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

Risks of developing major psychiatric disorders among child and adolescent intensive care unit survivors

BACKGROUND

The mental health of child and adolescent intensive care unit (ICU) survivors is increasingly being researched. However, the literature on how various types of critical illness influence specific psychiatric disorders remains limited.

METHODS

This study analyzed the data of 8704 child and adolescent ICU survivors and 87,040 age-, sex-, family income-, and residence-matched controls who were followed from enrollment to the end of 2013; the data covered the period from 1996 to 2013 and were extracted from a nationwide data set. The primary outcomes were the risks of five major psychiatric disorders (MPDs), namely schizophrenia, bipolar disorder (BD), major depressive disorder (MDD), obsessive compulsive disorder (OCD), and posttraumatic stress disorder (PTSD).

RESULTS

Relative to the controls, the child and adolescent ICU survivors (mean age = 10.33 years) exhibited higher risks of developing five MPDs. The associated hazard ratios (HRs) and confidence intervals (CIs) are as follows: PTSD, HR = 4.67, 95 % CI = 2.42-9.01; schizophrenia, HR = 3.19, 95 % CI = 2.27-4.47; BD, HR = 2.02, 95 % CI = 1.33-3.05; OCD, HR = 1.96, 95 % CI = 1.21-3.16; and MDD, HR = 1.68, 95 % CI = 1.44-1.95. The risks of developing MPDs varied across multiple types of critical illness related to ICU admission.

CONCLUSIONS

The risks of MPDs were significantly higher among the child and adolescent ICU survivors than among the controls. The development of appropriate MPD prevention strategies should be emphasized for this vulnerable population.

Impact of an Intervention Aimed at Improving Sleep Quality in Hospitalized Children

BACKGROUND

Hospitalized children need adequate sleep to favor early recovery.

METHODS

To study the sleep pattern of children admitted to a pediatric inpatient unit, a cross-sectional study was carried out at a reference hospital in northern Spain. The main study variables were medical specialty of admission, sleep-inducing treatment, hours of sleep at home and during admission, number of nocturnal awakenings, and reasons for awakening. Differences in the hours of sleep and nighttime awakenings between the initial period and at six months were calculated using the Student's t-test.

RESULTS

We included 100 baseline patients and 100 post-intervention patients. Up to 4% of the baseline sample and 3% of the six-month sample had been prescribed a sleep-promoting drug. Regarding awakenings, 79% of the children in the baseline sample suffered awakenings, with a mean of 1.98 awakenings (range 1-13). At six months, the percentage of children who experienced awakenings decreased by 17%, with a mean of 1.34 (range 1-5). In the baseline sample, 48% were caused by nursing care, decreasing to 34% after the intervention.

CONCLUSIONS

An educational intervention with the implementation of targeted evidence-based practices is a useful measure for improving the sleep pattern by decreasing the number of awakenings.

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.

"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.

Design and rationale of the Post-Intensive Care Syndrome - paediatrics (PICS-p) Longitudinal Cohort Study

INTRODUCTION

As paediatric intensive care unit (PICU) mortality declines, there is growing recognition of the morbidity experienced by children surviving critical illness and their families. A comprehensive understanding of the adverse physical, cognitive, emotional and social sequelae common to PICU survivors is limited, however, and the trajectory of recovery and risk factors for morbidity remain unknown.

METHODS AND ANALYSIS

The Post-Intensive Care Syndrome - paediatrics Longitudinal Cohort Study will evaluate child and family outcomes over 2 years following PICU discharge and identify child and clinical factors associated with impaired outcomes. We will enrol 750 children from 30 US PICUs during their first PICU hospitalisation, including 500 case participants experiencing ≥3 days of intensive care that include critical care therapies (eg, mechanical ventilation, vasoactive infusions) and 250 age-matched, sex-matched and medical complexity-matched control participants experiencing a single night in the PICU with no intensive care therapies. Children, parents and siblings will complete surveys about health-related quality of life, physical function, cognitive status, emotional health and peer and family relationships at multiple time points from baseline recall through 2 years post-PICU discharge. We will compare outcomes and recovery trajectories of case participants to control participants, identify risk factors associated with poor outcomes and determine the emotional and social health consequences of paediatric critical illness on parents and siblings.

ETHICS AND DISSEMINATION

This study has received ethical approval from the University of Pennsylvania Institutional Review Board (protocol #843844). Our overall objective is to characterise the ongoing impact of paediatric critical illness to guide development of interventions that optimise outcomes among children surviving critical illness and their families. Findings will be presented at key disciplinary meetings and in peer-reviewed publications at fixed data points. Published manuscripts will be added to our public study website to ensure findings are available to families, clinicians and researchers.

TRIALS REGISTRATION NUMBER

NCT04967365.

Quality of Life Among Chinese Child Survivors of Heart Failure After Discharge From Pediatric Intensive Care Unit

INTRODUCTION

This study investigated the current quality of life (QOL) status and related influencing factors in children with heart failure in the pediatric intensive care unit (PICU).

METHOD

One hundred eighty-three children admitted to the PICU with heart failure were consecutively sampled. They were assessed 3 months after discharge and compared with a control group of 160 healthy individuals. The Pediatric Quality of Life Inventory (version 4.0) and Children's Revised Impact of Event Scale were completed, and factors influencing QOL were analyzed.

RESULTS

Three months after discharge, the PICU group reported lower average scores on the overall QOL and the physical and emotional functioning scales than the control group. In particular, posttraumatic stress disorder status, age, and caregiver educational level greatly influenced the PICU children's QOL.

DISCUSSION

More interventions and attention are needed to improve the QOL for PICU heart failure patients after discharge.

The Development of a Communication Tool to Aid Parent-Centered Communication between Parents and Healthcare Professionals: A Quality Improvement Project

Good communication is central to good healthcare. As a result of poor communication between parents and healthcare professionals (HCPs) in clinical settings, this study aimed to address this problem by developing a communication tool to empower parents and act as a prompt for HCPs to talk about the child's care and gather information at the point of admission to hospital about what is important to families, therefore supporting patient-centered communication. A design thinking process was used to develop a physical copy of Chloe's card and evaluate its use. Design thinking is a problem-solving approach, which uses an empathetic lens to integrate viewpoints of different stakeholders throughout the process of creating solutions. Design thinking involves five processes: (1) empathise-including a literature review and data synthesis, (2) define-by completing semi-structured interviews with parents about their experience of communication and HCPs perceptions of parent's experience of communication, (3) ideate-iterate the design of Chloe's card with parents and HCPs, (4) prototype-develop the design of Chloe's card, and (5) test-pilot test in clinical practice. Results from this initial study suggest that a small hand-held card, with emoticons and a place to write concerns, was acceptable to parents and feasible to use in clinical practice. Parents do not always feel heard by HCPs and a tool such as Chloe's card may help facilitate sharing of information about matters important to them and their child. However, some HCPs felt the need for a communication tool undermined their clinical skills. Feedback from HCP participants suggests that the idea of Chloe's card was acceptable and perceived as potentially being useful in clinical practice. Further work is required, as part of a larger study, to further refine this communication tool, identify those parents who would benefit most from Chloe's card, as well as to further refine the HCP process prior to implementing it into clinical settings. It was noted future iterations would benefit from a digital version linked with a child's electronic record, as well as multi-language versions and information for parents.

Predictors of neurocognitive and psychological disorders in children after intensive care admission: A prospective cohort study

Background and Aims

Children admitted in the pediatric intensive care unit (PICU) often deal with long-term morbidities affecting physical, cognitive, emotional, social, and psychiatric symptoms. We aimed to identify the internal and external factors which predict the occurrence of neurocognitive and psychological disorders in survivors at 3 months after PICU discharge.

Methods

We identified 53 critically ill children, ages 4-18 years old, admitted in PICU for more than 24 h, and survived. We evaluated neurocognitive disorder with Pediatric Cerebral Perfomance Category (PCPC) and psychological disorders with Strengths and Difficulties Questionnaire (SDQ) at the time of PICU discharge and repeated in 3 months afterward. We evaluated the internal and external risk factors related to neurocognitive and psychological disorders in PICU survivors. The internal risk factors were age, gender, family composition, and socioeconomic status. The external risk factors were: surgical intervention, neurological disease, predicted death rate by pediatric index mortality (PIM)-2 score, PICU length of stay (LOS), days of mechanical ventilation, and the number of therapeutic interventions.

Results

There were significant improvement in neurocognitive disorders (p < 0.001), peer problems, (p = 0.01), and prosocial behaviors (p = 0.00) in children at 3 months after the PICU discharge. Age of 4-5 years has a significant effect on neurocognitive disorders (p = 0.04), while male gender (p = 0.02), low-social economy, non-intact family composition (p = 0.01), neurological disease (p = 0.04), surgical intervention (p = 0.01), and TISS score (p = 0.00) have a significant effect on psychological disorders in children at 3 months after the PICU discharge.

Conclusion

Neurocognitive disorders, peer problems, and prosocial behaviors improved in a few patients 3 months after PICU discharge. Age of 4-5 years was a risk factor of the persisted neurocognitive disorder, whereas male gender, low-social economy, non-intact family composition, neurological disease, surgical intervention, and TISS score were risk factors of persisted psychological disorder at 3 months after PICU.

Epidemiology of Intensive Care Admissions for Children in the US From 2001 to 2019

Importance

Estimates of the number of US children receiving intensive care unit (ICU) care and ICU admission patterns over time are lacking.

Objective

To determine how ICU admission patterns, use of critical care services, and the characteristics and outcomes of critically ill children have changed from 2001 to 2019.

Design, Setting, and Participants

This population-based retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient databases from a total of 21 US states in 2001, 2004, 2010, 2016, and 2019. Hospitalized children aged 0 to 17 years, excluding newborns (during birth hospitalization), were included. Patients admitted to rehabilitation institutions or psychiatric hospitals were also excluded. Data were analyzed from July 2021 to December 2022.

Exposures

Care in a nonneonatal ICU.

Main Outcomes and Measures

From extracted patient data, International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision, Clinical Modification, codes were used to identify diagnoses, comorbid conditions, organ failures, and mechanical ventilation. Generalized linear Poisson regression and the Cuzick test were used to evaluate trends. US Census data were used to generate age- and sex-adjusted national estimates of ICU admissions and costs.

Results

Of 2 157 991 pediatric admissions, 275 656 (12.8%) included ICU care. The mean (SD) age was 6.43 (6.10) years; 121 894 individuals were female (44.2%), and 153 731 were male (55.8%). From 2001 to 2019, the prevalence of ICU care among hospitalized children increased from 10.6% to 15.5%. The percentage of ICU admissions in children's hospitals rose from 51.2% to 85.1% (relative risk [RR], 1.66; 95% CI, 1.64-1.68). The percentage of children admitted to an ICU with an underlying comorbidity increased from 46.2% to 57.0% (RR, 1.23; 95% CI, 1.22-1.25), and the percentage with preadmission technology dependence increased from 16.4% to 23.5% (RR, 1.44; 95% CI, 1.40-1.48). The prevalence of multiple organ dysfunction syndrome increased from 6.8% to 21.0% (RR, 3.12; 95% CI, 2.98-3.26), while mortality decreased from 2.5% to 1.8% (RR, 0.72; 95% CI, 0.66-0.79). Hospital length of stay increased by 0.96 days (95% CI, 0.73-1.18) for ICU admissions from 2001 to 2019. After inflation adjustment, total costs for a pediatric admission involving ICU care nearly doubled between 2001 and 2019. Nationally, an estimated 239 000 children were admitted to a US ICU in 2019, corresponding to $11.6 billion in hospital costs.

Conclusions and Relevance

In this study, the prevalence of children receiving ICU care in the US increased, as did length of stay, technology use, and associated costs. The US health care system must be equipped to care for these children in the future.

Pediatric Critical Care Outcomes: State of the Science

Children who survive the pediatric intensive care unit (PICU) are at risk of developing post-intensive care syndrome in pediatrics (PICS-p). PICS-p, defined as new physical, cognitive, emotional, and/or social health dysfunction following critical illness, can affect the child and family. Historically, synthesizing PICU outcomes research has been challenging due to inconsistency in study design and in outcomes measurement. PICS-p risk may be mitigated by implementing intensive care unit best practices that limit iatrogenic injury and by supporting the resiliency of critically ill children and their families.

Risk factors of post-traumatic stress disorder after hospitalization in a pediatric intensive care unit: a systematic literature review

The number of studies on post-traumatic stress disorder after hospitalization in a pediatric intensive care unit raised since 2004. The objective of this systematic review was to summarize and critically examine the literature about risk factors for these children to develop post-traumatic stress disorder following admission to an intensive care unit. The data sources were PubMed, Cochrane, Web of Science, PsycInfo, SUDOC, Scopus, and ScienceDirect. Studies were selected if they were in English or French and published between 01/01/2004 and 31/01/2022. Studies were excluded if patients were less than 1 month old and if no post-traumatic stress disorder was found. The internal validity and risk of bias were assessed using the National Institutes of Health Study Quality Assessment Tools for observational studies and the Ottawa Scale was used for the interventional study. The search yielded 523 results and 22 articles met inclusion criteria. Three common risk factors were identified from the data: parental post-traumatic stress disorder (especially in mothers), severity of illness and delusional memories. Internalizing behavior in children, acute parent and child stress, emergency admission and sepsis are also potential risk factors that require further investigation. The prevalence of this pathology is substantial (between 14 and 36%) and increasing awareness among pediatricians and psychologists seems necessary. Prevention programs are being studied to reduce the incidence of post-traumatic stress disorder in this population. Child and adolescent psychiatry liaison should collaborate with pediatric teams to support this objective.

Incidence and associated factors of pediatric post-intensive care syndrome using the VSCAREMD model

Background: A novel comprehensive model called the VSCAREMD model has been proposed to detect post-intensive care syndrome (PICS) in children. This study aimed to outline the incidence of PICS in children using the VSCAREMD model and to describe the associated factors. Methods: All children ages 1 month to 15 years and admitted to the intensive care unit for at least 48 hours were evaluated using the VSCAREMD model within 1 week of intensive care discharge. The VSCAREMD model is used for evaluating vaccination, sleep, and parental care burden, which includes daily activity and social interaction, rehabilitation requirements, hearing, mood, and development. Abnormal findings were assorted into four domains: physical, cognitive, mental, and social. Descriptive statistics were performed using chi-square, univariate, and multivariate analyses.Results: A total of 78 of 95 children (82.1%) had at least one abnormal domain. Physical, cognitive, mental, and social morbidity were found in 64.2%, 26.3%, 13.7%, and 38.9% of the children, respectively. Prolonged intensive care unit stay greater than 7 days was associated with dysfunction in physical (adjusted odds ratio [aOR], 3.80; 95% confidence interval [CI], 1.31–11.00), cognitive (aOR, 10.11; 95% CI, 3.01–33.89), and social domains (aOR, 5.01; 95% CI, 2.01–12.73). Underlying medical conditions were associated with cognitive (aOR, 13.63; 95% CI, 2.64–70.26) and social morbidity (aOR, 2.81; 95% CI, 1.06–7.47). Conclusions: The incidence of PICS using the VSCAREMD model was substantially high and associated with prolonged intensive care. This model could help evaluate PICS in children.

Responding to the psychological needs of children following admission to paediatric Intensive Care for paediatric inflammatory multisystem syndrome: A Narrative Therapy based Photography Workshop

This article briefly describes the development of a novel narrative therapy-based photography workshop group for children following acute hospital admission for Paediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2 (PIMS-TS). The workshop was a collaboration between the psychology team, an artist and the medical multi-disciplinary team (MDT) to develop a group during the COVID-19 pandemic. The aims were to reduce isolation and promote resilience and psychological recovery post discharge from hospital. Nine children aged 8-11 years joined the photography group. Parents (n = 8) and children (n = 8) provided feedback on the group through semi-structured telephone interviews. Thematic analysis of the interviews identified three narrative themes for parents: reducing isolation through shared experience, creative activity as a different experience of hospital, and the positive sharing of experiences after the day. The resulting narrative themes for the children included that the workshop was a fun and interactive day and an opportunity to share in hospital experience with peers.

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.

Pediatric Medical Traumatic Stress (PMTS) following Surgery in Childhood and Adolescence: a Systematic Review

The purpose of the present review was to systematically review, synthesize and quantify prevalence rates of subclinical and clinical psychological symptoms in children and adolescents who have undergone surgery. Systematic literature searches were conducted twofold in April 8, 2020 and March 7, 2021 in PsycInfo and PubMed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Manuscripts were screened against eligibility criteria and were included if they investigated psychological symptoms in children or adolescents (age between 1 to 21 years at the time of study) who were hospitalized for pediatric surgery. Means and standard deviations weighted by sample size were calculated. Eleven articles met inclusion criteria. The review revealed that a small but substantial number of children and adolescents are at an elevated risk for postoperative psychological symptoms and disorders. Up to 13% had symptoms consistent with a diagnosis of a posttraumatic stress disorder, 6% to 8% exhibited elevated symptoms of depression or anxiety, and about 25% showed internalizing and externalizing symptoms. This review provides preliminary evidence that children and adolescents experience significant psychological distress and posttraumatic stress symptoms after pediatric surgery. Apart from better training of clinicians, prevention, early psychological screening and psychosocial care in surgical wards of hospitals are recommended. Well-designed studies of high methodological quality are necessary to replicate existing findings and provide a broader base of evidence.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00391-9.

Chronic critical illness and post-intensive care syndrome: from pathophysiology to clinical challenges

Background

Post‐intensive care syndrome (PICS) encompasses physical, cognition, and mental impairments persisting after intensive care unit (ICU) discharge. Ultimately it significantly impacts the long‐term prognosis, both in functional outcomes and survival. Thus, survivors often develop permanent disabilities, consume a lot of healthcare resources, and may experience prolonged suffering. This review aims to present the multiple facets of the PICS, decipher its underlying mechanisms, and highlight future research directions.

Main text

This review abridges the translational data underlying the multiple facets of chronic critical illness (CCI) and PICS. We focus first on ICU-acquired weakness, a syndrome characterized by impaired contractility, muscle wasting, and persisting muscle atrophy during the recovery phase, which involves anabolic resistance, impaired capacity of regeneration, mitochondrial dysfunction, and abnormalities in calcium homeostasis. Second, we discuss the clinical relevance of post-ICU cognitive impairment and neuropsychological disability, its association with delirium during the ICU stay, and the putative role of low-grade long-lasting inflammation. Third, we describe the profound and persistent qualitative and quantitative alteration of the innate and adaptive response. Fourth, we discuss the biological mechanisms of the progression from acute to chronic kidney injury, opening the field for renoprotective strategies. Fifth, we report long-lasting pulmonary consequences of ARDS and prolonged mechanical ventilation. Finally, we discuss several specificities in children, including the influence of the child’s pre-ICU condition, development, and maturation.

Conclusions

Recent understandings of the biological substratum of the PICS’ distinct features highlight the need to rethink our patient trajectories in the long term. A better knowledge of this syndrome and precipitating factors is necessary to develop protocols and strategies to alleviate the CCI and PICS and ultimately improve patient recovery.

[Child psychiatry in pediatric intensive care unit]

A study was conducted in the pediatric intensive care and resuscitation unit of the Nice pediatric hospitals, University Hospital Center Lenval (06) from January to March 2015. Its objective was to describe the events and child psychiatric interventions experienced by young patients. Of the 181 individuals managed during the research, 63 met the inclusion criteria.

The risk factors of the functional status, quality of life, and family psychological status in children with postintensive care syndrome: A cohort study

Background

Intensive care treatment has a side effect of several impairments after hospital discharge, known as postintensive care syndrome (PICS). PICS in children must be well evaluated because PICS can affect their global development and quality of life. Our specific aims are to determine the impact of intensive care treatment and the risk factors which contribute to PICS.

Methods

In this observational cohort study, we identified critically ill children treated in intensive care units (ICUs) for more than 24 h and survived. We evaluated the internal and external risk factors of the patients in the intensive care. We interviewed their parents to define the functional status and quality of life of the patients in 7 days before ICU admission and the psychological status of the family at the time of intensive care admission. The interview was repeated in 3 months after the intensive care discharge.

Results

There was a significant decrease in functional status and quality of life after intensive care treatment (P < 0.001). However, none of the internal risk factors were significantly associated with PICS. Neurologic involvement in the disease was associated with the significantly reduced functional status of patients, while the severity of the disease was significantly associated with both functional status and quality of life. Our study also showed a significant psychological disorder of the family in the intensive care.

Conclusion

The occurrence of PICS in children was associated with the severity of the disease, decreased the functional status and quality of life, and contributed to psychological disorders for the family.

Nurse-driven early rehabilitation protocol for critically ill children

BACKGROUND

Physical impairment is a major morbidity in children surviving intensive care. The main objective of this study was to evaluate the effectiveness of a nurse-driven protocol in the early mobilization of critically ill children in terms of reduction of motor dysfunction, pediatric intensive care unit stays, and ventilator days. The secondary objective was to evaluate safety, in terms of injury, dislodgement of medical devices, and cardiorespiratory instability attributable to the intervention.

METHODS

The early rehabilitation intervention was initiated in July 2020. This retrospective interrupted time-series study was divided into the pre-implementation phase (January-June 2020) and the post-implementation phase (July-December 2020). The motor function domain of the Functional Status Scale was used to define the motor dysfunction after pediatric intensive care unit discharge.

RESULTS

Twenty-five children were allocated in each group. The median age of the whole cohort was 11.5 months and approximately 58% of the population was male. The baseline characteristics of both groups were not statistically significant. There was a statistically significant reduction in motor dysfunction after protocol implementation (64.0% vs 36.0%; P = 0.044) with an absolute risk reduction of 28%. The number needed to treat was 3.6 children. There were no statistically significant differences in the median ventilator days, length of stay in the intensive care unit, and hospital length of stay. No complications were found.

CONCLUSIONS

A nurse-driven protocol for the early mobilization of critically ill children was feasible and could be effective in reducing post-intensive care motor dysfunction.

Risk Factors for Physical Function Impairments in Postintensive Care Syndrome: A Scoping Review

OBJECTIVE

Survivors of critical illness may experience short- and long-term physical function impairments. This review aimed to identify the risk factors for physical function impairments from the current literature.

DATA SOURCES

A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guideline was performed.

STUDY SELECTION

The risk factors reported in all human studies reporting physical function impairments in children admitted to the pediatric intensive care unit (PICU) were reviewed and categorized. Two investigators independently screened, evaluated, and selected studies for inclusion. Data from eligible studies were extracted by one investigator, and another investigator reviewed and verified the data. A systematic narrative approach was employed to review and summarize the data.

RESULTS

A total of 264 studies were found to be eligible, with 19 studies meeting the inclusion criteria. Children admitted to the PICU experienced physical function impairments during their stay, which can last for years. The studies varied primarily in the measurement timing and tools used. The most frequently reported risk factors for physical function impairments were age, race or ethnicity, a pre-admission chronic condition, sex, disease severity, duration or the presence of mechanical ventilation, and admission diagnosis.

CONCLUSIONS

Physical function impairments may be persistent in PICU survivors. To prevent these impairments in critically ill patients, pediatricians should pay attention to modifiable risk factors, such as the duration of mechanical ventilation. Future studies need to promote a combination of standardized measures for the detection and prevention of physical function impairments.

Current Knowledge Regarding Long-Term Consequences of Pediatric Intensive Care: A Staff Survey in Intensive Care Units in German-Speaking Countries

BACKGROUND

The Post Intensive Care Syndrome (PICS) describes new impairments of physical, cognitive, social, or mental health after critical illness. In recent years, prevention and therapy concepts have been developed. However, it is unclear whether and to what extent these concepts are known and implemented in hospitals in German-speaking countries.

METHODS

We conducted an anonymous online survey in German-speaking pediatric intensive care units on the current state of knowledge about the long-term consequences of intensive care treatment as well as about already established prevention and therapy measures. The request to participate in the survey was sent to the heads of the PICUs of 98 hospitals.

RESULTS

We received 98 responses, 54% of the responses came from nurses, 43% from physicians and 3% from psychologist, all working in intensive care. As a main finding, our survey showed that for only 31% of the respondents PICS has an importance in their daily clinical practice. On average, respondents estimated that about 42% of children receiving intensive care were affected by long-term consequences after intensive care. The existence of a follow-up outpatient clinic was mentioned by 14% of the respondents. Frequent reported barriers to providing follow-up clinics were lack of time and staff. Most frequent mentioned core outcome parameters were normal developmental trajectory (59%) and good quality of life (52%).

CONCLUSION

Overall, the concept of PICS seems to be underrepresented in German-speaking pediatric intensive care units. It is crucial to expand knowledge on long-term complications after pediatric critical care and to strive for further research through follow-up programs and therewith ultimately improve long-term outcomes.

Post-Intensive Care Syndrome in Children: A Concept Analysis

PROBLEM

Post-intensive care syndrome in paediatrics (PICS-p) is a term used to describe newly acquired or worsened impairment in one or more aspects of a child's physical, psychological, cognitive, and social functioning after discharge from the paediatric intensive care unit (PICU). However, consensus, conceptual insights, and assessment guidance are lacking for this syndrome. Therefore, this analysis aimed to define the concept of PICS-p to help practitioners and researchers understand the syndrome in detail using the Walker and Avant approach.

ELIGIBILITY CRITERIA

We reviewed studies retrieved from several databases, namely PubMed, Google Scholar, Web of Science, Ovid, ScienceDirect, and the Springer database, using the following keywords: 'post-intensive care syndrome', 'PICU', 'children', 'PICS-p', and 'concept analysis'. Both quantitative and qualitative studies on PICS-p were included in the search. The articles were limited to those published up to November 21, 2020.

SAMPLE

Of the 762 publications selected, 24 publications met the inclusion criteria.

RESULTS

PICS-p is defined on the basis of the following aspects: (1) Physical dysfunction; (2) Cognitive dysfunction; (3) Psychological dysfunction; and (4) Social dysfunction.

CONCLUSION

With the increasing success rate of PICU treatment, reduced case fatality is no longer the only outcome of critical illness in children. The long-term outcomes in children discharged from hospitals have attracted attention from families, hospitals, and communities.

IMPLICATIONS

A clear definition of PICS-p will help medical staff understand PICS-p in detail and provide a theoretical basis for the diagnosis and treatment of this syndrome.

Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice

Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.

Pediatric postintensive care syndrome: high burden and a gap in evaluation tools for limited-resource settings

This article aimed to summarize the impact and burden of pediatric postintensive care syndrome (PICS-p) in the physical, mental, cognitive, and social health domains after a review of the current pediatric literature in MEDLINE and PubMed. We also aimed to elucidate the limitations of the current evaluation tools used in limited-resource settings. PICS-p can impact a child's life for decades. Most validated tools are time-consuming, require qualifications, and expertise, are often limited to older children, and can evaluate only one domain. A novel, simple, and comprehensive surveillance tool can aid healthcare providers in the early detection and intervention of PICS-p. Further studies should validate and refine the parameters that will enhance the outcomes of pediatric intensive care unit survivors.

Pediatric Critical Care Nurses' Practices Related to Sedation and Analgesia

BACKGROUND

Pediatric intensive care unit (PICU) nurses may consider additional factors beyond validated tools when managing pain and sedation of children. However, these other factors and related beliefs, practices, and decision-making for analgesia and sedation have not been well described.

OBJECTIVES

This study describes nurses' beliefs, practices, and decision-making related to sedation and analgesia for mechanically ventilated children on a PICU and a pediatric cardiovascular ICU at a tertiary academic children's medical center in the United States.

METHODS

A 35-item web-based survey tool was developed to more fully identify nurses' pain, sedation, comfort, and analgesia beliefs, decisions, planning, and procedures for children who were mechanically ventilated in the ICU. It was distributed to 102 nurses in the PICU, pediatric cardiovascular ICU, and pediatric critical care float pool.

RESULTS

Twenty-six nurses (25%) responded; a majority worked the night shift and had 5 years or less of ICU experience. While participants believed intubated pediatric patients required moderate to deep sedation, approximately only half reported patients were adequately sedated. They reported that they were more likely to manage pain and sedation using specific behaviors and changes in vital signs than scores on a standardized scale. Nurses also reported routinely incorporating nonpharmacologic comfort measures. Premedication was more common for invasive procedures than for routine nursing care.

DISCUSSION

Pediatric ICU nurses in this study considered factors beyond standardized scales when evaluating and managing pain and sedation of ventilated children. Nurses prioritized children's specific behaviors, vital signs, and their own nursing judgment above standardized scales. Research is needed to describe nurses' practices beyond this small study and to define and validate additional assessment parameters to incorporate into decision-making to improve management and care outcomes.

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.

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.

Sleep in the Hospitalized Child: A Contemporary Review

Acute illness and hospitalization introduce several risk factors for sleep disruption in children that can negatively affect recovery and healing and potentially compromise long-term cognition and executive function. The hospital setting is not optimized for pediatric sleep promotion, and many of the pharmacologic interventions intended to promote sleep in the hospital actually may have deleterious effects on sleep quality and quantity. To date, evidence to support pharmacologic sleep promotion in the pediatric inpatient setting is sparse. Therefore, nonpharmacologic interventions to optimize sleep-wake patterns are of highest yield in a vulnerable population of patients undergoing active neurocognitive development. In this review, we briefly examine what is known about healthy sleep in children and describe risk factors for sleep disturbances, available sleep measurement tools, and potential interventions for sleep promotion in the pediatric inpatient setting.

Systemic Inflammation Is Associated With Neurologic Involvement in Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2

Objective

Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a severe immune-mediated disorder. We aim to report the neurologic features of children with PIMS-TS.

Methods

We identified children presenting to a large children's hospital with PIMS-TS from March to June 2020 and performed a retrospective medical note review, identifying clinical and investigative features alongside short-term outcome of children presenting with neurologic symptoms.

Results

Seventy-five patients with PIMS-TS were identified, 9 (12%) had neurologic involvement: altered conciseness (3), behavioral changes (3), focal neurology deficits (2), persistent headaches (2), hallucinations (2), excessive sleepiness (1), and new-onset focal seizures (1). Four patients had cranial images abnormalities. At 3-month follow-up, 1 child had died, 1 had hemiparesis, 3 had behavioral changes, and 4 completely recovered. Systemic inflammatory and prothrombotic markers were higher in patients with neurologic involvement (mean highest CRP 267 vs 202 mg/L, p = 0.05; procalcitonin 30.65 vs 13.11 μg/L, p = 0.04; fibrinogen 7.04 vs 6.17 g/L, p = 0.07; d-dimers 19.68 vs 7.35 mg/L, p = 0.005). Among patients with neurologic involvement, these markers were higher in those without full recovery at 3 months (ferritin 2284 vs 283 μg/L, p = 0.05; d-dimers 30.34 vs 6.37 mg/L, p = 0.04). Patients with and without neurologic involvement shared similar risk factors for PIMS-TS (Black, Asian and Minority Ethnic ethnicity 78% vs 70%, obese/overweight 56% vs 42%).

Conclusions

Broad neurologic features were found in 12% patients with PIMS-TS. By 3-month follow-up, half of these surviving children had recovered fully without neurologic impairment. Significantly higher systemic inflammatory markers were identified in children with neurologic involvement and in those who had not recovered fully.

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.

Family Members' Perceptions of Their Psychological Responses One Year Following Pediatric Intensive Care Unit (PICU) Hospitalization: Qualitative Findings From the Caring Intensively Study

Introduction: PICU hospitalization can have a profound impact on child survivors and their families. There is limited research on children's long-term recovery within the context of the family following critical illness. This study aimed to explore children's and parents' perceptions of long-term psychological and behavioral responses within the context of the family one year following PICU hospitalization. Materials and Methods: Caring Intensively is a mixed methods multi-site prospective cohort study that aims to examine children's psychological and behavioral responses over a 3-year period following PICU hospitalization. In this study, part of the qualitative arm of Caring Intensively, an interpretive descriptive design was used to explore children's recovery one year post-discharge. Purposive sampling was used to select 17 families, including 16 mothers, 6 fathers, and 9 children. Semi-structured, audio-recorded interviews were conducted. Data were analyzed iteratively using the constant comparison method. Results: Families described efforts to readapt to routine life and find a new normal following PICU hospitalization. Finding a New Normal consisted of four major themes: (1) Processing PICU Reminders and Memories, (2) Changing Perceptions of Health and Illness, (3) We Are Not the Same, and (4) Altered Relationships. Participants described significant emotional and behavioral changes during the year following discharge. The psychological impact of individual family members' experiences led to changes in their sense of self, which affected family dynamics. PICU memories and reminders impacted participants' perceptions of childhood health and illness and resulted in increased vigilance. Parents and siblings demonstrated increased concern for the child survivor's health, and the experience of long absences and new or altered caregiving roles resulted in changes in relationships and family dynamics. Conclusion: PICU hospitalization impacted the psychological well-being of all family members as they sought to re-establish a sense of normalcy one year following discharge. Parent and child experiences and responses were closely interconnected. Findings highlight the importance of increased follow-up care aimed at supporting the family's psychological recovery.

School Performance After Pediatric Intensive Care-Association of Mental Well-Being, Chronic Illnesses, and Family Socioeconomic Status

OBJECTIVES

To describe school performance in pediatric intensive care survivors, as well as the influence of chronic diseases, psychological well-being, and family socioeconomic status on poor school performance.

DESIGN

Register-based observational descriptive follow-up study.

SETTING

A multicenter national study.

PATIENTS

All pediatric patients who were admitted to an ICU in Finland in 2009-2010. Children and adolescents of or beyond school age.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Questionnaires regarding the child's coping in school classes, chronic illnesses, as well as family socioeconomic factors were sent to every child alive 6 years after discharge from intensive care in Finland. Mental well-being was measured with the Strengths and Difficulties Questionnaire. There were 1,109 responders in an ICU group of 3,674 children. Seven-hundred fifty-three of the respondents were of school age or older. Of these, 13% (101/753) demonstrated poor school performance. Children with difficulties in school more often had a need for regular medication (71.3% vs 32.4%; p < 0.001), healthcare visits (91.1% vs 80.6%; p = 0.01), some regular therapy (60.4% vs 13.7%; p < 0.001), chronic illnesses (86.3% vs 48.4%; p < 0.001), or additional ICU admissions (36.5% vs 14.9%; p = 0.003). Schooling difficulties were reported more often in children with abnormal Strengths and Difficulties Questionnaire scores compared to those with normal or borderline scores (24.8% vs 5.4%; p < 0.001). In an adjusted logistic regression model, which included age, number of chronic diseases, and need for therapy, poor school performance was predicted by abnormal Strengths and Difficulties Questionnaire scores, nonacademic parental education, and paternal manual labor status.

CONCLUSIONS

Difficulties in school were more frequent when the child had chronic comorbid illnesses, especially neurologic or chromosomal abnormalities, had poor mental health, father was employed in manual labor, or parents were uneducated.

Variations in pediatric hospitalization in seven European countries

OBJECTIVE

To compare rates of pediatric hospital utilization across seven European countries.

METHODS

Secondary data from WHO's European Hospital Morbidity Database from 2009 to 2012. Cross- country comparison of rates of admissions and bed days per 100 person-years by clinical service. We tabulated counts of admissions and bed days by principal diagnosis and age group for Ireland, Austria, Hungary, Belgium, Spain, Germany, and France. ICD 9 or ICD 10 or ISHMT diagnosis codes were allocated to clinical services. Normal newborn admissions were excluded from the analysis. Simple linear regression models, weighted by pediatric population size, were constructed to estimate the relationships between health care utilization and factors that may influence variation in care.

RESULTS

Hospital admission across the seven countries ranged from 9.41 (Spain) to 19.59 (Germany) admissions per 100 person-years. Bed days ranged from a low of 52.50 (Spain) to 135.44 (Germany) per 100 person-years. General pediatrics and neonatology led in clinical volume across all countries. Infectious disease admissions were the third most common. Bed supply and nurse supply were positively associated with health care utilization. Out-of-pocket payment was inversely associated with health care utilization CONCLUSIONS: A wide range of utilization of pediatric inpatient care was observed across seven European countries that have universal coverage. Variation in the provision of effective, supply-sensitive, and preference-sensitive care may explain some of the variations. Our study shows that it is probable that preventable hospital admissions are occurring in the pediatric population.

Exposure to Anticholinergic Medications in Pediatric Severe Sepsis and Feasibility of Delirium Screening

In sepsis, anticholinergic dysregulation may result in encephalopathy or delirium during severe illness, either as a result of central inflammation or because of exposure to medications with anticholinergic activity. In this retrospective study, we determined the magnitude of anticholinergic drug exposure in 75 children with severe sepsis. We found that exposure over the first 5 days was high-median (interquartile range) daily anticholinergic drug scale score 4 (2-5)-and associated with higher vasoactive scores and death. We conclude that anticholinergic drug exposure is significant in severe sepsis, which means it may be a modifiable factor that should be studied further.

Association Between Resilience and Psychological Morbidity in Parents of Critically Ill Children

OBJECTIVE

To determine whether parental resilience, measured at ICU admission, is associated with parent-reported symptoms of depression, anxiety, posttraumatic stress, and satisfaction with ICU care 3-5 weeks following ICU discharge.

DESIGN

Planned prospective, observational study nested in a randomized comparative trial.

SETTING

PICUs and cardiac ICUs in two, free-standing metropolitan area children's hospitals.

PARTICIPANTS

English- and Spanish-speaking parents whose children were younger than 18 years old and had anticipated ICU stay of greater than 24 hours or Pediatric Index of Mortality score of greater than or equal to 4 at the time of consent. All ICU admissions were screened for inclusion. Of 4,251 admissions reviewed, 1,360 were eligible. Five hundred families were approached and 382 enrolled. Two hundred thirty-two parents from 210 families with complete data were included in analysis.

INTERVENTIONS

All participating parents completed the Connor-Davidson Resilience Scale at the time of consent and outcome measures 3-5 weeks after ICU discharge.

MEASUREMENTS AND MAIN RESULTS

All parents completed the Patient-Reported Outcome Measurement Information System Short Forms 8a for Depression and Anxiety, Impact of Event Scale-Revised for posttraumatic stress, and Pediatric Family Satisfaction-ICU 24 for parental satisfaction 3-5 weeks after ICU discharge. Higher parental resilience was associated with fewer symptoms of depression, anxiety, and posttraumatic stress in the final model (all p < 0.0001). Shorter length of stay, early mechanical ventilation, Latino ethnicity, and lower illness severity (both objective and parental perceptions) were associated with less morbidity in some or all measured mental health outcomes.

CONCLUSIONS

Higher parental resilience is associated with fewer reported symptoms of anxiety, depression, and posttraumatic stress 3-5 weeks after ICU discharge. Parental resilience may impact parental post-ICU psychological morbidity. Measuring parental resilience could be one approach to identify parents at risk for post-ICU psychological morbidity. Future research into the impact of interventions designed to boost parental resilience is warranted.

Sleep-Wake Disturbances After Acquired Brain Injury in Children Surviving Critical Care

BACKGROUND

Sleep-wake disturbances are underevaluated among children with acquired brain injury surviving critical care. We aimed to quantify severity, phenotypes, and risk factors for sleep-wake disturbances.

METHODS

We performed a prospective cohort study of 78 children aged ≥3 years with acquired brain injury within three months of critical care hospitalization. Diagnoses included traumatic brain injury (n = 40), stroke (n = 11), infectious or inflammatory disease (n = 10), hypoxic-ischemic injury (n = 9), and other (n = 8). Sleep Disturbances Scale for Children standardized T scores measured sleep-wake disturbances. Overall sleep-wake disturbances were dichotomized as any total or subscale T score ≥60. Any T score ≥70 defined severe sleep-wake disturbances. Subscale T scores ≥60 identified sleep-wake disturbance phenotypes.

RESULTS

Sleep-wake disturbances were identified in 44 (56%) children and were classified as severe in 36 (46%). Sleep-wake disturbances affected ≥33% of patients within each diagnosis and were not associated with severity of illness measures. The most common phenotype was disturbance in initiation and maintenance of sleep (47%), although 68% had multiple concurrent sleep-wake disturbance phenotypes. One third of all patients had preadmission chronic conditions, and this increased risk for sleep-wake disturbances overall (43% vs 21%, P = 0.04) and in the traumatic brain injury subgroup (52% vs 5%, P = 0.001).

CONCLUSIONS

Over half of children surviving critical care with acquired brain injury have sleep-wake disturbances. Most of these children have severe sleep-wake disturbances independent of severity of illness measures. Many sleep-wake disturbances phenotypes were identified, but most children had disturbance in initiation and maintenance of sleep. Our study underscores the importance of evaluating sleep-wake disturbances after acquired brain injury.

Increased Psychiatric Risk in Children After Pediatric Intensive Care Unit Admission

We aimed to assess psychiatric risk in children after admission to pediatric intensive care units (PICUs) and its association with greater psychiatric morbidity. We examined 130 children aged 6 to 13 years in a cross-sectional study divided into two groups: 65 children discharged from PICU and another 65 from general wards. The PICU group scored worse on all measured scales of psychiatric morbidities. The child-specific assessment methods included the posttraumatic stress disorder (PTSD) scale as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and Impact of Event Scale Revised for PTSD; Revised Children's Manifest Anxiety Scale for anxiety; and Birleson Depression Scale for depression. The PICU group had significantly higher frequencies of PTSD compared with the general ward group (84.6% vs. 6.2%, respectively; p < 0.001). Hence, PICU survivors have higher risk of psychiatric morbidities such as PTSD, anxiety, and depression compared with general ward patients.

Gross motor developmental dysfunctional outcomes in infantile and toddler pediatric intensive care unit survivors

Background

Increasing studies have focused on motor function/dysfunction in PICU survivors; however, most studies have focused on adults and older children. This study investigated gross motor developmental function outcomes in infantile and toddler pediatric intensive care unit (PICU) survivors and the factors associated with gross motor developmental functions.

Methods

This observational study was conducted in the PICU of the First Hospital of Jilin University between January 2019 and March 2019. Thirty-five eligible patients were divided into the dysfunctional (n = 24) or non-dysfunctional (n = 11) group according to the results of the Peabody Developmental Motor Scales, Second Edition (PDMS-2). Baseline gross motor function for all participants before PICU admission was measured via the Age and Stages Questionnaires, Third Edition (ASQ-3). The PDMS-2 was used to evaluate gross motor development function before PICU discharge.

Results

The gross motor developmental dysfunction incidence was 68.6%. Linear correlation analysis showed that the gross motor quotient (GMQ) was positively correlated with the pediatric critical illness score (PCIS, r = 0.621, P < 0.001), and negatively correlated with length of PICU stay (r = − 0.556, P = 0.001), days sedated (r = − 0.602, P < 0.001), days on invasive mechanical ventilation (IMV; r = − 0.686, P < 0.001), and days on continuous renal replacement therapy (CRRT; r = − 0.538, P = 0.001). Linear regression analysis showed that IMV days (β = − 0.736, P = 0.001), sepsis (β = − 18.111, P = 0.003) and PCIS (β = 0.550, P = 0.021) were independent risk factors for gross motor developmental dysfunction.

Conclusions

Gross motor developmental dysfunction in infantile and toddler PICU survivors is more common and may be exacerbated by experiences associated with longer IMV days and increasing illness severity combined with sepsis.

Trial registration

The trial ‘Early rehabilitation intervention for critically ill children’ has been registered at http://www.chictr.org.cn/showproj.aspx?proj=23132. Registration number: ChiCTR1800020196.

Neighborhood Poverty and Pediatric Intensive Care Use

BACKGROUND

Disparities in health service use have been described across a range of sociodemographic factors. Patterns of PICU use have not been thoroughly assessed.

METHODS

This was a population-level, retrospective analysis of admissions to the Cincinnati Children's Hospital Medical Center PICU between 2011 and 2016. Residential addresses of patients were geocoded and spatially joined to census tracts. Pediatric patients were eligible for inclusion if they resided within Hamilton County, Ohio. PICU admission and bed-day rates were calculated by using numerators of admissions and bed days, respectively, over a denominator of tract child population. Relationships between tract-level PICU use and child poverty were assessed by using Spearman's ρ and analysis of variance. Analyses were event based; children admitted multiple times were counted as discrete admissions.

RESULTS

There were 4071 included admissions involving 3129 unique children contributing a total of 12 297 PICU bed days. Child poverty was positively associated with PICU admission rates (r = 0.59; P < .001) and bed-day rates (r = 0.47; P < .001). When tracts were grouped into quintiles based on child poverty rates, the PICU bed-day rate ranged from 23.4 days per 1000 children in the lowest poverty quintile to 81.9 days in the highest poverty quintile (P < .001).

CONCLUSIONS

The association between poverty and poor health outcomes includes pediatric intensive care use. This association exists for children who grow up in poverty and around poverty. Future efforts should characterize the interplay between patient- and neighborhood-level risk factors and explore neighborhood-level interventions to improve child health.

Strengths and Difficulties Questionnaire Assessment of Long-Term Psychological Outcome in Children After Intensive Care Admission

OBJECTIVES

We investigated the long-term psychologic symptoms of patients who survived pediatric intensive care admission.

DESIGN

Longitudinal follow-up study.

SETTING

Nationwide cohort study based on a national ICU register and a questionnaire survey.

PATIENTS

All pediatric patients (0-16 yr old) who were admitted to an ICU in Finland in 2009-2010.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six years after ICU admission, all surviving patients were sent the Strengths and Difficulties Questionnaire, and questionnaires regarding chronic diseases and need for medication and therapy. At the end of the follow-up period, there were 3,674 surviving children who had been admitted to an ICU in 2009-2010. Of these children, 1,105 completed the Strengths and Difficulties Questionnaire 6 years after admission. Strengths and Difficulties Questionnaire scores were abnormal for 84 children (7.6%), borderline for 80 (7.2%), and normal for 941 (85.2%). Participants with abnormal scores were younger at admission to the ICU (3.06 vs 4.70 yr; p = 0.02), and more commonly had a chronic disease (79.5% vs 47.4%; p < 0.001), a need for continuous medication (49.4% vs 31.7%; p < 0.001), a need for therapy (58.5% vs 15.9%; p < 0.001), and a need for annual healthcare visits (91.4% vs 85.2%; p = 0.05). Abnormal Strengths and Difficulties Questionnaire scores were associated with higher rates of neurologic (32.1% vs 10.2%), gastrointestinal (7.1% vs 3.9%), psychiatric (3.6% vs 0.5%), and chromosomal disorders (9.5% vs 1.3%), as well as with long-term pain (1.2% vs 0.6%).

CONCLUSIONS

Participants with abnormal Strengths and Difficulties Questionnaire scores (poor psychologic outcome) at 6 years after childhood ICU admission more commonly suffered neurologic, chromosomal, or psychiatric diagnoses or long-term pain, and generally required higher levels of healthcare services, therapies, and medication.

Risk Factors for Functional Decline and Impaired Quality of Life after Pediatric Respiratory Failure

Rationale: Poor outcomes of adults surviving critical illness are well documented, but data in children are limited.Objectives: To identify factors associated with worse postdischarge function and health-related quality of life (HRQL) after pediatric acute respiratory failure.Methods: We assessed functional status at baseline, discharge, and 6 months after pediatric ICU discharge and HRQL 6 months after discharge in 2-week- to 17-year-olds mechanically ventilated for acute respiratory failure in the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) trial. We assessed HRQL via Infant and Toddler Quality of Life Questionnaire-97 (<2 yr old) or Pediatric Quality of Life Inventory (≥2 yr old). We categorized patients with normal baseline function as having impaired HRQL if scores were greater than 1 SD below mean norms for Infant and Toddler Quality of Life Questionnaire-97 growth and development or Pediatric Quality of Life Inventory total score.Measurements and Main Results: One-fifth (n = 192) of 949 patients declined in function from baseline to postdischarge; 20% (55/271) had impaired growth and development; 19% (64/343) had impaired HRQL. In multivariable analyses, decline in function was associated with baseline impaired function, prematurity, cancer, respiratory failure etiology, ventilation duration, and clonidine (odds ratio [OR] = 2.14; 95% confidence interval [CI] = 1.22-3.76). Independent predictors of impaired growth and development included methadone (OR = 2.27; 95% CI = 1.18-4.36) and inadequate pain management (OR = 2.94; 95% CI = 1.39-6.19). Impaired HRQL was associated with older age, non-white or Hispanic race, cancer, and inadequate sedation management (OR = 3.15; 95% CI = 1.74-5.72).Conclusions: Postdischarge morbidity after respiratory failure is common and associated with admission factors, exposure to critical care therapies, and pain and sedation management.

PICU Follow-Up: The Impact of Missed School in a Cohort of Children Following PICU Admission

For children and their families, PICU admission can be one of the most stressful and traumatic experiences in their lives. Children admitted to the PICU and their parents experience sequelae following admission including psychologic symptoms and lower health-related quality of life. The impact of a PICU admission on school attendance and performance may influence these sequelae. The purpose of our study was to examine how community supports from pediatricians and schools influence school success after critical illness.

DESIGN

Parents were recruited during their child's admission to the PICU. Three months after discharge, parents completed follow-up questionnaires via telephone.

SETTING

PICU in an urban academic children's hospital.

SUBJECTS

Thirty-three parents were enrolled in the study, and 21 (64%) completed phone follow-up.

MEASUREMENTS AND MAIN RESULTS

Forty-three percent of children missed 7 or more days of school while admitted to the PICU. Sixty-seven percent of parents reported that their pediatrician did not ask about missed school, and 29% felt their child's grades worsened since admission. Twenty percent of respondents felt that their child's school did not provide adequate services to help their child catch up.

CONCLUSIONS

There are missed opportunities for care coordination and educational support after critical illness. The transition back to school is challenging for some children, as reported by parents who described inadequate support from the school after PICU hospitalization and a subsequent decline in their child's school performance. Additional studies are needed to develop proactive community supports to improve the transition back to school for a child after critical illness.

Self-Reported Fatigue in Children Following Intensive Care Treatment

OBJECTIVES

Adults report high levels of fatigue after intensive care, but little is known about pediatric survivors. This study aimed to explore rates of self-reported fatigue in children after critical illness.

DESIGN

Prospective cohort study.

SETTING

Tertiary children's hospital.

PATIENTS

Ninety-seven children aged 7-17 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Children completed the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale 3 months after discharge from PICU. Comparisons with normative data (n = 209) showed that PICU survivors reported similar mean (SD) total fatigue scores to their healthy peers (79.6 [16.3] vs 81.8 [12.5]; p = 0.239), but greater cognitive fatigue (77.4 [21.9] vs 82.4 [16.4]; p = 0.048). Also children who had sustained a traumatic brain injury reported "less" sleep/rest fatigue (84.6 [15.0] vs 76.8 [16.3]; p = 0.006). Baseline indices of severity of illness were not associated with fatigue.

CONCLUSIONS

The Pediatric Quality of Life Inventory Multidimensional Fatigue Scale appears to be a promising tool for use in outcomes research with PICU survivors. These results highlight the need to bear in mind the heterogeneity of PICU patients and the multidimensional nature of fatigue symptoms.

Supporting Optimal Neurodevelopmental Outcomes in Infants and Children With Congenital Heart Disease

Improved survival has led to increased recognition of developmental delays in infants and children with congenital heart disease. Risk factors for developmental delays in congenital heart disease survivors may not be modifiable; therefore, it is important that lifesaving, high-technology critical care interventions be combined with nursing interventions that are also developmentally supportive. Implementing developmental care in a pediatric cardiac intensive care unit requires change implementation strategies and widespread support from all levels of health care professionals. This manuscript reviews developmentally supportive interventions such as massage, developmentally supportive positioning, kangaroo care, cue-based feeding, effective pain/anxiety management, and procedural preparation and identifies strategies to implement developmentally supportive interventions in the care of infants and children with congenital heart disease. Improving developmental support for these infants and children at high risk for developmental delay may improve their outcomes and help promote family-centered care.