Screening for caregiver psychosocial risk in children with medical complexity: a cross-sectional study

The Evaluation of Change in Psychosocial Risk With Caregivers of Children With Chronic Kidney Disease: A Short-term Longitudinal Mixed-Methods Study

Background

The COVID-19 pandemic and its accompanying safeguards intensified many of the ongoing daily challenges faced by caregivers of young people with chronic kidney disease (CKD) both pre-transplant and post-transplant, and also created a variety of new and pressing concerns. Little is known about how these families managed this unexpected adversity in their lives.

Objective

To evaluate change in psychosocial risk for families of young people with CKD during the COVID-19 pandemic health emergency from the perspective of caregivers.

Design

A short-term longitudinal mixed-methods study with a convergent parallel design.

Setting

Manitoba, Canada.

Participants

Thirty-six caregivers of young people with CKD participated in a quantitative assessment prior to the pandemic; approximately half were transplant recipients. Thirteen were re-assessed during the pandemic (62% were caregivers of transplant recipients) using both qualitative and quantitative assessments.

Methods

First, caregivers completed the Psychosocial Assessment Tool (PAT) prior to the pandemic. Second, caregivers were re-assessed using the PAT during the pandemic. They were also interviewed about their experiences. Changes in PAT scores over time were evaluated, including an investigation of whether psychosocial risk was related to transplant status. Interviews were coded using thematic analysis. In the interpretation stage, the qualitative findings were combined with the quantitative results to help explain the latter and reach a more fulsome understanding of caregivers' experience.

Results

Quantitatively, overall family psychosocial risk scores increased significantly during the pandemic health emergency, as did the domain of Caregiver Problems. Families of transplant recipients were found to be at significantly lower psychosocial risk pre-pandemic than families of transplant candidates. Coding identified Negative Pandemic Experiences, Positive Pandemic Experiences, and Coping Mechanisms. Mixed-methods analyses revealed several areas of convergence and divergence between the quantitative and qualitative findings.

Limitations

Limitations included a small sample size that limited generalizability, single site data collection, and single caregiver report.

Conclusions

Although overall family psychosocial risk increased during the pandemic, caregivers described several resilience processes and characteristics. A mixed-method approach provided a unique perspective that highlighted the value of integrating quantitative and qualitative findings. Results were discussed within the pediatric psychosocial preventive health model framework.

Healthcare Use and Costs in Children Receiving Home Mechanical Ventilation in Ontario: A 14-Year Cohort Study

Rationale: Home mechanical ventilation (HMV) is an advanced medical therapy offered to children with medical complexity. Despite the growing pediatric HMV population in North America, there are limited studies describing healthcare use and predictors of highest costs using robust health administrative data. Objectives: To describe patterns of healthcare use and costs in children receiving HMV over a 14-year period in Ontario, Canada. Methods: We conducted a retrospective population-based cohort study (April 1, 2003, to March 31, 2017) of children aged 0-18 years receiving HMV via invasive mechanical ventilation or noninvasive ventilation. Paired t tests compared healthcare system use and costs 2 years before and 2 years after HMV approval. We developed linear models to analyze variables associated with children in the top quartile of health service use and costs. Results: We identified 835 children receiving HMV. In the 2 years after HMV approval compared with the 2 years prior, children had decreased hospitalization days (median, 9 [interquartile range, 3-30] vs. 29 [6-99]; P < 0.0001) and intensive care unit admission days (6.6 [1.9-18.0] vs. 17.1 [3.3-70.9]; P < 0.0001) but had increased homecare service approvals (195 [24-522] vs. 40 [12-225]; P < 0.0001) and outpatient pulmonology visits (3 [1-4] vs. 2 [1-3]; P < 0.0001). Total healthcare costs were higher in the 2 years after HMV approval (mean, CAD$164,892 [standard deviation, CAD$214,187] vs. CAD$128,941 [CAD$194,199]; P < 0.0001). However, all-cause hospital admission costs were reduced (CAD$66,546 [CAD$142,401] vs. CAD$81,578 [CAD$164,672]; P < 0.0001). The highest total 2-year costs were associated with invasive mechanical ventilation (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.24-5.31; reference noninvasive ventilation), number of medical devices at home (OR, 1.63; 95% CI, 1.35-1.96; reference no technology), and increased healthcare costs in the year before HMV initiation (OR, 2.23; 95% CI, 1.84-2.69). Conclusions: Children progressing to the need for HMV represent a worsening in their respiratory status that will undoubtedly increase healthcare use and costs. We found that the initiation of HMV in these children can reduce inpatient healthcare use and costs but can still increase overall healthcare expenditures, especially in the outpatient setting.

Family Caregivers of Children With Medical Complexity: Changes in Health-Related Quality of Life and Experiences of Care Coordination

OBJECTIVE

Examine the longitudinal association between family experiences of care coordination (FECC) and health-related quality of life (HR-QOL) for family caregivers of children with medical complexity (CMC).

METHODS

A longitudinal survey of family caregivers of CMC was completed between July 2018 and June 2020. Baseline data were collected at initial contact with a regional complex care center; follow-up data were collected 12 to 16 months later. Assessed receipt of care coordination and caregiver HR-QOL via FECC questionnaire and Center for Disease Control's HR-QOL-14 measure, respectively. Baseline and follow-up results were compared via McNemar's and Wilcoxon signed-rank tests. Relationships between changes in FECC and changes in HR-QOL were examined using multivariable logistic regression.

RESULTS

Of 185 eligible, 136 caregivers enrolled and completed baseline surveys (74%) and 103 (76% initial sample) follow-up surveys. Caregivers reported significant improvements in 8 of 9 FECC measures after 1 year of care within a complex care center (all P < .05). In contrast, caregiver HR-QOL (general health status, unhealthy days, symptom days) remained stable over the study period (all P > .05) except for monthly days of poor sleep (baseline vs follow-up median; 16 vs 15 [P = .05]). At both timepoints, >20% participants rated their general health status as fair-to-poor, and >50% reported frequent poor sleep and fatigue. No significant associations were observed between changes in FECC and changes in HR-QOL.

CONCLUSIONS

After receiving 1 year of care through a complex care center, CMC family caregivers report improvement in care coordination but not in HR-QOL. Caregivers' continued mentally unhealthy days and negative mental symptom days highlight the need for a directed intervention.

The impact of the COVID-19 pandemic on families of children with medical complexity: A qualitative study of caregivers' experiences

BACKGROUND

Families of children with medical complexity (CMC) have been negatively affected by the COVID-19 pandemic, experiencing challenges such as decreased access to services, increased financial hardship and increased isolation. However, there are few qualitative studies which explore parental experiences. The aim of the present study was to describe the impact of the COVID-19 pandemic on families of CMC.

METHODS

Caregivers of CMC were recruited from a large hospital in the Midwestern United States. They completed a semistructured qualitative interview assessing the impact of COVID-19 on their child's care, which was analysed using interpretive phenomenological analysis.

RESULTS

Twenty caregivers who were predominantly White, married and female participated. Emergent themes included the importance of protecting their child's health to ensure their physical safety, greater social isolation and missed medical services related to concerns about exposure, clinic closures and/or other logistical changes. Participants noted that the convenience of telehealth was a positive outcome of COVID-19 that facilitated care while reducing time and resource challenges.

CONCLUSIONS

This study highlights the importance of protecting the health of CMC through continued safe access to in-person or telehealth services. It is important to prioritise emotional support services for families of CMC as they have experienced increased stress and social isolation during and after the COVID-19 pandemic. This topic should be explored among diverse families with CMC across multiple healthcare systems.

Adaptation and pilot implementation of the Psychosocial Assessment Tool for Autism Spectrum Disorders (PAT-ASD)

Recognizing the multifaceted and chronic demands on families of children with Autism Spectrum Disorder (ASD) and challenges in providing care matched to need, we adapted the Psychosocial Assessment Tool (PAT), a brief caregiver-report screener of family psychosocial risk, for this population. Study methods included literature review, focus groups with providers, and feedback from caregivers. The PAT-ASD is consistent with the original PAT, with new items reflecting core behavioral manifestations of ASD and parent and family challenges associated with chronicity. The PAT-ASD was implemented in a four-month pilot and was completed online by 59% of families. Although further testing of its validity is necessary, the PAT-ASD is a promising means of assessing family psychosocial risk for families of children with ASD.

Relevance of Potential Contributing Factors for the Development and Maintenance of Irritability of Unknown Origin in Pediatric Palliative Care

Potential contributing factors (PCFs) for irritability of an unknown origin (IUO) in children with neurological conditions are identifiable through structured diagnostics. Uncertainty exists regarding the actual relevance of identified PCFs to IUO. Assessments from parents as well as nursing, psycho-social, and medical professionals were used to determine the contribution of different PCFs in the development and maintenance of IUO. For this, individual PCFs of N = 22 inpatient children with IUO were presented to four raters. Descriptive statistics, Kruskal-Wallis tests, and Krippendorff's alpha were used to determine which PCFs were most relevant to explain IUO and rater agreement. Psycho-social aspects (44.7%), hyperarousal (47.2%), pain (24.6%), and dystonia (18.1%) were identified as the most relevant PCFs for IUO. Descriptively, physicians' relevance rating regarding psycho-social aspects, hyperarousal, and dystonia deviated the most from the overall group rating. All professional raters considered psycho-social aspects to be more relevant than did parents. Parents rated pain as more relevant than the other raters. Kruskal-Wallis tests showed no significant differences between relevance ratings (H = 7.42, p = 0.059) or the four parties' deviations (H = 3.32, p = 0.344). A direct comparison of the six two-party constellations showed that across all factors, agreement was weak to moderate. The highest agreement was between physicians and nurses (α = 0.70), and the lowest was between nurses and psycho-social experts (α = 0.61). Understanding which psycho-social and various biological PCFs are significant for IUO can facilitate more targeted and individualized pediatric palliative care for affected patients.

Caring for children with new medical technology at home: parental perspectives

OBJECTIVES

This qualitative descriptive study explores the experiences of family caregivers (FCs) of children with medical complexity who are initiated on new medical technology in the hospital and transition to new daily life at home. The study aims to investigate FCs' response and readiness for medical technology use, the value of education and transition support and the challenges associated with managing new medical technology in the home.

STUDY DESIGN

A qualitative descriptive approach was used to conduct and analyse 14 semistructured interviews with a group of FCs composed of 11 mothers and 3 fathers. Content analysis was used to analyse transcripts of the caregiver interviews. The study was conducted at a tertiary paediatric hospital in Toronto, Canada.

RESULTS

Our study revealed three main themes: FC's response and readiness for medical technology use, the value of education and transition support for initiation of new medical technology and the challenges associated with managing new medical technology in the home. FCs expressed emotional distress related to coping with the realisation that their child required medical technology. Although the theoretical and hands-on practice training instilled confidence in families, FCs reported feeling overwhelmed when they transitioned home with new medical technology. Finally, FCs reported significant psychological, emotional and financial challenges while caring for their technology-dependent child.

CONCLUSIONS

Our study reveals the unique challenges faced by FCs who care for technology-dependent children. These findings highlight the need to implement a comprehensive education and transition programme that provides longitudinal support for all aspects of care.

Distress and the Long-Stay Pediatric Intensive Care Unit Admission: A Longitudinal Study of Parents and the Medical Team

Prolonged critical illness in children has emotional consequences for both parents and providers. In this observational cohort study, we longitudinally surveyed anxiety and depression in parents and moral distress in pediatric intensive care unit (PICU) providers (attendings, fellows, and bedside registered nurses) and explored their trajectories and relationships. Anxiety/depression and provider moral distress were measured using the Hospital Anxiety and Depression Scale and the Moral Distress Thermometer, respectively. The relationships of parental and provider distress were evaluated using Spearman's correlations, and their trajectories and potentially associated variables were explored using quadratic random slope and intercept models. Predetermined associated factors included demographic and clinical factors, including parent psychosocial risk and intubation status. We found parental anxiety and depression decreased over their child's admission, and parental psychosocial risk was significantly associated with anxiety (coefficient = 4.43, p  < 0.001). Clinicians in different roles had different mean levels and trajectories of moral distress, with fellows reporting greater distress early in admissions and nurses later in admissions. Parental anxiety/depression and provider distress were significantly, though moderately, correlated. We conclude that anxiety and depression in parents of children with prolonged PICU admissions and the moral distress of their clinicians correlate and vary over time and by provider role.

Screening for psychosocial risk in caregivers of children with medical complexity during the COVID-19 pandemic: a cross-sectional study

OBJECTIVE

The primary objective was to quantify psychosocial risk in family caregivers (FCs) of children with medical complexity (CMC) during the COVID-19 pandemic using the Psychosocial Assessment Tool (PAT). The secondary objectives were to compare this finding with the average PAT score of this population before the COVID-19 pandemic and to examine potential clinical predictors of psychosocial risk in FCs of CMC.

DESIGN

Cross-sectional study.

PARTICIPANTS

FCs of CMC were recruited from the Long-Term Ventilation Clinic at The Hospital for Sick Children, Toronto, Ontario, Canada. A total of 91 completed the demographic and PAT questionnaires online from 10 June 2021 through 13 December 2021.

MAIN OUTCOME MEASURES

Mean PAT scores in FCs were categorised as 'Universal' low risk, 'Targeted' intermediate risk or 'Clinical' high risk. The effect of sociodemographic and clinical variables on overall PAT scores was assessed using multiple linear regression analysis. Comparisons with a previous study were made using Mann-Whitney tests and χ² analysis.

RESULTS

Mean (SD) PAT score was 1.34 (0.69). Thirty-one (34%) caregivers were classified as Universal, 43 (47%) as Targeted and 17 (19%) as Clinical. The mean PAT score (1.34) was significantly higher compared with the mean PAT score (1.17) found prior to the COVID-19 pandemic. Multiple linear regression analysis demonstrated an overall significant model, with the number of hospital admissions since the onset of COVID-19 being the only variable associated with the overall PAT score.

CONCLUSION

FCs of CMC are experiencing significant psychosocial stress during the COVID-19 pandemic. Timely and effective interventions are warranted to ensure these individuals receive the appropriate support.

Exploring the experience of family caregivers of children with medical complexity during COVID-19: a qualitative study

BACKGROUND AND OBJECTIVES

Children with medical complexity have been disproportionately impacted by the COVID-19 pandemic and the associated changes in healthcare delivery. The primary objective of this study was to gain a thorough understanding of the lived experiences of family caregivers of children with medical complexity during the pandemic.

METHODS

We conducted semi-structured interviews with family caregivers of children with medical complexity from a tertiary pediatric hospital. Interview questions focused on the aspects of caregiving for children with medical complexity, impact on caregiver mental and physical well-being, changes to daily life secondary to the pandemic, and experiences receiving care in the healthcare system. Interviews were conducted until thematic saturation was achieved. Interviews were audio recorded, deidentified, transcribed verbatim, coded and analyzed using content analysis.

RESULTS

Twelve semi-structured interviews were conducted. The interviews revealed three major themes and several associated subthemes: (1) experiences with the healthcare system amid the pandemic (lack of access to healthcare services and increased hospital restrictions, negative clinical interactions and communication breakdowns, virtual care use); (2) common challenges during the pandemic (financial strain, balancing multiple roles, inadequate homecare nursing); and (3) the pandemic's impact on family caregiver well-being (mental toll, physical toll).

CONCLUSIONS

Family caregivers of children with medical complexity experienced mental and physical burden due to the intense nature of their caregiving responsibilities that were exacerbated during the pandemic. Our results highlight key priorities for the development of effective interventions to support family caregivers and their children.

Caregiver stress and social determinants of health in key populations: immigrant parents, parents of children with medical complexity, and adolescent parents

PURPOSE OF REVIEW

To examine the five domains of social determinants of health - economic stability, education access, healthcare access and quality, neighborhood and built environment, and social and community context - and how these relate to caregiver stress in under-resourced populations.

RECENT FINDINGS

Socioeconomic and family factors are increasingly understood as drivers of child health. Caregiver stress can impact family stability and child wellbeing. Immigrant parents, caregivers of children with medical complexity, and adolescent parents experience stressors due to the unique needs of their families. These groups of parents and caregivers also face various challenges identified as social determinants of health. Interventions to mitigate these challenges can promote resilience, care coordination, and community-based supports.

SUMMARY

Current research describes caregiver stress in key populations, how caregiver stress affects children, and approaches to minimize and mitigate these effects. Pediatric providers can implement best practices to support families who are navigating stress due to caregiving and social determinants of health.

The Child With Severe Chronic Illness in the ICU: A Concise Review

OBJECTIVES

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs.

DATA SOURCES

English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed.

STUDY SELECTION

Original articles, review articles, and commentaries were considered.

DATA EXTRACTION

Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review.

DATA SYNTHESIS

Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured.

CONCLUSIONS

The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

Validating the Factor Structure of the Psychosocial Assessment Tool Using Internet-Based Data

OBJECTIVE

The Psychosocial Assessment Tool (PAT) is a well-validated, brief screener of family psychosocial risk. Since 2014 a web-based version of the PAT (WebPAT) has been available for use by clinicians and researchers, but the psychometric properties have not been examined. The objective of this article was to examine the factor structure and internal consistency of the WebPAT, which was administered to caregivers of youth with cancer.

METHODS

The WebPAT was administered to 1,252 caregivers of youth with cancer across 29 institutions. Confirmatory factor analysis (CFA) was used to examine the factor structure of the WebPAT. Internal consistencies of the total and subscale scores were examined via the Kuder-Richardson 20 coefficient. The distribution of total PAT score across the three risk categories of the Pediatric Psychosocial Preventative Health Model (PPPHM) was also examined.

RESULTS

The CFA supported the original seven-factor structure of the PAT (Family Structure, Social Support, Child Problems, Sibling Problems, Family Problems, Stress Reactions, and Family Beliefs). Internal consistencies were strong for the total PAT score and four subscales (Social Support, Child Problems, Sibling Problems, and Family Problems). The distribution of total PAT scores across PPPHM risk categories was consistent with prior research.

CONCLUSIONS

The WebPAT is a psychometrically sound screener of psychosocial risk in families of youth with cancer. Healthcare providers can use the WebPAT to assess families' psychosocial risk and guide the provision of psychosocial care. Future research should evaluate the implementation of the PAT and identify barriers and facilitators to implementation.

Families following pediatric traumatic medical events: identifying psychosocial risk profiles using latent profile analysis

BACKGROUND

Post-traumatic stress symptoms (PTSS) are often experienced by children and family members after pediatric traumatic medical events (PTMEs). Assessing families' psychosocial risk factors is a crucial part of trauma-informed practice as it helps identify risk for PTSS in the aftermath of PTME.

OBJECTIVES

Using the Psychosocial Assessment Tool 2.0 (PAT2.0), this study describes the psychosocial risk of families following PTMEs in two ways: 1. Describing the psychosocial risk defined by the PAT2.0 based on three-tiered risk levels; 2. Using latent profile analysis (LPA); identifying psychosocial risk profiles and examining how child- and injury-related factors can affect profile membership.

METHODS

Caregivers of 374 children following PTMEs admitted to a pediatric rehabilitation department in Israel completed the PAT2.0. Total PAT2.0 score and the seven PAT2.0 subscales (family structure/resources, social support, child problems, sibling problems, family problems, caregiver stress reactions, and family beliefs) were included in the first analysis. Mean PAT2.0 scores of three risk categories (universal, targeted, clinical) were calculated; LPA, which allows for cross-sectional latent variable mixture models to identify heterogeneity within a population, and multinomial logistic regressions using six out of the seven PAT2.0 subscales, were used to determine distinct profile differences and predictors of profile membership.

RESULTS

The three-tiered risk levels revealed were relatively high, as compared to levels in families of children with other clinical diagnoses. LPA yielded a three-profile solution: low family risk (63.53%); high caregiver stress, above-average levels of family risk (22.5%); and sibling problems, above-average levels of family risk (13.94%). Ethnicity and type of injury predicted group membership.

CONCLUSION

Families of children following PTMEs are at increased psychosocial risk. A clinically useful approach to identifying and preventing PTSS may be to evaluate specific domain patterns rather than just the total PAT2.0 risk level alone, based on the PAT2.0 subscales.

Increased behavioral health needs and continued psychosocial stress among children with medical complexity and their families during the COVID-19 pandemic

Objective

Children with medical complexity (CMC) and their caregivers are at increased risk for multiple psychosocial stressors that can impact child and family well‐being and health outcomes. During the COVID‐19 pandemic, when access to supports diminished, psychosocial screening and integrated behavioral health (IBH) services in the primary care setting were crucial in identifying and addressing the unique needs of this population

Methods

Universal screening to identify psychosocial needs was implemented in a primary care clinic for CMC that includes IBH services. Data on the prevalence of psychosocial screening and IBH services for young children and their caregivers before and during the COVID‐19 pandemic were evaluated

Results

Psychosocial screening levels remained stable during the pandemic. Psychosocial needs were identified for 36% of screeners prior to the COVID‐19 pandemic and 33% during the COVID‐19 pandemic. The need for IBH services increased during the COVID‐19 time period resulting in a significant increase in IBH services

Conclusions

For CMC and their caregivers, psychosocial needs identified through psychosocial screening remained high during the pandemic, demonstrating the importance of screening for this population. The need for IBH services during the COVID‐19 pandemic increased, underscoring the value and demand for these services particularly during an unprecedented time.

Intervention research to improve care and outcomes for children with medical complexity and their families

Healthcare and outcomes for children with medical complexity (CMC) and their families can be improved by conducting well-conceived, designed, implemented, and analyzed research studies of clinical interventions. This article presents a framework for how to approach the study of clinical interventions for CMC, including 7 key questions and example answers to each: (1) What intervention questions should be our focus? (2) What barriers to intervention research exist? (3) How do we design and optimize interventions? (4) How do we characterize and select patients to enroll? (5) How can we enhance data collection and integration? (6) How can we improve enrollment and participation? And (7) which intervention experimental designs should we choose? By exploring each of these key aspects of intervention-based research, we hope to expand thinking about and spark ideas for specific research projects focused on clinical interventions for CMC.

Decannulation following tracheostomy in children: A systematic review of decannulation protocols

OBJECTIVE

To provide a systematic review of the existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes.

METHODS

Five online databases were searched from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Data extracted included patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location, and length of observation period, and clinical outcomes were also collected. Descriptive statistical analyses were performed.

RESULTS

A total of 24 studies including 1395 children were reviewed. Tracheostomy indications included upper airway obstruction at a well-defined anatomic site (35%), upper airway obstruction not at a well-defined site (12%) and need for long-term ventilation and pulmonary care (53%). Bronchoscopy was routinely used in 23 of 24 (96%) protocols. Tracheostomy tube modifications in the protocols included capping (n = 20, 83%), downsizing (n = 14, 58%), and fenestrations (n = 2, 8%). Measurements of gas exchange included polysomnography (n = 13/18, 72%), oximetry (n = 10/18, 56%), blood gases (n = 3,17%), and capnography (n = 3, 17%). After decannulation, children in 92% of protocols were transitioned to room air. Observation period of 48 h or less was used in 76% of children.

CONCLUSIONS

There exists large variability in pediatric decannulation protocols. Polysomnography plays an integral role in assessing most children for tracheostomy removal. Evidence-based guidelines to standardize pediatric tracheostomy care remain an urgent priority.