McMaster Children's Hospital Research Articles

Transition to Adulthood through Coaching and Empowerment in Rheumatology (TRACER): A feasibility study protocol.

The transition from pediatric to adult care for patients with chronic disease is a vulnerable period, with risks of disengagement from care and subsequent complications of inadequately managed disease. This period comes at a time when there are many other transitions occurring in the young person's life, including changes to vocation, social supports, and to their physiology. The aim of the TRACER study is to assess the feasibility of conducting a multi-center, randomized-controlled trial of a virtual Transition Coach Intervention in youth transferring from pediatric to adult rheumatology care. Patients are being recruited at their last pediatric rheumatology visit from McMaster Children's Hospital and Children's Hospital, London Health Sciences Centre in Ontario, Canada. Participants are then randomized to standard of care or to eight transition coaching sessions, covering topics around health management, future planning, and self-advocacy. The primary outcomes of the study are to demonstrate protocol feasibility, including optimal recruitment and consent rates, ≥ 90% coaching session completion, and complete data collection with ≤ 5% missing data. Baseline demographics, transition readiness, global functional assessment, disease activity, and self-efficacy will be collected to characterize the study population. Recruitment has begun and is estimated to last 19 months. This study will inform the design of a robust, multi-centered, randomized-controlled study to investigate the impact of a virtual transition coaching program in supporting the physical, mental, and social well-being of youth with rheumatic disease transitioning into adult care. Clinical trial registration: ClinicalTrials.Gov protocol ID: 14499.

Post-Intensive Care Sequelae in Pediatrics-Results of an Early Rehabilitation Implementation Study.

To compare post-PICU discharge functioning, health-related quality of life (HRQL), and parental stress before and after the implementation of an early rehabilitation bundle. Prospective cohort substudy within an early rehabilitation implementation program, conducted at the PICUs at McMaster Children's Hospital and London Health Sciences, London, Ontario, Canada. A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. Patients with an anticipated 48-hour PICU length of stay were approached for consent to participate. Critically ill children with an anticipated 48-hour PICU length of stay were approached for consent to participate. Patient-/proxy-reported outcome measures were assessed at baseline, PICU discharge, and 1 and 3 months post-PICU discharge using: 1) Pediatric Evaluation of Disability Inventory Computer Adaptive Test to assess physical, social, cognitive, and responsibility/caregiver domains of functioning; 2) KIDSCREEN to assess HRQL; and 3) the Pediatric Inventory for Parents to assess caregiver stress. A total of 117 participants were enrolled. Patient demographic characteristics were similar in the pre- and post-intervention groups. Following bundle implementation, 30 of 47 respondents (63.8%) experienced functional decline and 18 of 45 (40%) experienced low HRQL at PICU discharge. Eighteen of 36 (50%) at 1 month and 14 of 38 (36.8%) at 3 months experienced either persistent functional decline and/or low HRQL; 2.8% and 2.6% at 1- and 3-month follow-up, respectively, experienced both persistent functional decline and low HRQL. There were no significant differences in the rates of persistent functional decline, low HRQL, or caregiver stress scores post-bundle compared with pre-rehabilitation bundle implementation. We were unable to adequately determine the efficacy of a rehabilitation bundle on patient-centered outcomes as this substudy was not powered for these outcomes. Our results did reveal that persistent low functioning is common in PICU survivors, more common than low HRQL, while experiencing both functional decline and low HRQL was uncommon.

Malnutrition care in hospitalized pediatric inpatients: comparison of perceptions and experiences across two pediatric academic health sciences centres.

Malnutrition affects up to one in three Canadian children admitted to hospital. Awareness among pediatric healthcare providers (HCPs) of the prevalence and impacts of hospitalized malnutrition is critical for optimal management. The purpose of this study was to determine perceptions of malnutrition among pediatric HCP across two major academic health sciences centres, and to determine how the use of a standardized pediatric nutritional screening tool at one institution affects responses. Between 2020 and 2022, 192 HCPs representing nursing, dietetics, medicine, and other allied health were surveyed across McMaster Children's Hospital and The Hospital for Sick Children. 38% of respondents from both centres perceived rates of malnutrition between approximately one in three patients. Perceptions of the need for nutritional screening, assessment, and management were similar between centres. All respondents identified the need for better communication of hospitalized malnutrition status to community providers at discharge, and resource limitations affecting nutritional management of pediatric inpatients. This study represents the largest and most diverse survey of inpatient pediatric HCPs to date. We demonstrate high rates of baseline knowledge of hospital malnutrition, ongoing resource challenges, and the need for a systematic approach to pediatric nutritional management.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study.

To implement an early rehabilitation bundle in two Canadian PICUs. Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2). All children under 18 years old admitted to the PICU were eligible for the intervention. A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement. A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Assessment of care timelines in intestinal malrotation with volvulus: A retrospective chart review

BackgroundPatients with intestinal malrotation with volvulus (MWV) may suffer bowel ischemia, which can be correlated with the timing of surgical intervention. The purpose of this study was to identify and assess time-blocks in the care of patients from initial physician assessment (IPA) to surgical intervention to highlight potential opportunities for improvement. MethodsRetrospective chart review of patients with MWV presenting to McMaster Children's Hospital between January 1st, 2000 and December 31st, 2020 (n = 31). Demographic data and time-blocks of care were identified and analyzed (p < 0.05 considered significant). All times were reported as medians. Results22 males (71%) and 9 females (29%) were identified; median age was 9.8 d. IPA to incision was 10.7hrs and surgical consult to incision was 3.4hrs. Time to incision for patients <1 y was not significantly different than those >1 y (10.5hrs vs 10.7hrs, p = 0.737). The use of ultrasound did not significantly affect time to incision (7.9hrs vs 12.0hrs, p = 0.128). For patients requiring resection or having pan-necrosis there was no significant difference in time from IPA (10.9hrs vs 10.5hrs, p = 0.238) or surgical consult to incision (4.0hrs vs 3.3hrs, p = 0.808). ConclusionTime from IPA to surgical consult and time from surgical consult to surgical intervention represented the largest proportions of time. Age, use of ultrasound, and need for resection or having pan-necrosis did not significantly affect the time to incision. This data may be used to inform opportunities for expediting the management of patients with MWV once they have presented to a physician. Level of EvidenceIII.

Addressing adherence to guidelines on prevention of acute chemotherapy-induced nausea and vomiting in pediatric patients.

Chemotherapy-induced nausea and vomiting (CINV) is a distressing adverse effect in children receiving cancer treatment. There are evidence-based pediatric clinical practice guidelines (CPG) on chemotherapy emetogenicity and acute CINV prevention, but adherence to these guidelines is low. A quality improvement-based study was conducted at McMaster Children's Hospital. The SMART aim was to increase adherence to guidelines on prevention of acute CINV in hospitalized patients receiving high (HEC) and moderately emetogenic chemotherapy (MEC) from baseline 25% to more than 70% by June 2021. Barriers were identified by process mapping, and a series of interventions were implemented. Guideline adherence was assessed in 270 inpatient chemotherapy administrations (HEC, MEC). Data were collected on 131 charts pre interventions and 139 charts post interventions. Interventions included education, addition of guideline-recommended anti-emetics to the inpatient formulary, and implementation of a standardized CPG tool. Initial rates of total CINV guideline adherence were 25%, which improved to 72% post intervention (p<.001). In subgroup analysis, guideline adherence in the MEC group improved from 13% to 34% (p=.015), and in the HEC group from 32% to 93% (p<.001). The most common reason for nonadherence in the HEC group was failure to use aprepitant as anti-emetic, and in MEC was option for ondansetron monotherapy prophylaxis. Using quality improvement methodology, barriers to guideline adherence were identified and interventions implemented. Guideline adherence for prevention of CINV improved, particularly in the HEC group but less for the MEC group. Future steps will include sustainability of interventions and addressing adherence in the MEC group.

Universal Premedication for Pegylated (PEG)-Asparaginase Treatment in Children with Acute Lymphoblastic Leukemia (ALL) and Lymphoblastic Lymphoma (LLy) Has No Impact on Frequency of Hypersensitivity Reactions

Asparaginase is an established and critical chemotherapeutic agent in the treatment of Acute Lymphoblastic Leukemia (ALL) and Lymphoblastic Lymphoma (LLy). Currently, pegylated asparaginase (PEG-Asp), an E. coli derived enzyme, is the first-line asparaginase preparation used in most contemporary ALL therapy protocols. Hypersensitivity reactions are one of the main toxicities of PEG-Asp therapy occurring in up to 30% of patients (1) and is one of most common reasons for discontinuation of PEG-Asp requiring substitution. Infusion reactions are also seen in patients receiving intravenous (IV) PEG-Asp, but are clinically difficult to differentiate from hypersensitivity reactions, which are associated with neutralizing anti-asparaginase antibody-production. Reactions lead to a switch to more costly and more frequent treatment with Erwinia Asparaginase, an immunologically distinct formulation. Pre-medication with H1/H2 blockers has been shown to reduce the incidence of infusion reactions (2). This has led to adoption of premedication with H1/H2 blockers, including at our centre. However, the data remain mixed, with some data supporting and some disputing this claim (3-4). There also remain concerns regarding premedication masking of milder reactions due to neutralizing antibodies and as such we have implemented serum asparaginase activity (SAA) monitoring along with premedication. This study aimed to assess the impact of pre-medication with H2 blockers and diphenhydramine for PEG-Asparaginase treatment as well as to create a cost analysis to determine the cost-savings effects of universal premedication. To achieve this, we performed a retrospective chart review at the McMaster Children's Hospital comparing rates of hypersensitivity reactions in pediatric leukemia and lymphoma patients prior to universal pre-medication (PM-) from 2016-2018 and after implementation (PM+) from 2019-2021 at our centre. We also assessed the cost-saving effects of universal premedication at our centre. We reviewed a total of 107 charts of pediatric patients with ALL & LLy cared for at our centre over the period of 2016 - 2021. Our results demonstrate that there was no significant difference in reactions between PM- and PM+ patients across all risk stratifications (p = 0.25, CI -0.25, +0.07). There was no difference in median CTCAE grade reactions. There was a total of 2 patients that were diagnosed as a silent inactivation utilizing SAA monitoring. These findings suggest that universal premedication had no impact on the rate of hypersensitivity reactions or CTCAE grade of reaction in patients receiving PEG-Asparaginase, but SAA monitoring has proven effective in diagnosing silent inactivation that may have otherwise been missed. In determining the costs of universal pre-medication per patient, the cost at our centre ranged from $10.88 - $85.14 depending on ALL risk stratification as well as weight-based doses. This does not include the costs for administering the IV medications, nursing costs, time added to care, and hospital waste including vials and syringes. There was no statistically significant difference in number of Erwinia doses administered between groups. Our limitations include the retrospective nature of the study and small sample size. In conclusion, our data suggest that universal premedication did not impact the number and grade of hypersensitivity reactions to PEG-Asp, nor the number of Erwinia doses needed to be substituted. Larger studies are recommended to confirm our findings. We recommend continued SAA monitoring for patients receiving PEG-Asparaginase to identify patients with silent inactivation of asparaginase. References 1) Raetz EA, Salzer WL. Tolerability and efficacy of L-asparaginase therapy in pediatric patients with acute lymphoblastic leukemia. J Pediatr Hematol Oncol. 2010 Oct;32(7):554-63 2) Kurtzberg, J., et al (1993). Antibodies to asparaginase alter pharmacokinetics and decrease enzyme activity in patients on asparaginase therapy. In Proc Am Assoc Cancer Res (Vol. 34, p. 304). 3) Menig, S., et al. (2016). The Impact of PEG-Aspargase Premedication on Hypersensitivity Reaction in Pediatric Acute Lymphoblastic Leukemia (ALL) and Lymphoblastic Lymphoma (LLy) Patients. Poster Presentation. 4) Young, D., et al. Universal premedication for asparaginase-based therapy should be standard of care. ASPHO Conference Presentation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Letter to the Editor: Accuracy of Referrals to Canadian Pediatric Ophthalmology Services.

Letter to the Editor: Accuracy of Referrals to Canadian Pediatric Ophthalmology Services.

Patient triage to specialist outpatient clinics-time to standardize terminology.

The objectives of this study were to evaluate existing nomenclature used for outpatient referrals triage and propose a system, which meets the needs of McMaster Children's Hospital and can be modified for use in other hospitals. We reviewed triage practices in the Department of Pediatrics, McMaster Children Hospital, Hamilton, Ontario and conducted a literature search to assess terminology used for outpatient referrals triage at other institutions. There is lack of unified terminology for triaging outpatient referrals. Existing systems are not widely accepted, lack uniformity, and often miss recording the true acuity of the referral. We developed a system that covers most outpatient triage scenarios, allocates either flexible or precise visit timelines to referrals and plans for logistics of the patient's visit. Triage categories are iMMediate (MM), Acute (A) (1 to 14 days), Semi-Acute (S) (1 to 3 months), Timetabled (T) (next available appointment slot), Evaluated (E) (used for either forwarding to another provider or requesting additional information), and Rejected (R) categories-McMASTER triage system. Several numbered subcategories are used in each category to define precise timelines, if needed. Visit logistics categories are the following: Hub (H) (place to see the patient), How to notify patient and referring provider (HP) and (HD), need to Start with tests prior to appointment (S), and need to Complete (C) other relevant local processes-HHSC logistics system. Both these systems may be adapted for local use in other institutions. This is the first publication that proposes terminology standardization in triaging outpatient referrals for specialist paediatric services.

Evaluation of Hepatitis in Pediatric Patients With Presumed Nonalcoholic Fatty Liver Disease.

We conducted a retrospective chart review of patients presenting to McMaster Children's Hospital from 2017-2020 for evaluation of suspected NAFLD. Bloodwork was reviewed. Ninety-five patients met inclusion criteria. Abnormal bloodwork that required further testing was found in 28.4%; a different chronic liver disease was ultimately diagnosed in 11.6%. Only 9.5% received comprehensive, additional bloodwork for other causes of liver disease. A high proportion of patients evaluated for suspected NAFLD had bloodwork possibly suggesting an alternate diagnosis. Comprehensive testing was infrequently performed. These results reinforce the importance of maintaining a differential diagnosis among children presumed to have NAFLD.

Development of decision-making considerations to support equitable patient selection in paediatric haemophilia trials

Abstract Background Clinical trials for investigational haemophilia treatments such as gene therapy offer a potentially life-changing opportunity to those who are selected for enrolment. However, the number of enrolment slots available for these trials is often greatly exceeded by the number of eligible patients. Many of the strategies that are commonly used to select candidates for participation can be highly unsystematic, inequitable, and subjective. A more rigorous set of criteria is therefore needed to evaluate each candidate's suitability for trial participation in order to eliminate bias in selection and fulfill the ethical principle of justice. Aims To review current knowledge and issues in patient selection for paediatric haemophilia clinical trials with competitive availability, and to develop a more objective standard for decision-making that takes into account the needs of all involved parties. Methods A literature search on the ethics of trial participant selection and the practice of fairly distributing limited medical resources was conducted to identify previous literature and best practices in the area. A list of essential decision-making considerations was then designed to guide the selection of paediatric participants for haemophilia therapy trials through iterative group discussions between a diverse team of health professionals at McMaster Children's Hospital, Hamilton, ON, Canada. Results Current practices in resolving this ethical issue are highly heterogenous, although there are some common themes and recommendations. The three main criteria supported by the team and the literature search for inclusion in the considerations were: medical need, need for support, and potential safety considerations for the patient. Three measures for evaluating each criterion were developed and added for consideration during the decision-making process. The role of patient selection in meeting the scientific aims of the trial was also considered. Conclusion Attempting to create an equitable, systematic decision-making procedure for clinical trial participant selection involves a wide variety of competing values and ethical considerations, and discrepancies between recommendations are commonplace. The criteria presented here are intended to be used as a guideline to assist the equitable selection of paediatric patients for participation in haemophilia clinical trials with highly limited enrolment, although it may have some applicability to other areas of clinical research or therapeutic areas concerned with the allocation of scarce medical resources. Next steps should involve speaking with patients, community members and other stakeholders in order to include their perspectives. Assessment of medical need, potential support needs, and safety considerations form the basis of criteria for discussions around how to make enrolment in paediatric haemophilia clinical trials more equitable © Shutterstock

Pediatric Patients with a Dual Diagnosis of Inflammatory Bowel Disease and Chronic Recurrent Multifocal Osteomyelitis.

There is a paucity of information about the epidemiology, pathophysiology, and treatment of patients with a dual diagnosis of inflammatory bowel disease (IBD) and chronic recurrent multifocal osteomyelitis (CRMO). A retrospective chart review was performed of patients at McMaster Children's Hospital with a diagnosis of either IBD or CRMO, to identify those with the dual diagnosis over a 10-year period. A dual diagnosis was identified in seven patients. Most patients (6/7) had a diagnosis of IBD first and were subsequently diagnosed with CRMO. At the time of CRMO diagnosis, IBD treatment regimens included one or more of, sulfasalazine (1/6), infliximab (3/6), adalimumab (1/6), or no treatment (1/6). Although the etiology of the link remains unknown, there does not seem to be an association to a specific IBD subtype, age, or treatment. Our patient population demonstrated a response to biologic agents, specifically tumor necrosis factor-α inhibitors, as treatment for both conditions.

Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is a common occurrence in childhood; consequently, evidence-based recommendations for its treatment are required. To determine whether 5 days of high-dose amoxicillin for CAP was associated with noninferior rates of clinical cure compared with 10 days of high-dose amoxicillin. The SAFER (Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections) study was a 2-center, parallel-group, noninferiority randomized clinical trial consisting of a single-center pilot study from December 1, 2012, to March 31, 2014, and the follow-up main study from August 1, 2016, to December 31, 2019 at the emergency departments of McMaster Children's Hospital and the Children's Hospital of Eastern Ontario. Research staff, participants, and outcome assessors were blinded to treatment allocation. Eligible children were aged 6 months to 10 years and had fever within 48 hours, respiratory symptoms, chest radiography findings consistent with pneumonia as per the emergency department physician, and a primary diagnosis of pneumonia. Children were excluded if they required hospitalization, had comorbidities that would predispose them to severe disease and/or pneumonia of unusual origin, or had previous β-lactam antibiotic therapy. Data were analyzed from March 1 to July 8, 2020. Five days of high-dose amoxicillin therapy followed by 5 days of placebo (intervention group) vs 5 days of high-dose amoxicillin followed by a different formulation of 5 days of high-dose amoxicillin (control group). Clinical cure at 14 to 21 days. Among the 281 participants, the median age was 2.6 (interquartile range, 1.6-4.9) years (160 boys [57.7%] of 279 with sex listed). Clinical cure was observed in 101 of 114 children (88.6%) in the intervention group and in 99 of 109 (90.8%) in the control group in per-protocol analysis (risk difference, -0.016; 97.5% confidence limit, -0.087). Clinical cure at 14 to 21 days was observed in 108 of 126 (85.7%) in the intervention group and in 106 of 126 (84.1%) in the control group in the intention-to-treat analysis (risk difference, 0.023; 97.5% confidence limit, -0.061). Short-course antibiotic therapy appeared to be comparable to standard care for the treatment of previously healthy children with CAP not requiring hospitalization. Clinical practice guidelines should consider recommending 5 days of amoxicillin for pediatric pneumonia management in accordance with antimicrobial stewardship principles. ClinicalTrials.gov Identifier: NCT02380352.

Cord-Blood High-Sensitivity Troponin-I Reference Interval and Association with Early Neonatal Outcomes.

This study was aimed to establish a reference interval for high-sensitivity cardiac troponin I (hs-cTnI) in umbilical cord blood of infants and to assess its association with the risk of predetermined early neonatal outcomes in a high-acuity tertiary care hospital. Umbilical cord-blood samples were collected and hs-cTnI was measured in all infants born between August 2015 and September 2015 at McMaster Children's Hospital (n = 256). Gestational age, birth weight, Apgar's scores, age in days at which feeding was established, neonatal intensive care unit (NICU) admission, and discharge in days after birth were recorded. The 90th, 95th, and 99th percentiles for the term infant subcohort were 19.75, 41.45, and 166.30 ng/L, respectively. We observed decreased mean gestational ages and birth weights in both the 90th (37.7 weeks; 2,961.4 g) and 95th percentiles (37.1 weeks; 2,709.9 g) when compared with the remaining infants. Moreover, levels of hs-cTnI were significantly higher in infants with respiratory distress requiring intervention (p < 0.05), low birth weight infants (p < 0.01), preterm infants (p < 0.001), and those requiring NICU admission (p < 0.01). Multiple linear regression of the recorded demographic factors revealed prematurity (gestational age <35 weeks: coefficient 0.346 ± 0.160, p < 0.05; gestational age <37 weeks: coefficient 0.253 ± 0.105, p < 0.05) and male sex (coefficient 0.138 ± 0.047; p < 0.01) to be most predictive of log-hs-cTnI levels. This study establishes the reference values for cord-blood hs-cTnI in infants at a tertiary care center. Premature and sick infants requiring NICU admission had significantly higher levels of hs-cTnI. · Established the 90th, 95th, and 99th percentiles of neonatal cord-blood hs-cTnI in term infants as 19.75, 41.45, and 166.30 ng/L, respectively.. · Infants with hs-cTnI levels exceeding the 90th percentile had lower gestational ages and birth weights with higher rates of NICU admissions.. · Infants with respiratory distress or requiring NICU admission were found to have higher levels of hs-cTnI..

Web-based Application for the Population Pharmacokinetic Service (WAPPS)'s impact on dosage selection: a single paediatric centre experience

Abstract Background Current treatment for severe haemophilia includes prophylactic factor replacement to prevent bleeding. Coagulation factor products have significant inter-patient variability in pharmacokinetic (PK) parameters. Optimal management requires tailoring prophylaxis to individual PK parameters. Web-based Application for the Population Pharmacokinetic Service (WAPPS) is a tool that estimates individual PK values using a population approach. Despite its growing use to help guide dosing selection, few studies have investigated its clinical impact. Aim To investigate any change in prophylaxis regimen and hours per week where factor level is under 1%, pre- and post-PK testing using WAPPS, for paediatric patients with severe haemophilia. Methods A retrospective chart review was conducted for all paediatric patients with severe haemophilia receiving care between April 2013 and July 2018 at McMaster Children's Hospital who have used WAPPS. Data extracted included: patient demographics, PK data generated by WAPPS, prophylaxis regimen pre- and post-PK testing, and reason for regimen change. The number of hours per week where factor level was under 1% pre- and post-PK testing was calculated using WAPPS. Results Thirty-one patients were included; 42% (n=13) changed their prophylaxis regimen after PK testing. After using PK data to personalise prophylaxis recommendations, there was a decrease in the number of hours per week where factor level is under 1% (from an average of 13.1 hours/week to 11.8 hours/week), though not statistically significant (p=0.16). Conclusion PK data generated by WAPPS has direct impact by informing changes to prophylaxis recommendations. This individualised approach promotes patient-centred care and patient engagement without increasing the time spent with factor levels below 1%. It also confirms and validates clinical practice.

Non-neurophysiologist Physicians and Nurses Can Detect Subclinical Seizures in Children Using a Panel of Quantitative EEG Trends and a Seizure Detection Algorithm.

This study evaluated the sensitivity of nonconvulsive seizure detection by non-neurophysiologist physicians and nurses using a panel of quantitative EEG (QEEG) trends in the setting of a pediatric intensive care unit. Forty-five 1-hour QEEG epochs were obtained retrospectively from 10 patients admitted to the McMaster Children's Hospital pediatric intensive care unit, which included 184 electrographic seizures. Each epoch constituted 4 QEEG trends, a seizure probability marker, automated seizure detector, rhythmicity spectrograms, and amplitude-integrated EEG. Six pediatric residents and 5 pediatric intensive care unit nurses analyzed the epochs for possible seizures after a 15-minute power point presentation. This was compared with the gold standard of a board-certified epileptologist interpreting the conventional EEG data for seizures. Sensitivity of seizure detection for pediatric residents and intensive care unit nurses were 0.90. The specificity was 0.87 and 0.89, respectively. The interrater agreement among the pediatric residents was moderate with a kappa (κ) value of 0.45 (confidence interval: 0.41-0.49), and among the nurses were moderate with a κ value of 0.59 (confidence interval: 0.54-0.63). A post hoc analysis involving 2 neurophysiologists demonstrated a sensitivity of 0.90 and a specificity of 0.93 (confidence interval: 0.90-0.96) for seizure detection and a substantial interrater agreement of κ = 0.76 (confidence interval: 0.61-0.91). A panel of QEEG trends can be used by non-neurophysiologists in a pediatric critical care setting to detect nonconvulsive seizures with a reasonable accuracy, which may expedite subclinical seizure identification and timely intervention.

Central venous catheters are an important factor in paediatric thrombosis.

To establish the incidence and characteristics of paediatric thrombosis (PT) in a Canadian tertiary care centre during the era of low molecular weight heparin (LMWH). A retrospective observational case study of all patients <18years of age evaluated for arterial and venous thrombosis from May 2008 to July 2018 at McMaster Children's Hospital was conducted through the electronic medical record. The incidence of PT was 52.2 per 10000 hospital admissions (n=477/91462). Provoked thrombosis was more prevalent (88.9%, n=424/477) than unprovoked (2.9%, n=14/477) or idiopathic thrombosis (4%, n=19/477). Half of PT were in children <2years (51.2%, n=244/477). Central vascular catheterisation was a contributory factor in more than half of thrombotic events (56.2%, n=268/477), while trauma (1.1%, n=5/477), oral contraceptives (4%, n=19/477), infection (4%, n=19/477), surgery (6.9%, n=33/477) and malignancy (8.4%, n=40/477) were also risk factors. Arterial ischaemic stroke was diagnosed in 11.1% of cases (n=53/477), while pulmonary embolism was identified in 7.1% (n=34/477) and 1.7% of cases were fatal (n=8/477). LMWH was the first-line therapeutic of choice (47.8%, n=228/477), with 28.1% (n=134/477) requiring no intervention. These data reiterate the elevated thrombosis risk to which infants and children with central vascular access are exposed.

Study protocol for a randomized controlled trial of a child and parent mindfulness intervention for pediatric venipuncture.

Children commonly undergo painful needle procedures. Unmanaged procedural pain can have short‐ and long‐term consequences, including longer procedure times, greater distress at future procedures, and vaccine hesitancy. While parent behaviors are one of the strongest predictors of children's response to acute pain, pediatric procedural pain management interventions focus almost exclusively on the child. Further, existing parent‐involved pediatric pain management interventions typically fail to improve child self‐reported pain during painful procedures. The current protocol offers the first randomized controlled trial involving a mindfulness intervention for pediatric acute pain that includes children and their parents. This study aims to conduct a single‐site, two‐arm, parallel‐group RCT to examine the effects of a mindfulness intervention for parents and children before child venipuncture compared to a control group on primary (child self‐report of pain and fear), secondary (parent self‐report and child report of parent distress), and tertiary outcomes (parent report of child pain and fear). Parent‐child dyads (n = 150) will be recruited from the McMaster Children's Hospital outpatient blood laboratory. Dyads will be randomly assigned to either a mindfulness group guided through a mindfulness intervention or control group guided through an unfocused attention task. Parents will accompany their child for their venipuncture. Postvenipuncture measures will be collected (eg, child pain‐related outcomes as reported by parents and children). The first enrollment occurred in October 2019. We offer a novel intervention that aims to facilitate both parent and child coping during child venipuncture.

Sedative Medications for Critically Ill Children during and after Mechanical Ventilation: A Retrospective Observational Study

Providing safe and effective sedation to critically ill children is challenging. The assessment, prevention, and treatment of symptoms of iatrogenic withdrawal are critical aspects of sedation practice. To describe the use of sedative medications in critically ill children at McMaster Children's Hospital. This retrospective observational study included children admitted over a 12-month period who survived their illness and who received sedation and at least 48 h of invasive ventilation. We collected data from the time of admission to the pediatric intensive care unit to 3 days after discontinuation of sedation. We included 67 children. The median age was 1.6 (interquartile range [IQR] 0.2-6.2) years, and respiratory illnesses were the most common reason for admission (41 [61%]). The children received invasive ventilation for a median of 7 (IQR 4-11) days and sedation for a median of 12 (IQR 6-20) days. Sixty-six children (99%) received an opioid, and all received a benzodiazepine, with median cumulative doses of 14 (IQR 5-27) mg/kg morphine equivalents and 15 (IQR 6-32) mg/kg midazolam equivalents. Dexmedetomidine was given to 31 children (46%), for a median of 8 (IQR 4-12) days. Most children (67%) received sedation after extubation (median duration 7 [IQR 4-14] days). In addition, 32 children (48%) continued to receive sedative medications after transfer to the ward, for a median of 6 (IQR 4-13) days. Forty-two children (63%) had at least one Withdrawal Assessment Tool-1 (WAT-1) score indicative of iatrogenic withdrawal. Children who experienced withdrawal were exposed to more opioids and more benzodiazepines, both per day and overall, and for longer periods. The children in this study were exposed to multiple sedatives, and many continued to receive these medications for an extended period after discontinuation of mechanical ventilation. Iatrogenic withdrawal was common and represents an important opportunity to improve children's recovery after critical illness.

Epidemiology, Diagnosis and Management of Neonatal Thrombosis

Introduction: Current research on neonatal thrombosis is limited. It relies heavily on individual case reports and much of the data is extrapolated from the adult scientific literature. The aim of this descriptive study is to review the epidemiology, diagnosis and management of neonatal thrombosis at a single tertiary care institution. Methods: This is a retrospective study of apatients admitted to McMaster Children's Hospital, neonatal intensive care unite from 2005 to 2018. Data on patient demographics, diagnostic imaging, thrombophilia testing, co-morbidities, treatment, outcomes were collected from health records. Results: A total of 242 neonatal patients were included. The distribution of 251 thrombotic episodes was: 144 portal vein, 15 cerebral sino-venous, 12 cardiac, 2 pulmonary embolisms, 5 renal vein, 40 extremity and central venous and 13 arterial. Additionally, 20 cases categorized as miscellaneous, consisted of clots in sites such as the basilic vein or umbilical artery, among other locations. Male and female percentages were 55% and 45%, respectively. Preterm to term infant ratio was 1.5:1. The average age at diagnosis was 13.2 days. 70% of thrombotic episodes were line-related, while infection and surgery were associated with 19% and 12% of episodes, respectively. 52% of the patients were blood group O. 30% of the patients received initial anticoagulation treatment, while the rest were managed conservatively. There was a trend towards higher rate of complete clot resolution in patients who received anticoagulation (48%) compared to those who did not (40%). Conclusion: This is one of the largest, single institution, epidemiologic studies of neonatal thrombosis. In our group of patients, portal vein thrombosis was most prevalent compared to other sites of thrombosis and catheterization was the commonest risk factor. There was a trend towards improved resolution with anticoagulation. Further prospective studies are required to confirm these findings. Disclosures No relevant conflicts of interest to declare.