized. Records related to complete blood count (CBC) specially hemoglobin level, MCV, MCH, MCHC, peripheral blood findings, serum folic acid and vitamin B 12 amounts were noted from registers along with the other relevant medical presenting, past and family socioeconomic history. Results: Out of total 294 cases with CBC and peripheral blood findings of macrocytic anemia, 160 were males and 134 found to be females. Mean age was 57 months (4.75 years). Vitamin B12 insufficiency alone was noted in 162 (55.1%) cases, folic acid alone appeared to be deficient in only 8 cases where as combined paucity of both was noticed in 30 cases. Conclusion: Vitamin B12 deficiency found to be the predominant cause of macrocytic anemia in children referred to our institution with 65.3 % of total case population. Considering its significance in the regulation of nervous system, awareness programs with proper guidance are essential to deal this manageable issue. Key words: Megaloblastic anemia, macrocytosis, cobalamin, Vitamin B 12 deficiency, Folic acid deficiency, Anemia, Lahore Pakistan

Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance.

Children with kidney failure require kidney replacement therapy (KRT), namely maintenance dialysis and kidney transplant. Adequate kidney failure care consists of KRT or conservative treatment with palliative care. In the context of kidney failure, children depend on parents who are their surrogate decision-makers, and the pediatric nephrology team for taking decisions about KRT or conservative care. In this paper, we discuss the ethical challenges that arise relating to such decision-making, from a global perspective, using the framework of pediatric bioethics. While many ethical dilemmas in the care of children with KRT are universal, the most significant ethical dilemma is the inequitable access to KRT in low & middle income countries (LMICs) where rates of morbidity and mortality depend on the family's ability to pay. Children with kidney failure in LMICs have inadequate access to maintenance dialysis, timely kidney transplant and palliative care compared to their counterparts in high income countries. Using case vignettes, we highlight how these disparities place severe burdens on caregivers, resulting in difficult decision-making, and lead to moral distress among pediatric nephrologists. We conclude with key action points to change this status-quo, the most important being advocacy by the global pediatric nephrology community for better access to affordable kidney failure care for children.