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Chevignard M, Câmara-Costa H, Dellatolas G. Predicting and improving outcome in severe pediatric traumatic brain injury. Expert Rev Neurother 2024:1-21. [PMID: 39140714 DOI: 10.1080/14737175.2024.2389921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments. AREAS COVERED The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions. EXPERT OPINION There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.
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Affiliation(s)
- Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| | - Hugo Câmara-Costa
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| | - Georges Dellatolas
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
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Akinkuotu AC, Burkbauer L, Phillips MR, Gallaher J, Williams FN, McLean SE, Charles AG. Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury. Burns 2024; 50:1487-1493. [PMID: 38705778 DOI: 10.1016/j.burns.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/21/2024] [Accepted: 03/31/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. METHODS We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. RESULTS 2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56). CONCLUSION Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. TYPE OF STUDY Retrospective study LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Adesola C Akinkuotu
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA.
| | - Laura Burkbauer
- Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Michael R Phillips
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Jared Gallaher
- Division of Trauma and Acute Care, Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Felicia N Williams
- North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Sean E McLean
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Anthony G Charles
- Division of Trauma and Acute Care, Department of Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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McNamara CR, Kalinowski A, Horvat CM, Gaines BA, Richardson WM, Simon DW, Kochanek PM, Berger RP, Fink EL. New Functional Impairment After Hospital Discharge by Traumatic Brain Injury Mechanism in Younger Than 3 Years Old Admitted to the PICU in a Single Center Retrospective Study. Pediatr Crit Care Med 2024; 25:250-258. [PMID: 38088760 DOI: 10.1097/pcc.0000000000003417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES Children who suffer traumatic brain injury (TBI) are at high risk of morbidity and mortality. We hypothesized that in patients with TBI, the abusive head trauma (AHT) mechanism vs. accidental TBI (aTBI) would be associated with higher frequency of new functional impairment between baseline and later follow-up. DESIGN Retrospective single center cohort study. SETTING AND PATIENTS Children younger than 3 years old admitted with TBI to the PICU at a level 1 trauma center between 2014 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient characteristics, TBI mechanism, and Functional Status Scale (FSS) scores at baseline, hospital discharge, short-term (median, 10 mo [interquartile range 3-12 mo]), and long-term (median, 4 yr [3-6 yr]) postdischarge were abstracted from the electronic health record. New impairment was defined as an increase in FSS greater than 1 from baseline. Patients who died were assigned the highest score (30). Multivariable logistic regression was performed to determine the association between TBI mechanism with new impairment. Over 6 years, there were 460 TBI children (170 AHT, 290 aTBI), of which 13 with AHT and four with aTBI died. Frequency of new impairment by follow-up interval, in AHT vs. aTBI patients, were as follows: hospital discharge (42/157 [27%] vs. 27/286 [9%]; p < 0.001), short-term (42/153 [27%] vs. 26/259 [10%]; p < 0.001), and long-term (32/114 [28%] vs. 18/178 [10%]; p < 0.001). Sensory, communication, and motor domains were worse in AHT patients at the short- and long-term timepoint. On multivariable analysis, AHT mechanism was associated with greater odds (odds ratio [95% CI]) of poor outcome (death and new impairment) at hospital discharge (4.4 [2.2-8.9]), short-term (2.7 [1.5-4.9]), and long-term timepoints (2.4 [1.2-4.8]; p < 0.05). CONCLUSIONS In patients younger than 3 years old admitted to the PICU after TBI, the AHT mechanism-vs. aTBI-is associated with greater odds of poor outcome in the follow-up period through to ~5 years postdischarge. New impairment occurred in multiple domains and only AHT patients further declined in FSS over time.
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Affiliation(s)
- Caitlin R McNamara
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Anne Kalinowski
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Ward M Richardson
- Department of Pediatric Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Dennis W Simon
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Child Advocacy, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Berry JG, Ferrari L, Ward VL, Hall M, Desmarais A, Raval MV, Tian Y, Mathieu D, Incorvia J, Meara JG. Child Opportunity Index Disparities in Pediatric Surgical Encounters During the Coronavirus 2019 Pandemic. Acad Pediatr 2024; 24:43-50. [PMID: 37625667 DOI: 10.1016/j.acap.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/04/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Surgical encounters decreased during the coronavirus disease (COVID-19) pandemic and may have been deferred more in children with impeded health care access related to social/community risk factors. We compared surgery trends before and during the pandemic by Child Opportunity Index (COI). METHODS Retrospective analysis of 321,998 elective surgical encounters of children ages 0-to-18 years in 44 US children's hospitals from January 1, 2017 to December 31, 2021. We used auto-regression to compare observed versus predicted encounters by month in 2020-21, modeled from 2017 to 2019 trends. Encounters were compared by COI score (very low, low, moderate, high, very high) based on education, health/environment, and social/economic attributes of the zip code from the children's home residence. RESULTS Most surgeries were on the musculoskeletal (28.1%), ear/nose/pharynx (17.1%), cardiovascular (15.1%), and digestive (9.1%) systems; 20.6% of encounters were for children with very low COI, 20.8% low COI, 19.8% moderate COI, 18.6% high COI, and 20.1% very high COI. Reductions in observed volume of 2020-21 surgeries compared with predicted varied significantly by COI, ranging from -11.3% (95% confidence interval [CI] -14.1%, -8.7%) for very low COI to -2.6% (95%CI -3.9%, 0.7%) for high COI. Variation by COI emerged in June 2020, as the volume of elective surgery encounters neared baseline. For 12 of the next 18 months, the reduction in volume of elective surgery encounters was the greatest in children with very low COI. CONCLUSIONS Children from very low COI zip codes experienced the greatest reduction in elective surgery encounters during early COVID-19 without a subsequent increase in encounters over time to counterbalance the reduction.
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Affiliation(s)
- Jay G Berry
- Complex Care (JG Berry and A Desmarais), Division of General Pediatrics, Boston Children's Hospital, Mass; Department of Plastic and Oral Surgery (JG Berry, J Incorvia, and JG Meara), Boston Children's Hospital, Mass; Department of Pediatrics (JG Berry), Harvard Medical School, Boston, Mass.
| | - Lynne Ferrari
- Perioperative Anesthesia (L Ferrari), Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, Mass
| | - Valerie L Ward
- Department of Radiology (VL Ward), Boston Children's Hospital and Harvard Medical School, Mass; Office of Health Equity and Inclusion (VL Ward), Boston Children's Hospital, Mass; Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion (VL Ward), Boston Children's Hospital, Mass
| | - Matt Hall
- Children's Hospital Association (M Hall), Lenexa, Kans
| | - Anna Desmarais
- Complex Care (JG Berry and A Desmarais), Division of General Pediatrics, Boston Children's Hospital, Mass
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center (MV Raval and Y Tian), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Division of Pediatric Surgery (MV Raval), Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie Children's Hospital, Chicago, Ill
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center (MV Raval and Y Tian), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Derek Mathieu
- Department of Finance (D Mathieu), Boston Children's Hospital, Mass; Department of Surgery (D Mathieu), Harvard Medical School, Boston, Mass
| | - Joseph Incorvia
- Department of Plastic and Oral Surgery (JG Berry, J Incorvia, and JG Meara), Boston Children's Hospital, Mass
| | - John G Meara
- Department of Plastic and Oral Surgery (JG Berry, J Incorvia, and JG Meara), Boston Children's Hospital, Mass
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Alizadeh F, Gauvreau K, Mayourian J, Brown E, Barreto JA, Blossom J, Bucholz E, Newburger JW, Kheir J, Vitali S, Thiagarajan RR, Moynihan K. Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes. Pediatrics 2023; 152:e2023061305. [PMID: 37933403 DOI: 10.1542/peds.2023-061305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.
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Affiliation(s)
| | | | | | | | | | - Jeff Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | | | | | - John Kheir
- Departments of Cardiology
- Departments of Pediatrics
| | - Sally Vitali
- Anesthesia, Critical Care, Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | | - Katie Moynihan
- Departments of Cardiology
- Departments of Pediatrics
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Akande MY, Slain KN. Neighborhood Condition and PICU Admission: Facts and Fallacies. Chest 2023; 164:1341-1342. [PMID: 38070952 DOI: 10.1016/j.chest.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
| | - Katherine N Slain
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies & Children's Hospital, Cleveland, OH
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