Pediatric Tertiary Care Center Research Articles

The VE/VCO2 slope: A useful tool to evaluate the physiological status of children with congenital heart disease

Cardio-pulmonary exercise test (CPET) is becoming a key examination to assess physical capacity and disease severity in paediatric cardiology. The VE/VCO2 slope has been increasingly used as a surrogate marker for morbidity and mortality in adult heart failure, pulmonary arterial hypertension and for adult patients with CHD. Nevertheless, the use of the VE/VCO2 slope in children remains limited in the absence of reference values and clearly identified clinical determinants. This study aimed to compare the VE/VCO2 slope in a paediatric cohort with CHD to that of age- and gender-adjusted healthy controls. We also intended to identify the clinical and CPET variables associated with VE/VCO2 slope in this population. This cross-sectional study was carried out between November 2010 and September 2015 in two tertiary care paediatric cardiology reference centres. A total of 700 children were enrolled (399 CHD and 301 healthy controls). The mean VE/VCO2 slope was significantly higher in CHD than in healthy subjects (31.6 ± 4.8 vs. 29.3 ± 4.8; P < 0.001). When considering CHD sub-groups, the VE/VCO2 slope was impaired in single ventricle, complex anomalies of ventriculo-arterial connections, anomalies of the atrioventricular junctions and valves. The VE/VCO2 slope according to the CHD physiological status was illustrated in the Fig. 1, it was higher in children with significant pulmonary regurgitation, tricuspid regurgitation, right ventricular hypertension and right ventricle outflow tract (RVOT) obstacle. In the CHD group, VE/VCO2 slope increase was associated with BMI, the presence of a RVOT obstacle, the number of cardiac catheter procedures, as well as low age, FVC, tidal volume, and PetCO2 (Fig. 1). Increased VE/VCO2 slope was predominantly in children with single ventricle and/or residual right heart abnormalities suggesting that maldistribution of pulmonary blood flow during exercise is an important CHD-unique determinant of VE/VCO2 slope.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy.

There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. Level III, retrospective case-control study. A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware). A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy. Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Effective continuing interprofessional healthcare education to improve sepsis care in a tertiary children and women’s hospital in the State of Qatar “Culture of think sepsis”

Background: Sepsis is a medical emergency and a global economic and health burden. It is one of the leading causes of death worldwide with 1 death every 2.8 seconds and represents 20% of all deaths worldwide. Sidra Medicine, the only pediatric tertiary care centre in the State of Qatar, in collaboration with Qatar’s Ministry of Public Health, Hamad Medical Corporation (HMC), and Hamad Healthcare Improvement Institute (HHQI) share the national goal of reducing mortality due to sepsis and septic shock through an increase in healthcare provider compliance to the sepsis six bundle of care from 0% to 95% by the end of 2022. Methods: A multifaceted, interdisciplinary, comprehensive education and training program was designed and provided to healthcare practitioners across Sidra and comprised: • Pre-implementation education • Multidisciplinary education sessions and workshops • Train-the-trainer nurse educator workshop • Bedside interdisciplinary simulation-based education • Sepsis case discussions during morning reports, academic activities, grand rounds, and morbidity and mortality meetings • Annual Qatar National Sepsis Symposium • September Sepsis-Awareness Month • Pediatric and women sepsis e-learning module • National Patient Safety Collaborative (NPSC) training sessions and storyboards in collaboration with the Institute for Healthcare Improvement (IHI) and HHQI In addition, sepsis pathway posters, think-sepsis booklets and pocket cards, antibiotic preparation and administration cards, and family education materials in Arabic and English were produced and utilized. Results: Improved sepsis awareness and education was observed. 95% of providers successfully completed the e-learning module. Compliance to the sepsis six bundle of care subsequently reached 81%. Sepsis mortality rate was 1.8% in the first two quarters of 2020 which is well below international mortality rates. Conclusion: Since 2018, Sidra Medicine embraced sepsis education and care through a national evidence-based sepsis guideline for early recognition and treatment which is positively reflected in low sepsis mortality rates for 2020.

Outcomes of flexible fiberoptic laryngoscopy in patients with stridor: a cross-sectional study in a tertiary care pediatric center in Saudi Arabia

BACKGROUND: Successful evaluation of a patient with stridor requires a thorough history and physical examination followed by a flexible fiberoptic laryngoscopy (FFL), which provides visualization of the upper airway.OBJECTIVES: Estimate the prevalence of causes of stridor in children who underwent FFL and compare different age groups. Find any significant associations between symptoms and laryngoscopic findings. Identify patients who needed further evaluation using direct laryngobronchoscopy (DLB).DESIGN: Retrospective, cross-sectional.SETTING: Tertiary care center in Riyadh.PATIENTS AND METHODS: We included all pediatric patients aged 1 month to 14 years who underwent fiberoptic laryngoscopy for stridor evaluation from January 2015 to January 2018 (37 months). Patients older than the age of 14 years, and patients with a workable diagnosis with adenotonsillar hypertrophy, choanal atresia, or laryngotracheo-bronchitis (croup) were excluded.MAIN OUTCOME MEASURES: Findings of FFL.SAMPLE SIZE: 217 pediatric patients.RESULTS: The median (interquartile range) age of the patients was 5 (8) months. Laryngomalacia was the most common diagnosis (n=149, 69%) followed by laryngopharyngeal reflux (n=42, 19%). Subglottic stenosis was the most common finding in patients who underwent DLB for further evaluation (n=19, 49%). Laryngomalacia was more frequent in children ≤12 months of age (83% vs 43% in children >12 months, P<.001). Vocal cord paralysis was more common in children >12 months of age (27% vs 9%, P<.001). FFL was effective in finding the diagnosis in 178 (82%) patients; only 39 (18%) patients needed further assessment using DLB.CONCLUSION: FFL is an effective and important tool for evaluating patients with stridor.LIMITATIONS: Retrospective design and single-centered.CONFLICTS OF INTEREST: None.

Pediatric Nurse and Pharmacist Knowledge of Acute Kidney Injury.

In this study, we assessed the knowledge and experience of pediatric pharmacists and nurses at a US tertiary-care pediatric center regarding the risk factors for, recognition of, and best practices for managing an acute kidney injury (AKI) in children. The authors developed a survey to assess the attitudes and knowledge of nurses and pharmacists regarding AKI in hospitalized children, which was reviewed by a small multidisciplinary group for content and length. The final 16-item survey consisted of demographic, self-assessment and attitude, and knowledge questions. All pediatric pharmacists and nurses at the study site received a voluntary online survey via e-mail. Data were analyzed by using descriptive statistics. A survey was sent to 620 nurses and 50 pharmacists; 148 (25%) and 22 (44%), respectively, completed it. Most respondents were <35 years old and had ≤10 years of experience in both their professions and pediatrics. A total of 72% of pediatric nurses felt identification of AKI was within their scope of practice, and ∼60% felt confident in their ability to do so. More than 80% of pediatric pharmacists felt confident in their abilities to adjust medication doses in pediatric patients with AKI, but <60% felt confident in their ability to estimate the glomerular filtration rate in these patients. Nurses and pharmacists were able to correctly identify specific AKI criteria 60% to 70% and 70% to 90% of the time, respectively. Although pediatric nurses and pharmacists have knowledge of AKI prevention and mitigation, gaps exist, and there is a desire for education in recognition of their key roles in the clinical team.

Optimization of Antibiotic Prophylaxis Delivery for Pediatric Surgical Procedures.

To optimize prophylactic antibiotic timing and delivery across all surgeries performed at a single large pediatric tertiary care center. A multidisciplinary surgical quality team conducted a quality improvement initiative from July 2015 to December 2019 by using the A3 problem-solving method to identify and evaluate interventions for appropriate antibiotic administration. The primary outcome measure was the percentage of surgical encounters for pediatric patients with appropriate timing of antibiotic administration before surgical incision. Surgical site infection rates was the secondary outcome. Intervention effectiveness was assessed by using statistical process control. A total of 32 192 eligible surgical cases for pediatric patients were completed during the study period. Identified barriers to timely perioperative antibiotic administration included failure to order antibiotics before the surgical date and lack of antibiotic availability in the operating room at the time of administration. Resulting sequential interventions included updating institutional guidelines to reflect procedure-specific antibiotic choices and clarifying timing of administration to optimize pharmacokinetics, creating a hard-stop antibiotic order within electronic health record case requests, optimizing pharmacy and nursing workflow, and implementing an automatic antibiotic prophylaxis timer in the operating room. Administration of prophylactic antibiotics during the recommended preincision time window significantly improved; the correct timing was recorded in 38.6% of preintervention cases versus 94.0% at the conclusion of rollout of the sequential interventions (P < .001). Surgical site infection rates remained stable. Here we demonstrate utility of the A3 problem-solving schematic to successfully optimize prophylactic antibiotic timing and delivery in the surgical setting for pediatric patients by implementing systems-based interventions.

Comparing Apples to Apples in Post-COVID-Associated Multisystem Inflammatory Syndrome in Children (MIS-C)

Background: The full clinical continuum of post-COVID-associated multisystem inflammatory syndrome of childhood (MIS-C)/Paediatric Inflammatory Multi-system Syndrome (PIMS) is still being defined, with different names and case definitions continuing to be used across jurisdictions. Refinement of criteria and better stratification of affected children will facilitate international collaborations towards improving health outcomes. Our objective is to describe the clinical characteristics and outcomes of children with MIS-C/PIMS stratified by case definition and clinical phenotype.Methods: Prospective study of 137 multi-ethnic hospitalized patients with presumed MIS-C, at a tertiary care pediatric centre in Toronto, Canada from March 2020 to February 2021. Clinical and laboratory features at presentation, organ system complications, therapeutic management, and outcomes were captured. Descriptive statistics were performed to assess differences between case definitions and clinical phenotype.Findings: The most striking differences between the case definitions were reflected in measures of disease severity and outcomes, with the MIS-C classifications capturing the more severe end of the hyperinflammatory spectrum compared to PIMS. Children in the MIS-C group were older and had more cardiac abnormalities and macrophage activation syndrome, which were reflected in more intensive care admission and corticosteroid therapy. Comparisons of clinical phenotypes (shock, Kawasaki Disease, and fever with hyperinflammation) and COVID exposure demonstrate similar clinical features, disease severity and outcomes.Interpretation: Case definition had the greatest impact on measures of disease severity, course, and outcome. Stratification by known disease phenotype led to homogeneous groupings of patients regardless of SARS-CoV-2 exposure status, confirming that recognition of known clinical entities can guide case recognition, classification and management, with our data supporting the notion that KD and MIS-C both fit on the same disease spectrum. The use of a common case definition is needed to ensure comparability in studies among international networks, reliability of public health surveillance data, and proper case ascertainment.Funding: None to declare. Declaration of Interest: None to declare. Ethical Approval: These studies were approved by the institutional Research Ethics Board, and the requirement for individual consent was waived.

Ketorolac Is Safe and Associated With Lower Rate of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in Children With Pancreatic Duct Manipulation.

Use of non-steroidal anti-inflammatory drugs (NSAIDs) for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prevention in pediatrics is not well studied. Because of difficulty in accurately dosing indomethacin suppositories in pediatric patients, our center has used intravenous ketorolac for PEP prevention and present data on its safety and associated PEP rates. Prospective monitoring of PEP for all patients who underwent ERCP at a pediatric tertiary care center from July 2010 to June 2018. Retrospective review of patient and procedural factors and severity of PEP. Routine use of ketorolac for PEP prevention began in 2014. Two hundred and ninety-eight ERCPs were analyzed. One hundred and sixty-six patients received intraprocedural ketorolac and 132 did not. One patient had post-ERCP bleeding and bleeding rates were not significantly different between ketorolac and non-ketorolac groups (0.6% vs 0%, P = 1). Overall rates of PEP were not significantly different between the ketorolac and no ketorolac group (9% vs 13%, P = 0.29); however, for high-risk pediatric patients with injection of contrast into and/or cannulation of the pancreatic duct, the rates of PEP were significantly lower for patients who received ketorolac (11% vs 25%, P = 0.035). Pediatric patients undergoing ERCP with manipulation of the pancreatic duct are high risk for PEP, and ketorolac was associated with a lower rate of PEP in these patients. Ketorolac was well tolerated without a higher rate of bleeding after ERCP. These results are the first to provide evidence showing an association with intraprocedural NSAID use and lower rates of PEP in select pediatric patients.

Echis coloratus envenomation in children: a retrospective case series

Background Antivenom has been used successfully to treat systemic and progressive, local manifestations of envenomations inflicted by Echis coloratus, the second most common cause of snake envenomation in Israel. There is a paucity of published data regarding the use of monovalent (equine) immunoglobulin G antivenom in children. This study describes outcomes from the regimen used in two large, tertiary care pediatric centers. Methods A retrospective chart review of children admitted with definite or probable signs of Echis coloratus envenomation to Sourasky (Tel Aviv) and Soroka (Be’er Sheva) Medical Centers from January 1st 2008–to June 1st 2019. Extracted data included age, location of bite, time to hospital arrival, laboratory test results, complications, time to antivenom administration if indicated, adverse effects of the antivenom, and outcomes. Indications for antivenom were: diagnosis of Echis coloratus as the etiology of envenomation, local and systemic signs e.g. skin puncture wounds, swelling of the involved limb, local hematoma, and abnormal coagulation blood test results. Results During the study period, 11 children were treated with intravenous Echis coloratus antivenom. Median age was 9 years and 10 of 11 patients were male. Two patients underwent fasciotomy; in one, compartment syndrome was diagnosed by pressure measurement, and in the second, clinically. One patient developed mild urticaria 30 min after initiation of the antivenom; the treatment was stopped and then restarted at a slower rate after he was treated with hydrocortisone and diphenhydramine. No further adverse reactions were observed. Conclusions In children, Echis coloratus antivenom appeared to be effective and safe for the treatment of systemic and progressive local manifestations of envenomation by Echis coloratus.

Peripheral Venous Catheter-related Bloodstream Infections in Hospitalized Children: The Role of Gram-negative Bacteria.

Peripheral venous catheter (PVC) is the most used vascular access device in medicine, allowing administration of intravenous fluids and medications. Known complications associated with PVC include extravasation, phlebitis and rarely bloodstream infection (BSI). Data regarding PVC-related BSI in children are lacking. Our aim was to evaluate the epidemiology, clinical and microbiologic characteristics of pediatric inpatients with PVC-related BSI. A retrospective study was conducted in a pediatric tertiary care center. Children with BSI, admitted to general pediatric departments during 2010-2019, were identified and their medical records examined. Patients with BSI and phlebitis were further characterized and included in the analysis. We excluded patients with central venous catheters, other identified source of infection and with BSI upon admission. Data collected included patients' demographics and clinical and microbiologic characteristics. Twenty-seven children with PVC-related BSI were identified and included in the study, consisting of 0.2% of the total BSI cases. Patient's median age was 24 (range, 1.5-213) months, 14/27 (52%) were female and 6 (22%) were previously healthy while 21 (78%) had prior medical conditions. Sixteen (59.3%) patients had Gram-negative BSI and 6 (22.2%) Gram-positive bacteria. Polymicrobial infection occurred in 4 (14.8%) patients and Candida albicans in 1 (3.7%) patient. The most common isolated bacteria were Klebsiella spp and Staphylococcus aureus. Longer dwell-time was a predictor of Gram-negative bacteria. PVC-related BSI due to Gram-negative bacteria was more common than to Gram-positive bacteria. Clinicians should consider an initial broad-spectrum antibiotic coverage for PVC-related BSI in hospitalized pediatric patients.

The spectrum of acute leukoencephalopathy with restricted diffusion (ALERD): A case series and review of literature.

The clinico-etiological spectrum of Acute leukoencephalopathy with restricted diffusion (ALERD) is not well known in Indian population. This is likely to vary between populations and ethnicities. We retrospectively reviewed the clinicoetiological spectrum of ALERD at a tertiary care pediatric center, and described the clinical, imaging, etiological spectrum and short-term outcomes. Eleven out of 78 children with non-traumatic encephalopathy presenting to our center had a final diagnosis of ALERD. The mean age at presentation was 34.9 months (6-80 months) and 63.6% were males. The monophasic course (72.7%) and the diffuse pattern (63.6%) on neuroimaging were predominant in these children. Dengue haemorrhagic fever was the commonest underlying/triggering infection (5 of 11 children). Ten children required mechanical ventilation in view of neurogenic respiratory failure, with mean duration of ventilation of 6.4 days (Range 2-10 days). The duration of hospital stay varied from 11 to 25 days (Mean - 15.3 days). One child (9 %) died, 6 children (54.5 %) had varying degrees of cognitive impairment and 4 (36.3 %) children had a normal outcome. Children with a shorter duration of ventilation seemed to have a better outcome. Dengue haemorrhagic fever was the commonest cause, and diffuse imaging pattern with monophasic course was the commonest presentation in Indian children with ALERD. The clinical presentation and factors influencing outcome are possibly different from previously described literature.

CHANGES IN SUPERIOR DISPLACEMENT, ANGULATION, AND SHORTENING IN THE EARLY PHASE OF HEALING FOR COMPLETELY DISPLACED MIDSHAFT CLAVICLE FRACTURES IN ADOLESCENTS: RESULTS FROM A PROSPECTIVE, MULTICENTER STUDY

Background:Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from non-operative to operative treatment. Whether this occurs in adolescent patients has not been well investigated.Purpose:The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing.Methods:This was an IRB approved multi-center study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients age 10-18 years treated at one of three tertiary care pediatric trauma centers were included; all of which had standardized imaging within 2 weeks of the date of injury and throughout the course of healing (5-20 weeks post-injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment were noted, as well as the subsequent need for surgical intervention. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement.Results:One hundred patients met the inclusion criteria. The mean shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks post-injury, the fracture alignment improved across all three measurements for the overall cohort, with mean improvements in shortening of 15%, superior displacement of 15%, and angulation of 21% (Figures 1,2,3) Using a clinical threshold of a change in shortening or displacement of 10 mm or angulation of 10 degrees, 21% of fractures improved, 4% worsened, and 75% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than less displaced fractures (p<0.001). No patient underwent surgical intervention for progressive displacement.Conclusions:Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, a 20% improvement in shortening and 50% improvement in angulation was identified. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.Figures:Figure 1.Figure 2.Figure 3.

#39: An 11-year Review of Lactobacillus Bacteremia at a Pediatric Tertiary Care Center

Abstract Background Probiotics are used frequently in the pediatric population for treatment of diarrhea and promotion of gastrointestinal health. Lactobacillus is the most commonly used bacterial genus in probiotic formulations. Lactobacillus spp. has been a reported cause of bacteremia, particularly in immunocompromised populations and individuals with impaired gut integrity. To assess the risks and benefits of inpatient probiotic use in a pediatric tertiary care center, we aimed to identify the occurrence of Lactobacillus bacteremia among hospitalized patients and its association with probiotic use over an eleven-year period. Methods Cases of Lactobacillus bacteremia were identified through a search of positive blood culture reports from January 1st, 2010 through December 31st, 2020. The clinical chart for each case was independently reviewed for the following risk factors: documented probiotic uses, presence of a central venous catheter, immunocompromising condition or immunosuppressive agent, neutropenia, impaired intestinal function and age below 3 months. Additionally, we reviewed the clinical presentation including presence of fever, need for intensive care and gastrointestinal symptoms. Total inpatient probiotic administration was assessed over the same time period. Results Eight cases of Lactobacillus bacteremia were identified in inpatients during the study time period. Two cases had received probiotics in the hospital and a third case had documented outpatient administration of probiotics prior to development of bacteremia. The remaining five cases had no documented probiotic use. All 8 cases were febrile at the time of bacteremia. No patients required blood pressure support medications. Five cases had underlying impaired intestinal function. One case was in an oncology patient and there were no cases in solid organ or bone marrow transplant patients. Two cases, including the oncology patient and one patient with impaired intestinal function, were neutropenic at the time of bacteremia. All but one case, had a central line in place. All cases were treated with antibiotics and had resolution of bacteremia and associated symptoms. Probiotics were administered to 4,478 inpatients during the study period. Conclusions Lactobacillus bacteremia is uncommon and occurred in under 0.2% of patients who received probiotics during an inpatient admission. Nevertheless, all eight observed cases were symptomatic and received antibiotic therapy. Additionally, cases were most commonly seen in individuals with underlying impaired intestinal function. These considerations must be weighed in decisions regarding the risks and benefits of probiotic administration in the hospital.

The parental experience and perceptions of blenderized tube feeding for children with medical complexity.

ObjectivesParents of children with medical complexity are often expected to implement complicated plans of care, such as enteral tube feeding, to support the health of their child. Enteral feeding can have psychosocial implications for the parent, child, and family. Blenderized tube feeding (BTF) refers to the administration of pureed food and drinks through a feeding tube. Little is known regarding parents’ experiences with BTF. Therefore, the purpose of this qualitative study was to understand the lived experience of BTF from the parent’s perspective.MethodsThis qualitative study was a grounded theory analysis utilizing semi-structured interviews of parents who provided at least 50% of their child’s diet through BTF. Participants were recruited using purposive sampling from the Complex Care Program at a tertiary care paediatric centre. Interviews were conducted until thematic saturation was achieved. Themes were identified using constant comparative analysis of transcribed interviews.ResultsParents (n=10) felt that BTF positively affected the experience of tube feeding and enhanced their child’s health and wellbeing. Parents described BTF as a means of self-empowerment and a mechanism to normalize feeding and care for the entire family. Despite reporting BTF as more time consuming than formula feeding, all parents were satisfied with having made the change, and planned on continuing the diet.ConclusionBTFs can improve the experience of tube feeding and positively address some of the negative psychosocial implications of enteral tube feeding, providing a sense of normalcy and control for parents caring for a child with medical complexity.

Central Venous Catheters, a Major Culprit for Pediatric Venous Thrombosis: A Report from the Children's Hospital Acquired Thrombosis (CHAT) Project

Introduction: Incidence of venous thromboembolism (VTE), a potentially life-threatening condition, has increased in hospitalized pediatric patients by over 70% in the last decade leading to increased morbidity, mortality, and longer hospitalizations. In contrast to standardized thromboprophylaxis interventions for hospitalized adults, routine implementation of VTE prevention strategies have not been established in children. To develop a risk-prediction model for pediatric hospital-acquired VTE (HA-VTE) and identify a high-risk group in need of thromboprophylaxis, an observational case-cohort study was created, using the multi-institutional Children's Hospital Acquired Thrombosis (CHAT) Registry. Preliminary CHAT data confirm prior reports that central venous catheters (CVCs) are the greatest risk factor for pediatric HA-VTE. We describe clinical and CVC characteristics for Registry subjects with a CVC-related HA-VTE.Methods: An institutional review board-approved, multi-center CHAT Registry was created for this project to collect retrospective clinical and laboratory data on hospitalized subjects age 0-21 years diagnosed with imaging-confirmed HA-VTE, along with admission year matched controls. Seven hundred and fifty HA-VTE subjects hospitalized since January 1, 2012 are included in the Registry. Data include demographics (age and past medical history); hospital course (duration, infection, mobility, surgeries, trauma, etc.); VTE specifics (location, symptoms, treatment, prophylaxis); CVC details (type, brand, lumen number, duration, infection history); and pertinent laboratory data (thrombophilia and coagulation testing). Pertinent CVC related data were selected for analysis.Results: To date, 658 subjects with HA-VTE have been entered into the CHAT Registry from 01/01/12 to 07/01/2017 from five pediatric tertiary care centers. CVC-VTE was identified in 486 (74%) subjects. Most subjects with a CVC-VTE were male (58%) and the median age at diagnosis was 2 years (IQR 0.3-12.7). Infants <1 year of age accounted for 214 (44%) of CVC-VTE cases (Figure 1). In contrast, subjects diagnosed with a non-CVC-related VTE had a median age of 5 years (IQR 0.3-13.3) at diagnosis, with only 45 (29%) being <1 year. The average time from CVC placement to VTE diagnosis was 23 days. Time from femoral line placement to VTE was 7 days, peripherally inserted central catheters (PICC) placement to VTE was 16 days and tunneled line to VTE was 114 days. Mean hospital length of stay was 48 days for those diagnosed with a CVC-VTE.Subjects with PICCs made up 62% (310) of the CVC-VTE cases and 19% (95) were in subjects with femoral catheters (Figure 2). The majority of CVC-VTEs, 336 (67%), were with multi-lumen CVCs.Upper extremity CVCs were placed in 271 (54%) cases and 203 (41%) were in the lower extremity. The remaining 26 (5%) had CVCs in the umbilical vein or were unknown. CVC's were found to have a malfunction (damage to the line, fibrin sheath, medication precipitation or other blockage) prior to VTE diagnosis in 122 cases (24%), and tissue plasminogen activator (tPA) was used in 91 (75%) cases of malfunction.Conclusions: CVCs are a prominent risk factor for pediatric HA-VTE, yet a paucity of evidence exists to guide clinicians toward strategies to decrease pediatric CVC-VTE. Our preliminary analysis has shown the majority of subjects with a CVC-related HA-VTE were male, had a PICC, and almost half were less than 1 year of age. Subjects also tended to have multi-lumen CVCs placed in the upper extremity. This novel analysis of specific CVC characteristics in CVC-related HA-VTE among hospitalized patients from the CHAT Registry represents a first step in determining the true risk factors for CVC-related VTE in children.Once all control subjects are entered a more robust analysis of risk factors will be performed and a VTE risk prediction model will be created and prospectively validated for HA-VTE, including a specific CVC-related VTE model. This information will be essential for future risk-prediction models of pediatric HA-VTE that may guide randomized control trials to evaluate safety and efficacy of various thromboprophylaxis strategies in this population. [Display omitted] DisclosuresJaffray:CSL Behring: Consultancy; Bayer: Consultancy, Speakers Bureau. Croteau:ATHN/Hemophilia of Georgia: Research Funding; Aptevo, Baxalta/Shire, Bayer, CSL Behring, Genentech, Novo Nordisk, Octapharma, Pfizer: Consultancy; Octapharma: Honoraria; Baxalta, Dimension Therapeutics, Genentech, Pfizer: Research Funding. Silvey:Pfizer, CSL Behring, Octapharma: Consultancy. Young:Novo Nordisk: Consultancy; CSL Behring: Honoraria.

Temporary Screw Lateral Hemiepiphysiodesis of the First Metatarsal for Juvenile Hallux Valgus Deformity: A Case Series of 23 Feet

Juvenile hallux valgus (JHV) can limit the quality of life of the affected children. This study aims to evaluate the outcomes of temporary screw lateral hemiepiphysiodesis of the base of the first metatarsal. A chart review of patients who underwent temporary screw lateral hemiepiphysiodesis of the first metatarsal at a tertiary care pediatric orthopedic center was done. A total of 23 feet of 14 patients were included. The mean age of the patients was 10.6 ± 1.8 years, while the bone age was 11.1 ± 1.8 years. The mean follow-up duration was 24.7 ± 13.4 months (range: 12-60 months). The hallux valgus angle (HVA) improved from a mean of 30.9° ± 6.7° to a mean of 27.6° ± 8.2° (p = .001), while the intermetatarsal angle (IMA) improved from a mean of 14.6° ± 2.3° to a mean of 12.5° ± 3.0° (p < .001). Revision surgery was done for 5 (21.7%) feet of 3 patients for symptomatic uncorrected deformity (4 feet) or screw migration due to bone growth (1 foot). The mean HVA correction was 5.00° ± 3.7° in patients with bone age of 12 years or less compared to 1.50° ± 4.6° in patients with bone age of more than 12 years (p = .060). The radiological outcomes of temporary screw lateral hemiepiphysiodesis of the first metatarsal for JHV deformity correction are promising, especially in children with lesser bone age. The procedure was technically simple to perform and had minor complications.

Identification of Multisystem Inflammatory Syndrome in Children Classes and Development of Hyperinflammation Score in Pediatric COVID-19.

The aim of this study is to describe characteristics and hospital course of children admitted with COVID-19 to a tertiary care pediatric center in Southeastern United States, and to present the frequency of three classes of multisystem inflammatory syndrome in children (MIS-C) and develop pediatric COVID-19 associated hyperinflammation score (PcHIS). A retrospective cohort study of 68 children was performed. Critical illness was defined as any child requiring respiratory or cardiovascular support or renal replacement therapy. PcHIS was developed by using six variables: fever, hematological dysfunction, coagulopathy, hepatic injury, macrophage activation, and cytokinemia. Centers for Disease Control and Prevention criteria were used to identify MIS-C, and three classes of MIS-C were identified based on the findings of recently published latent class analysis (Class 1: MIS-C without Kawasaki like disease, Class 2: MIS-C with respiratory disease, and Class 3: MIS-C with Kawasaki like disease). The median age was 6.4 years. Fever, respiratory, and gastrointestinal were common presenting symptoms. MIS-C was present in 32 (47%), critical COVID-19 illness in 11 (16%), and 17 (25%) were admitted to the PICU. Children with critical illness were adolescents with elevated body mass index and premorbid conditions. PcHIS score of 3 had a sensitivity of 100% and a specificity of 77% for predicting critical COVID-19 illness. Among MIS-C patients, 15 (47%) were in Class 1, 8 (25%) were in Class 2, and 9 (28%) were in Class 3. We conclude that most children with COVID-19 have mild-to-moderate illness. Critical COVID-19 is mainly seen in obese adolescents with premorbid conditions. Three Classes of MIS-C are identifiable based on clinical features. Validation and clinical implication of inflammation score in pediatric COVID-19 need further investigation.

908-P: A Self-Assessment: Understanding Perceptions of New-Onset Type 1 Diabetes (T1D) Education in a Pediatric Tertiary Care Center

Youth newly diagnosed with T1D, and their families, require intensive education on management of this chronic condition. Traditionally, our center has conducted many hours of in-person training during a hospital admission. We studied family perceptions of our education method in an effort to elucidate strategies to augment education in the pandemic environment, where provider time in the room and visitation rules may limit face to face encounters. Eligible patients were ≤18y and diagnosed with T1D between 8/2019-11/2020. A request to complete an online questionnaire was sent to 66 patients, with 21% responding, to date. A 5-point Likert scale assessed attitudes towards education. Fourteen families completed the survey. Mean age at diagnosis was 9.5 ± 4.2 y with diabetes duration ranging from 2-57 weeks. Most (n=12) have been followed out to 6-months post-diagnosis with 17% using pumps and 92% using sensors. Almost all participants reported being satisfied with new onset education (Table). Current strategies utilized to educate families of youth newly diagnosed with T1D are well received by primary caregivers. Additional strategies are needed in educating families on sick day management and on how to train secondary caregivers. Based on these results we have developed video content as an adjunct to training and are evaluating the impact of this strategy on family perceptions. Disclosure G. Betancur: None. M. N. Brei: None. K. Weyman: None. L. R. Carria: None. K. R. Stephenson: None. M. A. Van name: None. J. Sherr: Advisory Panel; Self; Cecelia Health, Insulet Corporation, Medtronic, Consultant; Self; Insulet Corporation, Lexicon Pharmaceuticals, Inc., Lilly Diabetes, Medtronic, Research Support; Self; Dexcom, Inc., Insulet Corporation, Medtronic, Speaker’s Bureau; Self; Lilly Diabetes.

15-OR: The COVID-19 Pandemic and New-Onset Pediatric Type 2 Diabetes

Introduction: Reports are emerging about the impact of the COVID-19 pandemic on pediatric T1D, however few studies have explored pediatric T2D. We aimed to investigate changes in T2D initial clinical presentation and patient demographic characteristics during COVID-19. Methods: A retrospective cross-sectional review of youth diagnosed with T2D during the COVID-19 pandemic (3/11/2020-11/30/2020) and in the time matched period in 2019 was conducted at a pediatric tertiary care center. BMI Z-score (&amp;gt;1.64), age (&amp;gt;8) and the absence of DKA and autoantibodies at diabetes diagnosis (A1c &amp;gt;6.5%) were used to screen for T2D, with confirmation by chart review. Chi-square, Fisher’s exact, and independent samples t-tests were used for analyses. Results: During the pandemic, cases of T2D increased 233% from 2019 (n=36, Mage=14.1±2.6 years, 56% F) to 2020 (n=84, Mage=14.6±2.2 years, 42% F). Rates of new onset T2D increased as the pandemic continued, from 4-8 per month in April-June to 20 and 16 cases, respectively, in October and November. Only 3 youth were actively infected with COVID-19 at T2D diagnosis. Rates of DKA at diagnosis increased from 6% in 2019 to 21% in 2020 (p=0.03), with 6 cases of hyperosmolar DKA during the pandemic as compared to none in 2019. Before the pandemic, 53% of youth diagnosed with T2D were Black, compared to 77% during the pandemic (p=0.03). Similar increases were seen among those with public insurance, rising from 67% to 86% (p=0.02). Conclusions: Cases of T2D and severity of initial presentation increased during the first 9 months of the COVID-19 pandemic, particularly among Black and publicly insured youth. These findings align with prior reports highlighting the disproportionate impact of the COVID-19 pandemic on racial/ethnic and socioeconomically disadvantaged communities. As few youth were infected with COVID-19 at T2D diagnosis, pandemic-related social distancing measures may also have disproportionate impacts on these communities and serve to worsen pre-existing health disparities. Disclosure B. E. Marks: None. A. Khilnani: None. A. Meyers: None. D. E. Estrada: None. J. Boughton: None. J. Gai: None. R. Streisand: None. M. Monaghan: None.

Moving Toward a New Standard of Care for Acute Pediatric Stroke.

Acute pediatric stroke is growing in incidence with the longer survivorship of children with medical complexities, yet detection and treatment of this disease continues to be met with limitations. It is essential for the frontline provider to appropriately identify various presentations of acute pediatric stroke for timely management to occur. Although studies in thrombolytic and endovascular recanalization therapies are limited, the safety and efficacy of these treatments continues to be explored. As pediatric tertiary care centers improve their stroke management, it is increasingly important to implement hospital protocols with a multifaceted approach. This article summarizes the issues and presentations behind identifying acute pediatric stroke, the research behind these emerging therapies in children, and the process of successfully applying pediatric stroke protocols. [Pediatr Ann. 2021;50(6):e242-e244.].