Pediatric Tertiary Care Center Research Articles

Unusual sites of Rosai Dorfman disease in children: Case series from a tertiary care paediatric hemato-oncology centre

Unusual sites of Rosai Dorfman disease in children: Case series from a tertiary care paediatric hemato-oncology centre

A descriptive study on multisystem inflammatory syndrome in children in a single center in West Michigan

BackgroundMultisystem Inflammatory Syndrome in Children (MIS-C) is a rare hyperinflammatory condition that occurs following SARS-CoV-2 infection. There is a paucity of research describing risk factors, optimal management, and outcomes of this life-threatening condition.MethodsThis is a case series of 26 patients diagnosed with MIS-C in a West Michigan pediatric tertiary care center from April 2020 to February 2021. We describe the clinical, imaging, and laboratory characteristics of these patients and detail their treatments and outcomes with comparisons between Pediatric Intensive Care Unit (PICU) and non-PICU patients. Categorical testing utilized Chi-square and Fisher’s Exact tests. Comparison between groups used T-tests or Kruskal-Wallis.ResultsFifteen patients (57%) required intensive care. There was no statistically significant difference in demographics between PICU and non-PICU patients, however all Black patients required intensive care. Gastrointestinal symptoms were present in 22 patients (84%). Seventeen patients (65%) had Kawasaki-like features and 12 (46%) developed coronary artery dilation. Patients requiring intensive care were less likely to have a reported history of COVID-19 disease or exposure (p = 0.0362). Statistically significant differences were also noted in peak ferritin (p = 0.0075), procalcitonin, and BNP in those who required intensive care.ConclusionsAlthough overlap exists with other hyperinflammatory conditions, our study provides further evidence that MIS-C is a distinct, albeit heterogenous, disorder with various degrees of cardiac involvement. Anakinra, in conjunction with steroid use, appears to be effective and safe in the treatment of MIS-C. This report identifies procalcitonin, peak ferritin, and BNP as potentially useful biomarkers for severity of disease.

Transcatheter occlusion of coronary artery fistulas in pediatric patients: Experience of a tertiary care pediatric cardiac centre in South India

Transcatheter occlusion of coronary artery fistulas in pediatric patients: Experience of a tertiary care pediatric cardiac centre in South India

Telemedicine (virtual clinic) effectively delivers the required healthcare service for pediatric ambulatory surgical patients during the current era of COVID-19 pandemic: A mixed descriptive study

BackgroundChildren often suffer from congenital or acquired diseases. Ambulatory cases represent the vast majority of pediatric surgical cases. COVID-19 pandemic-associated regulatory precautions had made the process of seeking medical advice at a suitable appointment such a big problem. We utilized telemedicine (online encounter) to deliver the required healthcare service for sorting and guiding pediatric ambulatory surgical patients. In this article, we aimed to: (1) present our experience, (2) evaluate the effectiveness, and (3) document the results of this technology to solve the problem of difficult healthcare accessibility. Materials and methodsIn this study, we compared the utilization of telemedicine (virtual clinic via video consultation) prospectively in the current era of the COVID-19 pandemic in the period from June 2020 to July 2021 to the in-person clinic encounter at the outpatient department (OPD) retrospectively in the previous year (from June 2019 until the end of May 2020) for perioperative management of pediatric ambulatory surgical patients. The study was conducted at 3 tertiary care pediatric surgery centers. The information recorded for analysis included: demographic data, surgical condition distribution, time interval from the appointment request till the actual encounter with the surgeon, conversation duration, distance traveled, and ultimate fate of the consultations. For both groups, service was evaluated after the first follow-up visit by a patient survey questionnaire (Patient Experience Assessment form) including questions relevant to each encounter. ResultsA total of 1124 pediatric patients with various ambulatory surgical conditions had been scheduled for virtual clinic video encounters. Of them, 1056 cases were evaluated by video consultation, supervised by their parents or caregivers, thus, achieving an attendance rate of 94%. Of the remaining cases, 2% (n = 23) were canceled and 4% (n = 45) did not attend the virtual clinic. Two-thirds of the cases live in rural /remote areas. Patients’ overall satisfaction was 92%. This was in comparison to 872 pediatric ambulatory surgical patients scheduled for in-person clinic visits before the implementation of the virtual clinic. Of them, only 340 cases had attended the clinic, thus, achieving an attendance rate of 39%. Of the remaining cases, 450 cases (51.6%) were canceled and 82 cases (9.4%) did not attend the clinic (no show). About 48% of the cases live in rural areas. For this group, patients’ overall satisfaction was 63%.The mean encounter duration was similar for both groups (∼ 5 min). Surgical condition distribution was also similar (p-value: 0.694). For new cases, the time interval from appointment request till the actual encounter was very short for the virtual clinic group (range: 6–15 days) as compared to the in-person clinic group (range: 30–180 days). Patients were followed up for a median period of 14 ± 3.25 months (range: 6–22 months) with no patient loss to follow-up. ConclusionTelemedicine can effectively bridge the patient-physician communication gap caused by the regulatory precautions mandated by the current COVID-19 pandemic. It achieved an attendance rate of 94% and parents’ / patients’ overall satisfaction of 92%.

Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2.

ObjectivesTo know the clinical presentation and outcome of children with pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV- 2 (PIMS-TS) at a pediatric tertiary care center in Chennai.MethodsClinical and biochemical parameters of 65 children with PIMS-TS treated between July and October 2020 were studied. All children had their COVID RT-PCR and IgG COVID antibodies tests done.ResultsMean age of the study group was 5.65 ± 3.68 y. Fever with red eyes, rash, vomiting, abdominal pain, and shock were common presenting features. Sixty percent of the study group had Kawasaki/incomplete Kawasaki features. Sixty-seven percent of the study group had coronary dilatation, 41% presented with shock, and 25% had left ventricular dysfunction. Coronary aneurysms were documented in 58% of the study group (z score more than 2.5). Respiratory presentation with pneumonia was seen in 10%. Four children presented with acute abdomen. Acute kidney injury, acute liver failure, hemolysis, pancytopenia, macrophage activation syndrome, encephalopathy, and multiorgan dysfunction syndrome (MODS) were other features. Forty-three percent required noninvasive oxygen support and 15.4% required mechanical ventilation. Intravenous immunoglobulin (73.8%) and methylprednisolone (49.8%) were used for therapy. Mortality in the study was 6%, which was due to MODS.ConclusionsAcute febrile illness with mucocutaneous and gastrointestinal manifestations should have PIMS-TS as a possible differential diagnosis and needs evaluation with inflammatory markers and SARS-CoV-2 antibodies.

P174 PREVENTING FOOD ALLERGY BY EDUCATING FIRST-YEAR PEDIATRIC RESIDENT PHYSICIANS

Practice guidelines regarding early introduction of peanut and other allergenic solid foods have shifted in the last decade. We hypothesized that knowledge gaps and discomfort about these topics existed among first-year pediatric resident physicians at a pediatric tertiary care center.

Pediatric nasal septoplasty outcomes.

BackgroundCorrective nasal surgery has historically been avoided in the pediatric population out of concerns surrounding the potential disruption of nasal growth centers. There is a paucity of data on the rate of complications or revision surgery following septoplasty in this population. As such, the purpose of this study is to review the long-term outcomes of a large cohort of children who underwent nasal septoplasty and to compare outcomes of septoplasty patients under the age of 14 to those 14 years and older.MethodsA retrospective review was performed on all patients who received nasal septoplasty at our tertiary care pediatric referral center between October 2009 and September 2016. All patients who underwent septoplasty for a deviated nasal septum and were 0–18 years of age at the time of surgery were included in this analysis. Outcomes were compared between patients under the age of 14 to those 14 years and older. Demographic, surgical, and follow-up data were collected including complications and the need for revision surgery.ResultsA total of 194 pediatric patients were identified as meeting inclusion criteria for the study. Mean age for the total cohort was 14.6 years (0–18 years), with a mean of 15.9 years in the older group and 10.6 years in the younger group. Revision septoplasty was performed more frequently in the younger group. However, no significant difference in the rate of complications was seen between the two groups.ConclusionsTo the best of our knowledge, this is the largest retrospective study examining outcomes following septoplasty in pediatric patients. We also specifically examine outcomes of very young septoplasty patients, a population for which limited evidence exists. Further retrospective studies are needed to validate the use of nasal septoplasty in the pediatric population.

125 Reducing Displaced Forearm Fractures in Children: Are we following the guidelines?

Abstract Primary Subject area Emergency Medicine - Paediatric Background Forearm fractures account for 45% of pediatric fractures, mainly involving the distal third of the forearm. Some will be displaced, requiring a closed reduction and plaster cast immobilization. Re-displacement during follow-up is reported in 7 to 35% of the cases. Objectives To identity discrepancies between hospital guidelines and patient management for forearm fracture reduction in children aged 1 to 17. Design/Methods This retrospective case series was conducted by a medical audit committee of CHU Sainte-Justine for the purpose of improving quality of care. This project aimed to evaluate the clinical course following closed reduction of forearm fractures in patients presenting to the emergency department (ED) or to the orthopedic clinic in a pediatric tertiary care centre. Children aged 1 to 17 years old presenting between January 1 and December 31 2019 were considered for this study. We selected a convenience sample of 50 consecutive cases and reviewed their medical and radiological data from first consultation through follow-ups. The management of these cases was evaluated against established hospital guidelines for primary or secondary fracture reduction (primary outcome). The angulation and displacement of fractures were measured using original imaging taken prior to reduction, and at follow-up. At their last appointment, all patients’ range of motion and angulation were assessed. Complications of sedation and immobilization were also reviewed. Descriptive statistics were performed for all variables. Results From the 106 radiologic files retrieved of closed forearm fracture reduction using fluoroscopy, a convenient sample of 50 cases was reviewed. The mean age was 7 years and 60% of them were boys. Forty-eight (96%) had an initial fracture reduction consistent with the local practice guideline for need of reduction. Sedation adverse events were noted in 10 patients (20%), most often nausea, but no severe adverse event was identified. According to the local practice guideline, 13 (26%) patients suffered re-displacement at follow-up. Of these, 3 underwent a second closed reduction, 4 had a gypsotomy, and 6 had no attempt at a second reduction. Five patients (10%) had a second reduction during follow-up, despite the displacement not meeting the local guideline criteria for reduction. Cast-related issues were reported in 14 patients (28%), with the molding technique accounting for most of the problems observed. At their final follow-up, 40 patients (80%) had an excellent or good functional outcome. In the remaining 10 (20%), the range of motion was more limited, but measurements were done for many of them following immediate cast removal. Forty patients (80%) had either a normal or near normal alignment at their final follow-up. In the remaining 10 (20%), none of these patients had an angulation greater than 20 degrees. Conclusion From this audit of patients presenting with displaced forearm fractures in a pediatric tertiary care centre, the initial management of patients was in accordance with the established guidelines of practice in 96% of cases. Re-displacements at follow-up were identified in a quarter of patients. Nonetheless, angulation and the final range of motion of the wrist were favorable shortly after cast removal. Further improvement in the management could be achieved by improving the technique of cast immobilization.

Noninvasive Respiratory Support as an Alternative to Tracheostomy in Severe Laryngomalacia.

To analyze the role of noninvasive respiratory support (NRS) as an alternative to tracheostomy in the management of severe laryngomalacia. We conducted a monocentric retrospective study in a tertiary pediatric care center. All children under the age of 3 years with severe laryngomalacia, treated between January 2014 and December 2019, were included. Patient demographics, medical history, nutrition, surgery, NRS, and outcome were reviewed. Predictors for NRS were analyzed. One hundred and eighty-eight patients were included. Mean age was 4 ± 5 months and mean weight was 4,925 ± 1,933 g. An endoscopic bilateral supraglottoplasty was performed in 183 (97%) patients and successful in 159 (87%). NRS was initiated in 29 (15%) patients at a mean age of 3 ± 2 months (1-11 months): 15 (52%) patients were treated with NRS after surgical failure, 9 (31%) were treated with NRS initiated prior to surgery because of abnormal overnight gas exchange, and 5 (17%) were treated exclusively with NRS due to comorbidities contraindicating an endoscopic procedure. NRS was successfully performed in all patients with a mean duration of 6 ± 11 months. No patient required a tracheostomy. Univariate analysis identified the following predictors of NRS: neonatal respiratory distress (P=.003), neurological comorbidity (P < .001), associated laryngeal abnormality (P < .001), cardiac surgery (P=.039), surgical endoscopic revision (P=.007), and nutritional support (P < .001). NRS is a safe procedure, which may avoid a tracheostomy in severe laryngomalacia, in particular, in case of endoscopic surgery failure, respiratory failure before surgery, and/or severe co-morbidity. 3 Laryngoscope, 132:1861-1868, 2022.

99 Impact of COVID-19 pandemic on children with medical complexity: Parental perspective about the role of a Complex Care program

Primary Subject areaComplex CareBackgroundThe COVID-19 pandemic led to major and rapid organizational and structural healthcare changes including a switch from ambulatory services towards telemedicine and decreased access to home services. Children with medical complexity (CMC) require many medical services and are generally prone to infectious complications. Little is known about the impact of the pandemic on families of CMC. Understanding how CMC families experience the COVID-19 pandemic is essential to tailor healthcare services to answer their needs more effectively.ObjectivesWe explored parental experience of CMC during the COVID-19 pandemic, and how the complex care program (CCP) answers their new needs.Design/MethodsThis qualitative study was conducted between July 2020 and January 2021 in a tertiary care pediatric university hospital centre. Semi-structured interviews were done with parents of CMC, admitted in the CCP at least 1 year prior to the beginning of the pandemic. The interview guide was co-constructed by physicians and nurses from the CCP. Interviews were transcribed verbatim and analyzed using NVivo. Data were organized into codes and categories. Thematic content analysis was performed by grouping categories and highlighting emerging themes.ResultsEleven families (14 parents – 4 fathers, including 3 couples) were interviewed. The first wave of the pandemic seemed to have caused important uncertainty and anxiety amongst parents of CMC. Almost all the parents reported cancelling numerous appointments in order to avoid coming to the hospital at all costs. Some parents, worrying specifically about the fragility of their child, stopped working and stayed home to reduce transmission risks. Fear of facing shortages in medications, nutritional supplements and medical equipment for home care was frequently expressed. They did not express worries about the de-confinement periods. The support provided by the CCP’s staff was greatly appreciated, namely active problem-solving via phone calls, videoconferences, emails and pictures, leading to fewer hospital visits and less need to seek emergency care. Some reported that more general communication from the CCP (e.g., a weekly information email), would have helped to interpret the overwhelming amount of information from the media. Parents expressed a strong desire to maintain telemedicine services after the pandemic.ConclusionThe COVID-19 pandemic brought additional worries to parents of CMC enrolled in CCPs, including fear of shortages and virus transmission. Direct communication with the CCP and remote problem-solving were greatly appreciated by families. Improvement to follow-up include finding ways to help interpreting data from the media.

The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit.

Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.

Augmented Reality in Pediatric Septic Shock Simulation: Randomized Controlled Feasibility Trial.

BackgroundSeptic shock is a low-frequency but high-stakes condition in children requiring prompt resuscitation, which makes it an important target for simulation-based education.ObjectiveIn this study, we aimed to design and implement an augmented reality app (PediSepsisAR) for septic shock simulation, test the feasibility of measuring the timing and volume of fluid administration during septic shock simulation with and without PediSepsisAR, and describe PediSepsisAR as an educational tool. We hypothesized that we could feasibly measure our desired data during the simulation in 90% of the participants in each group. With regard to using PediSepsisAR as an educational tool, we hypothesized that the PediSepsisAR group would report that it enhanced their awareness of simulated patient blood flow and would more rapidly verbalize recognition of abnormal patient status and desired management steps.MethodsWe performed a randomized controlled feasibility trial with a convenience sample of pediatric care providers at a large tertiary care pediatric center. Participants completed a prestudy questionnaire and were randomized to either the PediSepsisAR or control (traditional simulation) arms. We measured the participants’ time to administer 20, 40, and 60 cc/kg of intravenous fluids during a septic shock simulation using each modality. In addition, facilitators timed how long participants took to verbalize they had recognized tachycardia, hypotension, or septic shock and desired to initiate the sepsis pathway and administer antibiotics. Participants in the PediSepsisAR arm completed a poststudy questionnaire. We analyzed data using descriptive statistics and a Wilcoxon rank-sum test to compare the median time with event variables between groups.ResultsWe enrolled 50 participants (n=25 in each arm). The timing and volume of fluid administration were captured in all the participants in each group. There was no statistically significant difference regarding time to administration of intravenous fluids between the two groups. Similarly, there was no statistically significant difference between the groups regarding time to verbalized recognition of patient status or desired management steps. Most participants in the PediSepsisAR group reported that PediSepsisAR enhanced their awareness of the patient’s perfusion.ConclusionsWe developed an augmented reality app for use in pediatric septic shock simulations and demonstrated the feasibility of measuring the volume and timing of fluid administration during simulation using this modality. In addition, our findings suggest that PediSepsisAR may enhance participants’ awareness of abnormal perfusion.

Increase in the Diagnosis and Severity of Presentation of Pediatric Type 1 and Type 2 Diabetes during the COVID-19 Pandemic

Introduction: The impact of the COVID-19 pandemic on the incidence of pediatric type 1 (T1D) and type 2 diabetes (T2D) and severity of presentation at diagnosis is unclear. Methods: A retrospective comparison of 737 youth diagnosed with T1D and T2D during the initial 12 months of the COVID-19 pandemic and in the preceding 2 years was conducted at a pediatric tertiary care center. Results: Incident cases of T1D rose from 152 to 158 in the 2 years before the pandemic (3.9% increase) to 182 cases during the pandemic (15.2% increase). The prevalence of diabetic ketoacidosis (DKA) at T1D diagnosis increased over 3 years (41.4%, 51.9%, and 57.7%, p = 0.003); severe DKA increased during the pandemic as compared to the 2 years before (16.8% vs. 28%, p = 0.004). Although there was no difference in the mean hemoglobin A1c (HbA1c) between racial and ethnic groups at T1D diagnosis in the 2-years pre-pandemic (p = 0.31), during the pandemic HbA1c at T1D diagnosis was higher in non-Hispanic Black (NHB) youth (11.3 ± 1.4%, non-Hispanic White 10.5 ± 1.6%, Latinx 10.8 ± 1.5%, p = 0.01). Incident cases of T2D decreased from 54 to 50 cases (7.4% decrease) over the 2-years pre-pandemic and increased 182% during the pandemic (n = 141, 1.45 cases/month, p < 0.001). As compared to the 2-years pre-pandemic, cases increased most among NHB youth (56.7% vs. 76.6%, p = 0.001) and males (40.4% vs. 58.9%, p = 0.005). Cases of DKA (5.8% vs. 23.4%, p < 0.001) and hyperosmolar DKA (0 vs. 9.2%, p = 0.001) increased among youth with T2D during the pandemic. Conclusions: During the pandemic, the incidence and severity of presentation of T1D increased modestly, while incident cases of T2D increased 182%, with a nearly 6-fold increase in DKA and nearly a 10% incidence of hyperosmolar DKA. NHB youth were disproportionately impacted, raising concern about worsening of pre-existing health disparities during and after the pandemic.

Well-Being of Ambulatory Adults With Cerebral Palsy: Education, Employment, and Physical Function of a Cohort Who Received Specialized Pediatric Care.

Introduction: The transition from pediatric health care and school systems presents enormous challenges for young adults with cerebral palsy (CP). The lack of strong societal support during this seminal life event is well-documented and leads many adults with CP to struggle with independence, higher education, and employment. Despite the relatively high prevalence of CP, information about the experiences and function of adults with CP in our society continues to be limited. The purpose of this project was to describe well-being by assessing education, employment, physical function, walking activity, and utilization of health care in an ambulatory adult cohort with CP who received specialized pediatric care at our center.Method: In this Institutional Review Board-approved prospective study, we invited former patients from our tertiary care pediatric CP center to complete a set of patient-reported outcomes including (1) the Patient-Reported Outcomes Measurement Information System domains of physical function and pain interference, (2) the Satisfaction with Life Scale, and a project-specific demographic questionnaire about education, employment, income, independence, pain, and health care utilization. Participants also wore a pedometer for 8 days to monitor community walking activity. Chi-squared pairwise or t-tests were used as appropriate to compare survey responses and walking activity data between three groups: participants who self-reported, those who reported by proxy, and published normative data from age-matched typically developing adult (TDA) samples.Results: One hundred twenty-six adults with CP consented to participate; 85 self-reported [age 29.7 ± 4.3 years; Gross Motor Function Classification System: I (28%), II (47%), and III, (25%)] and 41 reported by proxy [age 29.7 ± 4.1 years; Gross Motor Function Classification System: I (10%), II (68%), and III (22%)]. For the group who self-reported, high school graduation rate (99%) was similar to TDA (92%; p = 0.0173) but bachelor's degree achievement rate (55%) was higher than TDA (37%; p < 0.001). Despite more advanced education, the unemployment rate in this group was higher than national levels at 33% and was associated with high utilization of Social Security Disability Insurance (33%). Within the self-reporting group, 13% required a caregiver. For the group who reported by proxy, educational levels (73% high school graduates, 0 bachelor's degree) were lower than the general population (p < 0.001) and unemployment was higher than the national level, at 64%. Unemployment in this group was associated with high utilization of Social Security Disability Insurance (85%). Within the proxy-reporting group, 71% required a caregiver. The full cohort demonstrated lower levels of physical function according to the Patient-Reported Outcomes Measurement Information System and less community walking activity compared with TDA references (p < 0.001). This cohort of adults with CP reported significantly higher frequency of chronic pain (48 vs. 12% for TDA; p < 0.001), but less pain interference with daily activities than TDA based on Patient-Reported Outcomes Measurement Information System results (p < 0.001). This cohort reported good to excellent overall health (93%) and high utilization of primary care (98%), but limited utilization of specialty care, specifically orthopedic care (21%) and physical therapy (15%).Discussion: This cohort of adults with CP had similar levels of education as the general population, but had relatively high rates of unemployment, caretaker need, and Social Security Disability Insurance utilization. Although chronic pain was frequent, the impact of pain on work and independent living did not exceed reports from a typically developing reference. Better targeted societal resources for adults with physical disabilities are urgently needed to allow equitable access to employment, promote opportunities for independence, and enable full participation in community life.

Impact of COVID-19 lockdown on a tertiary center pediatric otolaryngology emergency department.

To assess the quantitative and qualitative impact of the COVID-19 lockdown on pediatric otolaryngology emergency activity. A retrospective study was conducted in a pediatric otolaryngology tertiary care center. Emergency activity during the lockdown period from March 17 to May 11, 2020, was compared to the 2019 and 2018 averages for the same period. Study data included a number of emergency consultations and the number and type of surgical procedures: infection management, endoscopic airway procedure, and post-tonsillectomy hemorrhage. Only 350 children were referred to the pediatric otolaryngology emergencies in our center during the lockdown, compared to 761 on the same period the year before (− 54%); 62 emergency surgeries were performed, compared to 93 (− 33%). The ratio between emergency surgeries and consultations was 18% in 2020, versus 12% previously (p = 0.014). The number of surgical procedures for infectious diseases decreased (− 68%), at 16% of surgical emergencies in 2020 compared to 33% previously (p = 0.017). In 2020, 52 emergency endoscopies were performed, versus 59 previously (− 12%), 27% being performed for suspected tracheobronchial or esophageal foreign bodies, compared to 66% in previous years (p < 0.0001). No post-tonsillectomy hemorrhages were managed in 2020.Conclusion: The COVID-19 lockdown changed pediatric ENT emergency activity quantitatively and also qualitatively. What is Known:• SARS-CoV-2 pandemic impacted pediatric ENT emergency activity quantitatively and qualitatively.What is New:• here was a 54% decrease in pediatric ENT emergency consultation and 33% decrease in emergency ENT surgeries.• Rates of surgery for infection of whatever type decreased by 68%.

Aerobic fitness in overweight/obese children with congenital heart disease: Benefit of adapted VO2 reference values

Overweight/obesity is a major public health problem in the general paediatric population with a prevalence of 21% in Europe. This prevalence is more important in children with chronic diseases [including congenital heart disease (CHD)]. We know that children with CHD have lower aerobic fitness than “healthy” children. Overweight/obesity also has a negative impact on this aerobic fitness. Overweight/Obese children with CHD should have lower aerobic fitness than healthy obese children, but until now there have been no reference values to assess aerobic fitness in this overweight subpopulation. Our team recently provided paediatric reference values with adapted Z scores for extreme weights. The main objective of this study is to assess whether these new reference values discriminate healthy obese children from obese children with CHD compared to the usual reference values of Cooper et al. This cross-sectional study was carried out between November 2010 and November 2020 in two tertiary care paediatric cardiology reference centres and included both “healthy” and CHD children with BMI > 85th percentiles. In total, 344 children were included (185 boys), 244 controls and 100 CHD. Using the usual standards (Cooper et al.), no significant difference in VO2 max between CHD and control groups was found (76 ± 18% vs. 77 ± 21%; P = 0.7). According to our new reference values, a significant difference was found for the Z-score of VO2 max between the CHD and control groups (−0.46 ± 1.31 vs. −0.10 ± 1.03; P = 0.006). The CHD subgroups in according with ACC-CHD classification found a lowest mean VO2 max Z-score in the single ventricle malformations, anomalies of the atrioventricular junctions and complex anomalies of the right ventricle outflow tract. This study reveals the benefit of these new references values adapted to extreme weights by discriminating a pathological group (CHD) from a control group.

Reference values of aerobic fitness in the contemporary paediatric population: VO2max Z-scores

Tremendous progress in paediatrics has significantly improved the overall prognosis of chronic diseases and transferred the mortality from childhood to adulthood in an era where sedentary lifestyle, obesity and associated cardiovascular risk factors are rapidly increasing. The promotion of regular exercise is of utmost priority in the management of these patients. The cardiopulmonary exercise test (CPET) gives important prognostic information on functional capacity, haemodynamic response and can facilitate a safe decision-making process when prescribing exercise programs and sport participation for these children. Despite a growing interest in CPET and individualized rehabilitation programs for chronic diseases, we still face the lack of reference values for paediatric CPET and even more for “extreme” patients (especially in terms of weight). The main aim of this study is to define references values VO2max and establish Z-scores in the paediatric population including extreme weights. This cross-sectional study was carried out between November 2010 and November 2020 in two tertiary care paediatric cardiology reference centres and included children referred for a non-severe functional symptom linked to exercise (murmur, palpitation or dyspnoea) or for a medical sports certificate. These children had a completely normal check-up, including physical examination, ECG, echocardiography and spirometry. In total, 909 children were included, 213 were overweight/obese and 107 were underweight. For both sexes, the best model was logarithmic with the combination of height and BMI. The equations are cited in the Fig. 1. For the first time, we have paediatric reference values giving VO2max Z-score that can be used for extreme weights. From this same cohort, we will soon publish the Z-score of the other CPET parameters and thus facilitate the interpretation of this paediatric examination and facilitate its use.

Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study

Introduction Pediatric complex chronic care patients present unique challenges regarding healthcare provision: complex medical regimes, complicated family/provider dynamics, and multiple healthcare teams that can result in inconsistent care. This study examined subspecialty providers’ perspectives regarding pediatric complex chronic care patients and compared them with acute care providers while exploring opportunities to better facilitate care provided to pediatric complex chronic care patients. Methods This survey study occurring within a Canadian tertiary care pediatric center, utilized REDCap to deploy surveys involving Likert Scale and short answer questions. The Kruskal–Wallis test compared subspecialty provider perspectives when providing care to pediatric complex chronic care patients versus non-pediatric complex chronic care patients; and perspectives between subspecialty and acute care providers. Results Survey response rate was 24/46 (52.2%). Eight overarching themes emerged from Likert scale questions. Short answer questions revealed factors that may facilitate care provided to pediatric complex chronic care patients: access to funding; discharge planning; communication methods between specialists; and healthcare provider continuity. Several differences were identified when working with pediatric complex chronic care patients, compared to non-pediatric complex chronic care patients: increased time/resource burden; managing expectations of patients/families; navigating discrepancies in goals of care; complexity of coordination between services; increased efforts in coordinating discharge from hospital and working with medicalized patients/families. Discussion Exploring pediatric subspecialty provider perspectives of pediatric complex chronic care patients revealed opportunities to enhance care provided: increased resources to ease the strain of care provision for parents, implementation of a discharge coordinator, complex care clinics with a pediatrician to “quarterback” care, and co-management between the complex care pediatrician and acute care physician when admitted to an acute care service. Implementation of these initiatives may improve the care provided to pediatric complex chronic care patients.

Epidemiology of Craniofacial Pathology in Northern Vietnam Using Digital Platforms: Utilization of Electronic Medical Records and an SMS-Based Reporting System in a Low-Middle Income Country.

Current disease surveillance in Vietnam relies on underdeveloped electronic medical record (EMR) systems, which are insufficient for timely standardized data collection about craniofacial and cleft pathologies. Concurrently, the World Bank reports Vietnamese mobile cellular subscription rates (per 100 people) of 128, some of the highest in the world. Herein, we discuss the development of a short messaging service (SMS)-based surveillance system based in Hanoi, Vietnam, and its utility in contrast to an EMR-based approach to craniofacial epidemiology study. Vietnam National Children's Hospital (VNCH) is a pediatric tertiary care center serving approximately 12 million children. Four plastic surgeons were trained in SMS data entry. The SMS database was designed using FrontlineSMS, a 2-way mobile gateway software application with automated messaging capabilities. The VNCH EMR database was queried for individual demographic data for patients seen by the department from 2010 to 2019. A corrected prevalence for cleft lip and palate of 0.098% (1 in 1020 live births) was calculated based on EMR data. Six rural provinces greater than 150 km from Hanoi were found to be significantly (P < 0.01) underserved surgically by the VNCH. A significantly (P < 0.01) higher rate of Pierre Robin in Lang Son province and facial clefts in Ha Tinh province were identified. The prospective data collection system received 7 patient data sets over 4 months, resulting in a capture rate of 2.9%. This feasibility study offers valuable insight into the true cleft and craniofacial prevalence in Vietnam and alternative methods to study in low- and middle-income countries.

Improving Discharge Instructions Following a Concussion Diagnosis in the Pediatric Emergency Department: A Pre-post Intervention Study.

Many children are discharged from the pediatric emergency department (PED) with incomplete or inappropriate instructions following a concussion. Our objective was to evaluate the effectiveness of a simple intervention in improving discharge instruction disbursement and completeness following PED diagnosis of concussion. A pre/post intervention study of 935 patients (375 preintervention and 560 postintervention) ages 5-19, diagnosed with a concussion and discharged from the PED between July 2016 and November 2019, was performed at a single United States pediatric tertiary-care center. Dedicated provider education sessions were held, and a consensus guideline-based set of discharge instructions were implemented in the electronic health record. Primary outcomes included the presence of return-to-play (RTP) instructions, return-to-learn (RTL) instructions, follow-up recommendations, and "complete" discharge (ie, all 3 components present). Statistical process control charts were generated and tested for special cause variation. More patients received instructions for RTP (87% versus 59%) and RTL (60% versus 3%), and a complete discharge was more frequent (45% versus 2%), following the conclusion of the intervention. Only the improvement in RTP instructions was completely sustained into the following academic year, whereas RTL and complete discharge rates declined to 27% and 20%, respectively. A simple, low-cost intervention such as peer-to-peer education and consensus guideline-based discharge instruction templates can significantly improve discharge readiness after pediatric concussion. Further work is needed to maintain progress and continue improvements, at our large academic trauma center.