Background:We aimed to compare health-related quality of life (HRQL) using a disease-specific and a generic instrument in children after complex cardiac surgery in early infancy. Methods:A prospectively followed inception cohort of children having complex cardiac surgery at age ≤6 weeks had HRQL assessed at age 4-5 years using Pediatric Quality of Life Inventory (PedsQL) 3.0 Cardiac Module. Scores were compared with the PedsQL Generic Core Scales in the same population. Predictors of Cardiac Module dimensions were determined by univariate and multivariate linear regression, with P ≤ 0.05 considered statistically significant. Results:Among 425 patients who had the PedsQL 3.0 Cardiac Module, the HRQL mean (standard deviation) scale scores were as follows: Heart Problems and Treatment, 78.7 (19.0); Treatment II, 94.5 (15.2); Perceived Physical Appearance, 93.6 (13.9); Treatment Anxiety, 71.1 (29.5); Cognitive Problems, 67.3 (22.7); and Communication, 67.5 (31.2). Correlations between Cardiac Module and Generic Core Scales were as follows: Heart Problems and Treatment × Physical Functioning 0.57; Perceived Physical Appearance × Psychosocial Summary 0.21; Cognitive Problems × School Functioning 0.48; Treatment Anxiety × Physical Functioning 0.38; and Communication × School Functioning 0.30. Thirteen predictor variables were independently associated with at least 1 dimension of the Cardiac Module, and these only partially overlapped with independent predictors of Generic Core Scale summary scores. Conclusions:The Cardiac Module measured a different HRQL construct than the Generic Core Scales, reflected by low correlations among scores and different independent predictors in the same population of children. Future studies should determine the relation of these scores with longer-term outcomes including school achievement, mental health, and well-being.

OBJECTIVE:Single-use supplies stored in bedside supply carts with paper packaging cannot be wiped with disinfectants. We aimed to determine the prevalence of pathogens on these unused supplies. DESIGN:Prospective study over 7 weeks in 2025. SETTING:Two pediatric ICUs at a university affiliated children's hospital. PATIENTS:The unit of analysis was the bedside supply cart from each discharged ICU patient. INTERVENTIONS:One swab was used to swab three supply items contained in a single drawer in a room's bedside cart. Carts had two drawers sampled, each with a swab for bacterial culture and respiratory viral nucleic acid amplification testing (NAAT). RESULTS:Paper-packaged supply items (n = 840) from 70 consecutive bedside carts were swabbed after patient discharge. All bacterial swabs had no growth of pathogen [0/140 (0%), 95% CI 0%, 2.3%)]. A non-pathogen was cultured from 8/140 (5.7%) swabs [7/70 (10.0%) carts], most with scant growth [7/8 (87.5%) only one colony]. Non-pathogens (common commensal skin and oral flora) included coagulase-negative staphylococci (n = 5), Actinomyces oris (n = 1), aerobic spore-forming Bacillus (n = 1), and viridans group streptococcus [non-anginosus] (n = 1). Of viral swabs, 3/140 (2.1%, 95% CI 0.5%, 6.4%) were NAAT positive (3/70 (4.3%) carts). Room isolation status, length of stay, and ICU were not associated with a positive bacterial or viral swab. CONCLUSIONS:Bacterial pathogen detection on supplies, a necessary step in transmission, was extremely low. Viral NAAT detection on supplies was low and likely exaggerated the risk of fomite transmission, as whether there was viable virus at sufficient concentration to transmit infection is unknown.

The majority of patients who undergo pediatric ventricular assist device implantation or heart transplant are expected to survive to adulthood. However, there is limited research into what their neurodevelopmental and neurocognitive trajectories will be. This narrative mini review summarizes the literature available, demonstrating the significant burden of neurodevelopmental and neurocognitive difficulties in survivors, and highlights the importance of improving anticoagulation and developmental care in this population aiming for patients to reach their full potential. There is ongoing need for further research, and collaboratives such as the Advanced Cardiac Therapies Improving Outcomes Network can play an integral role in facilitating our understanding of the risk factors and long-term outcomes in this complex and high-risk patient population.

Background:Executive function (EF) challenges occur in older children after complex cardiac surgery and can affect multiple aspects of daily life. Methods:This is a prospective inception-cohort study of children after complex cardiac surgery (2009-2019) in early infancy assessed at age 4.5 years using the Behavior Rating Inventory of Executive Function Preschool Version. Independent predictors of clinically significant EF difficulties (T scores ≥65) were determined using multiple logistic regressions, reported as odds ratios (OR) with 95% confidence intervals (CI). Results:EF outcomes were available for 318 of 581 (55%) eligible survivors; 20.4% showed clinically significant global EF difficulties. In model 1, independent predictors included birth year for the Inhibitory Self-Control Index, maternal years of education for the Emergent Metacognition Index and Global Executive Composite (GEC), and the number of medical specialists at age 4.5 years for GEC. In model 2, which excluded more distal variables, independent predictors for the Inhibitory Self-Control Index were birth year (OR: 1.16, 95% CI: 1.04, 1.31; P = 0.008) and life-saving support (OR: 2.59, 95% CI: 1.14, 5.74; P = 0.021); maternal education predicted the Emergent Metacognition Index (OR: 0.84, 95% CI: 0.74, 0.96; P = 0.011); and maternal education (OR: 0.82, 95% CI: 0.71, 0.93; P = 0.003) and life-saving support (OR: 2.41, 95% CI: 1.08, 5.18; P = 0.027) predicted GEC. Conclusions:The findings highlighted the risk of emerging EF difficulties in young children, especially those needing life-saving support. A study is needed to better understand how home environmental factors influence EF outcomes. Given the broad developmental impact of EF, early intervention may offer widespread, cumulative benefits.

We review the chronic phase ventilation (CPV) strategy recommended in infants with the most severe bronchopulmonary dysplasia (msBPD, mechanically ventilated at 36–40 weeks post-menstrual age). The safety and efficacy of CPV was important to scrutinize because msBPD is increasingly common, and infants with msBPD are often transferred to the Pediatric Intensive Care Unit (PICU) where the CPV strategy started in neonatal intensive care is expected to continue as the standard of care. First, we describe the CPV strategy, and the supporting evidence given by expert proponents. Second, we subject the supporting evidence to critical scrutiny and explain flaws that weaken support. Third, we give evidence that the strategy is based upon unsound pathophysiology and hence may be harmful. Fourth, we put this all together by making unstated (and unsupported) premises in explaining the benefit of CPV explicit. We made four conclusions. First, the literature suggested that CPV is based upon circular referencing among chapters and narrative reviews written by the same respected experts, and therefore, upon literature inadequately subjected to critical scrutiny. Second, these reviews explained physiologic theory with little supportive evidence that had likely been misinterpreted, and referred to outcome studies that did not examine the effect of the CPV strategy. Third, when implicit assumptions are made explicit, there is evidence to show a lack of consensus about and potential harms of the CPV strategy, and inaccurate interpretations of msBPD physiology. Fourth, there was no rationale that withstands critical scrutiny to suppose ventilated children with msBPD might be an exception to using a standard of care ventilation strategy used in acute lung disease. If the CPV strategy is beneficial, we urgently need better data to that effect; otherwise, it is too early to widely adopt what may be a harmful strategy as standard of care.

BACKGROUND:The majority of patients who undergo ventricular assist device (VAD) implant in childhood survive to adulthood. This study examined the neurodevelopmental trajectory post VAD and determined factors associated with non-optimal outcome. METHODS:Patients implanted with a VAD aged < 6 years between 01/2006 and 12/2020, who underwent assessment at 4.5-7-years of age (and > 6 months post decannulation) with the Complex Pediatric Therapies Follow-up Program were included in a prospective-inception-cohort study. Optimal neurodevelopmental outcome was defined as scores of ≥ 80 on the Wechsler Preschool and Primary Scales of Intelligence, the Beery-Buktenica Developmental Test of Visual-Motor Integration and on the Adaptive Behavior Assessment System, in the absence of cerebral palsy, permanent hearing loss, visual impairment, or seizure disorder. Firth multiple regression analysis was used to determine independent factors associated with non-optimal outcome. RESULTS:A total of 74 patients underwent VAD implant at age < 6 years with neurodevelopmental assessments available for 48/51 patients who survived to testing. Median age at implant was 0.63 years (IQR 0.20, 2.74), 37.5% were female and 39.6% had congenital heart disease. Optimal outcome occurred in 33% of patients. Optimal outcome was associated with female sex [OR 8.03 (95% CI 1.69-56.64) p = 0.007] and implant between 2015 and 2020 [OR 6.59 (95% CI 1.42-42.62) p = 0.016]. Neurological insult sustained pre-post-VAD [OR 0.10 (95% CI 0.01-0.63) p = 0.01] was associated with a non-optimal outcome. CONCLUSION:Optimal outcome was present in one-third of patients. Protective factors were female sex and implant between 2015 and 2020. Neurological insult was associated with a non-optimal outcome.

Hand grip strength (HGS) is a validated measure of muscle function. We aimed to determine HGS and its predictors in young children after complex cardiac surgery in early infancy. A prospective inception-cohort of children who had complex cardiac surgery in early infancy between 2010-2019 had HGS measured using the Martin Vigorimeter at age 4.5 years. Predictor variables (demographics, severity-of-illness perioperatively and at age 4-5 years, and outcomes at 4-5 years of age) association with HGS were determined using univariate and two multiple linear regression models (considering all variables, and excluding distal variables). Of 390 survivors, 165 (42%) completed and 162 (42%) did not complete HGS assessment, and 63 (16%) were lost to follow-up or pending. Children who did not complete HGS had significantly higher illness severity and adverse outcome variables versus children who had HGS assessed. Stronger hand Z-scores for HGS were mean 1.16 (SD 1.72). In model 1, lower HGS z-score was statistically associated with small for gestational age, while higher HGS z-score was statistically associated with full-scale intelligence quotient and height z-score. In model 2, highest lactate after surgery was statistically associated with lower HGS z-score (Effect Size -0.11 (95% CI -0.21, -0.02), p=0.022). HGS measurement was feasible in 42% of survivors, limiting its application at the young age of 4.5 years after having had complex cardiac surgery in infancy. Risk factors including small for gestational age and highest lactate after surgery may be modifiable.

Achieving antibiotic pharmacodynamic targets is critical to surviving sepsis. The purpose of this study was to determine the achievement of pharmacodynamic target-free minimum plasma concentration (fCmin)-during the first 2 days of high-dose 6-h intravenous meropenem or piperacillin-tazobactam in critically ill children, and to identify its predictors. This was a prospective observational study conducted in two pediatric intensive care units of children admitted between 2022 and 2023 who were prescribed meropenem or piperacillin-tazobactam. Primary outcomes were achievement of pharmacodynamic target fCmin (defined as fCmin>MIC or fCmin>4×MIC). Secondary outcomes included predictors of target concentrations and time to resolution of signs of severe infection using univariate and multivariable regressions. Of 49 patients, 47 had an antibiotic concentration measured at 24 h, and 38 at 48 h. At 24 h, 48 h, or either time point, augmented renal clearance (ARC) occurred in 13/30 (43%), 14/22 (64%), and 17/30 (57%), respectively. For epidemiologic cutoff values, fCmin>MIC occurred in 17/47 (36%) and 13/38 (34%) at 24 and 48 h, and fCmin>4×MIC occurred in 3/47 (6%) and 4/38 (11%). Target tazobactam concentrations (fCmin>0.5 or >2mg/L) occurred in 48% or 64% of the patients and 28% or 39% of the patients at 24 and 48 h. Potentially neurotoxic concentrations occurred in 1/9 (11%) patients on meropenem at 48 h, and in none receiving piperacillin-tazobactam. Only ARC independently predicted not achieving fCmin>MIC at 48 h (odds ratio 0.04 [95% CI 0.00, 0.69] P = 0.026). Therapeutic antibiotic concentration did not predict the time to resolution of severe symptoms and signs of sepsis (n = 32). In this cohort of critically ill children, high doses of piperacillin-tazobactam or meropenem did not often achieve pharmacodynamic targets and were rarely toxic.

BACKGROUND:To determine efficacy of early steroid therapy on outcomes in children with acute necrotizing encephalopathy. METHODS:We leveraged two 2023 systematic reviews to identify eligible publications, predefined as having ≥3 patients, objective study outcomes categorized as good or poor, and described according to steroid therapy. Data were combined by (i) adding raw data from included studies (as done in the previous systematic review) and (ii) random effects meta-analysis with relative risk (RR) and 95% confidence interval (CI). Sensitivity analysis used a more consistent definition of good outcome and excluded lower quality studies. P values ≤0.05 and ≤ 0.005 were considered statistically suggestive or significant. RESULTS:Nine retrospective observational studies were included, each with different definitions of good versus poor outcome. Combined numbers found a statistically suggestive effect for early steroids (RR 2.17 [95% CI 1.25, 3.76]; P = 0.006) and in the sensitivity analysis (RR 2.09 [95% CI 1.16, 3.93] P = 0.021) but not in subgroups with/without brainstem lesions. Meta-analysis found statistically suggestive effect for early steroids (RR 2.06 [95% CI 1.03, 4.09] P = 0.040); this was not statistically suggestive in sensitivity analysis (RR 2.03 [95% CI 0.99, 4.16] P = 0.052), in those without brainstem lesions, or for any steroids. CONCLUSIONS:Meta-analysis suggested that it may be premature to assert that early steroids, even in those without brainstem involvement, will improve neurologic outcomes in children with acute necrotizing encephalopathy. For a false positive rate 5%, the required prior probability of effect would be implausibly high. Good outcomes were not uncommon, questioning the label 'necrotizing' in all cases.

During the COVID-19 pandemic (2020-2023), governments around the world implemented an unprecedented array of non-pharmaceutical interventions (NPIs) to control the spread of SARS-CoV-2. From early 2021, these were accompanied by major population-wide COVID-19 vaccination programmes-often using novel mRNA/DNA technology, although some countries used traditional vaccines. Both the NPIs and the vaccine programmes were apparently justified by highly concerning model projections of how the pandemic could progress in their absence. Efforts to reduce the spread of misinformation during the pandemic meant that differing scientific opinions on each of these aspects inevitably received unequal weighting. In this perspective review, based on an international multi-disciplinary collaboration, we identify major problems with many aspects of these COVID-19 policies as they were implemented. We show how this resulted in adverse impacts for public health, society, and scientific progress. Therefore, we propose seven recommendations to reduce such adverse consequences in the future.

Survivors after pediatric critical care often have adverse sequelae in domains of cognition, executive function, attention, memory, visual-spatial skills, language, motor function, behavior, and emotional functioning, the post-intensive-care syndrome pediatric (PICS-p). The time from birth to approximately age 2 years is a period of rapid structural and functional brain development. The fundamental structural and functional architecture of the brain is in place by the second year of life. This narrative review focuses on how we, in the pediatric intensive care unit (PICU), can work towards maximizing each patient's full potential despite adverse experiences during hospitalization. In part I, concepts relevant to understanding the effects of hospitalization in PICU on brain development are clarified, including concepts of toxic stress and trauma, sensitive periods and cascades, experience-expectant neural plasticity in the early years, and resilience and buffering of adversity focused on relational care. In part II, evidence is presented that these concepts are important because they describe the effects of early childhood adversity that are pervasive on physical health, cognitive, and emotional outcomes throughout the lifespan. Evidence is presented to show that intervention to improve these outcomes can be effective. In part III, the concepts and evidence are synthesized by focusing on the opportunity before us, what we must and can do better while patients are in the PICU, in order to improve their long-term lifelong outcomes. We present evidence to argue that we in pediatric critical care must take a public-health approach to address the key environmental conditions necessary for optimal early childhood development and hence facilitate children's ability to thrive. Future research must aim to determine what works best and what does not work in the PICU. Early childhood investments to improve lifelong outcomes have great potential to help patients and reduce the growing burden of healthcare costs.

The risk of lumbar puncture (LP) to precipitate brain herniation in acute bacterial meningitis (ABM) was reviewed in this journal in 2007. We report the case of an infant with ABM who had acute apnea requiring intubation and tonic posturing (mistaken for seizure), and then had brain herniation within four hours of an LP. The case prompted this updated narrative review, from 2007 to 2024, focused on the twelve points made in 2007. The review included 14 case reports of brain herniation shortly after LP in ABM, 23 observational studies or systematic reviews, 28 narrative reviews, and 9 guidelines, each with evidence, advice, or recommendations important for the decision to perform LP in ABM. We found evidence to support, and did not find convincing evidence to refute, the twelve points. We found five additional claims made that were meant to refute some of the original points; however, these were based upon data that did not support the claims made. Limitation of the evidence reviewed was the absence of randomized trials to prove whether those patients who herniated may have been destined to herniate regardless of whether they had an LP. Reasons why ABM may be a unique circumstance where normal CT scan cannot determine the risk of herniation after an LP were discussed. We argue that the preponderance of evidence supported the conclusion that, in a patient with strongly suspected ABM who is clinically considered at high risk for herniation, interventions to control ICP and antibiotics administration should be the priority, followed secondarily by an urgent CT scan and, even with a normal CT, not an LP. The case report emphasized that respiratory arrest or suspected tonic seizure can be due to early herniation, and indicate CT scan, and prolonged LP deferral (for 3-4 days) even with a normal CT.

Background Health-Related Quality of Life (HRQL) is an important outcome measure in pediatrics. We aimed to determine HRQL of children who underwent complex cardiac surgery at age ≤6 weeks with follow-up at age 4-5-years. Methods We prospectively followed an inception-cohort of children after complex cardiac surgery (CCS) performed at age ≤6 weeks at Stollery Children’s Hospital between 2000-2014. At the 4-5-year follow-up visit, parents completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL). Scores were compared to a normative healthy population and to children with chronic illness of a similar age. Predictors of PedsQL scores were determined using univariate and multiple linear regressions, with p≤0.05 considered statistically significant. Results Of 712 children having CCS at ≤6 weeks of life, 119 (16.7%) died and 140 did not complete the HRQL questionnaire (for multiple reasons), leaving 453/593 (76.4%) of survivors included. At 4-5-year follow-up PedsQL total score (mean 79.5, SD 16.3) was significantly lower than the healthy normative population (mean 87.4, SD 12.7), and similar to children with chronic illness (mean 76.0, SD 19.3). Patients after single ventricle palliation had significantly lower PedsQL total score (mean 72.8, SD 17.1) than those after biventricular repairs (mean 82.4, SD 15.1). Independent risk factors for lower PedsQL scores consistently included single ventricle palliation, chromosomal abnormality, extracorporeal membrane oxygenation, and the number of non-cardiac hospitalizations. Conclusion The HRQL of children who had CCS in early infancy is lower than that of healthy children, but similar to children with other chronic illnesses.

This referral center's prospective inception-cohort study from 1989 to 2000 (Era 1) and 2000 to 2022 (Era 2) included 232 consecutive children having neonatal respiratory extracorporeal membrane oxygenation (ECMO). Kindergarten-age outcomes determined in 137/139 (95.8%) survivors were Wechsler Preschool and Primary Scales of Intelligence, Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI), and sensorimotor disability, with optimal outcome defined as scores greater than or equal to 80 and without disability. In Era 2, there were fewer patients/year, fewer neonates with meconium aspiration syndrome, and more with sepsis, lethal disease, or "other" diagnoses. Era 2 also had higher rates of venoarterial cannulation, cannulation after the first week of life, and extracorporeal cardiopulmonary resuscitation. In survivors, there was a shift in Full-Scale Intelligence Quotient (FSIQ), Verbal IQ, Performance IQ, and VMI to the left of population norms, with scores less than 70 in 16-40% (expected in 2.27% of the normative population), disability in 53%, and optimal outcome in 38%. Era was not independently associated with mortality, optimal outcome, or FSIQ outcomes. Congenital Diaphragmatic Hernia (CDH) was independently associated with lower optimal outcome and FSIQ. Sensorineural hearing loss (bilateral, predominantly high-frequency, often progressive, and of delayed onset) was eliminated from Era 2, despite a concerning incidence of 40% in Era 1. Survival and neurocognitive outcomes after neonatal respiratory ECMO have not changed over 34 years.

Background Although advances in cardiac surgery have increased survival rates from congenital heart disease, neurocognitive and functional outcomes have not significantly improved. We hypothesized that the absence of change in outcome scores may be due to survivorship bias. Our study aimed to address this by adjusting neurocognitive and functional outcome trend lines using k-mean clustering and propensity score (PS) methods. Methods Prospective follow-up was conducted on 266 children with single ventricle congenital heart disease who underwent the Norwood procedure at age ≤6 weeks at Stollery Children's Hospital, Edmonton, Alberta, between 1997 and 2016. PS and k-mean clustering methods were used to adjust outcomes for children with more complex conditions. Crude and adjusted trend lines for neurocognitive and functional outcomes were analyzed using multiple linear regression models. Results Multiple logistic regression determined age at surgery, total ventilation days, deep hypothermic circulatory arrest time, and total days chest open were significant in PS calculation. The adjusted linear time-trend analysis of neurocognitive and functional outcomes showed no change in Full Scale Intelligence Quotient and Visual Motor Integration scores. Although not robust to using the different PS adjustment methods, General Adaptive Composite scores may have decreased over time. Models with PS adjustment were not different from models without PS adjustment. Conclusions PS adjustment with clustering did not confirm survivorship bias. PS-adjusted models demonstrated stable Full Scale Intelligence Quotient and Visual Motor Integration scores over time, and inconsistent findings for General Adaptive Composite scores. Improved survival after more complex cardiac surgery was not associated with worse long-term neurocognitive outcomes.

Fluid accumulation (FA) is associated with morbidity and mortality in intensive care. We aimed to determine sources of FA in critically ill children admitted to pediatric intensive care. Prospective cohort study of children in a university affiliated tertiary pediatric intensive care unit. Primary outcome was to describe contributors to fluid intake. Secondary outcomes were independent associations between fluid intake and FA > 5