Functional Outcomes In Children Research Articles

Postsurgical Analysis of Gait, Radiological, and Functional Outcomes in Children with Developmental Dysplasia of the Hip.

Children undergoing DDH correction surgery may experience gait abnormalities following soft tissue releases and bony procedures. The purpose of this study was to compare the residual gait changes, radiological outcomes, and functional outcomes in children who underwent DDH surgery with those in healthy controls. Inertial motion sensors were used to record the gait of 14 children with DDH and 14 healthy children. Pelvic X-ray was performed to determine the Severin classification and the presence of femoral head osteonecrosis (Bucholz-Odgen classification). For functional evaluation, the Children's Hospital Oakland Hip Evaluation Scale (CHOHES) was used. There was no difference in spatial parameters between the two groups. In terms of temporal parameters, the DDH-affected limbs had a shorter stance phase (p < 0.001) and a longer swing phase (p < 0.001) than the control group. The kinematic study showed that the affected limb group had smaller hip adduction angle (p = 0.002) and increased internal rotation (p = 0.006) with reduced upward pelvic tilt (p = 0.020). Osteonecrosis was graded II, III, and IV in five, three, and one patients, respectively. Five patients had no AVN changes. The Severin classification was grade I, II, and III for six, three, and five patients, respectively. Most patients had good functional outcomes on the CHOHES, with a mean total score of 96.64 ± 5.719. Multivariate regression analysis revealed that weight, height, and femoral osteotomy were independent predictors for gait, radiological and functional outcome. Despite good functional scores overall, some children had poor radiological outcomes and gait abnormalities. Our results identified the risk factors for poor outcomes, and we recommend specified rehabilitative strategies for long-term management.

Changes in the Status of Spastic Diplegic Children in Terms of Gross Motor Function Classification System and Functional Mobility Scale Following Surgical Intervention: A Single Centre Experience.

Introduction Most centers in low- to mid-income countries (LMICs) lack facilities for a comprehensive instrumented gait analysis (IGA) which is often considered the preferred method for assessment of the functional results of surgery in children with spastic diplegia. We aimed to study if there wereany changes in the Gross Motor Function Classification System (GMFCS) levels and Functional Mobility Scale (FMS) scores after surgery and whether they can be used as an indirect indicatorofchange in the functional status of a child. Methods This prospective study was conducted at the Pediatric Orthopedic unit of a teaching hospitalon spastic diplegic children requiring surgical intervention. GMFCS levels and FMS scores were recorded before the surgery and at each follow-up visit,with the latest recordbeingtwo years post-surgery. The change in the scores was indicated as an improvement, deterioration, or no change from the baseline and compared to thescore of the preceding visit. In addition, it was examined whether the age at surgery had any effect on the temporal change in the scores. Results A total of 25children were included for analysis after excluding those who failed to fulfill the predefined inclusion and exclusion criteria. Both the GMFCS levels and FMS scores improved from the third month toone-year post-surgery, after whicha few patients had a worsening of their scores at the two years follow-up visit. The age at which surgery was performed had no significant effect on the pattern of change in the scores. Mostchildren soughtconsultations with the physical therapy department only when they visited the surgical team for follow-up. Conclusion This study shows that surgical interventions doimprove the functional outcomes in children with spastic CP when assessed using FMS scores while maintaining an undeteriorated GMFCS level in most children. While a peak improvementcan be expected one year after surgery in most patients, possible of worsening from baseline scores doexist, and the parents must be informed of the same. Any decision for surgery must involve the parents, and the usefulness of postoperative physical therapy must be impressed upon them before the surgery and during each follow-up visit too.

The Long-Term Outcome and Rehabilitative Approach of Intraventricular Hemorrhage at Preterm Birth.

Technological advances in neonatology led to the improvement of the survival rate in preterm babies with very low birth weights. However, intraventricular hemorrhage (IVH) has been one of the major complications of prematurity. IVH is relevant to neurodevelopmental disorders, such as cerebral palsy, language and cognitive impairments, and neurosensory and psychiatric problems, especially when combined with brain parenchymal injuries. Additionally, severe IVH requiring shunt insertion is associated with a higher risk of adverse neurodevelopmental outcomes. Multidisciplinary and longitudinal rehabilitation should be provided for these children based on the patients' life cycles. During the infantile period, it is essential to detect high-risk infants based on neuromotor examinations and provide early intervention as soon as possible. As babies grow up, close monitoring of language and cognitive development is needed. Moreover, providing continuous rehabilitation with task-specific and intensive repetitive training could improve functional outcomes in children with mild-to-moderate disabilities. After school age, maintaining the level of physical activity and managing complications are also needed.

Endocrine Abnormalities in Children With Traumatic Brain Injury at a Tertiary Care Center.

Objective Accidental traumatic brain injury (TBI) can lead to severe complications such as endocrine abnormalities and long-term morbidities and can negatively impact patient lives. These conditions are also associated with a high cost of treatment over a lifetime, a significant concern in low-to-middle-income countries (LMICs). In Pakistan, the prevalence of children with endocrine abnormalities secondary to TBI remains largely unexplored. We conducted a retrospective cross-sectional study to estimate the burden of endocrine abnormalities due to TBI among children in our population. Methods Twenty patients previously admitted with head injury between September and October 2019 were retrospectively reviewed with tests for baseline serum sodium, plasma osmolality, cortisol, adrenocorticotropin (ACTH), free thyroxine (fT4), growth hormone (GH), insulin growth factor-1 (IGF-1), follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), prolactin, estradiol, and testosterone. Data were collated from the electronic Health and Information Management System (HIMS) and analyzed using SPSS v25. Chi-square and t-tests were used to identify associations between variable groups. Outcomes of interest included correlations between hormonal levels and demographic factors, interventions and hormonal levels, and complication rates and hormonal levels. Results Our study reports three (15% of the total cohort) patients with pituitary hormone deficits (two with low IGF-1 and one with low TSH). High serum IGF-1 and ACTH levels were also observed in three (15%) children. High IGF-1 was associated with female gender (p=0.007), mechanical ventilation (p=0.038), and falls (p=0.028). IGF-1 (p=0.035) and GH (p=0.049) levels were associated with improvement in Extended Glasgow Outcome Scale (GOS-E) score. Testosterone was positively correlated with a high percentile for height (p=0.005) and GOS-E scores on follow-up (p=0.030). High testosterone levels (592.12 ± 102.28 ng/dl) were associated with good functional outcomes in post-pubescent patients (p<0.05). Serum fT4 was linked with a high GOS-E score at discharge in prepubescent patients (p=0.034). Neurosurgical decompression was the only risk factor for hormone deficiency, comprising 67% of the group with hormone deficiencies (p=0.028). The learning difficulties were observed exclusively in children with hormonal deficiencies (7 patients, p=0.000). Conclusion Hormonal dysfunction due to TBI in children can lead to poor outcomes. High serum IGF-1, testosterone, and free T4 levels were associated with improved functional outcomes in children with TBI. Limited follow-up and resources in LMICs are significant barriers to addressing the morbidity associated with these conditions and need to be addressed at a health policy level.

Clinico-Etiological Spectrum and Functional Outcomes of Children with Pre-Status Dystonicus and Status Dystonicus (SD): A Descriptive Study.

Status dystonicus (SD) is a life-threatening movement disorder emergency characterized by increasingly frequent and severe episodes of generalized dystonia, requiring urgent hospital admission. The diverse clinico-etiological spectrum, high risk of recurrence, and residual disabilities complicate functional outcomes. We aim to describe the clinico-etiological spectrum, radiology, therapeutic options, and follow-up of patients with pre-status dystonicus (pre-SD) and SD. A cross-sectional retrospective study was carried out in a tertiary care referral center. The clinical, laboratory, and radiology data of all patients aged less than 18 years with pre-SD and SD from January 2010 to December 2020 were collected. The Dystonia Severity Assessment Plan (DSAP) scale for grading severity and the modified Rankin Scale (mRS) for assessing outcome were used at the last follow-up visit. Twenty-eight patients (male:female: 2.1:1) experiencing 33 episodes of acute dystonia exacerbation were identified. The median age at the onset of dystonia and SD presentation was 8.71 (range: 0.25-15.75) and 9.12 (range: 1-16.75) years, respectively. Four patients experienced more than one episode of SD. The etiological spectrum of SD includes metabolic (Wilson's disease-13, L-aromatic amino acid decarboxylase deficiency-one, and Gaucher's disease-one), genetic (neurodegeneration with brain iron accumulation-three and KMT2B and THAP 1 gene-related-one each), structural-three, post-encephalitic sequelae (PES)-four, and immune-mediated (anti-NMDA receptor encephalitis-one). Five patients had pre-SD (DSAP grade 3), and 23 patients had established SD (DSAP grade 4-17 and DSAP grade 5-six). The Rapid escalation of chelation therapy precipitated SD in 11 patients with Wilson's disease. Febrile illness or pneumonia precipitated SD in nine patients. Twenty-three episodes of SD required midazolam infusion in addition to anti-dystonic medications. The median duration of hospital stay was 10 days (range: 3-29). Twenty-three patients had resolution of SD but residual dystonia persisted, while two patients had no residual dystonia at follow-up. Three patients succumbed owing to refractory SD and its complications. Early identification of triggers, etiology, and appropriate management are essential to calm the dystonic storm.

Surgical Debridement for Acute and Chronic Osteomyelitis in Children.

Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients. The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal. Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure. This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes. We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae10. Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner. MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant Staphylococcus aureusPDS = polydiaxonone.

Functional Outcome in Children with Hirschsprung’s Disease after Modified Duhamel’s Procedure: A Longitudinal Study

Introduction: The classical surgical treatment of Hirschsprung’s Disease (HD) is by resection of the aganglionic segment of the distal intestine and bringing down the ganglionic segment by Modified Duhamel’s procedure or other pull-through operations. The assessment of the postoperative functional outcome and continence scoring systems are important considerations during follow-up of these children. In the present study, a scoring system was used to analyse the postoperative functional outcome of HD as there are very few studies, that have objectively assessed the same. Aim: To assess the functional outcome in children under six years of age, who underwent Modified Duhamel’s procedure for HD. Materials and Methods: This descriptive longitudinal, study was conducted in the Tertiary Teaching Institution at Government Medical College, Thiruvananthapuram, Kerala, India. The duration of the study was one year and nine months, from February 2017 to November 2018. Forty cases of biopsy proven HD, who underwent Modified Duhamel’s procedure were analysed. Postoperative follow-up was done at one, two, and three years after the definitive surgical procedure. Patients were classified as good, fair and poor outcome groups depending based on the Taylor-Duthies-Zachary continence scoring system. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 22.0. Pretest comparison of scores and p-value were analysed by Wilcoxon signed-rank test. A p-value &lt;0.05 was considered as statistically significant. Results: The mean age of the study participants was 12.7±4.1 months and age ranges from three to 25 months. Median stool frequency per day after one, two, and three years of surgery, was 6.0, 4.0, and 3.0, respectively. The observed difference in median frequency between one and two year, one and three, and two year and three year was statistically significant (p&lt;0.05). Median continence score to assess the anal sphincter control at one, two and three years after surgery were 2.3, 4.0 and 4.5, respectively. The observed difference in scores over successive years, was statistically significant (p&lt;0.05). Conclusion: The functional outcome in patients, who underwent Duhamel’s procedure was good and the postoperative issues like increased stool frequency, and sphincter control improved over successive years.

33: LONG-TERM CARDIAC AND FUNCTIONAL OUTCOMES OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN

Introduction: Multi-system Inflammatory Syndrome (MIS-C) is a hyperinflammatory state involving two or more organs associated with a previous diagnosis of SARS-CoV-2. Cardiac dysfunction is described in 80-85% of cases. Currently, there is a knowledge gap regarding long-term cardiac and functional outcomes in children diagnosed with MIS-C. Methods: We conducted a retrospective chart review of children < 21 years admitted to our hospital for MIS-C between January 2020 and January 2022. We collected demographic, clinical, laboratory, imaging data [left ventricular ejection fraction (LVEF), coronary artery dilation (CAD)], and functional status score (FSS) during hospital stay and long-term (up to 6 months) follow up. Using a student t-test and chi-square test, we compared the outcomes of children admitted to the pediatric intensive care unit (PICU) vs outside the PICU. Results: Out of the 40 children admitted to the hospital with MIS-C during the study period, 16 (40%) were admitted to the PICU while 24 (60%) were admitted outside the PICU. Of the PICU patients, 13.33% showed CAD and 31.25% had a LVEF ≤55% on at least one echocardiogram during their hospital stay. Of the echocardiograms completed on the non-PICU patients (n=22), 18.18% showed CAD and 9.09% had a LVEF ≤55% on at least one echo during admission. Between PICU and non-PICU patients, there was a significant (p ≤ 0.05) difference in mean length of stay (13.56 vs. 6.16 days respectively), lowest LVEF (56.14% vs 62.58%), and change in Functional Status Score (ΔFSS) (0.5 vs 0.0). Of the 16 PICU patients, 11 had follow-up echocardiogram and none had persistent CAD and/or LVEF ≤55%. Of the 20/24 (83.33%) non-PICU patients with echocardiograms at follow-up, 10% displayed persistent coronary artery dilation while none had LVEF ≤55%. At follow-up, a significant proportion of non-PICU patients had persistent CAD as compared to PICU patients (p≤0.0001), but there was no difference in LVEF and ΔFSS amongst the two cohorts. Conclusions: A significant proportion of children admitted outside the PICU had persistent coronary abnormalities at up to 6 month follow up compared to patients admitted in the PICU. However, none of the patients had persistent low LVEF (≤55%) or functional disability at up to 6 month follow up (ΔFSS).

417: COMBINATION IMMUNE THERAPIES FOR ACUTE MANAGEMENT OF MIS-C AND LONG-TERM OUTCOMES

Introduction: Since the recognition of Multisystem Inflammatory Syndrome in Children (MIS-C), different immune therapies have been utilized as monotherapy (MT) or combination therapy (CT). Currently there is a lack of sufficient literature examining the long-term cardiac and functional outcomes in children following MT versus CT for MIS-C. Methods: We conducted a retrospective chart review of children < 21 years old admitted to our tertiary care children’s hospital for MIS-C from January 2020 to January 2022. We collected clinical data, especially cardiac imaging data [left ventricular ejection fraction (LVEF), coronary artery dilation (CAD)], and functional status scores (FSS) during hospital stay and long-term (up to 6 months) follow up. We then compared the long-term outcomes of children who received three different treatment regimens during hospitalization: Steroid only (S), Steroid and IVIg (S + IVIg), and Steroid, IVIg, and Anakinra (S + IVIg + Ana), using a student t-test and Fisher’s exact test. Results: Of the 40 children admitted with MIS-C during the study period, one who did not receive any immune therapy was excluded and of the remaining 39, the number of patients in each treatment group (S, S+IVIg, S+IVIg+Ana) was 13 (33%), 14 (36%) and 12 (31%) respectively. During hospitalization, among the S, S+IVIg, and S+IVIg+Ana groups, the mean (SD) LVEF were 63.9 (4.9)%, 60.0 (7.2)%, 55.9 (9.1)% respectively and CAD was documented in 1/11 (9.1%), 3/14 (21.4%) and 2/11 (18.2%) patients, respectively and at up to 6-month follow-up, the mean (SD) LVEF were 63.9 (2.8)%, 63.5 (4.0)%, and 66.3 (3.1)%, respectively, and CAD was documented in 0/11 (0%), 0/10 (0%), 2/10 (20%) patients, respectively. There was no significant difference in the proportion of patients with persistent low (≤ 55%) LVEF or CAD across the groups at long-term follow-up (p>0.05). There was no significant difference in ΔFSS across the 3 groups at discharge [mean (SD): S 0 (0), S+IVIg 0.3 (1.1), and S+IVIg+Ana 0.3 (0.9)] as well as at follow-up [mean (SD): S 0 (0), S+IVIg 0 (0), and S+IVIg+Ana 0.3 (0.7)]. Conclusions: In our cohort of MIS-C patients, cardiac and functional outcomes were favorable at follow-up irrespective of combination of immune therapies offered during hospitalization.

The Heritability of ADHD in Children of ADHD Parents: A Post-hoc Analysis of Longitudinal Data

Objective: A growing literature suggests attention-deficit/hyperactivity disorder (ADHD) is a heritable disorder. We evaluated children at risk for ADHD by virtue of having parents with ADHD and compared them with children of parents without ADHD to assess the degree of heritability of ADHD. Method: The sample for this study was derived from three longitudinal studies that tracked families with various disorders, including ADHD. Children were stratified based on presence of parental ADHD, and clinical assessments were taken to evaluate presence of ADHD and related psychiatric and functional outcomes in children. Results: Children with parental ADHD had significantly more full or subthreshold psychiatric disorders (including ADHD) as well as functional impairments compared to children without parental ADHD. Conclusion: Our findings suggest that offspring of parents with ADHD are at significant risk for ADHD and its associated psychiatric, cognitive, and educational impairments. These findings aid in identifying early manifestations of ADHD in young children at risk.

Long-term functional outcomes of children after critical illnesses: A cohort study

ObjectiveTo assess children's functional outcomes one year after critical illness and identify which factors influenced these functional outcomes. DesignAmbispective cohort study. SettingPediatric intensive care unit (PICU) in a tertiary academic center. ParticipantsChildren (1 month–17-year-old) and their caregivers. InterventionsNone. Main variables of interestDemographic, clinical, and functional status. ResultsOf 242 patients screened, 128 completed the year follow-up. These children had significant changes in functional status over time (p<0.001). The functional decline occurred in 62% of children at discharge and, after one year, was persistent in 33%. Age>12 months was a protective factor against poor functional outcomes in two regression models (p<0.05). A moderately abnormal functional status and a severely/very severely abnormal functional status at discharge increased the risks of poor functional outcomes by 4.14 (95% CI 1.02–16.72; p=0.04), and 4.76 (CI 95% 1.19–19.0; p=0.02). A functional decline at discharge increased by 6.86 (95%CI: 2.16-21.79; p=0.001) the risks of children's long-term poor functional outcomes, regardless of the FSS scores. ConclusionThis is the first study evaluating long-term functional outcomes after pediatric critical illnesses in Latin America. Our findings show baseline data and raise relevant questions for future multicentre studies in this field in Latin America, contributing to a better understanding of the effects of critical illnesses on long-term functional outcomes in children.

Upper limb manual training for children with cerebral palsy: A systematic review and network meta-analysis of randomized controlled trials

Objective There are different upper limb manual training protocols, namely constraint-induced movement therapy, modified constraint-induced movement therapy, hand–arm bimanual intensive training, hand–arm bimanual intensive training including lower extremity, action observation training, and mirror therapy, available for improving functional outcomes in children with cerebral palsy. However, the effect and priority of these strategies remain unclear. Data sources We searched the PubMed, Cochrane Library, and Embase databases for relevant articles from inception to October 12, 2022. Review methods To assess the effect and priority of different strategies of upper limb manual training protocols through a systematic review and network meta-analysis of randomized controlled trials. Results We included 22 randomized controlled trials in this network meta-analysis. The ranking probability and standard mean differences with 95% credible intervals of the comparison between placebo and other forms of upper limb manual training were as follows: mirror therapy = 2.83 (1.78, 3.88), hand–arm bimanual intensive training including the lower extremity = 0.53 (0.09, 0.96), constraint-induced movement therapy = 0.44 (0.18, 0.71), hand–arm bimanual intensive training = 0.41 (0.15, 0.67), modified constraint-induced movement therapy = 0.39 (0.03, 0.74), and action observation training = 0.18 ( − 0.29, 0.65). No significant inconsistency was noted between the results of direct and indirect comparisons. Conclusion We suggest that mirror therapy could be the upper limb manual training protocol of choice for improving functional outcomes in patients with cerebral palsy.

Recanalization Treatments for Pediatric Acute Ischemic Stroke in France

There is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS). To report clinical outcomes and provide estimates of revascularization strategy safety and efficacy profiles of intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) in children with AIS. The KidClot multicenter nationwide cohort study retrospectively collected data of children (neonates excluded) with AIS and recanalization treatment between January 1, 2015, and May 31, 2018. Data analysis was performed from January 1, 2015, to May 31, 2019. IVT and/or EVT. Primary outcome was day 90 favorable outcome (modified Rankin Scale [mRs] 0-2, with 0 indicating no symptoms and 6 indicating death). Secondary end points included 1-year favorable outcome (mRs, 0-2), mortality, and symptomatic intracerebral hemorrhage. Other measures included the Pediatric National Institutes of Health Stroke Scale (pedNIHSS), with pedNIHSS 0 indicating no symptoms, 1 to 4 corresponding to a minor stroke, 5 to 15 corresponding to a mild stroke, greater than 15 to 20: severe stroke, and the adult Alberta Stroke Program Early CT Score (ASPECTS), which provides segmental assessment of the vascular territory, with 1 point deducted from the initial score of 10 for every region involved (from 10 [no lesion] to 0 [maximum lesions]). Overall, 68 children were included in 30 centers (IVT [n = 44]; EVT [n = 40]; 44 boys [64.7%]; median [IQR] age, 11 [4-16] years; anterior circulation involvement, 57 [83.8%]). Median (IQR) pedNIHSS score at admission was 13 (7-19), higher in the EVT group at 16 (IQR, 10-20) vs 9 (6-17) in the IVT only group (P < .01). Median time from stroke onset to imaging was higher in the EVT group at 3 hours and 7 minutes (IQR, 2 hours and 3 minutes to 6 hours and 24 minutes) vs 2 hours and 39 minutes (IQR, 1 hour and 51 minutes to 4 hours and 13 minutes) (P = .04). Median admission ASPECTS score was 8 (IQR, 6-9). The main stroke etiologies were cardioembolic (21 [30.9%]) and focal cerebral arteriopathy (17 [25.0%]). Median (IQR) time from stroke onset to IVT was 3 hours and 30 minutes (IQR, 2 hours and 33 minutes to 4 hours and 28 minutes). In the EVT group, the rate of postprocedure successful reperfusion (≥modified Treatment in Cerebral Infarction 2b) was 80.0% (32 of 40). Persistent proximal arterial stenosis was more frequent in focal cerebral arteriopathy (P < .01). Death occurred in 3 patients (4.4%). Median pedNIHSS reduction at 24 hours was 4 (IQR, 0-9) points. Intracerebral hemorrhage occurred in 4 patients and symptomatic intracerebral hemorrhage occurred in 1 patient, all in the EVT group. The median mRS was 2 (IQR, 0-3) at day 90 and 1 (IQR, 0-2) at 1 year, which was not significantly different between EVT and IVT only groups, although different in initial severity. The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.

The Role of Electroencephalography in the Prognostication of Clinical Outcomes in Critically Ill Children: A Review.

Electroencephalography (EEG) is a neurologic monitoring modality that allows for the identification of seizures and the understanding of cerebral function. Not only can EEG data provide real-time information about a patient’s clinical status, but providers are increasingly using these results to understand short and long-term prognosis in critical illnesses. Adult studies have explored these associations for many years, and now the focus has turned to applying these concepts to the pediatric literature. The aim of this review is to characterize how EEG can be utilized clinically in pediatric intensive care settings and to highlight the current data available to understand EEG features in association with functional outcomes in children after critical illness. In the evaluation of seizures and seizure burden in children, there is abundant data to suggest that the presence of status epilepticus during illness is associated with poorer outcomes and a higher risk of mortality. There is also emerging evidence indicating that poorly organized EEG backgrounds, lack of normal sleep features and lack of electrographic reactivity to clinical exams portend worse outcomes in this population. Prognostication in pediatric critical illness must be informed by the comprehensive evaluation of a patient’s clinical status but the utilization of EEG may help contribute to this assessment in a meaningful way.

Patient-Reported Pain and Function Outcomes in Children With Congenital Vertical Talus Treated With the Minimally Invasive Method.

In 2006, a new minimally invasive method was introduced for the definitive correction of congenital vertical talus (CVT) deformity. There are no studies to date that have utilized the Patient-Reported Outcome Measurement Information System (PROMIS) to evaluate long-term quality of life outcomes in these patients. We identified all children with CVT who underwent treatment with the minimally invasive method and were seen at our institution after 2015. A retrospective chart review was then performed on these patients, and PROMIS scores were recorded for the following domains: Pain Interference, Mobility, and Peer Relations. Subgroup analysis was performed on patients who experienced recurrence and those who required a second corrective surgery. An alpha level of 0.05 was used for all analyses. There were 24 children who were treated for CVT at our institution after 2015 and had completed PROMIS surveys. Seven (29.2%) of these patients developed recurrence during the follow-up period. Among the entire cohort, the mean PROMIS pain interference score was 48±9, the mean PROMIS mobility score was 42±13, and the mean PROMIS peer relations score was 54±9. There were no statistically significant differences in the PROMIS scores between the entire cohort and those who experienced radiographic recurrence in any of the 3 domains ( P >0.05). Children who initiated treatment after the age of 12 months had lower PROMIS mobility scores than those who initiated treatment before 12 months of age (32.48 vs. 47.31, P =0.02). On average, children who undergo treatment with this technique end up within 1 SD of the reference population in all 3 domains that were measured (pain interference, mobility, and peer relations) regardless of sex, age, and status of recurrence. However, there was a trend towards lower mobility scores in this population compared with the reference population (42±13 vs. 50±10). Treatment should be initiated at less than 12 months of age whenever possible to maximize patient-reported outcomes. Level III.

Functional outcomes of extended-release methylphenidate and atomoxetine in children: retrospective chart analysis

BackgroundRecent guidelines emphasize the importance of functional outcomes in children with attention-deficit/hyperactivity disorder (ADHD). Here, we assess the functional outcomes of the oral delivery system of osmotic-release methylphenidate (OROS-MPH) and atomoxetine (ATX) from the retrospective review of the chart for the last 2 years in the clinic.ResultsLinear mixed-effects models were performed with outcome measures of difference in ADHD symptoms and functional impairment. After 9–12 weeks, OROS-MPH and ATX were statistically equivalent for total Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) scores (difference in slope is β = 0.004, p = 1.000). However, OROS-MPH was superior to ATX in terms of school domain (difference in slope is β = 0.139, p < 0.001); ATX was superior in the family domain (slope difference in slope is β = 0.103, p < 0.001). The other domains of functioning both were not responsive to pharmacotherapy and were similar between the two medications.ConclusionsOptimal management should monitor functional progress in ADHD beyond the core symptoms. As expected, ADHD medications provide a distinct pattern of functional improvement. Pharmacotherapy alone offers promising and reliable outcomes to improve school and family functions in ADHD. Some functional improvements did not respond to the medication; therefore, many of the techniques derived from behavioral interventions should be considered.

Prevalence, clinico-laboratory features, and the functional outcome of children with scrub typhus meningoencephalitis-a cohort study.

Scrub typhus is being reported as the most common cause of childhood meningoencephalitis (ME) in India. Hence, we planned to estimate the proportion of scrub typhus infection among children aged 1 month to 12 years with the clinical diagnosis of ME and to evaluate their demographic, clinical and laboratory characteristics. This cohort study was conducted in the Department of Pediatrics of a tertiary care teaching hospital in south India. One hundred and twenty-seven consecutive children aged 1 month to 12 years with the clinical diagnosis of ME were the participants. Their socio-demographic factors, clinical details, laboratory reports and outcomes were analyzed. The etiological agent was identified in 71 (56%) children. Orientia tsutsugamushi (Scrub typhus) was the most common infection (24.4%), of all children with ME. Children aged ≥5 years were frequently affected by scrub typhus ME. Eschar, capillary leak, hepatomegaly and splenomegaly were the predominant clinical features of scrub typhus ME. Thrombocytopenia and deranged liver function tests were common in scrub typhus ME. To conclude, Orientia tsutsugamushi was the most common organism identified in our study. Prompt recognition of some tell-tale clinical signs of scrub typhus (such as eschar, thrombocytopenia and hepatosplenomegaly), and timely initiation of antibiotics would lead to better outcomes as evident from the study.

Brain volumes and functional outcomes in children without cerebral palsy after therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy.

To investigate whether brain volumes were reduced in children aged 6 to 8 years without cerebral palsy, who underwent therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy (patients), and matched controls, and to examine the relation between subcortical volumes and functional outcome. We measured regional brain volumes in 31 patients and 32 controls (median age 7 years and 7 years 2 months respectively) from T1-weighted magnetic resonance imaging (MRI). We assessed cognition using the Wechsler Intelligence Scales for Children, Fourth Edition and motor ability using the Movement Assessment Battery for Children, Second Edition (MABC-2). Patients had lower volume of whole-brain grey matter, white matter, pallidi, hippocampi, and thalami than controls (false discovery rate-corrected p < 0.05). Differences in subcortical grey-matter volumes were not independent of total brain volume (TBV). In patients, hippocampal and thalamic volumes correlated with full-scale IQ (hippocampi, r=0.477, p=0.010; thalami, r=0.452, p=0.016) and MABC-2 total score (hippocampi, r=0.526, p=0.004; thalami, r=0.505, p=0.006) independent of age, sex, and TBV. No significant correlations were found in controls. In patients, cortical injury on neonatal MRI was associated with reduced volumes of hippocampi (p=0.001), thalami (p=0.002), grey matter (p=0.015), and white matter (p=0.013). Children who underwent therapeutic hypothermia have reduced whole-brain grey and white-matter volumes, with associations between hippocampal and thalamic volumes and functional outcomes.

Functional Outcomes for Children, Adolescents, and Young Adults with Osteonecrosis following Hip Core Decompression.

Patients with pediatric leukemia and sickle cell disease are at risk for developing osteonecrosis (ON), a disease that can result in pain, loss of function, and disability. Hip core decompression surgery is an option aimed to prevent femoral head collapse and avoid future arthroplasty. Describe functional outcomes and gait quality among a young population with hip ON before and after hip core decompression. Study included participants with hip ON secondary to treatment for hematologic malignancy or sickle cell disease, between 8 and 29 years old, requiring hip core decompression surgery. At one-year follow-up, 13 participants (9 male, median age 17 years) completed the Functional Mobility Assessment (FMA), range of motion, and GAITRite® testing. Participants demonstrated improved mobility and endurance on the FMA at 1-year post-operatively compared to pre-operatively, with higher scores for time on the Timed Up and Go (mean FMA score = 2.92 [SD = 1.32] vs. 2.07 [SD = 1.70]), time on the Timed Up and Down Stairs (3.69 [0.85] vs. 2.92 [1.66]), and 9-Minute Walk Test scores for distance walked (2.69 [0.63] vs. 2.23 [0.93]) and heart rate (4.54 [0.66] vs. 3.31 [1.38]). GAITRite® analysis also showed improvements in many gait parameters at one-year follow-up. Cancer treatment complications other than ON could have contributed to results, not all eligible participants agreed to participate, and follow-up was only one year. Young patients with hip ON demonstrated improvements in functional mobility, endurance, and gait quality one year following hip core decompression.

Musculoskeletal pain and its effect on daily activity and behaviour in Icelandic children and youths with juvenile idiopathic arthritis: a cross-sectional case-control study

BackgroundJuvenile idiopathic arthritis is characterised by recurring episodes of acute inflammation, with joint swelling in one or more joints, often accompanied by pain. These episodes can now be controlled better than in the past because of a new category of medications. However, despite more stable disease activity, pain may continue to cause problems in the children with juvenile idiopathic arthritis and can reduce their performance of routine physical activities and participation in social or school activities.AimTo evaluate the prevalence of pain, pain intensity, pain behaviour, and pain interference in Icelandic children with juvenile idiopathic arthritis compared with healthy peers.MethodsA cross-sectional, case-control study including 8-18 years old children; 28 with juvenile idiopathic arthritis and 36 in a control group. The children answered questions on pain experienced during the last 7 days, painful areas of the body and pain frequency. They completed short form versions of the Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires on pain intensity, pain behaviour, and pain interference.ResultsSignificantly more children with juvenile idiopathic arthritis had pain compared with the control group (p = 0.02). Children with JIA also had a greater number of painful body areas (p = 0.03), more pain intensity (p = 0.009), and showed more pain behaviour (p = 0.006), and pain interference (p = 0.002). Children with juvenile idiopathic arthritis who had pain, experienced more pain interference (p = 0.023) than their peers who had pain. However, the groups did not differ in terms of pain intensity (p = 0.102) and pain behaviour (p = 0.058).ConclusionThe research results indicate that pain experience was different between children with juvenile idiopathic arthritis and the control group. The results suggest that further research of the role of pain management on functional outcomes in children with juvenile idiopathic arthritis is needed.