Children's self-reported quality of life after intensive care treatment

Adherence with post-hospitalization follow-up after pediatric critical illness due to respiratory failure

BACKGROUND

Adherence with follow-up appointments after a pediatric intensive care unit (PICU) admission is likely a key component in managing post-PICU sequalae. However, prior work on PICU follow-up adherence is limited. The objective of this study is to identify hospitalization characteristics, discharge child health metrics, and follow-up characteristics associated with full adherence with recommended follow-up at a quaternary care center after a PICU admission due to respiratory failure.

METHODS

We conducted a retrospective cohort study of patients ≤ 18 years with respiratory failure admitted between 1/2013-12/2014 to a quaternary care PICU. Post-hospitalization full adherence with recommended follow-up in the two years post discharge (1/2013-3/2017) at the quaternary care center was quantified and compared by demographics, baseline child health metrics, hospitalization characteristics, discharge child health metrics, and follow-up characteristics in bivariate and multivariate analyses. Patients were dichotomized into being non-adherent with follow-up (patients who attended less than 100% of recommended appointments at the quaternary care center) and fully adherent (patients who attended 100% of recommended appointments at the quaternary care center).

RESULTS

Of 155 patients alive at hospital discharge, 140 (90.3%) were recommended to follow-up at the quaternary care center. Of the 140 patients with recommended follow-up at the quaternary care center, 32.1% were non-adherent with follow-up and 67.9% were fully adherent. In a multivariable logistic regression model, each additional recommended unique follow-up appointment was associated with lower odds of being fully adherent with follow-up (OR 0.74, 95% CI 0.60-0.91, p = 0.005), and each 10% increase in the proportion of appointments scheduled before discharge was associated with higher odds of being fully adherent with follow-up (OR 1.02, 95% CI 1.01-1.03, p = 0.004).

CONCLUSIONS

After admission for acute respiratory failure, only two-thirds of children were fully adherent with recommended follow-up at a quaternary care center. Our findings suggest that limiting the recommended follow-up to only key essential healthcare providers and working to schedule as many appointments as possible before discharge could improve follow-up adherence. However, a better understanding of the factors that lead to non-adherence with follow-up appointments is needed to inform broader system-level approaches could help improve PICU follow-up adherence.

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.

Stress Symptoms Among Children and Their Parents After ICU Hospitalization

Objective: Child survival after intensive care unit (ICU) hospitalization has increased, yet many children experience acute stress that may precipitate mental/behavioral health comorbidities. Parents report stress after their child's hospitalization. Little is known about the individual and family characteristics that may moderate intergenerational relationships of acute stress. Design: Following ICU admission at a large academic medical center, a prospective cross-sectional cohort study assessed the associations between intergenerational characteristics and acute stress among children and families. Patients: Parent-child dyads (N = 88) were recruited from the pediatric ICU and pediatric cardiovascular ICU (CVICU) following ICU discharge. Eligible children were between 8 and 18 years old with ICU stays longer than 24 hours. Children with developmental delays were excluded. Caregivers were proficient in English or Spanish. Surveys were collected before hospital discharge. Measurements/Main Results: The primary outcome was "child stress" defined as a score≥17, measured by the Children's Revised Impact of Events Scale (CRIES-8). "Parent stress" was defined as an elevated composite score on the Stanford Acute Stress Reaction Questionnaire. We used validated scales to assess the child's clinical and family social characteristics. Acute stress was identified in 34 (39.8%) children and 50 (56.8%) parents. In multivariate linear regression analyses adjusting for social characteristics, parent stress was associated with increased risk of child stress (adjusted odds ratio 2.58, 95% confidence interval 0.69, 4.46, p < .01). In unadjusted analyses, Hispanic ethnicity was associated with greater child stress. In adjusted analyses, race, income, ICU length of stay, and language were not associated with child stress and did not moderate the parent-child stress relationship. Conclusions: Parent stress is closely correlated with child stress during ICU hospitalization. Hispanic ethnicity may be associated with increased risk for child stress, but further studies are required to define the roles of other social and clinical measures.

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.

Predicting functional and quality-of-life outcomes following pediatric sepsis: performance of PRISM-III and PELOD-2

BACKGROUND

Illness severity scores predict mortality following pediatric critical illness. Given declining PICU mortality, we assessed the ability of the Pediatric Risk of Mortality-III (PRISM) and Pediatric Logistic Organ Dysfunction-2 (PELOD) scores to predict morbidity outcomes.

METHODS

Among 359 survivors <18 years in the Life After Pediatric Sepsis Evaluation multicenter prospective cohort study, we assessed functional morbidity at hospital discharge (Functional Status Scale increase ≥3 points from baseline) and health-related quality of life (HRQL; Pediatric Quality of Life Inventory or Functional Status II-R) deterioration >25% from baseline at 1, 3, 6, and 12 months post-admission. We determined discrimination of admission PRISM and admission, maximum, and cumulative 28-day PELOD with functional and HRQL morbidity at each timepoint.

RESULTS

Cumulative PELOD provided the best discrimination of discharge functional morbidity (area under the receive operating characteristics curve [AUROC] 0.81, 95% CI 0.76-0.87) and 3-month HRQL deterioration (AUROC 0.71, 95% CI 0.61-0.81). Prediction was inferior for admission PRISM and PELOD and for 6- and 12-month HRQL assessments.

CONCLUSIONS

Illness severity scores have a good prediction of early functional morbidity but a more limited ability to predict longer-term HRQL. Identification of factors beyond illness severity that contribute to HRQL outcomes may offer opportunities for intervention to improve outcomes.

IMPACT

Illness severity scores are commonly used for mortality prediction and risk stratification in pediatric critical care research, quality improvement, and resource allocation algorithms. Prediction of morbidity rather than mortality may be beneficial given declining pediatric intensive care unit mortality. The PRISM and PELOD scores have moderate to good ability to predict new functional morbidity at hospital discharge following pediatric septic shock but limited ability to predict health-related quality of life outcomes in the year following PICU admission. Further research is needed to identify additional factors beyond illness severity that may impact post-discharge health-related quality of life.

Medical traumatic stress in cystic fibrosis: A qualitative analysis

BACKGROUND

People living with cystic fibrosis (PwCF) face a lifetime of potentially traumatic illness-related experiences that can lead to posttraumatic stress symptoms. Existing criteria for this type of posttraumatic stress, called medical traumatic stress (MTS), may not fully capture the CF experience. In this study we aimed to explore: 1) illness-related experiences perceived as traumatic in the setting of CF, 2) perceived MTS symptoms in PwCF, and 3) perceived health-related functional impairments from MTS.

METHODS

Informed by our aims, we developed and piloted guides for semi-structured interviews and focus groups with PwCF, family members of PwCF, and CF medical providers. We then conducted a series of interviews and focus groups. The qualitative analytical process followed Deterding and Waters' three stages of flexible coding for in-depth interviews, generating key themes and sub-themes in each domain of study inquiry.

RESULTS

We recruited 51 participants, including 24 PwCF, 7 family members of PwCF, and 20 CF care team members. Illness-related experiences perceived as traumatic were often characterized by themes of loss of agency, threats of bodily harm, and shifts in identity. Prominent MTS symptoms included shame, survivor guilt, burden guilt, germaphobia, and symptom panic. Health-related themes of functional impairments perceived to result from MTS included poor adherence and strained relationships between providers and patients/families.

CONCLUSIONS

This is the first study to explore the specific experiences of MTS in PwCF. It highlights the need for screening that includes these specific exposure types and symptoms, which may be mitigatable with medical trauma-focused interventions.

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 for Positive Post-Traumatic Stress Disorder Screening and Associated Outcomes in Children Surviving Acute Respiratory Failure: A Secondary Analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure Clinical Trial

OBJECTIVES

To identify risk factors and outcomes associated with a positive post-traumatic stress disorder (PTSD) screen following pediatric acute respiratory failure treated with invasive mechanical ventilation.

DESIGN

Nonprespecified secondary analysis of a randomized clinical trial.

SETTING

Thirty-one U.S. PICUs.

PATIENTS

Children in the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial (NCT00814099, ClinicalTrials.gov ) over 8 years old who completed PTSD screening 6 months after discharge.

INTERVENTIONS

RESTORE sites were randomized to a targeted, nurse-directed sedation strategy versus usual care.

MEASUREMENTS AND MAIN RESULTS

PTSD screening was completed by 102 subjects using the Child Post-Traumatic Stress Disorder Symptom Scale; a score of greater than or equal to 11 was considered screening positive for PTSD. Cognitive status was categorized using Pediatric Cerebral Performance Category; health-related quality of life (HRQL) was evaluated using child-reported Pediatric Quality of Life Inventory, Version 4.0. Thirty-one children (30%) screened positive for PTSD. Children with a positive screen endorsed symptoms in all categories: reexperiencing, avoidance, and hyperarousal. Most endorsed that symptoms interfered with schoolwork ( n = 18, 58%) and happiness ( n = 17, 55%). Screening positive was not associated with RESTORE treatment group. In a multivariable logistic model adjusting for age, sex, and treatment group, screening positive was independently associated with lower median income in the family's residential zip code (compared with income ≥ $80,000; income < $40,000 odds ratio [OR], 32.8; 95% CI, 2.3-458.1 and $40,000-$79,999 OR, 15.6; 95% CI, 1.3-182.8), renal dysfunction (OR 5.3, 95% CI 1.7-16.7), and clinically significant pain in the PICU (OR, 8.3; 95% CI, 1.9-35.7). Children with a positive screen experienced decline in cognitive function and impaired HRQL more frequently than children with a negative screen.

CONCLUSIONS

Screening positive for PTSD is common among children following acute respiratory failure and is associated with lower HRQL and decline in cognitive function. Routine PTSD screening may be warranted to optimize recovery.

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.

Measuring Social Health Following Pediatric Critical Illness: A Scoping Review and Conceptual Framework

OBJECTIVE

Social health is an important component of recovery following critical illness as modeled in the pediatric Post-Intensive Care Syndrome framework. We conducted a scoping review of studies measuring social outcomes (measurable components of social health) following pediatric critical illness and propose a conceptual framework of the social outcomes measured in these studies.

DATA SOURCES

PubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane Registry.

STUDY SELECTION

We identified studies evaluating social outcomes in pediatric intensive care unit (PICU) survivors or their families from 1970-2017 as part of a broader scoping review of outcomes after pediatric critical illness.

DATA EXTRACTION

We identified articles by dual review and dual-extracted study characteristics, instruments, and instrument validation and administration information. For instruments used in studies evaluating a social outcome, we collected instrument content and described it using qualitative methods adapted to a scoping review.

DATA SYNTHESIS

Of 407 articles identified in the scoping review, 223 (55%) evaluated a social outcome. The majority were conducted in North America and the United Kingdom, with wide variation in methodology and population. Among these studies, 38 unique instruments were used to evaluate a social outcome. Specific social outcomes measured included individual (independence, attachment, empathy, social behaviors, social cognition, and social interest), environmental (community perceptions and environment), and network (activities and relationships) characteristics, together with school and family outcomes. While many instruments assessed more than one social outcome, no instrument evaluated all areas of social outcome.

CONCLUSIONS

The full range of social outcomes reported following pediatric critical illness were not captured by any single instrument. The lack of a comprehensive instrument focused on social outcomes may contribute to under-appreciation of the importance of social outcomes and their under-representation in PICU outcomes research. A more comprehensive evaluation of social outcomes will improve understanding of overall recovery following pediatric critical illness.

Brain-Directed Care: Why Neuroscience Principles Direct PICU Management beyond the ABCs

Major advances in pediatric intensive care (PICU) have led to increased child survival. However, the long-term outcomes among these children following PICU discharge are a concern. Most children admitted to PICU are under five years of age, and the stressors of critical illness and necessary interventions can affect their ability to meet crucial developmental milestones. Understanding the neuroscience of brain development and vulnerability can inform PICU clinicians of new ways to enhance and support the care of these most vulnerable children and families. This review paper first explores the evidence-based neuroscience principles of brain development and vulnerability and the impact of illness and care on children's brains and ultimately wellbeing. Implications for clinical practice and training are further discussed to help optimize brain health in children who are experiencing and surviving a critical illness or injury.

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

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

The association of severe pain experienced in the pediatric intensive care unit and postdischarge health-related quality of life: A retrospective cohort study

BACKGROUND

Pain may be a modifiable risk factor for lower health-related quality of life after pediatric critical illness.

AIM

To evaluate the association between severe pain experienced in the (pediatrc intensive care unit) and postdischarge health-related quality of life.

METHODS

This was a retrospective cohort study. Children aged 1 month to 18 years admitted to the pediatric intensive care unit and enrolled in the Seattle Children's Hospital Outcomes Assessment Program were included. Pain was assessed every 2 h by bedside nursing staff using a behavioral pain scale or numeric pain scale. A day of severe pain was defined as a pediatric intensive care unit day with ≥25% of pain scores ≥7/10. Baseline (preadmission) and postdischarge (median 6 weeks) health-related quality of life was assessed by the Pediatric Quality of Life Inventory (PedsQL™) or the Stein Jessop Functional Status II-R (FS II-R, for children with developmental disability). The cohort was stratified by diagnosis category (surgical vs. medical), and associations were measured using linear regression models.

RESULTS

Among 546 patients, 11.9% experienced ≥1 day of severe pain. In multivariable linear regression, each day of severe pain was independently associated with a lower postdischarge health-related quality of life score by 3.6 points (95% CI -6.3 to -0.9) adjusted for baseline health-related quality of life score, age, baseline cognitive function, days with multi-organ dysfunction, pediatric intensive care unit length of stay, and decline in overall function. This association was stronger among surgical patients than medical patients with each day of severe pain resulting in a lower postdischarge health-related quality of life score by 5.3 points (95% CI -9.6 to -0.9) versus 2.6 points (95% CI -5.8 to 0.6). Surgical patients had lower postdischarge emotional functioning than physical functioning subdomain scores.

CONCLUSIONS

Children who experience severe pain in the pediatric intensive care unit have lower postdischarge health-related quality of life adjusting for baseline health-related quality of life, particularly among children who have undergone surgery. Attention to pain management may be important to improve postdischarge health-related quality of life.

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

IMPORTANCE

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Health-Related Quality of Life Following Delirium in the PICU

OBJECTIVES

To evaluate whether delirium during pediatric critical illness is associated with post-discharge health-related quality of life.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary care center.

PATIENTS

Children 1 month to 18 years old admitted to the PICU or cardiac ICU and enrolled in the Seattle Children's Hospital Outcomes Assessment Program.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Delirium was assessed twice daily using the Cornell Assessment of Pediatric Delirium; a score greater than or equal to 9 (with fluctuating level of arousal for children with developmental disability) indicated delirium. Baseline (pre-admission) and post-discharge health-related quality of life were assessed by the Pediatric Quality of Life Inventory (Mapi Research Trust, Lyon, France) or the Functional Status II-R (for children with developmental disability). Among 534 patients, delirium was common (44%), as was clinically important decline in health-related quality of life (≥ 4.5 points) from baseline to follow-up (22%), measured at median 6.6 weeks post-hospital discharge (interquartile range, 5.1-8.5). On univariate analysis, children with delirium had similar likelihood of health-related quality of life decline compared with those without (25.5% vs 19.7%; p = 0.1). Using multivariable logistic regression adjusting for age, medical complexity, predicted risk of mortality, admission diagnosis, receipt of noninvasive ventilation, hospital length of stay, time to follow-up, and parent age, delirium was independently associated with health-related quality of life decline among children assessed by the Pediatric Quality of Life Inventory (adjusted odds ratio, 2.0; 95% CI, 1.1-3.5). Among children evaluated with the Functional Status II-R, delirium was not independently associated with health-related quality of life decline (odds ratio, 1.4; 95% CI, 0.6-3.2). In both groups, longer time to follow-up was also independently associated with improvements in health-related quality of life.

CONCLUSIONS

Delirium during the ICU stay is associated with decline in health-related quality of life from baseline to post-discharge follow-up among children assessed by the Pediatric Quality of Life Inventory, who were generally characterized by normal baseline cognitive function and less medical comorbidity. This association was not present among children assessed by the Functional Status II-R, potentially due to their higher overall risk of health-related quality of life decline, or other clinical differences that modify the effects of delirium in this group.

Components of Health-Related Quality of Life Most Affected Following Pediatric Critical Illness

OBJECTIVES

To evaluate which individual elements of health-related quality of life contribute most to decline in overall health-related quality of life status following pediatric critical care.

DESIGN

Retrospective cohort study.

SETTING

Seattle Children's Hospital.

PATIENTS

ICU patients age 1 month to 18 years admitted between December 2011 and February 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed health-relatedquality of life decline from baseline to postdischarge (median, 6 wk) and determined the individual items of the Pediatric Quality of Life Inventory Infant Scales (< 2 yr) and Generic Core Scales (2-18 yr) with the highest prevalence of decline. We used multivariable regression to estimate the risk of decline in each of seven thematic categories by patient age, baseline health status, diagnosis, Pediatric Risk of Mortality score, and ICU length of stay. Decline from baseline health-related quality of life occurred in 22.5% of 539 patients. Items most commonly affected for infants less than 2 years were primarily emotional (cranky/crying, sleep, and self-soothing). Children 2-18 years most commonly experienced declines in physical functioning (play/exercise, lifting, and pain). Across the entire cohort, declines in categories of energy (31.5%), activity (31.0%), sleep (28.0%), and fear (24.7%) were most commonly endorsed. Risk of decline in each category varied with patient age, medical complexity, and diagnosis.

CONCLUSIONS

Deconditioning, sleep, fear, and pain are important targets for intervention to improve health-related quality of life outcomes for critically ill children.

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.

The parental psychological distress caused by separation from their critically ill child during the COVID-19 pandemic: A tale of two cities

INTRODUCTION

A child's critical illness is a stressful event for the entire family, causing significant emotional distress among parents and changes to family functioning. The Severe Acute Respiratory Syndrome-Related Coronavirus 2 (SARS-CoV-2) pandemic has abruptly caused modifications in visitation policies of Pediatric Intensive Care Units (PICUs) in many countries. We hypothesized that caregivers with no or severely restricted access to PICUs would demonstrate increased psychological distress as compared to those who had limitless access (LA) to PICUs.

METHODS

Sociodemographic variables, levels of psychological distress, ratings of family functioning, and ability to cope with stressful events were collected with an online survey in a group of caregivers after their child's hospitalization. Ratings of psychological distress were compared between caregivers with no/severely restricted (NA) and with LA to PICUs.

RESULTS

Measures of depression, anxiety, and global severity index (GSI) of psychological distress were significantly higher in NA caregivers as compared to LA. Among demographic characteristics of the sample, only gender influenced the severity of psychological symptoms: women showed an increased score on levels of somatization, depression, anxiety, and GSI. Avoidant coping style positively correlated with measures of depression. Univariate General Linear Model (GLM) analyses of the effects of sex, age, visitation policies of PICUs, and score of avoidant coping strategies on measures of psychological distress confirmed a significant univariate effect of no access to PICUs on parents' psychopathological scores.

CONCLUSION

Restrictions imposed on visitation policies in PICU during the pandemic negatively impacted families' psychological wellbeing. A balance between the safety of patients, families, and health care professionals and meeting the needs of families is of utmost importance.

[Untact Visit Service Development Based on an Application Reflecting the Circumstances during COVID-19: Focusing on Utilization in the Pediatric Intensive Care Units]

PURPOSE

This study aimed to develop an untact visit service based on an application that can be utilized in the pediatric intensive care unit (PICU) during COVID-19.

METHODS

This study adopted the double diamond process of service design comprising the discovery, defining, and development stages.

RESULTS

We developed an untact visit service based on an application that considered the child's status, schedule, photo, and video messages, and so on. Moreover, we derived a service flow regarding the required roles and the type of flow shown between each stakeholder.

CONCLUSION

Considering the ongoing pandemic, the untact visit service is designed to increase rapport and participation of parents, share the child's information in real-time, and provide one-stop service without increasing healthcare providers' work. It will be a useful visit service that can be applied and evaluated in various hospital settings and the PICU.

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.

PICU Follow-Up Clinic: Patient and Family Outcomes 2 Months After Discharge

OBJECTIVES

Hospitalization in a PICU is a life-altering experience for children and their families. Yet, little is known about the well-being of these children after their discharge. We are describing the outcome of PICU survivors at a PICU clinic 2 months after discharge.

DESIGN

Prospective cohort study.

SETTING

PICU and PICU clinic of CHU Sainte-Justine.

PATIENTS

Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, odds ratio greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine.

PATIENTS

Prospective cohort study of children admitted for greater than or equal to 4 days, greater than or equal to 2 days of invasive ventilation, or greater than or equal to 4 days of noninvasive ventilation at Centre Hospitalier Universitaire Sainte-Justine PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were evaluated by a pediatric intensivist 2 months after discharge at the follow-up clinic. They were asked to fill out validated questionnaires. One hundred thirty-two patients were followed from October 2018 to September 2020. The PICU diagnoses were respiratory illness (40.9%), head trauma, and septic shock (7.6%). Average length of PICU stay was 28.5 ± 84.2 days (median 7 d). Sixty-one percent were intubated. Symptoms reported by families were as follows: fatigue (9.9%), sleep disturbances (20.5%), feeding difficulties (12.1%), and voice change and/or stridor (9.8%). Twenty-one percent of school-aged children reported school delays. Twenty-seven children demonstrated communication delays, 45% gross motor function delays, 41% fine motor delays, 37% delays in problem-solving, and 49% delays in personal-social functioning. Quality of Life scores were 78.1 ± 20.5 and 80.0 ± 17.5 for physical and psychosocial aspects, respectively. Fourteen percent of parents reported financial difficulties, 42% reported symptoms of anxiety, 29% symptoms of depression.

CONCLUSIONS

PICU survivors and their families experience significant physical and psychosocial morbidities after their critical illness. PICU follow-up is crucial to determine the outcome of these children and develop interventions.

Physical Functioning After Admission to the PICU: A Scoping Review

Supplemental Digital Content is available in the text.

Objectives:

To conduct a scoping review to 1) describe findings and determinants of physical functioning in children during and/or after PICU stay, 2) identify which domains of physical functioning are measured, 3) and synthesize the clinical and research knowledge gaps.

Data Sources:

A systematic search was conducted in PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines.

Study Selection:

Two investigators independently screened and included studies against predetermined criteria.

Data Extraction:

One investigator extracted data with review by a second investigator. A narrative analyses approach was used.

Data Synthesis:

A total of 2,610 articles were identified, leaving 68 studies for inclusion. Post-PICU/hospital discharge scores show that PICU survivors report difficulties in physical functioning during and years after PICU stay. Although sustained improvements in the long-term have been reported, most of the reported levels were lower compared with the reference and baseline values. Decreased physical functioning was associated with longer hospital stay and presence of comorbidities. A diversity of instruments was used in which mobility and self-care were mostly addressed.

CONCLUSIONS:

The results show that children perceive moderate to severe difficulties in physical functioning during and years after PICU stay. Longitudinal assessments during and after PICU stay should be incorporated, especially for children with a higher risk for poor functional outcomes. There is need for consensus on the most suitable methods to assess physical functioning in children admitted to the PICU.

Association Between Pediatric Delirium and Quality of Life After Discharge

OBJECTIVE

Delirium occurs frequently in critically ill children, with highest rates reported in children under 5 years old. The objective of this study was to measure the residual effect of delirium on quality of life at 1 and 3 months after hospital discharge.

DESIGN

Prospective observational cohort study.

SETTING

Urban academic PICU.

PATIENTS

Children younger than five years of age at time of admission to the PICU.

INTERVENTIONS

All children were screened for delirium (using the Cornell Assessment for Pediatric Delirium) throughout their stay in the PICU. Quality of life was measured using the Infant-Toddler Quality of Life questionnaire at three time points: baseline, 1 month, and 3 months after hospital discharge. Infant-Toddler Quality of Life scores were compared between children who did and did not develop delirium.

MEASUREMENTS AND MAIN RESULTS

Two hundred seven children were enrolled. One hundred twenty-two completed the 1-month follow-up, and 117 completed the 3-month follow-up. Fifty-six children (27%) developed delirium during their PICU stay. At follow-up, Infant-Toddler Quality of Life scores for the PICU cohort overall were consistently lower than age-related norms. When analyzed by delirium status, children who had experienced delirium scored lower in every quality of life domain when compared with children who did not experience delirium. Even after controlling for severity of illness, delirious patients demonstrated an average 11-point lower general health score than nondelirious patients (p = 0.029).

CONCLUSION

This pilot study shows an independent association between delirium and decreased quality of life after hospital discharge in young children.

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.

Admission Psychosocial Characteristics of Critically Ill Children and Acute Stress

OBJECTIVES

Children are at increased risk for developing acute stress and post-traumatic stress following admission to the PICU. The primary objective of this investigation was to explore the prehospitalization psychosocial characteristics of children admitted to the PICU and their association with acute stress.

DESIGN

Observational.

SETTING

The PICU at an urban, academic, pediatric medical center.

PATIENTS

Children, 8-17 years old with an expected PICU stay greater than 24 hours were recruited.

MEASUREMENTS AND MAIN RESULTS

During the admission, they completed questionnaires and a semistructured interview evaluating prehospitalization psychosocial symptoms, including prehospitalization post-traumatic stress, quality of life, and current acute stress. One hundred eleven children were enrolled (mean age = 12.9 yr; 60% male; 58% Latino). Half (51%) reported a prehospitalization history of trauma and nearly all (96%) of these children had post-traumatic stress. They had significant impairment on all domains of quality of life. Children reported high rates of acute stress during their hospitalization, 74.8% acute stress symptoms, and 6% met diagnostic criteria for acute stress disorder. Univariate analysis showed associations between child age, quality of life, chronic illness, and post-traumatic stress with more severe acute stress. Multiple linear regression modeling of acute stress was done accounting for child age, acute versus chronic illness, quality of life, and post-traumatic stress; prehospitalization quality of life and post-traumatic stress remained significantly associated with the development of inhospital acute stress and accounted for 34% of the variance of the model.

CONCLUSIONS

The current investigation is a novel evaluation of the prehospitalization psychosocial characteristics of children admitted to a PICU. The children enrolled reported high rates of acute stress, which was associated with a history of post-traumatic stress and worsened quality of life. The relation with post-traumatic stress is consistent with prior research into complex post-traumatic stress disorder and increases concerns about long-term psychosocial outcomes. Our data advance understanding of the factors contributing to acute stress during hospitalizations and may add to recognizing the importance of models integrating psychosocial support.

Traumatic Stress Among Children After Surgical Intervention for Congenital Melanocytic Nevi: A Pilot Study

BACKGROUND

Hospitalization and surgery are traumatic experiences that can result after traumatic stress symptoms (PTSS). Surgical interventions for congenital melanocytic nevus (CMN) can be very stressful, but their potential for causing PTSS has not been studied. We aim to determine prospectively whether children undergoing surgery for CMN develop PTSS and what are the specific risk factors for such an event.

OBJECTIVE

The authors aim to determine prospectively whether children undergoing surgery for CMN develop PTSS and what the specific risk factors for such an event are.

METHODS

Thirty children who were consecutively hospitalized in a pediatric surgery ward for CMN removal during the study period were recruited voluntarily. About 4 months after discharge from the hospital, the children and their parents were assessed for psychological distress.

RESULTS

At the assessment 4 months after hospitalization, the children displayed a significant increase in symptoms of distress in comparison with baseline levels. Moreover, 33.3% met full post-traumatic stress disorder (PTSD) diagnostic criteria. The number of invasive procedures, family resources, and parental distress predicted 40% of the variance in PTSS, with parental distress predicting it most significantly.

CONCLUSION

The high prevalence of PTSS among children undergoing CMN removal and among their parents emphasizes the importance of actions for prevention and early treatment of psychological distress.

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.

Trajectories and Risk Factors for Altered Physical and Psychosocial Health-Related Quality of Life After Pediatric Community-Acquired Septic Shock

OBJECTIVES

To evaluate the physical and psychosocial domains of health-related quality of life among children during the first year following community-acquired septic shock, and explore factors associated with poor physical and psychosocial health-related quality of life outcomes.

DESIGN

Secondary analysis of the Life After Pediatric Sepsis Evaluation.

SETTING

Twelve academic PICUs in the United States.

PATIENTS

Children greater than or equal to 1 month and less than 18 years old who were perceived to be without severe developmental disability by their family caregiver at baseline and who survived hospitalization for community-acquired septic shock.

INTERVENTIONS

Family caregivers completed the Pediatric Quality of Life Inventory for children 2-18 years old or the Pediatric Quality of Life Inventory Infant Scales for children less than 2 years old at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Higher Pediatric Quality of Life Inventory Physical and Psychosocial Health Summary Scores indicate better health-related quality of life.

MEASUREMENTS AND MAIN RESULTS

Of 204 children, 58 (28.2%) had a complex chronic comorbid condition. Children with complex chronic comorbid conditions had lower baseline physical health-related quality of life (62.7 ± 22.6 vs 84.1 ± 19.7; p < 0.001) and psychosocial health-related quality of life (68.4 ± 14.1 vs 81.2 ± 15.3; p < 0.001) than reference norms, whereas children without such conditions had baseline scores similar to reference norms. Children with complex chronic comorbid conditions recovered to their baseline health-related quality of life, whereas children without such conditions did not (physical health-related quality of life 75.3 ± 23.7 vs 83.2 ± 20.1; p = 0.008 and psychosocial health-related quality of life 74.5 ± 18.7 vs 80.5 ± 17.9; p = 0.006). Age less than 2 years was independently associated with higher month 12 physical health-related quality of life, and abnormal neurologic examination and neurologic injury suspected by a healthcare provider during the PICU course were independently associated with lower month 12 physical health-related quality of life. Treatment of increased intracranial pressure and medical device use at month 1 were independently associated with lower month 12 psychosocial health-related quality of life.

CONCLUSIONS

Physical and psychosocial health-related quality of life were reduced among children during the first year following community-acquired septic shock compared with reference norms, although many recovered to baseline. Risk factors for poor health-related quality of life included neurologic complications during the hospitalization and dependence on a medical device 1 month postadmission.

Longitudinal Trajectories of Caregiver Distress and Family Functioning After Community-Acquired Pediatric Septic Shock

OBJECTIVES

To identify trajectories and correlates of caregiver distress and family functioning in families of children who survived community-acquired septic shock. We hypothesized that: 1) a substantial subset of families would demonstrate trajectories of persistent elevated caregiver distress and impaired family functioning 12 months after hospitalization and 2) sociodemographic and clinical risk factors would be associated with trajectories of persistent distress and family dysfunction.

DESIGN

Prospective cohort.

SETTING

Fourteen PICUs in the United States.

PATIENTS

Caregivers of 260 children who survived community-acquired septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Caregivers completed ratings of distress on the Brief Symptom Inventory and of family functioning on the Family Assessment Device at baseline, 1, 3, 6, and 12 months after hospitalization. Results from group-based trajectory modeling indicated that 67% of the current sample was characterized by persistent low caregiver distress, 26% by persistent moderate to high distress that remained stable across 12 months (high-risk caregiver distress group), and 8% by initial high distress followed by gradual recovery. Forty percent of the sample was characterized by stable high family functioning, 15% by persistent high dysfunction across 12 months (high-risk family functioning group), 12% by gradually improving functioning, and 32% by deteriorating function over time. Independently of age, child race was associated with membership in the high-risk caregiver distress group (non-white/Hispanic; effect size, -0.12; p = 0.010). There were no significant sociodemographic or clinical correlates of the high-risk family functioning group in multivariable analyses.

CONCLUSIONS

Although the majority of families whose children survived community-acquired septic shock were characterized by resilience, a subgroup demonstrated trajectories of persistently elevated distress and family dysfunction during the 12 months after hospitalization. Results suggest a need for family-based psychosocial screening after pediatric septic shock to identify and support at-risk families.

Study protocol for a multicentre longitudinal mixed methods study to explore the Outcomes of ChildrEn and fAmilies in the first year after paediatric Intensive Care: the OCEANIC study

INTRODUCTION

Annually in the UK, 20 000 children become very ill or injured and need specialist care within a paediatric intensive care unit (PICU). Most children survive. However, some children and their families may experience problems after they have left the PICU including physical, functional and/or emotional problems. It is unknown which children and families experience such problems, when these occur or what causes them. The aim of this mixed-method longitudinal cohort study is to understand the physical, functional, emotional and social impact of children surviving PICU (aged: 1 month-17 years), their parents and siblings, during the first year after a PICU admission.

METHODS AND ANALYSIS

A quantitative study involving 300 child survivors of PICU; 300 parents; and 150-300 siblings will collect data (using self-completion questionnaires) at baseline, PICU discharge, 1, 3, 6 and 12 months post-PICU discharge. Questionnaires will comprise validated and reliable instruments. Demographic data, PICU admission and treatment data, health-related quality of life, functional status, strengths and difficulties behaviour and post-traumatic stress symptoms will be collected from the child. Parent and sibling data will be collected on the impact of paediatric health conditions on the family's functioning capabilities, levels of anxiety and social impact of the child's PICU admission. Data will be analysed using descriptive and inferential statistics. Concurrently, an embedded qualitative study involving semistructured interviews with 24 enrolled families at 3 months and 9 months post-PICU discharge will be undertaken. Framework analysis will be used to analyse the qualitative data.

ETHICS AND DISSEMINATION

The study has received ethical approval from the National Health Services Research Ethics Committee (Ref: 19/WM/0290) and full governance clearance. This will be the first UK study to comprehensively investigate physical, functional, emotional and social consequences of PICU survival in the first-year postdischarge.Clinical Trials Registration Number: ISRCTN28072812 [Pre-results].

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.

When Treatment is Traumatic: An Empirical Review of Interventions for Pediatric Medical Traumatic Stress

Pediatric medical traumatic stress (PMTS) is common among injured/ill children and is associated with elevated distress, treatment non-adherence, and poor health outcomes. As survivorship of life-threatening pediatric injury and illness continues to increase alongside rapid medical advancements, rates of PMTS and negative sequelae are expected to grow; however, research on prevention and treatment of PMTS is limited. The current study sought to systematically review the literature using a developmental framework to highlight research gaps. Sixteen peer-reviewed studies were identified via a systematic literature search. Consistent with best practices for treatment of childhood trauma, caregiver involvement and CBT principles served as the foundation for most interventions. All studies reported improvements in PMTS; however, among the most methodologically rigorous, few found statistically superior reductions in PMTS between intervention and control groups. While many studies focused on a specific developmental stage and discussed developmental considerations, others took a "one-size-fits" approach. Interventions that demonstrated the most promising findings were online, self-guided, or time-limited. Future research would benefit from expanding diversity of participants, continuing to evaluate novel delivery methods, and integrating developmental considerations along with trauma-informed care (TIC) approaches, given their useful framework for understanding child traumatic stress responses and avenues for prevention and treatment.

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.

Health-Related Quality of Life Among Survivors of Pediatric Sepsis

OBJECTIVES

Mortality from pediatric sepsis has steadily declined over the past several decades; however, little is known about morbidity among survivors. We aimed to determine the prevalence of and risk factors for failure to recover to baseline health-related quality of life following community-acquired pediatric sepsis.

DESIGN

Retrospective cohort study.

SETTING

Seattle Children's Hospital.

PATIENTS

Children aged 1 month to 21 years admitted to the inpatient wards or ICUs from 2012 to 2015 who met 2005 consensus sepsis criteria within 4 hours of hospitalization and were enrolled in the hospital's Outcomes Assessment Program with baseline, admission, and post-discharge health-related quality of life data available.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed health-related quality of life with the Pediatric Quality of Life Inventory for pre-admission baseline, admission, and post-discharge (median, 31 d) status. We determined associations between patient and illness characteristics with failure to recover within 4.5 points of baseline at follow-up (the minimum clinically significant difference between two scores). Of 790 patients, 23.8% failed to recover to baseline health-related quality of life at follow-up. Factors associated with failure to recover were septic shock, older age, private insurance, complex chronic disease, immune compromise, CNS infection or bacteremia, ICU admission, and longer length of stay. On multivariable analysis controlling for time to follow-up, failure to recover was independently associated with septic shock (relative risk, 1.79; 95% CI, 1.24-2.58), older age (relative risk, 1.02/yr; 95% CI, 1.01-1.05), immune compromise (relative risk, 1.83; 95% CI, 1.40-2.40), and length of stay (relative risk, 1.03/d; 95% CI, 1.01-1.04).

CONCLUSIONS

Nearly one-quarter of children surviving hospitalization for community-acquired sepsis experienced a clinically significant deterioration in health-related quality of life. We identify risk factors for poor outcomes following sepsis and highlight the need for ongoing evaluation and treatment by primary and specialty care providers for pediatric sepsis survivors after hospital discharge.

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.

Opportunities for nurses to support recovery after pediatric injury: Relationships among posttraumatic stress, hope, and quality of life

PURPOSE

Nurses are at the forefront of children's postinjury recovery; this unique role provides an opportunity for nurses to recognize and screen for symptoms that may interfere with children's quality of life (QOL). As such, aims of the present investigation were to explore selected variables (e.g., posttraumatic stress symptoms [PTSS], hope) that have the potential to impact QOL after pediatric injury, with a larger goal of contributing to recommendations for nursing practice to support children's full (physical and emotional) recovery during the peritrauma period following injury.

DESIGN AND METHODS

Sixty children (aged 7-13) completed measures of PTSS, hope, and QOL while receiving injury treatment.

RESULTS

PTSS significantly predicted concurrent QOL, β = -0.42, p = 0.001. Exploratory results demonstrated that specific PTSS clusters (re-experiencing [ β = -0.39; p = 0.003), avoidance [ β = -0.35; p = 0.009], arousal [ β = -0.34; p = .012]) all significantly predicted QOL. Specific PTSS were explored. Hope (overall, domains of pathways, general agency, goal setting) did not significantly predict concurrent QOL.

PRACTICE IMPLICATIONS

While this study is exploratory and more research is needed, current results suggest that nurses' awareness of PTSS (including symptoms of re-experiencing, avoidance, arousal) may help medical teams in identifying children that are at risk for impaired functional recovery (e.g., QOL) during the peritrauma period. Nurses may want to consider advocating for the integration of PTSS screeners into standard medical care. In addition, nurses have the opportunity to serve as key medical professionals in the delivery of trauma-informed medical care (which aims to minimize further trauma or re-traumatization). Nursing leadership may want to consider offering training in how nurses can identify and respond to children who have experienced an injury (such as trauma-informed care).

The Burden of Pediatric Neurocritical Care in the United States

BACKGROUND

Disorders requiring pediatric neurocritical care (PNCC) affect thousands of children annually. We aimed to quantify the burden of PNCC through generation of national estimates of disease incidence, utilization of critical care interventions (CCI), and hospital outcomes.

METHODS

We performed a retrospective cohort analysis of the Kids Inpatient Database over three years to evaluate pediatric traumatic brain injury, neuro-infection or inflammatory diseases, status epilepticus, stroke, hypoxic ischemic injury after cardiac arrest, and spinal cord injury. We evaluated use of CCI, death, length of stay, hospital charges, and poor functional outcome defined as receipt of tracheostomy or gastrostomy or discharge to a medical care facility.

RESULTS

At least one CCI was recorded in 67,058 (23%) children with a primary neurological diagnosis, and considered a PNCC admission. Over half of PNCC admissions had at least one chronic condition, and 23% were treated in children's hospitals. Mechanical ventilation was the most common CCI, but utilization of CCIs varied significantly by diagnosis. Among PNCC admissions, 8110 (12%) children died during hospitalization and 14,067 (21%) children had poor functional outcomes. PNCC admissions cumulatively accounted for over 1.5 million hospital days and over $4 billion in hospital costs in the study years. Most PNCC admissions, across all diagnoses, had prolonged hospitalizations (more than one week) with an average cost of $39.9 thousand per admission.

CONCLUSIONS

This large, nationally representative study shows PNCC diseases are a significant public health burden with substantial risk to children's health. More research is needed to improve outcomes in these vulnerable children.

Health-Related Quality of Life after Pediatric Severe Sepsis

BACKGROUND

Pediatric severe sepsis is a public health problem with significant morbidities in those who survive. In this article, we aim to present an overview of the important studies highlighting the limited data available pertaining to long-term outcomes of survivors of pediatric severe sepsis.

MATERIALS AND METHODS

A review of literature available was conducted using PUBMED/Medline on pediatric severe sepsis outcomes. Long-term outcomes and health-related quality of life (HRQL) following severe sepsis was defined as any outcome occurring after discharge from the hospital following an episode of severe sepsis which affected either the survivor or the survivor's family members.

RESULTS

Many children are discharged with worse clinical and functional outcomes, depending on their diagnosis, treatments received, psychological effects, and the impact of their illness on their parents. Additionally, they utilize healthcare services more than their peers and are often readmitted soon after discharge. However, pediatric HRQL studies with worthwhile outcome measures are limited and the current data on pediatric sepsis is mainly retrospective.

CONCLUSIONS

There is significant and longstanding morbidity seen in children and their families following a severe sepsis illness. Further prospective data are required to study the long-term outcomes of sepsis in the pediatric population.

Factors associated with health-related quality of life 6 years after ICU discharge in a Finnish paediatric population: a cohort study

PURPOSE

Long-term data are urgently needed in children after intensive care. The aim of this study was to measure health-related quality of life 6 years after intensive care in a paediatric intensive care population.

METHODS

This national, multicentre study enrolled all children and young people admitted to intensive care units (ICUs) in Finland in 2009 and 2010. The data concerning ICU stay were collected retrospectively from the ICU data registries and combined with prospective data from Paediatric Quality of Life Inventory (PedsQL 4.0) questionnaires, the generic 15D, 16D or 17D instrument, and data regarding children's chronic diagnoses and need for healthcare support.

RESULTS

The questionnaires were answered by 1109 of 3682 living children and adolescents admitted to an ICU, response rate was 30.1%. Among the responders, 90 children (8.4%) had poor (under - 2 SD) PedsQL scores. Children with low scores had a higher rate of chronic diagnoses (94.4% vs. 47.6%), medication on a daily basis (78.7% vs. 29.4%) and a greater need for healthcare services (97.7% vs. 82.2%) than those with normal scores. Diagnoses associated with poor quality of life were asthma, epilepsy, cerebral palsy and other neurological diseases, chromosomal alterations, cancer and long-term pain. These children were mostly admitted electively, and less frequently on an emergency basis, but no other significant differences were found during the intensive care stay.

CONCLUSIONS

The long-term quality of life after paediatric intensive care is good for the majority of children and young people, and it is dependent on the number of chronic diagnoses and the burden of the chronic disease, especially neurological diseases.

"Keeping pace according to the child" during procedures in the paediatric intensive care unit: A grounded theory study

OBJECTIVE

The goal was to explore how nurses interact with children in the paediatric intensive care unit during potentially painful procedures.

RESEARCH METHODOLOGY/DESIGN

This was a qualitative research study that used grounded theory approach. Data were collected through participant observation and interviews. Nurse-child interactions were observed and recorded during potentially painful procedures performed by nurses. Following observation of a procedure, nurses were interviewed about their intentions, feelings and emotions during the procedure.

SETTING

The study took place in a seven-bed paediatric intensive care unit in an academic teaching hospital in Japan.

FINDINGS

Children's acceptance of a procedure was induced by nurses' pacing, particularly in a pattern of "keeping pace according to the child." Such pacing involved soothing the child, explaining what was being done to the child at each step and acknowledging the child's emotions. All of these child-centred procedures provoked cooperation from the children even during painful procedures.

CONCLUSIONS

Our study suggests that a collaborative practice approach, in which nurses use a series of calming tactics, might improve children's perceptions of painful procedures.

Health Related Quality of Life and Neurocognitive Outcomes in the First Year after Pediatric Acute Liver Failure

OBJECTIVE

To determine health-related quality of life (HRQoL) and neurocognitive impairment in survivors of pediatric acute liver failure (PALF).

STUDY DESIGN

A longitudinal prospective study was conducted. At 6 and 12 months after PALF presentation, surveys of HRQoL were completed for 2- to 19-year-olds and executive functioning for ages 2-16 years. At 12 months, patients 3-16 years of age completed neurocognitive testing. HRQoL scores were compared with a healthy, matched sample. Neurocognitive scores were compared with norms; executive functioning scores were examined categorically.

RESULTS

A total of 52 parent-report HRQoL surveys were completed at 6 months, 48 at 12 months; 25 patients completed neurocognitive testing. The median age at 6 months was 7.9 years (range 3.5-15.0), and final diagnosis was indeterminate for 46.2% (n = 24). Self and parent-report on Pediatric Quality of Life Inventory Generic and Multidimensional Fatigue scales fell below the healthy sample at 6 months and 12 months (almost all P < .001). Children reported lower mean scores on cognitive fatigue at 12 months (60.91 ± 22.99) compared with 6 months (73.61 ± 27.49, P = .006) . The distribution of Behavior Rating Inventory of Executive Function scores was shifted downward on parent-report (preschool) for all indices at 6 months (n = 14, P ≤ .003); Global Executive Composite and Emergent Metacognition at 12 months (n = 10, P = .03). Visual Motor Integration (VMI-6) Copying (mean = 90.3 ± 13.8, P = .0002) and VMI-6 Motor Coordination (mean = 85.1 ± 15.2 P = .0002) fell below norms, but full scale IQ (Wechsler Scales) and Attention (Conners' Continuous Performance Test) did not.

CONCLUSIONS

Survivors of PALF appear to show deficits in motor skills, executive functioning, HRQoL, and evidence for worsening cognitive fatigue from 6 to 12 months following PALF presentation.