Long-term Sequelae of Pediatric Neurocritical Care: The Parent Perspective

Feasibility and Acceptability of Mobile Phone-Based Surveys to Identify Mental Health Symptoms in Parents/Guardians of PICU Patients

OBJECTIVE

Parents experience psychologic distress during their child's admission to a PICU, but effective screening for parental mental health symptoms is not the standard of care. We aimed to test the feasibility and acceptability of a mobile phone-based mental health survey for parents/guardians of PICU patients to facilitate their support by the PICU team.

DESIGN

Post hoc analysis of a single-institution pilot study conducted in 2022. Mental health surveys were delivered by text message to parents/guardians of PICU patients over 1 month, beginning 3 days after their child's PICU admission. In-person interviews 1 month after hospital discharge were used to solicit participants' opinions on the survey platform and content.

SETTING

A quaternary U.S. academic medical center.

PARTICIPANTS

Parents/guardians of PICU patients.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Of the 53 participants who consented, 31 (58%) completed the study. Symptoms of acute stress (ASS) were the most common and most severe: 21 participants screened positive for ASS, and 20 of those that screened positive had "moderate" or "severe" symptoms. Among the 23 participants who screened positive for one mental health condition, 10 met the thresholds for all three. Scoring of the protocol's usability, acceptability, and feasibility showed a System Usability Scale equal to 82 of 100, an Acceptability of Intervention Measure score equal to 4.2 of 5, an Intervention Appropriateness Measure score equal to 4.5 of 5, and Feasibility of Intervention Measure score equal to 4.5 of 5.

CONCLUSIONS AND RELEVANCE

Mobile phone-based screening for parental mental health symptoms is acceptable and may offer the advantage of privacy and flexibility.

"I Didn't Realize How Hard It Was Going to Be Just Transitioning Back into Life": A Qualitative Exploration of Outcomes for Survivors of Pediatric Septic Shock

Recovery following pediatric critical illness is multifaceted and complex. While most critically ill children survive, many experience morbidities in physical, emotional, cognitive, and social function. We aimed to deeply explore and describe the multidimensional impact of pediatric septic shock for affected children and their families at the granular level using exploratory qualitative methodology. We performed semistructured telephone interviews of adolescents and caregivers of children admitted with community-acquired septic shock to two tertiary pediatric intensive care units in the United States. Interviews were conducted within two years of hospital admission, and were recorded, transcribed, and analyzed using thematic analysis. Two adolescents and 10 caregivers were interviewed. Participants described meaningful and long-lasting outcomes of septic shock on multiple dimensions of their lives. The adolescents and caregivers described substantial negative consequences on physical health and function which resulted in increased medical complexity and heightened caregiver vigilance. The physical impact led to substantial psychosocial consequences for both the child and family, including social isolation. Most caregivers expressed that septic shock was transformational in their lives, with some caregivers describing posttraumatic growth. This preliminary study provides a novel, granular view of the multidimensional impact of septic shock in pediatric patients and their families. Exploring these experiences through qualitative methodology provides greater insight into important patient and family outcomes. Deeper understanding of these outcomes may support the development of meaningful interventions to improve quality of life for children and their families following critical illness.

Long-term multidisciplinary follow-up programs in pediatric cardiac arrest survivors

Long-term outcome studies after pediatric cardiac arrest (CA) are few. They require a CA registry and dedicated outcome teams. Learning about the long-term outcomes is very important for developing prognostication guidelines, improving post-cardiac care, counseling caregivers about the future of their child, and creating opportunities for therapeutic intervention studies to improve outcomes. Few PICUs worldwide provide a multidisciplinary follow-up program as routine practice at an outpatient clinic with standardized measurements, using validated instruments including neuropsychological assessments by psychologists. The primary goal of such a follow-up program should be to provide excellent care to children and their caregivers, thereby resulting in a high attendance. Pediatric psychologists, neurologists and pediatricians/pediatric intensivists should ideally be involved to screen for delayed development and psychosocial problems and offer appropriate care at the same time. Preferably, outcomes should consist of evaluation of morbidity (physical and neuropsychological), functional health and Health Related Quality Of Life (QoL) of the patient and their caregivers.

Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury

STUDY OBJECTIVES

We aimed to investigate the use of sleep efficiency (SE) as a measure of sleep disturbance in infants and toddlers with acquired brain injury (ABI) and evaluate associations between SE and child health-related quality of life and family outcomes.

METHODS

Retrospective cohort study of 101 children ages 3-36 months who survived critical care for ABI. SE was quantified from the Brief Infant Sleep Questionnaire as a ratio of nighttime sleep to total time in bed; poor SE was defined as < 80%. Outcome measures included the Pediatric Quality of Life Inventory Core Total Score (health-related quality of life) and Family Impact Module Total Score. Spearman's correlation quantified associations between SE and outcomes. Multivariable linear regression tested association between poor SE and health-related quality of life controlling for significant covariates (age, diagnosis, comorbidities, worsening Functional Status Scale).

RESULTS

Following ABI, median SE was 91.7 (interquartile range = 83.3, 95.5). Nineteen (19%) children had poor SE (< 80%). SE correlated significantly with quality of life (Spearman's correlation = .307) and Family Impact Module (Spearman's correlation = .309; both P < .01). When controlling for covariates, poor SE significantly increased risk for lower health-related quality of life (β-coefficient = -7.0; 95% confidence interval= -13.4, -0.6).

CONCLUSIONS

One in five infants and young children with ABI have poor SE that is associated with poorer child and family health outcomes. Our study underscores the potential importance of sleep following ABI to optimize recovery and the need for additional investigation of SE in infants and young children.

CITATION

Klapp JM, Hall TA, Riley AR, Janzen D, Williams CN. Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury. J Clin Sleep Med. 2024;20(1):75-83.

The Impact of Sleep Disturbances on Health-Related Quality of Life in Children With Acquired Brain Injury After Critical Care

BACKGROUND

Over 60,000 children with acquired brain injury (ABI) in the United States require admission to pediatric intensive care units annually. Over 50% suffer sleep-wake disturbances (SWDs) months after discharge. Given the importance of sleep to brain repair, we hypothesized that SWD would be associated with poorer health-related quality of life (HRQOL).

METHODS

Cross-sectional analysis of prospectively collected data in children with ABI aged 3 to 18 years evaluated 1 to 3 months after critical care hospitalization (N = 151). SWD measured by Sleep Disturbances Scale for Children and defined as T-score ≥60 signifying moderate-severe risk of sleep disorders. HRQOL measured by Pediatric Quality of Life Inventory, which defines minimal clinically important difference as 4.5 points in total score. Secondary outcomes included scores for Physical, Emotional, Social, and School Function domains. SWD groups were compared with Mann-Whitney tests. Multiple linear regression evaluated association between SWD and HRQOL controlling for patient and ABI characteristics. Significance was defined as P < 0.05.

RESULTS

SWDs were present in 66% (n = 100). HRQOL total score was significantly lower in children with SWD (median = 70; interquartile range [IQR] = 54, 80) versus without (median = 85; IQR = 67, 94; P < 0.001). Median scores in emotional, social, and school domains were significantly lower in SWD group (all P < 0.01). When controlling for age, sex, critical care interventions, preadmission comorbidities, and decline from preadmission Functional Status Scale, presence of SWD significantly reduced HRQOL total score nearly three times minimal clinically important difference (β-coefficient = -12.1; 95% confidence Interval = -17.9, -6.2).

CONCLUSIONS

SWD following ABI significantly decreased HRQOL overall and across multiple health domains. Sleep is potentially modifiable. Our data support future studies targeting sleep to improve outcomes after ABI.

Variability Across Caregiver and Performance-Based Measures of Executive Functioning in an Acute Pediatric Neurocritical Care Population

Youth admitted to the pediatric intensive care unit (PICU) for traumatic brain injury (TBI) commonly struggle with long-term residual effects in the domains of physical, cognitive, emotional, and psychosocial/family functioning. In the cognitive domain, executive functioning (EF) deficits are often observed. The Behavior Rating Inventory of Executive Functioning, Second Edition (BRIEF-2) is a parent/caregiver-completed measure that is regularly utilized to assess caregivers' perspectives of daily EF abilities. Using parent/caregiver-completed measures like the BRIEF-2 in isolation as outcome measures for capturing symptom presence and severity might be problematic given that caregiver ratings are vulnerable to influence from external factors. As such, this study aimed to investigate the association between the BRIEF-2 and performance-based measures of EF in youth during the acute recovery period post-PICU admission for TBI. A secondary aim was to explore associations among potential confounding factors, including family-level distress, injury severity, and the impact of pre-existing neurodevelopmental conditions. Participants included 65 youths, 8-19 years of age, admitted to the PICU for TBI, who survived hospital discharge and were referred for follow-up care. Non-significant correlations were found between BRIEF-2 outcomes and performance-based measures of EF. Measures of injury severity were strongly correlated with scores from performance-based EF measures, but not BRIEF-2. Parent/caregiver-reported measures of their own health-related quality of life were related to caregiver responses on the BRIEF-2. Results demonstrate the differences captured by performance-based versus caregiver-report measures of EF, and also highlight the importance of considering other morbidities related to PICU admission.

Impact of ethnicity on parental health outcomes and experiences after paediatric intensive care unit discharge: a mixed-methods systematic review

The impact of ethnicity on parental health outcome after paediatric intensive care unit (PICU) discharge remains unclear. Thirteen medical and healthcare databases, unpublished studies and grey literature were searched up to November 5, 2021. We performed a mixed-method systematic review to understand the impact of ethnicity on parental outcomes after PICU discharge, including eight quantitative and eight qualitative studies. Among 1529 parents included, 1064 (72%) were White. Higher prevalence of post-traumatic stress disorder was seen in Black parents (17% White vs 36% Black, p = .03). Latino ethnicity was found to have protective effect against anxiety as compared to White parents (coefficient - 4.27, p < .001). A total of 91 findings were aggregated into 14 categories, and the five synthesized themes from the eight qualitative studies were long-term psychological impact after PICU, use of coping strategies, challenges of re-integration, changes in relationships and the utilization of formal support services and resources. Mixed-method synthesis found that parents of ethnic minority group were underrepresented (18%) and had higher attrition rates in a longitudinal study as compared to White parents following childhood critical illness.   Conclusion: There are significant gaps in evidence related to the impact of ethnicity on long-term parental health outcomes after PICU discharge. Ethnic diversity and inclusiveness in long-term PICU research may aid understanding of the parental experiences and outcomes to close the gap in health disparity.

Is Pediatric Intensive Care Trauma-Informed? A Review of Principles and Evidence

Pediatric critical illness and injury, along with the experience of recovering from critical illness are among the most potentially traumatic experiences for children and their families. Additionally, children often come to the Pediatric Intensive Care Unit (PICU) with pre-existing trauma that may sensitize them to PICU-related distress. Trauma-informed care (TIC) in the PICU, while under-examined, has the potential to enhance quality of care, mitigate trauma-related symptoms, encourage positive coping, and provide anticipatory guidance for the recovery process. This narrative review paper first describes the need for TIC in the PICU and then introduces the principles of TIC as outlined by the American Academy of Pediatrics: awareness, readiness, detection and assessment, management, and integration. Current clinical practices within PICU settings are reviewed according to each TIC principle. Discussion about opportunities for further development of TIC programs to improve patient care and advance knowledge is also included.

Effectiveness of Training Programs for Reducing Adverse Psychological Outcomes in Parents of Children with Acquired Brain Injury: A Systematic Review and Meta-Analysis

INTRODUCTION

Parental stress following critical illness in their child has the potential to impact functional outcomes and quality of life for the child and whole family. Parent emotional functioning may also be an important clinical target to optimize child outcomes. This study assessed the effectiveness of training programs for parents aimed at reducing adverse psychological outcomes in parents of children with acute brain injury (ABI).

METHODS

We conducted searches of Embase, PubMed, Web of Science, and Cochrane Library to November 13, 2020. Randomized controlled trials (RCTs) that compared parent training programs with usual care, or an active comparator, and assessed psychological outcomes (depression, anxiety, stress) in parents of children with ABI were included. Two reviewers independently extracted data on study characteristics, participants, interventions, outcome measures, and results before and after intervention. Risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Four RCTs involving 318 parents of children with ABI were eligible for review. Compared with usual care or active comparator, parent training was associated with significant reduction in parent stress (four RCTs; standardized mean difference [SMD], - 0.32 on a numerical rating scale [95% CI, - 0.60, - 0.05]; I-squared = 7.5%, p = 0.356); significant reduction in parent depression (three RCTs; SMD, - 0.43 [95% CI, - 0.72, - 0.14]; I-squared = 0.0%, p = 0.393); and significant reduction in parent anxiety (two RCTs; SMD, - 0.63 [95% CI, - 1.05, - 0.21]; I-squared = 0.0%, p = 0.629). Overall risk of bias was high for randomization process (one RCT), missing outcome data (three RCTs), measurement of the outcome (three RCTs), and selection of reported result (two RCTs). Heterogeneity between studies by country of study origin was not significant.

CONCLUSIONS

Compared with usual care or an active comparator, parent training was associated with short-term reduction in stress, depression, and anxiety in parents of children with ABI. Future clinical trials of parent interventions are needed as there may be some short-term beneficial effects.

Post-Intensive Care Syndrome in a Cohort of School-Aged Children and Adolescent ICU Survivors: The Importance of Follow-up in the Acute Recovery Phase

Pediatric intensive care unit (PICU) survivors experience a collection of physical, cognitive, emotional, and social symptoms named post-intensive care syndrome (PICS). We aimed to quantify PICS morbidities from multiple stakeholder perspectives across domains. Using physician, neuropsychologist, and parent/caregiver-completed outcome measures across domains in a cross-sectional analysis of 186 children between the ages of 8 and 19 years with data from a PICU follow-up clinic 1 to 3 months after PICU discharge, we quantified PICS morbidities and used Spearman correlation to evaluate interdependence of PICS domains. Compared with pre-hospitalization functioning, new PICS-related morbidities were observed and significant correlations were identified between the PICS domains. Results highlight the need to identify and support patients and families for multiple morbidities simultaneously across all relevant PICS domains; moreover, an important divergence between caregiver report, physician, and neuropsychologist assessment was also found, showcasing the importance of multiple assessments and perspectives. New PICS morbidities across domains are common after discharge from the PICU, and timely follow-up care is needed that involves collaboration/integration of physicians, neuropsychologists, youth, and families to effectively identify and treat PICS-related issues.

Continuing Care For Critically Ill Children Beyond Hospital Discharge: Current State of Follow-up

OBJECTIVES

Survivors of the PICU face long-term morbidities across health domains. In this study, we detail active PICU follow-up programs (PFUPs) and identify perceptions and barriers about development and maintenance of PFUPs.

METHODS

A web link to an adaptive survey was distributed through organizational listservs. Descriptive statistics characterized the sample and details of existing PFUPs. Likert responses regarding benefits and barriers were summarized.

RESULTS

One hundred eleven respondents represented 60 institutions located in the United States (n = 55), Canada (n = 3), Australia (n = 1), and the United Kingdom (n = 1). Details for 17 active programs were provided. Five programs included broad PICU populations, while the majority were neurocritical care (53%) focused. Despite strong agreement on the need to assess and treat morbidity across multiple health domains, 29% were physician only programs, and considerable variation existed in services provided by programs across settings. More than 80% of all respondents agreed PFUPs provide direct benefits and are essential to advancing knowledge on long-term PICU outcomes. Respondents identified "lack of support" as the most important barrier, particularly funding for providers and staff, and lack of clinical space, though successful programs overcome this challenge using a variety of funding resources.

CONCLUSIONS

Few systematic multidisciplinary PFUPs exist despite strong agreement about importance of this care and direct benefit to patients and families. We recommend stakeholders use our description of successful programs as a framework to develop multidisciplinary models to elevate continuity across inpatient and outpatient settings, improve patient care, and foster collaboration to advance knowledge.

Parent and Physician Report of Discussions About Prognosis for Critically Ill Children

OBJECTIVES

Parents value clear communication with PICU clinicians about possible patient and family outcomes (prognostic conversations). We describe PICU parent and attending physician reports and agreement regarding the occurrence of prognostic conversations. We queried parents and physicians about prognostic conversation content, which healthcare providers had prognostic conversations, and whether parents wanted more prognostic information.

DESIGN

Prospective cross-sectional survey study.

SETTING

University-based 40-bed PICU.

PARTICIPANTS

Parents and attending physicians of PICU patients with multiple organ dysfunction within 24 hours of PICU admission.

INTERVENTIONS

Surveys administered to parents and attending PICU physicians 5-10 days after PICU admission.

MEASUREMENTS AND MAIN RESULTS

Surveys asked parents and physicians to report the occurrence of prognostic conversations related to PICU length of stay, risk of PICU mortality, and anticipated post-PICU physical, neurologic, and psychologic morbidities for patients and post-PICU psychologic morbidities for parents. Of 101 participants, 87 parents and 83 physicians reported having prognostic conversations. Overall concordance between parents and physicians was fair (Kappa = 0.22). Parents and physicians most commonly reported prognostic conversations about PICU length of stay (67.3% and 63.3%, respectively) and patient post-PICU physical morbidity (n = 48; 48.5% and n = 45; 44.5% respectively). Conversations reported less often by parents and physicians were about patient post-PICU psychologic morbidity (n = 13; 12.9% and n = 20; 19.8%, respectively). Per parent report, bedside nurses and physicians provided most prognostic information. Chaplains (n = 14; 50%) and social workers (n = 17; 60%) were more involved in conversations regarding parent psychologic morbidities. Most commonly, parents requested more information about length of stay and their child's physical morbidities. Parents less frequently wanted information about their own psychologic morbidities.

CONCLUSIONS

Most parents and physicians report having prognostic conversations, primarily about length of stay and post-ICU physical morbidities. Concordance between parents and physicians is suboptimal. Future studies should evaluate prognostic conversations at other timepoints, how information is delivered, and how these conversations impact the PICU experience.

Familial experience of acute bacterial meningitis in children: a transversal qualitative study using interpretative phenomenological analysis

OBJECTIVES

To capture the subjective experience of close family ascendants of acute bacterial meningitis survivors and to explore how they give meaning to this specific experience.

DESIGN

A qualitative study of indepth interviews using interpretative phenomenological analysis.

PRIMARY OUTCOME

Main meaning-making processes of participants' experience.

SETTINGS

Participants were recruited through two associations of people affected by meningitis and their family ascendants.

PARTICIPANTS

Convenience sampling of 11 women whose children or grandchildren were between 0.2 and 20 years old at the time of their meningitis diagnosis (M=4.06, SD=7.3). On average, 9.39 (SD=5.4) years had passed between the onset of illness and the interview.

RESULTS

Six superordinate themes (meningitis disease; healthcare services and professionals; knowledge/ignorance; repercussions of the meningitis experience: 'life afterwards'; sick child attitudes/behaviour; and sibling attitudes/behaviour) and two main meaning-making processes in relation to participants' experience of meningitis were identified: (1) the sick child becoming a 'hero': comparison with other children; and (2) engaging action/attitude: finding the 'positive' of the traumatic experience and engaging action to improve the care system. These two processes underpin the psychological adjustment to meningitis and its consequences.

CONCLUSIONS

This study provides a unique insight into close family members' first-hand experience with acute bacterial meningitis. Findings highlighted factors characterising the disease experience, the psychological adjustment of meningitis survivors' families and their meaning-making processes. These findings are important for research and clinical practice, demonstrating the multidimensional impact of the disease on family ascendants, their need for professional psychological support and the importance of direct involvement of parents in identifying key aspects of care.

Parental Posttraumatic Stress Symptoms in the Context of Pediatric Post Intensive Care Syndrome: Impact on the Family and Opportunities for Intervention

OBJECTIVE

Pediatric intensive care unit (PICU) survivors and their families experience ongoing impacts on physical, cognitive, and psychosocial functioning, described as Post-Intensive Care Syndrome (PICS). The objective of this study was to determine whether the posttraumatic stress symptoms (PTSS) of parents predict the impact of critical illness on families following PICU admission beyond other factors (e.g., sex, race/ethnicity, age, insurance status, illness severity, family involvement or death).

METHOD

We conducted a retrospective analysis of data from 88 children aged 1 month to 18 years who were hospitalized with critical illness and acquired brain injury in the PICU and their families. Patients and their families participated in a 1-3 month post-discharge follow-up assessment, during which data on demographics, medical diagnoses, parent self-report of PTSS, and family impact of critical illness (via the Pediatric Quality of Life Family Impact Module) were collected. We used a hierarchical linear regression to determine whether parent PTSS predicted family impact above and beyond demographic and injury/illness factors.

RESULTS

One-third of parents reported elevated PTSS. Among those with complete available data (n = 56), PTSS were the only significant predictor of family impact (β = -.52, t = -3.58, p = .001), with the overall model accounting for 41% of variance.

CONCLUSION

In addition to the direct effects on parents of children who survive the PICU, PTSS may negatively impact families and interfere with rehabilitative progress. We provide a rationale and conceptual model for integrating interventions designed to address parent PTSS into post-PICU care.

Emotional Aspects of Pediatric Post-Intensive Care Syndrome Following Traumatic Brain Injury

Children with traumatic brain injury (TBI) requiring neurocritical care are at risk for neurocognitive, emotional, physical, and psychosocial difficulties, collectively known as Post-Intensive Care Syndrome. Our study assessed parent-reported emotional functioning and identified risk factors for emotional sequelae in the acute recovery phase. Fifty-three children between 5 and 18 years old hospitalized for TBI were assessed 1-month following discharge. Relevant injury-, child-, and family-specific variables were collected. Emotional functioning was assessed using PROMIS Parent Proxy Report Short Forms for Anxiety and Depressive Symptoms. We used Chi-square tests to evaluate differences between children with and without elevations in anxiety and depressive symptoms. Logistic regression determined predictors of elevations in symptoms among significant variables. Parents frequently endorsed moderate or worse anxiety (45.2%) and depressive (32.1%) symptoms among children. Mechanism of injury and elevated parent post-traumatic stress disorder (PTSD) symptoms were associated with elevated anxiety and depressive symptoms, while direct family involvement in the accident/injury was associated only with elevated anxiety symptoms. Results from logistic regression indicated that only elevated parent PTSD symptoms were a significant predictor for child anxiety and depressive symptoms. Anxiety and depressive symptoms are prevalent in the acute recovery phase of TBI. Consistent with previous research, elevations in anxiety and depressive symptoms were more related to psychosocial factors than injury severity. High levels of parent PTSD symptoms and their relationship with children's internalizing symptoms highlight the need for mental health treatment for TBI patients and their families.

Parental Mental Health Care After Their Child's Pediatric Intensive Care Hospitalization

OBJECTIVES

Post-traumatic stress disorder, depression, and anxiety have all been found in parents of PICU survivors. How these research findings translate to actual use of mental health services by parents remains unknown.

DESIGN

Retrospective observational cohort study.

SETTING

Insurance claims data from 2006 to 2013 obtained from the IBM MarketScan Commercial Database.

PATIENTS

Parents of PICU survivors.

INTERVENTIONS

We examined rates of: 1) mental health diagnoses, 2) outpatient mental health visits, and 3) prescriptions for antidepressants and anxiolytics among parents, 6 months before and 6 months after their child's PICU admission, using each parent as their own control.

MEASUREMENTS AND MAIN RESULTS

Of the 95,070 parents identified, 9.5% received a new mental health diagnosis in the 6 months after their child's PICU hospitalization, which represented a 110% increase from pre-PICU rates. A smaller proportion of parents were given new prescriptions for antidepressants (3.4%) and anxiolytics (3.9%) in the 6 months after their child's PICU hospitalization. Mothers were twice as likely to receive a new mental health diagnosis and be taking a new medication than fathers in the post-PICU period. The parental diagnosis of acute stress disorder or post-traumatic stress disorder increased by 87% from the pre-PICU to the post-PICU period.

CONCLUSIONS

After their child's PICU hospitalization, the proportion of parents with a new mental health diagnosis nearly doubled. Mothers were at nearly twice the risk of receiving a new mental health diagnosis and receiving a new mental health medication compared with fathers. The proportion of parents receiving mental healthcare is much lower than the proportion reporting mental health symptoms in long-term outcomes studies. Whether this indicates a gap in healthcare delivery for parents with mental health symptoms remains unknown.

Impact of late-onset group B streptococcus infection on families: An observational study

OBJECTIVES

Understand the parental impact of having a baby affected by late-onset group B Strep (LOGBS) infection. Understand the social, mental and financial impact on parents/carers or family members of those affected by LOGBS infection. Investigate family information needs and experiences of information provided.

STUDY DESIGN

We devised a 57-item online survey, composing of binary and matrix questions and free text answers. The survey was distributed internationally to families with a baby(ies) affected by LOGBS infection. The questionnaire was designed as a collaborative effort by Group B Strep Support, its medical advisory panel members, midwives, neonatologists, parents and volunteer analysts. Data were collected from June to September in 2018.

RESULTS

531 participants responded. 252 babies (55 %) made a full recovery from their LOGBS infection, 145 (32 %) recovered with long term sequelae and 61 (13 %) died. 126 respondents (32 %) felt there was a minor to substantial impact on their child's day to day life as a consequence of LOGBS infection. 343 respondents (69 %) had not heard about GBS before their child developed LOGBS infection. 338 respondents (77 %) did not receive an information leaflet on GBS. As a result of their child's LOGBS infection, 177 respondents (39 %) experienced either minor or substantial financial difficulty and 314 respondents (70 %) felt that their own or a family member's mental health was affected. 300 respondents (66 %) experienced problems with planning or reduced enjoyment of subsequent pregnancies. 102 respondents (29 %) reported their other children experienced difficulty due to their sibling's LOGBS infection.

CONCLUSIONS

The results of our study provide a novel insight into families' experiences following a baby affected by LOGBS infection. Study findings suggests that families suffer significant financial and psychological difficulties as a result of LOGBS infection. Furthermore, information needs are frequently being left unmet.

Post-intensive care syndrome in a cohort of infants & young children receiving integrated care via a pediatric critical care & neurotrauma recovery program: A pilot investigation

OBJECTIVE

Children treated in the pediatric intensive care unit (PICU) often face difficulties with long-term morbidities associated with neurologic injuries and lifesaving PICU interventions termed Post-Intensive Care Syndrome (PICS). In an effort to identify and address critical issues related to PICS, we developed an integrated model of care whereby children and families participate in follow-up clinics with a neuropsychologist and a critical care physician. To demonstrate preliminary impact, we present pilot findings on the early identification and treatment of PICS in a cohort of infants and young children in our program through a combination of multi-professional direct assessment and parent proxy questionnaires.

METHOD

Thirty-three infants and children, ages 3-72 months, participated in our initial follow-up clinic where issues related to physical health/recovery, development/cognition, mood/behavior, and quality of life were screened 1-3 months after discharge from the PICU.

RESULTS

In comparison to pre-hospitalization functioning, direct assessment revealed new neurological concerns identified by the critical care physician in 33.3% of participants and new neurocognitive concerns identified by the neuropsychologist in 36.4% of participants. Caregiver reported measures showed significant issues with patient cognitive functioning, emotional functioning, sleep, and impact on the family. Participants and families experienced significant difficulties related to changes in functioning and disability. Parents/caregivers and clinicians demonstrated agreement on functioning across a variety of indicators; however, important divergence in assessments were also found highlighting the importance of multiple assessments and perspectives.

CONCLUSIONS

New PICS morbidities are common in the early phase of recovery after discharge in infants, young children and their families. Results demonstrate the benefits and need for timely PICU follow-up care that involves collaboration/integration of physicians, neuropsychologists, and families to identify and treat PICS issues.

Post-Intensive-Care Syndrome for the Pediatric Neurologist

The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.

Hospital Mortality and Functional Outcomes in Pediatric Neurocritical Care

OBJECTIVES

Pediatric neurocritical care (PNCC) outcomes research is scarce. We aimed to expand knowledge about outcomes in PNCC by evaluating death and changes in Functional Status Scale (FSS) from baseline among PNCC diagnoses.

METHODS

We conducted a 2-year observational study of children aged 0 to 18 years admitted to the ICU with a primary neurologic diagnosis (N = 325). Primary outcomes were death and change in FSS from preadmission baseline to discharge. New disability was defined as an FSS change of ≥1 from baseline, and severe disability was defined as an FSS change of ≥3. Categorical results are reported as relative risk (RR) with 95% confidence interval (CI).

RESULTS

Thirty (9%) patients died. New disability (n = 103; 35%) and severe disability (n = 37; 13%) were common in PNCC survivors. New disability (range 14%-54%) and severe disability (range 3%-33%) outcomes varied significantly among primary diagnoses (lowest in status epilepticus; highest in infectious and/or inflammatory and stroke cohorts). Disability occurred in all FSS domains: mental status (15%), sensory (52%), communication (38%), motor (48%), feeding (40%), and respiratory (12%). Most (64%) patients with severe disability had changes in ≥3 domains. Requiring critical care interventions (RR 2.1; 95% CI 1.5-3.1) and having seizures (RR 1.5; 95% CI 1.1-2.0) during hospitalization were associated with new disability.

CONCLUSIONS

PNCC patients have high rates of death and new disability at discharge, varying significantly between PNCC diagnoses. Multiple domains of disability are affected, underscoring the ongoing multidisciplinary health care needs of survivors. Our study quantified hospital outcomes of PNCC patients that can be used to advance future research in this vulnerable population.

Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations

INTRODUCTION

Traumatic brain injury (TBI) remains a primary cause of pediatric morbidity. The improved characterization of healthcare disparities for pediatric TBI in United States (U.S.) rural communities is needed to advance care.

METHODS

The PubMed database was queried using keywords (("brain/head trauma" OR "brain/head injury") AND "rural/underserved" AND "pediatric/child"). All qualifying articles focusing on rural pediatric TBI, including the subtopics epidemiology (N = 3), intervention/healthcare cost (N = 6), and prevention (N = 1), were reviewed.

RESULTS

Rural pediatric TBIs were more likely to have increased trauma and head injury severity, with higher-velocity mechanisms (e.g., motor vehicle collisions). Rural patients were at risk of delays in care due to protracted transport times, inclement weather, and mis-triage to non-trauma centers. They were also more likely than urban patients to be unnecessarily transferred to another hospital, incurring greater costs. In general, rural centers had decreased access to mental health and/or specialist care, while the average healthcare costs were greater. Prevention efforts, such as mandating bicycle helmet use through education by the police department, showed improved compliance in children aged 5-12 years.

CONCLUSIONS

U.S. rural pediatric patients are at higher risk of dangerous injury mechanisms, trauma severity, and TBI severity compared to urban. The barriers to care include protracted transport times, transfer to less-resourced centers, increased healthcare costs, missing data, and decreased access to mental health and/or specialty care during hospitalization and follow-up. Preventative efforts can be successful and will require an improved multidisciplinary awareness and education.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.