Tertiary Referral Pediatric Hospital Research Articles

Burden of SARS-CoV-2 infection prior to vaccine eligibility among immunocompromised children aged 1-11years at a pediatric tertiary referral hospital in Toronto, Canada.

SARS-CoV-2 seroprevalence reflects the efficacy of pandemic infection prevention and control measures. We performed anti-spike IgG serological testing on residual sera of children 1-11years old at a tertiary care referral center between October and November 2021. Immunocompromised patients had the highest SARS-CoV-2 seroprevalence, at 40.5%, compared to 19.3% in non-immunocompromised patients. Targeted infection prevention and public health interventions are warranted for pediatric immunocompromised patients in future pandemics.

Modified by the Innovative Drugs and Strategies-Pattern of Selected Indications for Pediatric Liver Transplantation.

Liver transplantation (LTx) constitutes a major life-saving routine treatment for children with end-stage liver disease. However, the analysis of LTx registries in children provides much information about changes in the indication profiles in the recent years. The article provides a comprehensive review about the successes, hopes, and challenges related to changing indications for LTx in children based on the literature review and our own experience. Retrospective review of the indications for LTx at a tertiary referral pediatric hospital was also presented. In the context of the new therapies that have emerged, the need for LTx has decreased in patients with chronic hepatitis B and C infection and tyrosinemia type 1. In primary hyperoxaluria type 1, new RNAi-based therapy has eliminated the requirement for LTx (both isolated or combined). There is a hope that introduction of ileal bile acid transporter (IBAT) blockers reduces the need for LTx in patients with Alagille syndrome or progressive familial intrahepatic cholestasis. The number of children qualified for LTx with urea cycle disorders (UCDs) as a prophylaxis of neurodevelopmental impairment is increasing.

The risk of under-nutrition in hospitalised Malaysian children: Use of 3-minute nutrition screening-paediatrics (Paediatric 3-MinNS).

To evaluate the under-nutrition risk of children admitted to hospitals using a validated tool. The cross-sectional study was conducted from September 2017 to June 2018 in the paediatrics wards of a tertiary referral paediatric government hospital, a tertiary teaching hospital and a government district hospital in Malaysia. The sample comprised paediatric patients aged 2-12 years within 24-72 hours of hospital admission. Data was collected using the 3-Minute Nutrition Screening-Paediatrics tool. Data was analysed using SPSS 20. Of the 341 patients screened, 284(83.3%) were included; 170(59.9%) boys and 114(40.1%) girls. The overall median age was 4.85 years (interquartile range: 4.33 years). The median length of hospital stay was 3 days (interquartile range: 3 days). There were 72(25.4%) participants at high under-nutrition risk, with the highest proportion being at the district government hospital 31(33%). Among those with high risk, 5.4% subjects had severe acute malnutrition, 9.7% had severe chronic malnutrition, and 11.1% had severe thinness. The 3-Minute Nutrition Screening-Paediatrics scale was found to be effective as a nutrition screening tool for hospitalised children in Malaysia.

Molecular epidemiology and antimicrobial resistance in Clostridioides difficile strains isolated from children and adolescents in a tertiary referral pediatric hospital in Fortaleza, Brazil

BackgroundC. difficile has been increasingly reported as a cause of gastrointestinal disease in children, ranging from mild self-limiting diarrhea to severe conditions such as pseudomembranous colitis and toxic megacolon. Only two pediatric research groups reported the presence of C. difficile infection in Brazilian children, but no previous research has examined C. difficile infection among children in northeastern Brazil. This prospective cross-sectional study investigated the molecular epidemiology and antimicrobial resistance of C. difficile strains isolated from children and adolescents with diarrhea referred to a tertiary pediatric hospital in Brazil while exploring the associated risk factors. ResultsToxin positivity or C. difficile isolation was found in 30.4 % (17/56) samples. C. difficile was isolated from 35 % (6/17) samples. Four toxigenic strains were identified (tpi+, tcdA+, tcdB+, cdtB-, without tcdC deletions) belonging to PCR ribotypes and PFGE-pulsotypes: 046 (new pulsotype 1174), 106 (NAP11), 002 (new pulsotype 1274), 012 (new pulsotype NML-1235). Two of the six isolates belonging to ribotypes 143 and 133 were non-toxigenic. All toxigenic strains were sensitive to metronidazole and vancomycin. Regarding the clinical manifestation, diarrhea lasted an average of 11 days, ranging from 3 to 50 days and was often associated with mucus and/or blood. All six patients from whom the C. difficile was isolated had a chronic disease diagnosis, with these comorbidities as the main risk factors. ConclusionOur study enhances our understanding of the present epidemiological landscape of C. difficile-associated diarrhea (CDI) among children in northeastern Brazil, reveling a substantial CDI frequency of 30.4 %, with toxigenic strains detected in 76.4 % of cases, highlighting a higher prevalence compared to earlier Brazilian studies. In the globalized world, an understanding of disease-generating strains, the associated risk factors, clinical manifestation, and antimicrobial sensitivity has fundamental epidemiological importance and draws attention to preventive measures, allowing for more decisive action.

Minimally-invasive airway management and early cleft palate repair in infants born with Robin sequence

The objective of this study was to report outcomes of early cleft palate repair in infants born with Robin sequence (RS). A retrospective case series in a tertiary referral paediatric hospital was carried out, examining a consecutive series of 69 infants born with RS and cleft palate. A minimally invasive approach was taken to upper airway obstruction, with liberal nasopharyngeal airway (NPA) and non-invasive ventilation (NIV) use, guided by sleep studies. The palate was repaired between 6 and 9 months with a modified Malek technique. The most frequently used airway adjunct (59.4% of patients) was an NPA and the median duration of use was 5.6 months. All patients underwent a modified Malek cleft palate repair at a median of 7 months of age. Overnight oximetry demonstrated higher mean oxygen saturation (SpO2) across the group from initial neonatal admission to discharge (median 96.5% (interquartile range [IQR] 95–98%) vs 97.45% (IQR 96.5–98%) (P = 0.2, N = 34). Of those with a cardiorespiratory polysomnogram, the obstructive apnoea-hypopnea index (OAHI) was significantly lower postoperatively (5.9 vs 2.8, P = 0.028). This study supports the use of non-surgical airway strategies and early cleft palate repair in infants born with RS and cleft palate.

Retinoblastoma in Ceara: An epidemiological study in a Brazilian pediatric oncology referral center.

Although Brazil has a high prevalence of retinoblastoma, there is a lack of epidemiological data on the disease. Thus, in this study, we aimed to evaluate the epidemiological profile of patients diagnosed with retinoblastoma in the ophthalmology department of a pediatric tertiary referral hospital in Ceara, Brazil. A descriptive and cross-sectional study was conducted by retrospectively analyzing the clinical and socioeconomic data from the medical records of pediatric patients followed-up at the hospital between 2007 and 2021. Retinoblastoma was diagnosed on the basis of a fundoscopic or histopathologic examination. The data of 105 patients were included in the study, and the mean patient age at the time of diagnosis was 1.7 years. Most of the patients were women (50.5%) and hailed from rural areas (57.4%), which was associated with a higher tumor stage. Of the 150 patients, 57.1% initially presented with leukocoria. Ocular hyperemia was associated with more advanced stages of retinoblastoma (p=0.004). Bilateral involvement was observed in 25.7% of the patients and at a significantly younger age (p=0.009). The presence of retinal detachment, vascularized lesions, and vitreous seeds significantly increased the likelihood of requiring enucleation. This study presents an epidemiological description of retinoblastoma in Brazil, which highlights the significance of early detection. Delayed diagnosis is associated with a poorer visual prognosis and higher mortality rate, particularly in patients with unilateral disease. Risk factors for a more severe disease were retinal detachment, vascularized lesions, and vitreous seeds. The correlation between histopathological features and clinical outcomes was limited. Further studies are required to assess the influence of ocular hyperemia, fundoscopic assessment, and histopathologic findings on the prognosis of retinoblastoma. Moreover, it is critical to devise interventions to reduce the time-to-diagnosis in rural areas.

A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis

ObjectivesImage-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis. MethodsPatients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed. ResultsOf eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage. ConclusionUltrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital.

International practice regarding the method used to nonoperatively reduce pediatric intussusception is variable. To provide an overview of ultrasound-guided pneumatic intussusception reduction and assess its safety and effectiveness. A single-center prospective study was conducted in a tertiary referral pediatric hospital during the 15-year period between January 2008 and February 2023. All patients with ileocolic intussusception underwent abdominal sonographic examination for diagnosis. An ultrasound-guided pneumatic reduction of intussusception was then attempted. Children who were hemodynamically unstable, with signs of peritonitis or bowel perforation and those with sonographically detected pathologic lead points were excluded. A total of 131 children (age range 2months to 6years) were enrolled in this study. Pneumatic intussusception reduction was successful in 128 patients (overall success rate 97.7%). In 117 patients, the intussusception was reduced on the first attempt and in the remaining on the second. In three cases, after three consecutive attempts, the intussusception was only partially reduced. As subsequently surgically proven, two of them were idiopathic and the third was secondary to an ileal polyp. No bowel perforation occurred during the reduction attempts. There was recurrence of intussusception in three patients within 24h after initial reduction which were again reduced by the same method. Ultrasound-guided pneumatic intussusception reduction is a well-tolerated, simple, safe and effective technique with a high success rate, no complications and no ionizing radiation exposure. It may be adopted as the first-line nonsurgical treatment of pediatric intussusception.

Evolving microbial patterns of acute mastoiditis in pediatric patients undergoing mastoidectomy.

To investigate the microbial patterns and clinical outcomes of pediatric patients undergoing mastoidectomy for acute coalescent mastoiditis and to identify factors associated with poor outcomes and/or prolonged treatment. Monocentric retrospective cohort study. Tertiary referral pediatric hospital in Indiana. By cross-referencing database data from the Pediatric Health Information System (PHIS) querying for all inpatient stays (patients younger than eighteen) with a diagnostic code of mastoiditis between January 1st, 2010 and August 31, 2019, and the electronic health record (Cerner) for Riley Hospital for Children, 46 patients with mastoidectomy were included. A two-tailed T-test was used to evaluate continuous parametric data. Statistical significance was determined as P<0.05. For continuous variables, data was analyzed using continuous logistic regression. A criteria of p>0.1 was used for inclusion in the multivariate regression. Inclusion criteria was met by 46 patients. From 2010 to 2019, S. pyogenes and S. pneumoniae were the most common bacteria, each isolated in 11 of 42 bacterial isolates (26.2%). There was no growth in 35.4% (17/48) of intra-operative wound cultures. On univariate analysis, patients with negative cultures had longer length of hospital stay (LOS) (7.7 days [6.5] vs. 4.3 [2.8]; p=0.018) as well as higher rates of PICC (peripherally inserted central catheter) placement (53.3% vs. 19.4%; p=0.021). There was a statistically significant difference in terms of gender (p=0.021), with 15 males and 16 females in the positive culture cohort and 13 males and 2 females in the negative culture cohort. On multivariate analysis, which included gender, PICC placement, both intracranial and extracranial complications, duration of antibiotics, and LOS, female gender was the only significant predictor of positive culture status (p=0.039). S. pyogenes and S. pneumoniae were the predominant etiologic agents in acute coalescent mastoiditis between 2010 and 2019, and negative wound cultures were associated with worse clinical outcomes.

Use of bi-caval cannulae for veno-venous ECMO in neonates and children

PurposeVeno-arterial ECMO remains the most common mode of extracorporeal support in infants and children, and despite increases in overall ECMO numbers the utilisation of veno-venous ECMO in neonates appears to be decreasing. We report here outcomes of neonatal and paediatric patients managed with veno-venous ECMO via bi-caval cannulae over a 10-year period in a tertiary referral ICU.MethodsRetrospective single-centre case series of veno-venous ECMO cases using dual lumen cannulae over a 10-year period at a tertiary referral paediatric hospital with a low volume ECMO program.ResultsIn the 10-year period 2013–2022, 33 patients required ECMO with 23 receiving veno-arterial ECMO and 10 managed with veno-venous cannulation - 8 with bi-caval cannulae and 2 with multi-site cannulation. Overall survival was 23/33 (69.6%) and in the veno-venous group survival was 7/10 (70%). Median oxygenation index prior to veno-venous cannulation in the 8 patients undergoing bi-caval cannulation was 48 (range 34–54) and median PaO2 was 42 mmHg (range 34–59 mmHg). Duration of ECMO ranged from 7 to 14 days (median 9 days). Complications included migration of the cannula into the hepatic vein, minor and major bleeding, and compromised blood flow secondary to pneumomediastinum.ConclusionsVeno-venous ECMO can be reliably established via a single bi-caval cannula in the majority of patients. Outcomes in this small series from a low volume centre are broadly comparable to those reported from the ELSO database.

Association of body mass index with COVID-19 outcome in a pediatric tertiary referral hospital in Iran

BackgroundOne of the challenging risk factors for severe COVID-19 infection is obesity and high body mass index (BMI). In this study we assessed the association between BMI and outcomes of hospitalized pediatric patients with COVID-19 in Iran. MethodThis retrospective cross-sectional study was performed in the biggest referral pediatric hospital in Tehran from March 7 to August 17, 2020. All hospitalized children ≺18 years of age with laboratory-confirmed COVID-19 were included in the study. We evaluated the association of BMI with COVID-19 outcomes (death, severity of clinical course, oxygen therapy, intensive care unit [ICU] admission, ventilator requirement). The secondary objectives were investigating the association of gender, underlying comorbidity, and patient age with COVID-19 outcomes. The limits for obesity, overweight, and underweight were set at BMI >95 percentile, 85≤ BMI ≤ 95, and BMI<5 percentile, respectively. ResultsIn total, 189 confirmed pediatric cases of COVID-19 (0.1–17 years) with a mean age of 6.4 ± 4.7 years were included. Overall, 18.5% of the patients were obese and 33% were underweight. We found that BMI had no significant relation with COVID outcomes in pediatric cases but after subgrouping the participants, underlying comorbidities and lower BMI in previously ill children were independently associated with a poor clinical outcome of COVID-19. In addition, the previously ill children with higher BMI percentiles were at a relatively lower risk of ICU admission (95% CI: 0.971–0.998, OR: 0.98, p = 0.025) and better clinical course of COVID-19 (95% CI: 0.970–0.996, OR: 0.98, p = 0.009). The BMI percentile had a statistically significant direct relationship with age (Spearman correlation coefficient= 0.26, p<0.001). When we separated the children with underlying comorbidity, the BMI percentile was significantly lower (p<0.001) in comparison to the previously healthy children. ConclusionBased on our results, obesity is not related to COVID-19 outcomes in pediatric patients, but after controlling for confounding effects, underweight in children with underlying comorbidities was more likely to be associated with a poor prognosis of COVID-19.

Evaluating the efficacy of inhaled amikacin as an adjunct to intravenous combination therapy (ceftazidime and amikacin) in pediatric cystic fibrosis pulmonary exacerbation.

Background: Pseudomonas aeruginosa is the most common microorganism found in the sputum culture of Cystic fibrosis (CF) patients causing the pulmonary destruction. Aminoglycosides have a low diffuse rate from lipid membranes, and respiratory system secretions. Regarding the burden of pulmonary exacerbation caused by the pseudomonas aeruginosa in cystic fibrosis patients in the long term and the limited number of clinical trials focused on appropriate treatment strategies, the present study evaluated the concurrent inhaled and intravenous aminoglycoside antibiotics for pulmonary exacerbation caused by the pseudomonas aeruginosa as a safe and effective treatment in children. Method: This study was a blinded, randomized clinical trial phase conducted in a tertiary referral pediatric teaching hospital from May 2021 to May 2022. The patients were randomly allocated to receive intravenously administered ceftazidime and Amikacin alone or with inhaled Amikacin. Forced expiratory volume (FEV1), Amikacin via the level, kidney function tests, audiometry, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), hospital stay, and bacterial eradication rate were compared in two therapy groups. Results: the average FEV1 has increased by 47% in Neb + group compared to Neb- group following treatment. Hospital stay was lower in Neb + group. No renal toxicity or ototoxicity was observed in both therapy groups. Pseudomonas aeruginosa eradication rate Neb- and Neb + groups were 44% and 69%, respectively (p-value = 0.15). Conclusion: Concurrent inhaled and intravenous Amikacin is safe and effective to treat Pseudomonas aeruginosa exacerbation in CF patients. Moreover, co-delivery antibiotics' route treatment increased the eradication rate. Although not statistically significant, never the less, it is clinically relevant. The intervention reduced the length of hospitalization in this group. Clinical Trial Registration: clinicaltrials.gov, identifier [IRCT20120415009475N10].

Exploring the lived experience of families with a COVID-19 positive child: The journey from a critical grounded theory approach.

COVID-19 and associated public health policies have significantly disrupted the lives of both adults and children. Experiences of COVID-positive adults are well described but less is known about the experiences of families of children who receive a positive diagnosis, and the impact of public health policies on this experience. This study aimed to develop a framework to understand the lived experience of families with a child testing positive for COVID-19. We applied a qualitative study design, using grounded theory. The study took place in Melbourne, Australia between July and December 2020, during the first major Australian COVID-19 wave. Parents of children 0-18 years tested at a walk-in clinic at a paediatric tertiary referral hospital were invited to participate. Two interviewers jointly undertook in-depth interviews with parents of children who tested positive. Interviews were transcribed and two analysts used an inductive, critical realist analysis approach with NVivo and a virtual whiteboard. Results are presented incorporating a stratified reality (empirical, actual, real). Families described seven sequential stages of the COVID-19 positive testing journey: COVID-19 close to home; time to be tested; waiting for the test result; receiving the result; dealing with the diagnosis; coping with isolation; and moving forward/looking back. Our findings highlight how public health policies and messages targeting the general (adult) public were experienced by families. We provide a framework that families move through when their child tests positive for COVID-19. Within each phase, we report unmet needs and identify strategies to improve future pandemic planning for parents and children.

Drug self-poisoning in adolescents: A report of 267 cases.

The current study aims at describing a sample of adolescents admitted to a tertiary referral pediatric hospital for drug self-poisoning and to identify variables that could explain and predict a higher severity of intoxication. We retrospectively reviewed the cases of drug self-poisoning in adolescents admitted to the Bambino Gesù Children's Hospital between January 2014 and June 2022 requiring consultation by the local Pediatric Poison Control Center (PPCC). We reported the type and class of drug ingested and correlated the clinical characteristics of the patients with their Poison Severity Score. The data of 267 patients were reported. Most patients were female (85.8 %), with a median age of 15.8 years at presentation. Half of the patients were symptomatic at admission (44.2 %), and most had at least one psychiatric comorbidity (71.1 %). Most patients were hospitalized (79.6 %), 16.6 % of cases required antidote administration and a minority required intensive care. Most patients received a PSS score of 0 (59.6 %). The most frequently ingested drug was acetaminophen (28.1 %) followed by ibuprofen (10.1 %) and aripiprazole (10.1 %). Antipsychotics as a class were the most abused drugs (33.1 %). The correlation of clinical variables with the PSS showed that older and male patients were more prone to be severely intoxicated. This single-center study identifies the most commonly ingested drugs in a large sample of adolescents with voluntary drug self-poisoning, also showing that older and male patients are more susceptible to severe intoxication.

Incidence of Emergency Department Presentations of Symptomatic Stone Disease in Pediatric Patients: A Southeastern Study.

Background The incidence of nephrolithiasis during childhood has increased significantly over recent decades. Some studies indicate a rapid rise in adolescents, particularly in African American women. This study serves to identify trends in symptomatic pediatric nephrolithiasis presentations to the emergency department (ED) as a result of increasing incidence and to determine associations between demographic variables at our single-site tertiary pediatric hospital in the Southeast United States. Methods After IRB approval, a review of the data provided by the Pediatric Health Information System, a pediatric database that includes clinical and resource utilization data for 51 of the largest children's hospitals in the nation, yielded 644 pediatric occurrences of nephrolithiasis at single-site emergency departments from 2006 to 2020. The percent change and average percent change in three-year intervals were calculated to establish a trend over time. A chi-square test of independence was performed to assess associations between race, gender, and age groups. Results A total of 780 stone occurrences and associated patient demographic data were reviewed for 644 children (364, 56.52% female) with median age of 183 ± 45.11 months (9-397 months). Of the 644 children, 79 (12.3%) were noted to have recurrent symptomatic nephrolithiasis, contributing to 136/780 stone events. There was a marked increase of 84.4% in confirmed pediatric nephrolithiasis occurrences over 15 years, with an average percent increase of 16.1% every three years. A Chi2 test of independence was performed between gender and age group (>/< 10yr), gender and race, and race and age group. No expected cell frequencies were less than five. There is no statistically significant relationship between gender and age group, χ2 (1, N=644) = 3.30, p=0.692. There is no significant association between race (Caucasian vs. non-Caucasian) and age group (>/< 10yr), χ2 (1, N=644) = 0.393, p=0.531. There is a statistically significant relationship between gender and race (Caucasian vs. non-Caucasian), χ2 (1, N=644) = 5.28, p=0.021. Caucasian females were more likely to present to our tertiary pediatric hospital's emergency department with nephrolithiasis than Caucasian males or non-Caucasian males or females. Additionally, our data reflected a greater percentage of symptomatic nephrolithiasis presentations occurred in the second decade of life (85.4% vs 14.3%, 552 vs 92 stone events). Conclusion Based on our data, there is a marked increase of 84.4% in pediatric nephrolithiasis occurrences from 2006 to 2020, with a mean increase of 16.1% every three years at our single-site tertiary referral pediatric hospital in the Southeast. Among demographic groups, white adolescent females have an increased risk of developing kidney stones.

Clinical Characteristics and Complications of Mechanically Ventilated Children in a Pediatric Intensive Care Unit in Iran: Comparing Different Modes

Background: Mechanical ventilation (MV) is among the most common therapeutic modalities in pediatric intensive care units (PICU), which works based on a defined ventilation mode. Nowadays, conventional and alternative modes including adaptive pressure control (APC) and non-APC modes are frequently employed. Although MV can be helpful in many cases, it may cause some complications resulting in significant morbidity and mortality. Objectives: This study aimed to investigate the demographic features and complications of mechanically ventilated children in a PICU in Iran, as well as to compare different ventilation modes. Methods: A retrospective case-control study was conducted in PICUs of children’s medical center hospital - a tertiary referral pediatric hospital. Results: Of 66 patients included in this study, 33 patients were treated with APC modes, whereas 33 patients were treated with non-APC modes. The most common indications for intubation were respiratory failure (53%) and loss of consciousness (13.6%). The mean duration for intubation in patients with and without underlying disorder were 11.7 and 5.2 days, respectively (P-value &lt; 0.01). The means of time for intubation in the APC and non-APC groups were 10 and 11.9 days, respectively (P-value = 0.145). A total of 23 (34.8%) patients had complications, including death, misplacement of the endotracheal tube, atelectasis, unplanned extubation, etc. There was no significant difference between groups regarding the rates of complications, except for atelectasis. Thirteen (19.7%) patients had atelectasis (2 patients in APC group (6%) and 11 patients in non-APC group (33.3%)) (P-value = 0.022). The mortality rate was the same for the both groups (P-value = 1). Conclusions: In sum, the most common indication for intubation was respiratory failure. No significant difference was observed among patients treated with the APC, and non-APC modes in terms of the complications occurred, except for atelectasis which occurred more frequently in the non-APC group. Therefore, it was concluded that there was no difference between conventional and alternative modes of mechanical ventilation in terms of morbidity and mortality.

Pediatric central venous access devices: practice, performance, and costs

BackgroundHealthcare delivery is reliant on a functional central venous access device (CVAD), but the knowledge surrounding the burden of pediatric CVAD-associated harm is limited.MethodsA prospective cohort study at a tertiary-referral pediatric hospital in Australia. Children <18 years undergoing insertion of a CVAD were screened from the operating theatre and intensive care unit records, then assessed bi-weekly for up to 3 months. Outcomes were CVAD failure and complications, and associated healthcare costs (cost of complications).Results163 patients with 200 CVADs were recruited and followed for 6993 catheter days, with peripherally inserted central catheters most common (n = 119; 60%). CVAD failure occurred in 20% of devices (n = 30; 95% CI: 15–26), at an incidence rate (IR) of 5.72 per 1000 catheter days (95% CI: 4.09–7.78). CVAD complications were evident in 43% of all CVADs (n = 86; 95% CI: 36–50), at a rate of 12.29 per 1000 catheter days (95% CI: 9.84–15.16). CVAD failure costs were A$826 per episode, and A$165,372 per 1000 CVADs. Comparisons between current and recommended practice revealed inconsistent use of ultrasound guidance for insertion, sub-optimal tip-positioning, and appropriate device selection.ConclusionsCVAD complications and failures represent substantial burdens to children and healthcare. Future efforts need to focus on the inconsistent use of best practices.ImpactCurrent surveillance of central venous access device (CVAD) performance is likely under-estimating actual burden on pediatric patients and the healthcare system.CVAD failure due to complication was evident in 20% of CVADs. Costs associated with CVAD complications average at $2327 (AUD, 2020) per episode.Further investment in key diverse practice areas, including new CVAD types, CVAD pathology-based occlusion and dislodgment strategies, the appropriate use of device types, and tip-positioning technologies, will likely lead to extensive benefit.

Routine Catheter Lock Solutions in Pediatric Cancer Care: A Pilot Randomized Controlled Trial of Heparin vs Saline.

BackgroundCentral venous access devices (CVADs) are integral to cancer care provision. Despite the high prevalence of CVAD complications in children with cancer, preventative strategies are understudied.ObjectiveThe aim of this study was to assess study feasibility, occlusive events, thrombolytic use, adverse events, and direct costs of catheter lock solutions.MethodsA single-center, parallel-group, pilot randomized controlled trial was undertaken at a tertiary-referral pediatric hospital in Australia. Children 18 years or younger with an oncological or malignant hematological condition and a CVAD were eligible. Participants were 1:1 randomized to (1) normal or (2) heparinized (10–100 U/mL; CVAD-type dependent) saline lock solutions.ResultsOf 217 children assessed for eligibility, 61 were recruited and randomized to normal (n = 30; 3850 CVAD days) or heparinized (n = 31; 4036 CVAD days) saline. Eligibility (52%) and recruitment (54%) feasibility targets were not met. Protocol adherence was high (95% assessments), with no attrition. Parent/clinician satisfaction of interventions was high (median, 10/10 clinicians/parents). Complete CVAD occlusion occurred in heparin only (n = 2, 6.7% CVADs; incidence rate [IR], 0.49/1000 CVAD days [0.06–1.78]). Central venous access device partial occlusion was detected in 23.3% of CVADs in heparin (n = 7; IR, 2.73/1000 CVAD days [1.36–4.87]) and 13.8% of CVADs in normal saline (n = 4; IR, 2.59/1000 CVAD days [1.24–4.77]). Thrombolytic agents were used in 16.7% heparin (5 CVADs) and 3.5% normal saline (1 CVAD). Adverse events did not differ between groups.ConclusionMultisite randomized controlled trials examining CVAD locks are safe, but strategies and resources to increase recruitment and eligibility are required.Implications for PracticeBoth routine CVAD lock solutions seem safe but may not prevent all forms of CVAD-associated harm.

Fat soluble vitamin status in children on home parenteral nutrition in a tertiary paediatric intestinal rehabilitation unit.

Children with intestinal failure on home parenteral nutrition are at risk of fat malabsorption and fat soluble vitamin deficiency. Fish oil containing mixed lipid emulsions (SMOFlipid®) with higher vitamin E content, have a theoretical risk of exceeding current recommendations for vitamin E dosing and, may influence other fat soluble vitamin status in these children. The aim of this study was to assess for fat soluble vitamin status in children on long-term home parental nutrition receiving a mixed lipid emulsion (SMOFlipid®) compared with those receiving traditional soy or soy/olive oil based (non- SMOFlipid®) lipid emulsions and whether this is influenced by the underlying cause of intestinal failure. Retrospective longitudinal study in a tertiary referral paediatric hospital of children on home parental nutrition during the period January 2000 to June 2019. Data was retrieved using medical and pharmacy records, laboratory database, and summarised using inferential statistics. 111 patients (n=58 female) received home parental nutrition in 121 discrete episodes (range 45-5329 days). N=61 (55%) were diagnosed with anatomical short bowel syndrome, of which necrotising enterocolitis was the most common cause (n=14). SMOFlipid® was used exclusively in n=79 patients, non-SMOFlipid® exclusively in n=19, and n=13 changed from non-SMOFlipid® to SMOFlipid® during the study period. The median vitamin E level and vitamin E:lipid ratio were significantly higher for patients on SMOFlipid® compared to non-SMOFlipid® (27.9 vs 18.3μmol/L respectively, p<0.001; 7.10 vs 4.00μmol/mmol; p<0.001). Median vitamin A level was comparable (1.19 vs 1.12μmol/L, p=0.241), while median vitamin D level was significantly lower in the non-SMOFlipid® group consistent with mild deficiency (63.7 vs 43.0nmol/L, p<0.001). The use of SMOFlipid® correlated with higher Vitamin E level in paediatric home parental nutrition patients. Lower vitamin D level appears to correlate with the use of non-SMOFlipid®. A larger prospective cohort is required to delineate any clinical significance from these findings.

Retrospective study of postoperative mortality at a tertiary children's hospital in Iran: A cross sectional study

IntroductionAlthough mortality rates among children after surgery in developing countries are higher than in developed nations, little is known about the causes of post-operative pediatric death. Further insight into post-operative mortality rates and causes of death may help improve postoperative care. The present study investigates in-hospital mortality rates and causes of death at a major pediatric tertiary referral hospital in Iran. MethodsPatients younger than 18 years of age who underwent surgery with anesthesia between January 1, 2015 and Jan 1, 2018 at Dr. Sheikh Children's Hospital in Mashhad, Iran, were included in this retrospective study. Factors connected to the surgery and mortality rate were analyzed, including patient demographics and comorbidities, surgery type and emergency level, length of operation, and the mortality rate at different time intervals after surgery, were analyzed. ResultsA total of 55,027 surgeries were performed between 2015 and 2018, resulting in 214 deaths. Pediatric mortality within 30 days was 78.6 deaths per 10,000 procedures. The highest mortality rate was observed in children under three years of age (67.2 per 10,000), and females were more likely than males to die after an operation (52.8%). The most common comorbidity associated with postoperative death was cardiac disease(18.9%). There was a significant relationship between age and time interval between surgery and death showed (p < 0.0001), and type of surgery (p = 0.013) with the time interval between surgery and death. ConclusionThis study demonstrated that patient age and type of surgery were the main predictors of post-operative mortality. Study typePrognosis study. Level of evidenceLevel II.