Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation

The burden and contemporary epidemiology of sepsis in children

Sepsis is a dysregulated host response to infection that leads to life-threatening organ dysfunction. Half of the 50 million people affected by sepsis globally every year are neonates and children younger than 19 years. This burden on the paediatric population translates into a disproportionate impact on global child health in terms of years of life lost, morbidity, and lost opportunities for children to reach their developmental potential. This Series on paediatric sepsis presents the current state of diagnosis and treatment of sepsis in children, and maps the challenges in alleviating the burden on children, their families, and society. Drawing on diverse experience and multidisciplinary expertise, we offer a roadmap to improving outcomes for children with sepsis. This first paper of the Series is a narrative review of the burden of paediatric sepsis from low-income to high-income settings. Advances towards improved operationalisation of paediatric sepsis across all age groups have facilitated more standardised assessment of the Global Burden of Disease estimates of the impact of sepsis on child health, and these estimates are expected to gain further precision with the roll out of the new Phoenix criteria for sepsis. Sepsis remains one of the leading causes of childhood morbidity and mortality, with immense direct and indirect societal costs. Although substantial regional differences persist in relation to incidence, microbiological epidemiology, and outcomes, these cannot be explained by differences in income level alone. Recent insights into post-discharge sequelae after paediatric sepsis, ranging from late mortality and persistent neurodevelopmental impairment to reduced health-related quality of life, show how common post-sepsis syndrome is in children. Targeting sepsis as a key contributor to poor health outcomes in children is therefore an essential component of efforts to meet the Sustainable Development Goals.

Post-traumatic stress disorder in children after discharge from the pediatric intensive care unit: a scoping review

As the prevalence of post-traumatic stress disorder (PTSD) among children discharged from pediatric intensive care unit (PICU) continues to rise, corresponding research efforts have also increased. This scoping review aimed to review the PTSD prevalence, influencing factors, and tools used for PTSD measurements in children discharged from the PICU. This review employed the five-stage framework proposed by Arksey and O'Malley. The data sources included PubMed, Web of Science, Ovid, ScienceDirect, Springer, Scopus, CNKI, and WANFANG. Studies in English or Chinese published up to September 2023 were eligible for inclusion. The search yielded a total of 3536 results, with 31 articles meeting the inclusion criteria. The included studies reported that the prevalence of PTSD ranged from a minimum of 13% to a maximum of 84.6%. Risk factors for PTSD included medical interventions, child-related factors, and family environment. A total of 17 assessment tools for PTSD in PICU patients were reported. Given the significance of PTSD in this pediatric population, further attention, research, and intervention are warranted to help alleviate the burden of PTSD.

Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care

The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.

Follow-up after PICU discharge for patients with acquired brain injury: the role of an abbreviated neuropsychological evaluation and a return-to-school program

Objective

To present the results of an abbreviated testing protocol used to screen for neurocognitive and psychological sequelae of critical illness among pediatric intensive care unit (PICU) survivors with acquired brain injury in our post-discharge follow-up programs, and describe our process for facilitating this population's return to academic life.

Design

Retrospective cohort study.

Setting

Neurocritical care follow-up programs at two U.S. academic, tertiary medical/surgical PICUs.

Patients

Children age > 4 years enrolled in the neurocritical care follow-up programs (n=289) at these institutions who underwent neurocognitive and psychological testing between 2017-2021.

Interventions

None.

Measurements and Main Results

One month after discharge from the hospital, nearly half of the children and/or their parents (48%) in our neurocritical care follow-up programs identified some type of emotional or behavioral concern compared to their premorbid state, and 15% reported some type of cognitive concern. On evaluation, 35% of the children were given a new neurocognitive diagnosis. Neurocognitive domains regulated by the executive functioning system were the most commonly affected, including attention (54%), memory (31%) and processing speed (27%). One-quarter of the children were given a new psychological diagnosis, most commonly post-traumatic stress disorder (PTSD) or stress-related symptoms (12%). Over 80% of patients in the programs were given new recommendations for school, for both new academic services and new classroom accommodations. Over half of children (57%) were referred for comprehensive follow-up neuropsychological evaluation.

Conclusions

Abbreviated neurocognitive and psychological evaluation successfully identifies the same deficits commonly found among PICU survivors who undergo longer, more complete testing protocols. When combined with services aimed at successfully re-integrating PICU survivors back to school, this focused evaluation can provide an effective and efficient means of screening for cognitive and emotional deficits among PICU survivors, and establish a rationale for early academic support upon the child's return to school.

Abcc8 (sulfonylurea receptor-1) knockout mice exhibit reduced axonal injury, cytotoxic edema and cognitive dysfunction vs. wild-type in a cecal ligation and puncture model of sepsis

Sepsis-associated brain injury (SABI) is characterized by an acute deterioration of mental status resulting in cognitive impairment and acquisition of new and persistent functional limitations in sepsis survivors. Previously, we reported that septic mice had evidence of axonal injury, robust microglial activation, and cytotoxic edema in the cerebral cortex, thalamus, and hippocampus in the absence of blood-brain barrier disruption. A key conceptual advance in the field was identification of sulfonylurea receptor 1 (SUR1), a member of the adenosine triphosphate (ATP)-binding cassette protein superfamily, that associates with the transient receptor potential melastatin 4 (TRPM4) cation channel to play a crucial role in cerebral edema development. Therefore, we hypothesized that knockout (KO) of Abcc8 (Sur1 gene) is associated with a decrease in microglial activation, cerebral edema, and improved neurobehavioral outcomes in a murine cecal ligation and puncture (CLP) model of sepsis. Sepsis was induced in 4-6-week-old Abcc8 KO and wild-type (WT) littermate control male mice by CLP. We used immunohistochemistry to define neuropathology and microglial activation along with parallel studies using magnetic resonance imaging, focusing on cerebral edema on days 1 and 4 after CLP. Abcc8 KO mice exhibited a decrease in axonal injury and cytotoxic edema vs. WT on day 1. Abcc8 KO mice also had decreased microglial activation in the cerebral cortex vs. WT. These findings were associated with improved spatial memory on days 7-8 after CLP. Our study challenges a key concept in sepsis and suggests that brain injury may not occur merely as an extension of systemic inflammation. We advance the field further and demonstrate that deletion of the SUR1 gene ameliorates CNS pathobiology in sepsis including edema, axonal injury, neuroinflammation, and behavioral deficits. Benefits conferred by Abcc8 KO in the murine CLP model warrant studies of pharmacological Abcc8 inhibition as a new potential therapeutic strategy for SABI.

Impact of paediatric intensive care unit admission on neurocognitive function in children

Background

Advances in paediatric critical care have resulted in a reduction in mortality. This has shifted the focus to paediatric intensive care unit (PICU)-related morbidities and how to reduce or prevent them. In this study, we aimed to study the impact of paediatric intensive care unit (PICU) admission on neurocognitive performance.

Methods

Intelligence quotient (IQ) was tested in 50 children (27 boys, 23 girls; mean age 6.98 years) 3 months after PICU discharge and in 75 controls using the Stanford-Binet IQ test.

Results

There was no statistically significant difference between patients and controls with regard to IQ scores, and no difference between medical and surgical patients (p > 0.05). IQ was unaffected by sedation, blood transfusion, or blood product transfusion. Patients who underwent a major surgical procedure, needed inotropic support, and needed mechanical ventilation had non-significantly lower IQ scores than those who did not. A non-significant negative correlation was observed between the length of PICU stay, mechanical ventilation duration, sedative use, and inotropic support.

Conclusions

PICU admission does not appear to significantly affect cognitive outcomes in paediatric survivors.

Assessment of Long-term Psychological Outcomes After Pediatric Intensive Care Unit Admission: A Systematic Review and Meta-analysis

IMPORTANCE

The pediatric intensive care unit (PICU) exposes children to stressful experiences with potential long-term psychological repercussions. However, current understanding of post-PICU psychological outcomes is incomplete.

OBJECTIVE

To systematically review and evaluate reported long-term psychological outcomes among children previously admitted to the PICU.

DATA SOURCES

A systematic search of the Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE (PubMed), and PsycINFO was conducted from database inception to June 2021. Search terms included phrases related to intensive care (eg, intensive care units and critical care) and terms for psychological disorders (eg, posttraumatic stress disorder, depressive disorder, conduct disorder, and neurodevelopmental disorder) limited to the pediatric population.

STUDY SELECTION

This systematic review and meta-analysis included randomized clinical trials and observational studies reporting psychological disorders among children younger than 18 years who were admitted to the PICU with follow-up for at least 3 months. Psychological disorders were defined using the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Children were excluded if they were admitted to the PICU for primary brain conditions (eg, traumatic brain injury, meningoencephalitis, and brain tumors) or discharged to the home for palliative care.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were independently screened by 2 reviewers, with data extraction conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were pooled using a random-effects model during meta-analysis.

MAIN OUTCOMES AND MEASURES

Age-corrected IQ scores and long-term psychological outcomes measured by scales such as the Child Behavior Checklist (higher scores indicate more behavioral problems) among children admitted to the PICU.

RESULTS

Of 9193 records identified, 31 independent studies (5 randomized clinical trials and 26 observational studies) involving 7786 children (mean age, 7.3 years [95% CI, 6.2-8.4 years]; 4267 boys [54.8%]; race and ethnicity were not reported by all studies) admitted to the PICU were included. Overall, 1 of 19 children (5.3%) to 14 of 16 children (88.0%) previously admitted to the PICU were reported to have at least 1 psychological disorder. Studies that examined posttraumatic stress disorder reported that 6 of 60 children (10.0%) to 31 of 102 children (30.4%) met the diagnostic criteria for the disorder at 3 to 6 months of follow-up. Compared with healthy children, those admitted to the PICU had lower IQ scores at 1 to 2 years of follow-up (mean, 89.40 points [95% CI, 88.33-90.47 points] vs 100.70 points [95% CI, 99.43-101.97 points]; P < .001) and 3 to 5 years of follow-up (mean, 88.54 points [95% CI, 83.92-93.16 points] vs 103.18 [95% CI, 100.36-105.99 points]; P < .001) and greater total emotional and behavioral problems at 4 years of follow-up (mean, 51.69 points [95% CI, 50.37-53.01 points] vs 46.66 points [95% CI, 45.20-48.13 points]; P < .001).

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found a high burden of psychological sequelae among children previously admitted to the PICU, suggesting that risk stratification and early interventions are needed for high-risk groups.

Association of Acute Respiratory Failure in Early Childhood With Long-term Neurocognitive Outcomes

IMPORTANCE

Approximately 23 700 US children undergo invasive mechanical ventilation for acute respiratory failure annually, with unknown long-term effects on neurocognitive function.

OBJECTIVE

To evaluate neurocognitive outcomes of children who survive pediatric intensive care unit (PICU) hospitalization for acute respiratory failure compared with their biological siblings.

DESIGN, SETTING, AND PARTICIPANTS

Prospective sibling-matched cohort study conducted at 31 US PICUs and associated neuropsychology testing centers. Patients were 8 years or younger with a Pediatric Cerebral Performance Category score of 1 (normal) before PICU admission and less than or equal to 3 (no worse than moderate neurocognitive dysfunction) at PICU discharge, excluding patients with a history of neurocognitive deficits or who were readmitted and underwent mechanical ventilation. Biological siblings were aged 4 to 16 years at testing, with Pediatric Cerebral Performance Category score of 1 and no history of mechanical ventilation or general anesthesia. A total of 121 sibling pairs were enrolled from September 2, 2014, to December 13, 2017, and underwent neurocognitive testing starting March 14, 2015. The date of the final follow-up was November 6, 2018.

EXPOSURES

Critical illness and PICU treatment for acute respiratory failure.

MAIN OUTCOMES AND MEASURES

The primary outcome was IQ, estimated by the age-appropriate Vocabulary and Block Design subtests of the Wechsler Intelligence Scale. Secondary outcomes included measures of attention, processing speed, learning and memory, visuospatial skills, motor skills, language, and executive function. Evaluations occurred 3 to 8 years after hospital discharge.

RESULTS

Patients (n = 121; 55 [45%] female patients) underwent PICU care at a median (IQR) age of 1.0 (0.2-3.2) years, received a median (IQR) of 5.5 (3.1-7.7) days of invasive mechanical ventilation, and were tested at a median (IQR) age of 6.6 (5.4-9.1) years. Matched siblings (n = 121; 72 [60%] female siblings) were tested at a median (IQR) age of 8.4 (7.0-10.2) years. Patients had a lower mean estimated IQ than matched siblings (101.5 vs 104.3; mean difference, -2.8 [95% CI, -5.4 to -0.2]). Among secondary outcomes, patients had significantly lower scores than matched siblings on nonverbal memory (mean difference, -0.9 [95% CI, -1.6 to -0.3]), visuospatial skills (mean difference, -0.9 [95% CI, -1.8 to -0.1]), and fine motor control (mean difference, -3.1 [95% CI, -4.9 to -1.4]) and significantly higher scores on processing speed (mean difference, 4.4 [95% CI, 0.2-8.5]). There were no significant differences in the remaining secondary outcomes, including attention, verbal memory, expressive language, and executive function.

CONCLUSIONS AND RELEVANCE

Among children, survival of PICU hospitalization for respiratory failure and discharge without severe cognitive dysfunction was associated with significantly lower subsequent IQ scores compared with matched siblings. However, the magnitude of the difference was small and of uncertain clinical importance.

Cognitive Dysfunction After Analgesia and Sedation: Out of the Operating Room and Into the Pediatric Intensive Care Unit

In the midst of concerns for potential neurodevelopmental effects after surgical anesthesia, there is a growing awareness that children who require sedation during critical illness are susceptible to neurologic dysfunctions collectively termed pediatric post-intensive care syndrome, or PICS-p. In contrast to healthy children undergoing elective surgery, critically ill children are subject to inordinate neurologic stress or injury and need to be considered separately. Despite recognition of PICS-p, inconsistency in techniques and timing of post-discharge assessments continues to be a significant barrier to understanding the specific role of sedation in later cognitive dysfunction. Nonetheless, available pediatric studies that account for analgesia and sedation consistently identify sedative and opioid analgesic exposures as risk factors for both in-hospital delirium and post-discharge neurologic sequelae. Clinical observations are supported by animal models showing neuroinflammation, increased neuronal death, dysmyelination, and altered synaptic plasticity and neurotransmission. Additionally, intensive care sedation also contributes to sleep disruption, an important and overlooked variable during acute illness and post-discharge recovery. Because analgesia and sedation are potentially modifiable, understanding the underlying mechanisms could transform sedation strategies to improve outcomes. To move the needle on this, prospective clinical studies would benefit from cohesion with regard to datasets and core outcome assessments, including sleep quality. Analyses should also account for the wide range of diagnoses, heterogeneity of this population, and the dynamic nature of neurodevelopment in age cohorts. Much of the related preclinical evidence has been studied in comparatively brief anesthetic exposures in healthy animals during infancy and is not generalizable to critically ill children. Thus, complementary animal models that more accurately "reverse translate" critical illness paradigms and the effect of analgesia and sedation on neuropathology and functional outcomes are needed. This review explores the interactive role of sedatives and the neurologic vulnerability of critically ill children as it pertains to survivorship and functional outcomes, which is the next frontier in pediatric intensive care.

Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective

Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.

Outcomes following admission to paediatric intensive care: A systematic review

AIM

To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.

METHODS

A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.

RESULTS

One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.

CONCLUSIONS

There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.

Neurocognitive Functioning in Early School-age Children With Intestinal Failure

OBJECTIVES

Little is known about school-age functioning in children with intestinal failure (IF). This study examines neurocognitive outcomes of children with IF at ages 4 to 8 years treated at a single centre, along with relevant medical and demographic variables.

METHODS

Between 2012 and 2016, neurocognitive assessments were administered to 28 children receiving treatment in our IF rehabilitation program, and included measures of intelligence, academics, learning/memory, language, visual-motor integration, and fine-motor dexterity. DSM-IV/V criteria were used to diagnose Learning Disability, Intellectual Disability, and/or Attention Deficit/Hyperactivity Disorder.

RESULTS

Intellectual functioning ranged from extremely low to superior (Full Scale IQ range 53-123, mean = 89). Forty-six percentage received a cognitive/learning DSM diagnosis. Total number of first-year septic episodes correlated with poorer outcomes on the most cognitive measures. Adjusting for gestational age (61% were born <37 weeks), number of first-year septic episodes negatively predicted working memory, visual-motor integration, and visual memory scores. Additional factors correlating with poorer outcomes on ≥2 cognitive measures included length of first-year admissions, necrotizing enterocolitis diagnosis, and first-year sustained conjugated hyperbilirubinemia. Having ≥2 first-year septic episodes increased the likelihood of poorer outcome. Having a sibling was a significant positive predictor of working memory, processing speed, reading, and verbal learning skills.

CONCLUSIONS

Our data provides preliminary evidence that children with IF are at risk of neurocognitive problems at early school age. Managing septic events during the first year is one strategy that may help reduce long-term neurocognitive risks in this population.

The Life Course Health Development Model: A theoretical research framework for paediatric delirium

AIMS AND OBJECTIVES

To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium.

BACKGROUND

Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory.

DESIGN

Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed.

METHODS

The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change.

CONCLUSIONS

The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory.

RELEVANCE TO CLINICAL PRACTICE

By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.

Post-Intensive Care Syndrome: Educational Interventions for Parents of Hospitalized Children

BACKGROUND

Targeted education to help parents and caregivers recognize the signs and symptoms of post-intensive care syndrome may increase their awareness and willingness to seek support during their child's admission. The optimal strategy for this education has not been established.

METHODS

A pilot study to test 3 educational strategies for caregivers of pediatric intensive care unit patients. The 3 strategies were compared using the Practical, Robust Implementation and Sustainability Model framework for effectiveness of the education, the effect of each educational intervention on the intensive care unit nursing environment, and costs. Nursing responses were scored on a 3-point Likert scale.

RESULTS

A total of 62 caregivers randomly received 1 of 3 educational strategies: brochures (n = 22), scripted conversation (n = 20), or a 3-minute video (n = 20). All 3 strategies were associated with a notable improvement in understanding of post-intensive care syndrome, with no single strategy being superior. Nineteen bedside nurses completed a survey on how daily workflow was affected and education was perceived. The survey indicated that all 3 interventions minimally disrupted workflow and all were recognized as useful. Final analysis indicated that brochures have the greatest likelihood of successful and sustainable implementation in the study hospital.

CONCLUSION

Simple, low-cost education can improve caregivers' knowledge of post-intensive care syndrome and can be well supported by nursing staff. To ensure sustainable implementation, the characteristics of the unit should be considered when selecting an educational program.

Cognitive and Behavioral Consequences of Pediatric Delirium: A Pilot Study

OBJECTIVES

To investigate the long-term impact of postoperative delirium in children.

DESIGN

Single-center point prevalence study.

SETTING

Twenty-two bed PICU.

PATIENTS

Forty-seven patients 1-16 years old.

INTERVENTIONS

Standardized neuropsychologic follow-up investigation after a mean time of 17.7 ± 2.9 months after PICU discharge.

MEASUREMENTS AND MAIN RESULTS

Pediatric delirium did not have significant long-term impact on global cognition, executive functions, or behavior. Severity of delirium did not influence the outcome. Different predictors were identified for later cognitive functioning, executive functions, and behavioral problems. Younger age was confirmed to be a relevant risk factor for delirium as well as for the cognitive and behavioral outcome.

CONCLUSIONS

Contrary to the findings in adults, there was no clear association between pediatric delirium and long-term cognition or behavior in this cohort. However, this is a first pilot study with several limitations that should promote more comprehensive prospective trials.

Design and rationale of the "Sedation strategy and cognitive outcome after critical illness in early childhood" study

There is increasing concern that sedatives commonly used during critical illness may be neurotoxic during the period of early brain development. The Sedation strategy and cognitive outcome after critical illness in early childhood (RESTORE-cognition) study is a prospective cohort study designed to examine the relationships between sedative exposure during pediatric critical illness and long-term neurocognitive outcomes. We assess multiple domains of neurocognitive function 2.5-5 years post-hospital discharge, at a single time point and depending on participant and clinician availability, in up to 500 subjects who had normal baseline cognitive function, were aged 2 weeks to 8 years at pediatric intensive care unit admission, and were enrolled in a cluster randomized controlled trial of a sedation protocol (the RESTORE trial; U01 HL086622 and HL086649). In addition, to provide comparable data on an unexposed group with similar baseline biological characteristics and environment, we are studying matched, healthy siblings of RESTORE patients. Our goal is to increase understanding of the relationships between sedative exposure, critical illness, and long-term neurocognitive outcomes in infants and young children by studying these subjects 2.5 to 5 years after their index hospitalization. This paper highlights the design challenges in conducting comprehensive neurocognitive assessment procedures across a broad age span at multiple testing centers across the United States. Our approach, which includes building interprofessional teams and novel cohort retention strategies, may be of help in future longitudinal trials.

A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness

OBJECTIVES

To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness.

DATA SOURCES

For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017.

STUDY SELECTION

Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment.

DATA EXTRACTION

Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale.

DATA SYNTHESIS

Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications.

CONCLUSIONS

Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.

Psychological and Psychiatric Outcomes Following PICU Admission: A Systematic Review of Cohort Studies

OBJECTIVE

Admissions to PICU places pediatric patients at increased risk of persistent psychological and psychiatric morbidity. This systematic review aimed to summarize and critically examine literature regarding psychological and psychiatric outcomes of pediatric patients following PICU admission.

DATA SOURCES

MEDLINE, Web of Science, Cochrane Library, Science Direct, PsycInfo, CINAHL, LILACS, and SciELO were searched up to May 2016.

STUDY SELECTION

Cohort studies about psychological and psychiatric outcomes of pediatric patients following PICU admission; full-text records published in English, Spanish, or Portuguese in peer-reviewed journals from 2000 to 2015 were included. Neonatal patient population (age, <1 mo), follow-up after PICU discharge (<3 mo), and nonprimary literature were excluded. Two reviewers independently screened studies based on the predetermined exclusion criteria.

DATA EXTRACTION

Data were extracted using an adapted tool. The internal validity and risk of bias were assessed using Newcastle-Ottawa Scale.

DATA SYNTHESIS

The search yielded 1,825 studies after the removal of duplications, of which eight met the inclusion criteria. Methodologic quality of the studies ranged from low to high, with an average score of five of nine. Of all the studies, half had a control group. Regarding the length of follow-up, most of the studies ranged from 3 to 12 months.

CONCLUSIONS

Psychological and psychiatric outcomes after pediatric critical illness appear to be substantial issues that need to be further studied. Our review highlights the need for psychological screening of pediatric patients and their parents following PICU admission since these patients are a vulnerable population at risk for developing psychiatric responses.

Hippocampal-dependent memory deficit induced by perinatal exposure to polutted eels in middle-aged offspring mice: Sex differential effects

The effects of perinatal exposure to low, intermediate, or highly polluted eels on neonatal, postnatal, adult and middle-aged brain inflammation, and on cognitive performances of middle-aged offspring mice were compared to those of offspring controls. Inflammatory markers in microglia were assessed in offspring on the postnatal days-PNDs 1, 21, 100 and 330. Activated p38MAPK, ERK-1/2 and p65, and acetylcholine levels were assessed in the middle-aged hippocampus. Plasma myeloperoxidase and corticosterone levels were evaluated at PND 330. Learning and its retention, and working memory in middle-aged offspring were assessed using the Morris water maze, and Y-maze. Our results showed enhanced microglia production of inflammatory markers across the lifespan of male as well as female exposed offspring. Inflammation and increased p38 MAPK activation were detected in the exposed middle-aged hippocampus of both exposed sexes. Significant levels of MPO, but not corticosterone, were found in middle-aged males and females perinatally exposed to eels. However, decreases in ERK1/2 and p65 activation, and acetylcholine levels were only detected in female hippocampus exposed to either intermediately or highly polluted eels. Sex selective effects were also detected with regard to memory, the only altered cognitive function. Thus, middle-aged females, but not males, perinatally exposed to either intermediately or highly polluted eels take longer to locate the escape platform, spend considerably less time in the platform and perform less visit to the platform in the retention test. Our results suggest perinatal programming of hippocampal-dependent memory deficit by inflammation in middle-aged offspring, in sex and dose dependent manner.

Prolonged Hospital Discharge for Children with Technology Dependency: A Source of Health Care Disparities

Children with ventilator assistance have been supported in living at home since 1981 when parental advocacy ushered in a change to Medicaid policy. As the population of children who use medical technology such as long-term ventilation increases, we must critically evaluate our systems for preparing families for home life. Discharge delays persist in the modern era because of fragmentation between hospital and home systems. These discharge delays result in children spending time in less developmentally rich environments, further exacerbating the health and development disparities of children with complex disabilities. In this article, we discuss the complication of hospital discharge and how it contributes to health and developmental disparities. We also describe a hospital-to-home transitional care model, which presents a home-like environment to provide developmental support while focusing on parental training, home nursing, and public-funding arrangements. [Pediatr Ann. 2017;46(10):e365-e370.].

Delirium in the Critically Ill Child: Assessment and Sequelae

Delirium is a common and serious neuropsychiatric complication in critically ill patients of all ages. In the context of critical illness, delirium may emerge as a result of a cascade of underlying pathophysiologic mechanisms and signals organ failure of the brain. Awareness of the clinical importance of delirium in adults is growing as emerging research demonstrates that delirium represents a serious medical problem with significant sequelae. However, our understanding of delirium in children lags significantly behind the adult literature. In particular, our knowledge of how to assess delirium is complicated by challenges in recognizing symptoms of delirium in pediatric patients especially in critical and intensive care settings, and our understanding of its impact on acute and long-term functioning remains in its infancy. This paper focuses on (a) the challenges associated with assessing delirium in critically ill children, (b) the current literature on the outcomes of delirium including morbidity following discharge from PICU, and care-giver well-being, and (c) the importance of assessment in determining impact of delirium on outcome. Current evidence suggests that delirium is a diagnostic challenge for clinicians and may play a detrimental role in a child's recovery after discharge from the pediatric intensive care unit (PICU). Recommendations are proposed for how our knowledge and assessment of delirium in children could be improved.

High Frequency of Neuroimaging Abnormalities Among Pediatric Patients With Sepsis Who Undergo Neuroimaging

OBJECTIVES

This study was intended to describe and correlate the neuroimaging findings in pediatric patients after sepsis.

DESIGN

Retrospective chart review.

SETTING

Single tertiary care PICU.

PATIENTS

Patients admitted to Cincinnati Children's Hospital Medical Center with a discharge diagnosis of sepsis or septic shock between 2004 and 2013 were crossmatched with patients who underwent neuroimaging during the same time period.

INTERVENTIONS

All neuroimaging studies that occurred during or subsequent to a septic event were reviewed, and all new imaging findings were recorded and classified. As many patients experienced multiple septic events and/or had multiple neuroimaging studies after sepsis, our statistical analysis utilized the most recent or "final" imaging study available for each patient so that only brain imaging findings that persisted were included.

MEASUREMENTS AND MAIN RESULTS

A total of 389 children with sepsis and 1,705 concurrent or subsequent neuroimaging studies were included in the study. Median age at first septic event was 3.4 years (interquartile range, 0.7-11.5). Median time from first sepsis event to final neuroimaging was 157 days (interquartile range, 10-1,054). The most common indications for final imaging were follow-up (21%), altered mental status (18%), and fever/concern for infection (15%). Sixty-three percentage (n = 243) of final imaging studies demonstrated abnormal findings, the most common of which were volume loss (39%) and MRI signal and/or CT attenuation abnormalities (21%). On multivariable logistic regression, highest Pediatric Risk of Mortality score and presence of oncologic diagnosis/organ transplantation were independently associated with any abnormal final neuroimaging study findings (odds ratio, 1.032; p = 0.048 and odds ratio, 1.632; p = 0.041), although early timing of neuroimaging demonstrated a negative association (odds ratio, 0.606; p = 0.039). The most common abnormal finding of volume loss was independently associated with highest Pediatric Risk of Mortality score (odds ratio, 1.037; p = 0.016) and oncologic diagnosis/organ transplantation (odds ratio, 2.207; p = 0.001) and was negatively associated with early timing of neuroimaging (odds ratio, 0.575; p = 0.037).

CONCLUSIONS

The majority of pediatric patients with sepsis and concurrent or subsequent neuroimaging have abnormal neuroimaging findings. The implications of this high incidence for long-term neurologic outcomes and follow-up require further exploration.

Epidemiology and Outcomes of Pediatric Multiple Organ Dysfunction Syndrome

OBJECTIVE

To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by the relevant literature.

CONCLUSIONS

A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

Neurodevelopmental and Behavioral Outcomes in Children With Sepsis-Associated Encephalopathy Admitted to Pediatric Intensive Care Unit: A Prospective Case Control Study

The authors prospectively compared the neurodevelopmental and behavioral outcomes in 50 consecutive children with sepsis-associated encephalopathy admitted to intensive care unit with healthy controls. Children with sepsis-associated encephalopathy had significantly worse mean verbal IQ, full-scale IQ, General Development Score, and its physical, adaptive, social-emotional, cognitive, and communication subscales. Significant proportion of cases (52% vs 32% in controls) had low intelligence. Decline in school performance (44%), disobedience (28%), and stubbornness/irritable behavior (26%) were the most common behavior changes. Children with Glasgow Coma Scale score ≤10 and ≤8 had impairments in full-scale IQ even though overall Glasgow Coma Scale score did not show significant correlation with developmental outcomes. In conclusion, children with sepsis-associated encephalopathy have delayed neurodevelopment, low verbal IQ, decline in school performance and low intelligence at short-term follow-up. Irritability, shock and duration of sedation are associated with poor behavioral outcomes, especially scholastic performance.

Transforming PICU Culture to Facilitate Early Rehabilitation

Children who survive a critical illness are at risk of developing significant, long-lasting morbidities that may include neuromuscular weakness, cognitive impairments, and new mental health disorders. These morbidities, collectively known as post-intensive care syndrome (PICS), may lead to functional impairments, difficulty in school and social settings, and reduced quality of life. Interventions aimed at rehabilitation such as early mobilization, sedation minimization and prevention of ICU-acquired weakness, delirium, and posttraumatic stress disorder may lead to improved clinical outcomes and functional recovery in critically ill children. Acute rehabilitation is challenging to implement in a pediatric intensive care unit (PICU), and a culture change is needed to effect widespread transformation in this setting. Our objectives in this article are to review the evidence on PICS in children and strategies for affecting culture change to facilitate early rehabilitation in the PICU.

Psychological Aspects of Care of the Critically Ill Child

Recent improvements in mortality rates in pediatric intensive care have led to an increasing focus on the physical and psychological morbidity of pediatric patients. In this review, guidance on the acute psychological management of children, during and shortly after their intensive care treatment, is provided. This is informed by the current state of knowledge regarding the nature of children's experiences of intensive care and the expanding literature on their subsequent psychological symptoms. The relevance to pediatric settings of the current debate about the significance of delirium, and other recent research and guidance regarding the management of psychological issues in adult intensive care settings, is considered. The importance of distinguishing between children's self-report and parents' proxy report is also discussed in relation to establishing the causes of the child's distress in this situation and suggestions are made of ways to help children better understand what has happened to them.

Mental and physical well-being following admission to pediatric intensive care

OBJECTIVE

To assess mental and physical well-being in school-aged children following admission to pediatric intensive care and to examine risk factors for worse outcome.

DESIGN

A prospective cohort study.

SETTING

Two PICUs.

SUBJECTS

A consecutive sample of 88 patients 5-16 years old (median age, 10.00 yr; interquartile range, 6.00-13.00 yr) admitted to PICU from 2007 to 2010 with septic illness, meningoencephalitis, or other critical illnesses were assessed a median of 5 months following discharge and outcomes compared with 100 healthy controls.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Parents completed questionnaires documenting child mental and physical well-being, including the Strengths and Difficulties Questionnaires, Chalder Fatigue Scale, and Child Sleep Habits Questionnaire. Children over 8 years completed the Impact of Event Scale -8. The children admitted to PICU scored worse on all measures in comparison with the healthy controls, with 20% scoring at risk for psychiatric disorder, 34% with high levels of post-traumatic stress symptoms, 38% at risk for fatigue disorder, and 80% scoring at risk for sleep disturbance. In the PICU group, multivariable regression analyses identified septic illness as an independent predictor of post-traumatic stress symptoms and family status, past child health problems, and PICU length of stay as predictors of reduced general mental well-being.

CONCLUSIONS

Our findings indicate that a significant minority of school-aged children admitted to PICU are at risk for reduced mental and physical well-being in the short term. Symptoms of poor mental well-being were linked to both vulnerability factors and critical illness factors.

The outcomes of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To provide additional details and evidence behind the recommendations for outcomes assessment of patients with pediatric acute respiratory distress syndrome from the Pediatric Acute Lung Injury Consensus Conference.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The outcomes subgroup comprised four experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, seven of which related to outcomes after pediatric acute respiratory distress syndrome. All seven recommendations had strong agreement. Children with acute respiratory distress syndrome continue to have a high mortality, specifically, in relation to certain comorbidities and etiologies related to pediatric acute respiratory distress syndrome. Comorbid conditions, such as an immunocompromised state, increase the risk of mortality even further. Likewise, certain etiologies, such as non-pulmonary sepsis, also place children at a higher risk of mortality. Significant long-term effects were reported in adult survivors of acute respiratory distress syndrome: diminished lung function and exercise tolerance, reduced quality of life, and diminished neurocognitive function. Little knowledge of long-term outcomes exists in children who survive pediatric acute respiratory distress syndrome. Characterization of the longer term consequences of pediatric acute respiratory distress syndrome in children is vital to help identify opportunities for improved therapeutic and rehabilitative strategies that will lessen the long-term burden of pediatric acute respiratory distress syndrome and improve the quality of life in children.

CONCLUSIONS

The Consensus Conference developed pediatric-specific recommendations for pediatric acute respiratory distress syndrome regarding outcome measures and future research priorities. These recommendations are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Risk factors for acquiring functional and cognitive disabilities during admission to a PICU*

OBJECTIVE

To describe the risk factors for acquiring functional or cognitive disabilities during admission to a PICU.

DESIGN

Retrospective analysis of a multicenter PICU database.

SETTING

Twenty-four PICUs in the Virtual PICU Performance System network from January 1, 2009, through December 31, 2010.

PATIENTS

Consecutive patients, who are 1 month to 18 years old, who survived to discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were acquired global functional disability and cognitive disability during admission to a PICU, measured by change in Pediatric Overall Performance Category or in Pediatric Cerebral Performance Category scores, respectively. The primary analysis cohort consisted of 29,352 admissions to the 24 Virtual PICU Performance System sites which collected the main outcome variables. Respectively, 10.3% and 3.4% of the cohort acquired global functional or cognitive disability. Trauma diagnosis (odds ratio, 4.50; 95% CI, 3.83-5.29; odds ratio, 3.91; 95% CI, 3.07-4.98), unscheduled admission to the PICU (odds ratio, 2.67; 95% CI, 2.27-3.12; odds ratio, 1.52; 95% CI, 1.16-2.00), highest risk of mortality category (odds ratio, 1.19; 95% CI, 1.02-1.39; odds ratio, 2.70; 95% CI, 2.15-3.40), oncologic primary diagnoses (odds ratio, 5.61; 95% CI, 4.56-6.91; odds ratio, 4.30; 95% CI, 2.97-6.24), and neurologic primary diagnoses (odds ratio, 2.04, 95% CI, 1.70-2.44; odds ratio, 4.29, 95% CI, 3.18-5.78) were independently associated with acquiring both functional and cognitive disability. Intervention risk factors for acquiring both functional and cognitive disability included invasive mechanical ventilation (odds ratio, 1.79; 95% CI, 1.60-2.00; odds ratio, 2.83; 95% CI, 2.36-3.39), renal replacement therapy (odds ratio, 2.43; 95% CI, 1.73-3.42; odds ratio, 1.76, 95% CI, 1.08-2.85), cardiopulmonary resuscitation (odds ratio, 1.91; 95% CI, 1.24-2.95; odds ratio, 1.81; 95% CI, 1.02-3.23), and extracorporeal membrane oxygenation (odds ratio, 7.40, 95% CI, 4.10-13.36; odds ratio, 14.04, 95% CI, 7.51-26.26).

CONCLUSIONS

We identified a subset of patients whose potential for acquiring global functional and cognitive disability during admission to the PICU is high. This population may benefit from interventions that could mitigate this risk and from focused follow-up after discharge from the PICU.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children

OBJECTIVE

To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection.

DESIGN

A prospective observational case-control study.

SETTING

Two PICUs.

SUBJECTS

A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02).

CONCLUSIONS

Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Cognitive dysfunction with aging and the role of inflammation

As the average lifespan continues to climb because of advances in medical care, there is a greater need to understand the factors that contribute to quality of life in the elderly. The capacity to live independently is highly significant in this regard, but is compromised by cognitive dysfunction. Aging is associated with decreases in cognitive function, including impairments in episodic memory and executive functioning. The prefrontal cortex appears to be particularly vulnerable to the effects of advancing age. Although the mechanism of age-related cognitive decline is not yet known, age-related inflammatory changes are likely to play a role. New insights from preclinical and clinical research may give rise to novel therapeutics which may have efficacy in slowing or preventing cognitive decline with advancing age.

Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: a review

OBJECTIVE

To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families.

DATA SOURCES

Studies were identified through PubMed, MEDLINE, and Ovid.

STUDY SELECTION

All descriptive, observational, and controlled studies with a focus on posttraumatic stress disorder and the pediatric intensive care unit were included.

DATA EXTRACTION AND DATA SYNTHESIS

Posttraumatic stress disorder rates in children following admission to the pediatric intensive care unit were between 5% and 28%, while rates of posttraumatic stress disorder symptoms were significantly higher, 35% to 62%. There have been inconsistencies noted across risk factors. Objective and subjective measurements of disease severity were intermittently positively associated with development of posttraumatic stress disorder. There was a positive relationship identified between the child's symptoms of posttraumatic stress disorder and their parents' symptoms.The biological mechanisms associated with the development of posttraumatic stress disorder in children admitted to the pediatric intensive care unit have yet to be explored. Studies in children following burn or other unintentional injury demonstrate potential relationships between adrenergic hormone levels and a diagnosis of posttraumatic stress disorder. Likewise genetic studies suggest the importance of the adrenergic system in this pathway.The rates of posttraumatic stress disorder in parents following their child's admission to the pediatric intensive care unit ranged between 10.5% and 21%, with symptom rates approaching 84%. It has been suggested that mothers are at increased risk for the development of posttraumatic stress disorder compared to fathers. Objective and subjective measures of disease severity yielded mixed findings with regard to the development of posttraumatic stress disorder. Protective parental factors may include education or the opportunity to discuss the parents' feelings during the admission.

CONCLUSIONS

Following admission to the pediatric intensive care unit, both children and their parents have high rates of trauma exposure, both personally and secondary exposure via other children and their families, and subsequently are reporting significant rates of posttraumatic stress disorder. To effectively treat our patients, we must recognize the signs of posttraumatic stress disorder and strive to mitigate the negative effects.

Psychosocial stress exposure impairs memory retrieval in children

Negative consequences of stress on working memory and delayed memory retrieval have been observed in adult humans. Little is known about the occurrence of similar effects in children. Forty-four German full-term children, aged 8-10 years, were randomly assigned to a stressful (Trier Social Stress Test for Children--TSST-C) or to a non-stressful control condition. Afterwards, delayed memory retrieval was tested using a computerized version of the well-known card game "Memory". It contained positive, neutral and negative stimuli. In addition, working memory of verbal and non-verbal material was assessed. The stressed children showed pronounced cortisol increases accompanied by a decrease in mood. Children exposed to the stressor performed poorer in the delayed memory retrieval test (memory card game). They committed more errors. No differences were found for working memory. The stress-induced memory retrieval impairment mirrors findings in adults. In contrast, the missing working memory effects could suggest developmental differences in stress sensitivity.

Pediatric neurocritical care

Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.

Survivors of septic shock caused by Neisseria meningitidis in childhood: psychosocial outcomes in young adulthood

OBJECTIVE

To investigate long-term psychosocial outcomes in young adults who survived septic shock caused by Neisseria meningitidis (meningococcal septic shock) during childhood.

DESIGN

A cross-sectional study.

SETTING

The psychological investigation took place in the department of Child and Adolescent Psychiatry of the Erasmus MC-Sophia Children's Hospital.

PATIENTS

All consecutive surviving patients with meningococcal septic shock requiring intensive care treatment at the pediatric intensive care unit between 1988 and 2001.

INTERVENTION

To explore biographical characteristics (such as living conditions, educational, occupational, and marital status) and illness-related physical or social consequences a structured interview was used. To assess intellectual functioning the Groninger Intelligence Test 2 was used and to assess behavioral/emotional problems, the Adult Self-Report was used.

MEASUREMENTS AND MAIN RESULTS

Fifty-eight of 83 eligible septic shock survivors were evaluated (response rate: 70%). The patients were 16-31 yrs old at time of follow-up (median age: 21 yrs old). These patients had had meningococcal septic shock before 18 yrs of age. Median follow-up interval was 13 yrs, with a range of 4 to 16 yrs. For the vast majority of meningococcal septic shock patients, outcomes on biographical characteristics, intellectual functioning, and levels of behavioral/emotional problems were comparable to those of reference groups. A minority (5% to 20%) still report illness-related physical or social consequences, behavioral and emotional problems, and lower intellectual functioning.

CONCLUSIONS

Despite favorable outcomes for the majority of meningococcal septic shock patients in the long term, an important minority (5% to 20%) still struggles with ongoing problems as to behavioral/emotional problems, intellectual functioning, biographical characteristics, and illness-related physical or social consequences.

Psychiatric morbidity in pediatric critical illness survivors: a comprehensive review of the literature

OBJECTIVES

To review the prevalence of psychiatric syndromes in pediatric critical illness survivors as well as to summarize data on vulnerabilities and pediatric intensive care unit exposures that may increase risk of developing these syndromes.

DATA SOURCES

MEDLINE (1966-2009), the Cochrane Library (2009, issue 3), and PsycINFO (1967-2009) as of August 9, 2009.

STUDY SELECTION

Case-control, cross-sectional, prospective cohort and retrospective cohort studies as well as randomized controlled trials.

MAIN EXPOSURES

Hospitalization for the treatment of a critical illness.

MAIN OUTCOME MEASURES

Assessments of psychiatric symptoms/disorders at least once after discharge.

RESULTS

Seventeen studies were eligible. The most commonly assessed psychiatric disorders were posttraumatic stress disorder and major depression. The point prevalence of clinically significant posttraumatic stress disorder symptoms ranged from 10% to 28% (5 studies). The point prevalence of clinically significant depressive symptoms ranged from 7% to 13% (2 studies). Preillness psychiatric and/or developmental problems and parental psychopathology were associated with vulnerability to psychiatric morbidity. Neither age nor sex of a child consistently increased vulnerability to postillness psychopathology. Exposure to increased severity of medical illness and pediatric intensive care unit service-delivery characteristics (eg, invasive procedures) were predictors of psychiatric illness in some but not all studies. Early postillness psychiatric symptoms were predictors of later psychiatric morbidity.

CONCLUSIONS

Psychiatric morbidity appears to be a substantial problem for pediatric critical illness survivors. Future research should include more in-depth assessment of post-critical illness depressive, anxiety, and psychotic symptoms, validate existing psychiatric instruments, and clarify how vulnerability factors, pediatric intensive care unit service-delivery characteristics, and severity of critical illnesses are associated with subsequent psychopathology.

Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child

OBJECTIVE

To study posttraumatic stress disorder (PTSD) in parents after unexpected pediatric intensive care unit (PICU) treatment of their child and to identify risk factors for its development.

METHOD

Parents completed PTSD questionnaires 3 and 9 months (N = 190) after PICU treatment. Risk factors included pretrauma data, medical data, social demographics and posttraumatic stress responses at 3 months.

RESULTS

In total, 30.3% of parents met criteria for subclinical PTSD and 12.6% for clinical PTSD at 3 months. Clinical PTSD prevalence rates did not change over time. At 9 months, 10.5% of parents still met criteria for PTSD. Number of earlier stressful life events, earlier psychosocial care and posttraumatic stress responses at 3 months predicted persistent subclinical and clinical PTSD.

CONCLUSIONS

PICU admission is a stressful event associated with persistent parental PTSD. Assessment of risk factors can facilitate detection of persistent PTSD for early intervention.

An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock

OBJECTIVE

To evaluate self-reported health-related quality of life, anxiety, depression, and cognitive function in pediatric septic shock survivors.

DESIGN

A retrospective cohort study.

SETTING

A 14-bed tertiary pediatric intensive care unit.

PATIENTS

Children aged >or=8 yrs at the time of the follow-up who were admitted between 1995 and 2004 for septic shock. Inotropic and or vasoconstrictive agents were administered to these patients for >or=24 hrs.

INTERVENTION

Health-related quality of life was assessed with the KIDSCREEN-52, anxiety with the State Trait Anxiety Inventory for Children, depression with the Children's Depression Inventory, and cognitive function with the cognitive scale of the TNO-AZL Children's Quality of Life Questionnaire Child Form.

MEASUREMENTS AND MAIN RESULTS

Fifty of 82 eligible pediatric septic shock survivors were evaluated. The median age of the children at pediatric intensive care unit admission was 4.2 yrs (range, 0.0-17.0 yrs); the median age at follow-up was 10.7 yrs (range, 8.0-20.4 yrs). Health-related quality of life and anxiety scores were comparable to the age-related Dutch norm population. Depression scores were significantly better than the norm population, whereas cognitive function was significantly lower than the norm population. We found that 44% of the children had cognitive scores <25% of the norm population. Young age at the time of pediatric intensive care unit admission was predictive of cognitive problems, and cognitive problems were associated with lower emotional function.

CONCLUSIONS

In this group of septic shock survivors, health-related quality of life, anxiety, and depression are equal to or slightly better than the age-related Dutch norm population. Cognitive function is decreased, especially in children admitted at younger ages. Follow-up studies with adequate neuropsychological testing are warranted to evaluate the association between septic shock, cognitive function, and risk factors for cognitive problems.