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Gill PJ, Buchanan F, Fahim C, Borkhoff CM, Raza S, Buba M, Wahi G, Bayliss A, Zhou K, Kanani R, Sakran M, De Castris-Garcia K, Barrowman N, Klassen T, Schuh S, Hulst J, Straus S, Macarthur C, Sozer A, Elwyn G, Breen-Reid K, Mahant S. Parenteral versus enteral fluids for infants hospitalized with bronchiolitis: The PREFER shared decision-making prospective observational study protocol. J Hosp Med 2024. [PMID: 38923338 DOI: 10.1002/jhm.13426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Incorporating shared decision-making (SDM) with children and families in hospitals was a top priority identified by patients, caregivers, and clinicians. Bronchiolitis, a common and costly reason for hospitalization in children, is an exemplar condition to study SDM in hospitals. Internationally, clinical practice guidelines differ when recommending intravenous (IV or parenteral) or nasogastric (NG or enteral) fluids for hospitalized infants with bronchiolitis who are unsafe to be fed orally. While evidence indicates that either IV or NG fluids are safe and effective, parent involvement in SDM in selecting IV or NG fluids is unknown. Our aim is to generate knowledge of SDM with parents in choosing between IV or NG fluids and the benefits and harms of these two treatment options for hospitalized children with bronchiolitis. METHOD This is a multicenter, prospective, observational study, including children aged <12 months admitted to hospital with bronchiolitis requiring supplemental IV or NG fluids. The primary outcome will evaluate the extent of SDM in choosing IV versus NG fluids using the validated CollaboRATE tool. Secondary outcomes include the proportion of parents provided a choice of IV versus NG fluids; parent knowledge of fluid therapy; rate of fluids; length of hospital stay; and complications. DISCUSSION This study will evaluate the extent of SDM in hospitalized infants with bronchiolitis who require IV or NG fluids and will evaluate both patient-centered and clinical outcomes that are relevant to clinical practice.
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Affiliation(s)
- Peter J Gill
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Francine Buchanan
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Christine Fahim
- Implementation, Evaluation and Sustainability, Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Cornelia M Borkhoff
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Shamama Raza
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Buba
- Division of Pediatric Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Paediatrics, Trillium Health Partners Credit Valley Hospital, Mississauga, Ontario, Canada
| | - Kim Zhou
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Kim De Castris-Garcia
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Terry Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jessie Hulst
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Straus
- Implementation, Evaluation and Sustainability, Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Geriatrics, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Colin Macarthur
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Aubrey Sozer
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire, USA
| | - Karen Breen-Reid
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
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Milési C, Baudin F, Durand P, Emeriaud G, Essouri S, Pouyau R, Baleine J, Beldjilali S, Bordessoule A, Breinig S, Demaret P, Desprez P, Gaillard-Leroux B, Guichoux J, Guilbert AS, Guillot C, Jean S, Levy M, Noizet-Yverneau O, Rambaud J, Recher M, Reynaud S, Valla F, Radoui K, Faure MA, Ferraro G, Mortamet G. Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit. Intensive Care Med 2023; 49:5-25. [PMID: 36592200 DOI: 10.1007/s00134-022-06918-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/13/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. METHODS Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. RESULTS This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. CONCLUSION These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.
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Affiliation(s)
- Christophe Milési
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France.
| | - Florent Baudin
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Philippe Durand
- Pediatric Intensive Care Unit, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris, Kremlin-Bicêtre, France
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Sainte-Justine University Hospital, Montreal, Canada
| | - Sandrine Essouri
- Pediatric Department, Sainte-Justine University Hospital, Montreal, Canada
| | - Robin Pouyau
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Sophie Beldjilali
- Pediatric Intensive Care Unit, La Timone University Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Alice Bordessoule
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - Sophie Breinig
- Pediatric Intensive Care Unit, Toulouse University Hospital, Toulouse, France
| | - Pierre Demaret
- Intensive Care Unit, Liège University Hospital, Liège, Belgium
| | - Philippe Desprez
- Pediatric Intensive Care Unit, Point-à-Pitre University Hospital, Point-à-Pitre, France
| | | | - Julie Guichoux
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Anne-Sophie Guilbert
- Pediatric Intensive Care Unit, Strasbourg University Hospital, Strasbourg, France
| | - Camille Guillot
- Pediatric Intensive Care Unit, Lille University Hospital, Lille, France
| | - Sandrine Jean
- Pediatric Intensive Care Unit, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Michael Levy
- Pediatric Intensive Care Unit, Robert Debré Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Jérôme Rambaud
- Pediatric Intensive Care Unit, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Morgan Recher
- Pediatric Intensive Care Unit, Lille University Hospital, Lille, France
| | - Stéphanie Reynaud
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Fréderic Valla
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Karim Radoui
- Pneumology EHS Pediatric Department, Faculté de Médecine d'Oran, Canastel, Oran, Algeria
| | | | - Guillaume Ferraro
- Pediatric Emergency Department, Nice University Hospital, Nice, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
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Feeding Pathway for Children on High Flow Nasal Cannula Decreases Time to Enteral Nutrition. Pediatr Qual Saf 2022; 7:e608. [PMID: 36518156 PMCID: PMC9742081 DOI: 10.1097/pq9.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 09/01/2022] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED High Flow Nasal Cannula (HFNC) is commonly used for children with respiratory failure, yet no standardized guidelines exist on how to initiate, escalate, and maintain enteral nutrition (EN) for these patients. EN in critically ill children is associated with decreased hospital length of stay, decreased ventilator days, and fewer acquired infections. We aimed to decrease the mean time to EN initiation by 50% after the start of HFNC in 6 months. METHODS This quality improvement project used the Model for Improvement to inform interventions. A multidisciplinary team created an EN pathway for critically ill patients on HFNC. We conducted Plan-Do-Study-Act cycles related to implementing a standardized pathway for EN on HFNC. The primary outcome was time to EN initiation once on HFNC. Secondary outcomes were time to goal caloric EN, duration of HFNC, and adverse events. Outcomes were plotted on statistical process control charts and analyzed for special cause variation between baseline and intervention periods. RESULTS We included 112 patients in the study. Special cause variation occurred for both primary and secondary outcomes. The mean time to EN initiation decreased from 24.6 hours to 11.7 hours (47.5%). Mean time to goal feeds decreased from 25.8 hours to 15.1 hours (58.5%). Mean HFNC duration did not show any special cause variation. There were no episodes of aspiration. CONCLUSION Implementation of a standardized pathway for EN on patients receiving HFNC resulted in decreased time to initiation of EN and time to goal caloric EN with no significant increase in adverse events.
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Ahearn MA, Stephens JR, Zwemer EK, Hall M, Ahuja A, Chatterjee A, Coletti H, Fuchs J, Lewis E, Liles EA, Reade E, Sutton AG, Sweeney A, Weinberg S, Harrison WN. Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes. Hosp Pediatr 2022; 12:969-980. [PMID: 36285567 DOI: 10.1542/hpeds.2022-006627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization. METHODS Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement. RESULTS We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year. CONCLUSIONS Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.
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Affiliation(s)
- M Alex Ahearn
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John R Stephens
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Eric K Zwemer
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matt Hall
- Department of Analytics, Children's Hospital Association, Overland Park, Kansas
| | - Arshiya Ahuja
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashmita Chatterjee
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hannah Coletti
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer Fuchs
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emilee Lewis
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - E Allen Liles
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Reade
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashley G Sutton
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Alison Sweeney
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Steven Weinberg
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Wade N Harrison
- Division of Hospital Pediatrics, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Shadman KA, Srinivasan M. Continuous Versus Bolus Feeds in Bronchiolitis: Is it Time to Stop the Debate? Hosp Pediatr 2022; 12:e44-e47. [PMID: 34927676 DOI: 10.1542/hpeds.2021-006396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Courtney A, Bernard A, Burgess S, Davies K, Foster K, Kapoor V, Levitt D, Sly PD. Bolus Versus Continuous Nasogastric Feeds for Infants With Bronchiolitis: A Randomized Trial. Hosp Pediatr 2022; 12:1-10. [PMID: 34927683 DOI: 10.1542/hpeds.2020-005702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Infants hospitalized with bronchiolitis are commenced on nasogastric feeding to maintain hydration. Feeding strategies vary according to physician or institution preference. The current study hypothesized that continuous nasogastric feeding would prolong length of stay (LOS) when compared to bolus feeding. METHODS A randomized, parallel-group, superiority clinical trial was performed within an Australian children's hospital throughout 2 bronchiolitis seasons from May 2018 to October 2019. Infants <12 months hospitalized with bronchiolitis and requiring supplemental nasogastric feeding were randomly assigned to continuous or bolus nasogastric regimens. LOS was the primary outcome. Secondary outcome measures included pulmonary aspirations and admissions to intensive care. RESULTS The intention-to-treat analysis included 189 patients: 98 in the bolus nasogastric feeding group and 91 in the continuous group. There was no significant difference in LOS (median LOS of the bolus group was 54.25 hours [interquartile range 40.25-82] and 56 hours [interquartile range 38-78.75] in the continuous group). A higher proportion of admissions to intensive care was detected in the continuous group (28.57% [26 of 91] of the continuous group vs 11.22% [11 of 98] of the bolus group [P value 0.004]). There were no clinically significant pulmonary aspirations or statistically significant differences in vital signs between the groups within 6 hours of feed initiation. CONCLUSIONS No significant difference in LOS was found between bolus and continuous nasogastric feeding strategies for infants hospitalized with bronchiolitis. The continuous feeding group had a higher proportion of intensive care admissions, and there were no aspiration events.
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Affiliation(s)
- Alyssa Courtney
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia
| | - Anne Bernard
- The University of Queensland, Queensland, Australia.,Queensland Cyber Infrastructure Foundation (QCIF) Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Queensland, Australia
| | - Scott Burgess
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia.,Queensland Children's Lung and Sleep Specialists, Queensland, Australia
| | - Katie Davies
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia
| | - Kelly Foster
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,University of Southern Queensland, Ipswich, Queensland, Australia
| | - Vishal Kapoor
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - David Levitt
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia
| | - Peter D Sly
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Children's Health and Environment Program, Child Health Research Centre University of Queensland, Queensland, Australia
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Gill PJ, Anwar MR, Kornelsen E, Parkin P, Mahood Q, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Cochrane Database Syst Rev 2021; 12:CD013552. [PMID: 34852398 PMCID: PMC8635777 DOI: 10.1002/14651858.cd013552.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The main focus of treatment for children hospitalised with bronchiolitis is supportive, including oxygen supplementation, respiratory support, and fluid therapy. Up to half of infants hospitalised with bronchiolitis require non-oral fluid therapy due to dehydration or concerns related to the safety of oral feeding. The two main modalities used for non-oral fluid therapy are parenteral (intravenous (IV)) and enteral tube (nasogastric (NG) or orogastric (OG)). However, it is not known which mode is optimal in young children. OBJECTIVES To systematically review randomised clinical trials (RCTs) of the effectiveness and safety of parenteral and enteral tube fluid therapy for children under two years of age hospitalised with bronchiolitis. SEARCH METHODS We conducted a search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 March 2021. We handsearched conference proceedings, conducted forward and backward searching of citation lists of relevant articles, and contacted experts. SELECTION CRITERIA We included RCTs and quasi-RCTs of children aged up to two years admitted to hospital with a clinical diagnosis of bronchiolitis who required fluid therapy. The trials compared enteral tube fluid therapy with parenteral fluid therapy. The primary outcome was difference in length of hospital stay in hours after each non-oral fluid therapy modality. As actual time of discharge can be impacted by various factors, we also assessed theoretical length of stay (i.e. time when a patient is safe for discharge). We assessed several secondary outcomes. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS: The searches yielded 615 unique records, of which four articles underwent full-text screening. We included two trials (810 children). Oakley 2013 was an open, non-blinded RCT of infants aged two to 12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons. The trial enrolled 759 children, of which 381 were randomised to NG tube therapy and 378 to IV therapy. Risk of bias was low in most domains. Kugelman 2013 was an open, non-blinded RCT that enrolled infants aged less than six months with a clinical diagnosis of "moderate bronchiolitis" at a single hospital in Israel. The study enrolled 51 infants, of which 31 were assigned to NG or OG tube therapy and 20 to IV therapy. Risk of bias was unclear in most domains. The application of enteral tube fluid therapy compared to IV fluid therapy probably makes little to no difference for actual length of hospital stay (mean difference (MD) 6.8 hours, 95% confidence interval (CI) -4.7 to 18.4 hours; 2 studies, 810 children, moderate certainty evidence). There was also little to no difference for theoretical length of stay (MD 4.4 hours, 95% CI -3.6 to 12.4 hours; 2 studies, 810 children, moderate certainty evidence). For the secondary outcomes, enteral tube fluid therapy probably makes little to no difference for time to resume full oral feeding compared to IV fluid therapy (MD 2.8 hours, 95% CI -3.6 to 9.2 hours; 2 studies, 810 children, moderate certainty evidence). The use of enteral tube for fluid therapy probably results in a large increase in the success of insertion of fluid modality at first attempt (risk ratio (RR) 1.52, 95% CI 1.36 to 1.69; 1 study, 617 children, moderate certainty evidence), and probably largely reduces the chances of change in fluid therapy modality (RR 0.52, 95% CI 0.38 to 0.71; 1 study, 759 children, moderate certainty evidence) compared to IV fluid. Oakley 2013 reported 47 local complication events after discharge in the IV fluid group compared to 30 events in the NG tube group. They also evaluated parental satisfaction, which was high with both modalities. Enteral tube fluid therapy makes little to no difference to the duration of oxygen supplementation (MD 2.2 hours, 95% CI -5.0 to 9.5 hours; 2 studies, 810 children, moderate certainty evidence). Compared with the IV fluid therapy group, there was a 17% relative reduction in the number of intensive care unit admissions (RR 0.83, 95% CI 0.47 to 1.46; 1 study, 759 children, moderate certainty evidence) and a 19% relative reduction in number of readmissions to hospital (RR 0.81, 95% CI 0.33 to 2.04; 1 study, 678 children, moderate certainty evidence) in the enteral tube fluid therapy group. Adverse events were uncommon in both trials, with likely little to no differences between groups. AUTHORS' CONCLUSIONS Based on two RCTs, enteral tube feeding likely results in little to no difference in length of hospital stay compared with the IV fluid group. However, enteral tube fluid therapy likely results in a large increase in the success of insertion of fluid modality at first attempt, and a large reduction in change in modality of fluid therapy. It also probably reduces local complications compared to the IV fluid group. Despite bronchiolitis being one of the most prevalent childhood conditions, we identified only two studies with under 1000 participants in total, which highlights the need for multicentre trials. Future studies should explore type of fluid administered, parent-reported outcomes and preferences, and the role of shared decision-making.
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Affiliation(s)
- Peter J Gill
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluation Sciences, The Hospital for Sick Children (SickKids), Toronto, Canada
| | | | - Patricia Parkin
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Quenby Mahood
- The Hospital for Sick Children (SickKids), Toronto, Canada
| | - Sanjay Mahant
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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8
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Saqib S, Mugford G, Chan K, Porter R. Method of Hydration for Infants Admitted With Bronchiolitis: Physician or Parental Choice? Cureus 2021; 13:e13896. [PMID: 33880252 PMCID: PMC8046684 DOI: 10.7759/cureus.13896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives This study examines the practice patterns with respect to the technique of non-oral hydration of infants admitted with bronchiolitis at one Canadian tertiary care institution. Additionally, the authors assess the infants' parents' attitudes regarding hydration through a nasogastric (NG) tube instead of an intravenous (IV) line. Methods A retrospective chart review was conducted for all infants admitted with bronchiolitis from May 1, 2016, to April 30, 2018, with a focus on the method of hydration, investigation with chest radiography, and use of IV antibiotics. Parents of infants who received IV fluids during the admission were surveyed by mail to assess their perceptions surrounding their child's experience with IV fluid therapy as well as their attitudes toward NG hydration, particularly in cases of difficult IV access. Results Of the 101 hospitalized infants, 54 received IV fluids and four received NG fluids. Of the 54 eligible for the survey, 17 completed surveys were returned. Parents were likely to consider NG hydration if suggested by their pediatrician. The proportion was extremely or very likely to consider this intervention increased from 29% in a generic situation to 53% in a scenario where there was more than one unsuccessful IV attempt (p=0.03). Conclusions In the institution studied, NG hydration was rarely used. Parents seemed receptive to the idea of NG hydration as an alternative, particularly when IV access is difficult.
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Affiliation(s)
- Saima Saqib
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, CAN
| | - Gerald Mugford
- Community Health and Humanities, Memorial University of Newfoundland, St. John's, CAN
| | - Kevin Chan
- Pediatrics, University of Toronto, Toronto, CAN
| | - Robert Porter
- Pediatrics, Memorial University of Newfoundland, St. John's, CAN
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9
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Komashie A, Ward J, Bashford T, Dickerson T, Kaya GK, Liu Y, Kuhn I, Günay A, Kohler K, Boddy N, O'Kelly E, Masters J, Dean J, Meads C, Clarkson PJ. Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis. BMJ Open 2021; 11:e037667. [PMID: 33468455 PMCID: PMC7817809 DOI: 10.1136/bmjopen-2020-037667] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 10/02/2020] [Accepted: 11/18/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement. DESIGN Systematic review with meta-analyses. METHODS Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs-heterogeneity was assessed using I2 statistics. RESULTS Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%). CONCLUSIONS This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.
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Affiliation(s)
- Alexander Komashie
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, Cambridgeshire, UK
- NIHR Global Health Research Group on Neurotrauma, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - James Ward
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Tom Bashford
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
- NIHR Global Health Research Group on Neurotrauma, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
- Division of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Terry Dickerson
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Gulsum Kubra Kaya
- Faculty of Engineering and Natural Sciences, Istanbul Medeniyet University, Istanbul, Turkey
| | - Yuanyuan Liu
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Isla Kuhn
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Aslι Günay
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
- Media and Visual Arts, Koc University, Istanbul, Turkey
| | - Katharina Kohler
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
- Division of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Nicholas Boddy
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Eugenia O'Kelly
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Joseph Masters
- Major Trauma Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - John Dean
- Department of Care Quality Improvement, Royal College of Physicians, London, London, UK
| | - Catherine Meads
- School of Nursing and Midwifery, Anglia Ruskin University - Cambridge Campus, Cambridge, Cambridgeshire, UK
| | - P John Clarkson
- Department of Engineering, University of Cambridge, Cambridge, Cambridgeshire, UK
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10
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Fuchs J, Rubenstein J, Chase L. Things We DON'T Do for No Reason. Hosp Pediatr 2020; 10:1014-1016. [PMID: 33023922 DOI: 10.1542/hpeds.2020-000760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Jennifer Fuchs
- University of North Carolina Children's Hospital, Chapel Hill, North Carolina; and
| | - Jared Rubenstein
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Lindsay Chase
- University of North Carolina Children's Hospital, Chapel Hill, North Carolina; and
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11
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Abstract
Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.
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Affiliation(s)
- Lauren Paluch
- At the time this article was written, Lauren Paluch was assistant fellowship director in the urgent care system of Children's Hospital of the King's Daughters in Norfolk, Va. She now is an assistant professor at Eastern Virginia Medical School in Norfolk, Va. The author has disclosed no potential conflicts of interest, financial or otherwise
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12
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Gill PJ, Parkin P, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Peter J Gill
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
- University of Toronto; Department of Pediatrics, Faculty of Medicine; Toronto Ontario Canada
- SickKids Research Institute; Child Health Evaluative Sciences; Toronto Ontario Canada
- University of Toronto; Institute for Health Policy, Management and Evaluation; Toronto Ontario Canada
| | - Patricia Parkin
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
- University of Toronto; Department of Pediatrics, Faculty of Medicine; Toronto Ontario Canada
- SickKids Research Institute; Child Health Evaluative Sciences; Toronto Ontario Canada
- University of Toronto; Institute for Health Policy, Management and Evaluation; Toronto Ontario Canada
| | - Sanjay Mahant
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
- University of Toronto; Department of Pediatrics, Faculty of Medicine; Toronto Ontario Canada
- SickKids Research Institute; Child Health Evaluative Sciences; Toronto Ontario Canada
- University of Toronto; Institute for Health Policy, Management and Evaluation; Toronto Ontario Canada
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13
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Subramony A, Kocolas I, Srivastava R. Pediatric Hospitalists Improving Patient Care Through Quality Improvement. Pediatr Clin North Am 2019; 66:697-712. [PMID: 31230617 DOI: 10.1016/j.pcl.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article reviews the industrial underpinnings of the quality improvement (QI) movement and describes how QI became integrated within the larger health care landscape, including hospital medicine. QI methodologies and a framework for using them are described. Key components that make up a successful QI clinical project are outlined, with a focus on the essential role of pediatric hospitalists and practical professional tips to be successful. QI training opportunities are reviewed with opportunities for hospitalists to get involved in QI on a national level. National QI networks are showcased, with multiple examples of advanced improvement projects that have significantly improved patient outcomes highlighted.
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Affiliation(s)
- Anupama Subramony
- Department of Pediatrics, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 269-01 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Irene Kocolas
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine/Primary Children's Hospital, Intermountain Healthcare, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Raj Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine/Primary Children's Hospital, Healthcare Delivery Institute, Intermountain Healthcare, 5026 State Street, Murray, UT 84107, USA
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14
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Valla FV, Baudin F, Demaret P, Rooze S, Moullet C, Cotting J, Ford-Chessel C, Pouyau R, Peretti N, Tume LN, Milesi C, Le Roux BG. Nutritional management of young infants presenting with acute bronchiolitis in Belgium, France and Switzerland: survey of current practices and documentary search of national guidelines worldwide. Eur J Pediatr 2019; 178:331-340. [PMID: 30506396 DOI: 10.1007/s00431-018-3300-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022]
Abstract
Feeding difficulties are common in young infants presenting with acute bronchiolitis, but limited data is available to guide clinicians adapting nutritional management. We aimed to assess paediatricians' nutritional practices among Western Europe French speaking countries. A survey was disseminated to describe advice given to parents for at home nutritional support, in hospital nutritional management, and preferred methods for enteral nutrition and for intravenous fluid management. A documentary search of international guidelines was concomitantly conducted. Ninety-three (66%) contacted physicians responded. Feeding difficulties were a common indication for infants' admission. Written protocols were rarely available. Enteral nutrition was favoured most of the time when oral nutrition was insufficient and might be withheld in case of severe dyspnoea to decrease respiratory workload. Half of physicians were aware of hyponatremia risk and pathophysiology, and isotonic intravenous solutions were used in less than 15% of centres. International guideline search (23 countries) showed a lack of detailed nutritional management recommendations in most of them.Conclusion: practices were inconsistent among physicians. Guidelines detailed nutritional management poorly. Awareness of hyponatremia risk in relation to intravenous hypotonic fluids and of the safety of enteral hydration and nutrition is insufficient. New guidelines including detailed nutritional management recommendations are urgently needed. What is Known? • Infants presenting with acute bronchiolitis face feeding difficulties. • Underfeeding may promote undernutrition, and intravenous hydration with hypotonic fluids may induce hyponatremia. What is New? • Physicians' nutritional practices are inconsistent and awareness of hyponatremia risk and pathophysiology is insufficient among physicians. • Awareness of hyponatremia risk and pathophysiology is insufficient among physicians. • The reasons for enteral nutrition withholding in bronchiolitis infants are not evidence based, and national guidelines of acute bronchiolitis across the world are elusive regarding nutritional management. • National guidelines of acute bronchiolitis across the world are elusive regarding nutritional management.
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Affiliation(s)
- Frédéric V Valla
- Paediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500, Lyon-Bron, France.
- Faculty of Health and Applied Sciences, The University of the West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD, UK.
- CarMEN INSERM UMR 1060 Equipe INFOLIP, 69100, Villeurbanne, France.
| | - Florent Baudin
- Paediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500, Lyon-Bron, France
- Université Claude Bernard Lyon 1, Ifsttar, UMRESTTE, UMR T 9405, 69373, Lyon, France
| | - Pierre Demaret
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, CHC, Liège, Belgium
| | - Shancy Rooze
- Paediatric Intensive Care, Hôpital Universitaire des Enfants Reine Fabiola, 1020, Laeken-Brussels, Belgium
| | - Clémence Moullet
- Department of Nutrition and Dietetics, Haute Ecole de Santé, University of Applied Sciences of Western Switzerland, Carouge, Geneva, Switzerland
| | - Jacques Cotting
- Paediatric Intensive Care, University Hospitals of Lausanne, Lausanne, Switzerland
| | - Carole Ford-Chessel
- Paediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500, Lyon-Bron, France
- Paediatric Nutrition and Dietetic Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500, Lyon-Bron, France
| | - Robin Pouyau
- Paediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500, Lyon-Bron, France
| | - Noël Peretti
- CarMEN INSERM UMR 1060 Equipe INFOLIP, 69100, Villeurbanne, France
- Paediatric Gastroenerology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel, 69500, Lyon-Bron, France
| | - Lyvonne N Tume
- Faculty of Health and Applied Sciences, The University of the West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD, UK
- Paediatric Intensive Care Unit, Bristol Children's Hospital, Upper Maudlin Street, Bristol, UK
| | - Christophe Milesi
- Paediatric Intensive Care, Hôpital Arnaud de Villeneuve, 371 av Doyen Giraud, 34296, Montpellier, France
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15
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Srinivasan M, Casper TJ. Nasogastric Hydration for Bronchiolitis: Sustaining Change in Practice. Glob Pediatr Health 2018; 5:2333794X18759398. [PMID: 29511709 PMCID: PMC5833212 DOI: 10.1177/2333794x18759398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/15/2022] Open
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