OBJECTIVES:The authors hypothesized that establishing a one-stop clinic for the management of Developmental Dysplasia of the Hip (DDH) at our institution would enhance screening procedures, referral processes, patient compliance, early diagnosis, and timely treatment for this condition. To inform clinical practice, the authors conducted a collaborative development of flowcharts for evidence-based patient care protocols, based on the Graf method and patient journey optimization. METHODS:A weekly DDH clinic was established in a tertiary/quaternary public teaching hospital in Brazil, integrating pediatrics, radiology, and orthopedics. Flowcharts were collaboratively designed during ten interdisciplinary meetings. As a pilot study, the authors included an initial cohort involved in an observational retrospective study during the period from October 2023 to December 2024. RESULTS:A novel system of grouping Graf types and subtypes was presented, accompanied by a treatment algorithm and phased therapeutic approach, based on the underlying hip pathology and immediate therapeutic requirements to promote hip centralization and acetabular development. A total of 98 infants were examined at the clinic during the specified period, with 22 receiving non-surgical treatment utilizing the Pavlik harness. CONCLUSION:The establishment of a one-stop DDH clinic demonstrated a successful interdisciplinary approach, contributing to early diagnosis and effective treatment of DDH. The collaborative development of flowcharts facilitated the standardization of patient management protocols. Continued refinement of screening procedures and data collection methods is necessary to optimize care and inform future research on DDH management.

To evaluate the association between maternal anti-Ro and anti-La antibody levels and the occurrence of congenital heart block (CHB) in fetuses and newborns. This retrospective cohort study included 182 pregnant women with positive anti-Ro and/or anti-La antibodies who received prenatal care at our tertiary center between 2002 and 2022. Maternal clinical, laboratory, and obstetric variables were analyzed. Thirteen fetuses (7.1

OBJECTIVE:The aim of this study was to develop and validate the content of a nutritional risk screening tool for critically ill children and adolescents in pediatric intensive care units (PICUs). METHODS:Care-convergent study for the development and content validation of an instrument for assessing nutritional risk in children admitted to the PICU. The initial development was based on a literature review and the clinical experience of the authors. Content validation was conducted using the Delphi technique in two successive rounds with intentionally selected experts, each with a minimum of 5 years of experience in pediatric intensive nutritional therapy (NT). Consensus analysis was performed using the content validity index (CVI), with minimum values of 0.70 for individual items and 0.90 for the overall instrument. RESULTS:Validation occurred in two rounds. In the first round, 18 experts suggested adjustments, and the revised version was reassessed by 12 experts in the second round. The final tool achieved an overall CVI of 0.958. The validated version included age subgroups, presence of chronic diseases, length of prior hospitalization, subjective impression of malnutrition risk, type of NT at admission, and C-reactive protein (CRP) levels. CONCLUSIONS:The nutritional risk screening tool for critically ill pediatric patients, named NutriRisKids-ICU, was developed, and its content was validated by expert consensus. The tool combines theoretical evidence and clinical expertise, showing potential for application in PICUs. However, further studies are needed to assess its applicability, sensitivity, and specificity.

Burnout, characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment, is common among healthcare workers, particularly in pediatric intensive care units (PICUs). Longitudinal data from low- and middle-income countries are limited. Repeated cross-sectional surveys were conducted among PICU staff at a Brazilian public hospital from 2020 to 2023 using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Participants were classified into behavioral profiles (engaged, ineffective, overextended, disengaged, burnout). Emotional exhaustion increased from 2.47 ± 1.17 in 2020 to 3.33 ± 1.30 in 2023 (p = 0.027), while depersonalization rose from 1.13 ± 1.07 to 1.86 ± 0.98 (p = 0.014). Personal accomplishment declined from 4.62 ± 0.79 to 4.11 ± 0.84 (p = 0.048). Overextended staff increased from 22.5% to 44%, whereas engaged workers fell from 45% to 16%. Burnout worsened over time among PICU staff in this Brazilian tertiary center. Protected breaks, peer support, and AI-assisted monitoring may help preserve staff wellbeing and workforce stability in resource-limited settings.

BACKGROUND:Mechanical power (MP) estimates the energy delivered to the lungs during ventilation. This study reviews pediatric research on MP and its association with ventilation duration and mortality. METHODS:According to the PRISMA guidelines, a systematic search was conducted in the databases Pubmed, Embase, Scopus, Web of Science, Lilacs, and Cochrane. A manual search was performed in the bibliography of the included studies and in the grey literature. All articles on mechanical power were included, and then studies focusing on the pediatric population were selected. The risk of bias was assessed using the Newcastle-Ottawa scale. RESULTS:Nine articles were included. No randomized controlled trials were found. A total of 1769 children were included, of whom 1417 were diagnosed with acute respiratory distress syndrome (ARDS), while 148 had no evidence of lung injury. The median age ranged from 5.7 to 114 months, and 275 children died. MP values were found to be associated with increased mortality. Most studies utilized adaptations of the Gattinoni or Becher formulas. In children without lung pathology, average MP values were 3.93 ± 1.1 J/min. For children with ARDS, median MP values were 10 J/min in survivors and 15 J/min in non-survivors. Elevated MP values, particularly when assessed dynamically within the first 24 h of ventilation and adjusted for body weight, were consistently associated with increased mortality and, in some studies, prolonged ventilation duration. CONCLUSION:Mechanical power can be measured in children on pressure-controlled ventilation, preferably adjusted for body weight. Further research is needed to define risk thresholds.

Objective To evaluate and monitor, through electrophysiological assessment of hearing, the integrity of the peripheral and central auditory pathways in infants with Peri-intraventricular hemorrhage and/or Periventricular Leukomalacia (PIVH/PVL) who stayed in a Neonatal Intensive Care Unit (NICU), aiming to verify the occurrence of possible neural dysfunctions in this system. Material and methods This prospective longitudinal study evaluated preterm Newborns (NBs) and infants at the time of hospital discharge and after 3- and 6-months. The Study Group (SG) had 12 females and 11 males, with gestational age between 25- and 33-weeks, and a mean gestational age of 29.82-weeks at birth. The Control Group (CG) had 26 healthy NBs, distributed in 13 females and 13 males, with gestational age between 27- and 33-weeks and a mean of 30.67-weeks of gestational age at birth. All participants underwent Auditory Brainstem Response (ABR) and Cortical Auditory Evoked Potentials (CAEP) P1, N1, P2, at the time of hospital discharge, and 3- and 6-months after discharge. Each group’s results were compared using statistical tests. Results Evolutionary study of mean ABR and CAEP latencies in infants in the study and control group showed a similar pattern over the six months after hospital discharge. Conclusion The comparison of brainstem and cortical potentials showed that auditory function is symmetrical in the peripheral and central portions of the auditory pathway in both groups. The maturation of the ABR and CAEP waves in both groups developed in a very similar way over the six months after hospital discharge.

One of the main complications of liver failure, whether acute or chronic, is the progression to Hepatic Encephalopathy (HE), cerebral edema, and, consequently, intracranial hypertension. Several mechanisms explain the progression to HE, but the key point is the impairment of the hepatic metabolism of ammonia and other toxic metabolites, causing vasogenic and cytotoxic cerebral edema and alteration of cerebral autoregulation. In the pediatric population, the diagnosis of HE is more challenging due to the difficulties in neurologic assessment in this group. Thus, the role of multimodal assessment with several monitoring methods is increasingly more important. Among these methods, invasive monitoring of ICP is increasingly being discouraged, giving way to other noninvasive assessments such as methods of assessing intracranial pressure (Brain4Care®, optic nerve sheath diameter), cerebral blood flow (transcranial doppler), and cerebral SatO2 and O2 consumption (Near-Infrared Spectroscopy, Jugular venous oxygen saturation). Thus, the multimodal evaluation of these patients has been gaining strength for better diagnosis and management of neurological conditions in pediatric patients with liver failure.

While pharmacological interventions promote PDA closure, their impact on overall outcomes remains uncertain due to conflicting results. These inconsistent results indicate that the effectiveness of these treatments may vary considerably among preterm infants, suggesting potential heterogeneity. This meta-analysis and meta-regression aimed to assess the effect of pharmacological interventions on mortality and PDA closure in preterm infants, while critically examining sources of heterogeneity. We searched Ovid MEDLINE and EMBASE for relevant studies. Studies comparing ibuprofen, acetaminophen, indomethacin, or placebo/expectant management in preterm infants with PDA, where the outcome of interest was either mortality or PDA closure. We extracted data on mortality, PDA closure, study design, and patient baseline characteristics following PRISMA guidelines. We used a random-effects model to account for the heterogeneity observed in the studies. Meta-analysis of 72 RCTs revealed that while interventions significantly improved PDA closure rates (OR 5.31, p < 0.00001), they did not consistently reduce mortality (OR 1.03, p = 0.84). Notably, interventions appeared to increase mortality in infants with hemodynamically significant PDA (OR 1.45, p = 0.05). Our analysis revealed substantial heterogeneity (I2 = 55

Background Diagnosing late-onset neonatal sepsis (LOS) continues to be a complex task, highlighting the need for continued research to discover reliable biomarkers that can improve both diagnostic accuracy and prognostic evaluation. This experimental prospective cohort study aimed to assess the potential of TREM-1 as a diagnostic and prognostic marker for LOS. Methods This study included 121 newborns (NBs) distributed as follows: 84 blood samples from NBs with LOS, categorized into Gram-negative sepsis, Gram-positive sepsis, and culture-negative sepsis groups, along with 37 infection-free controls. sTREM-1 levels were measured using an immunoenzymatic assay on samples collected at diagnosis and on days 3 and 7 afterward, while TREM1 gene expression was assessed by RT-qPCR on the day of diagnosis. Results Despite not being a significant diagnostic tool, the univariate logistic regression indicated that high sTREM-1 levels were strongly associated with septic shock, in addition to thermal instability and male sex. The adjusted multivariate analysis confirmed that elevated sTREM-1 levels (OR = 3.85, p = 0.032), and male sex (OR = 5.67, p = 0.016) were significantly associated with septic shock. Gene expression analysis revealed reduced TREM1 gene expression in infected neonates relative to controls; however, patients who died showed significantly higher expression levels (p < 0.001), indicating its potential as a prognostic marker in neonatal sepsis. Conclusion sTREM-1 showed good accuracy as a predictor of severity in LOS. TREM1 high expression was associated with a worse prognosis in septic neonates. However, additional studies involving a larger number of individuals are necessary to validate the clinical utility of this biomarker in practice.

This systematic review and meta-analysis aimed to evaluate the clinical outcomes of cardiac surgery in neonates with trisomy 13 (T13) or trisomy 18 (T18) compared to those managed with palliative care. A literature search was conducted in PubMed® and EMBASE®, following PRISMA guidelines, and included five retrospective cohort studies (1627 patients). Outcomes analyzed included in-hospital mortality, survival at 12 months, length of stay (LOS), hospital discharge rates, and the need for mechanical ventilation. The meta-analysis showed that cardiac surgery significantly reduced the odds of in-hospital mortality (OR 0.12, CI 95

Background: This was a 30-year retrospective cohort study that approximates closely to the natural history of cardiac tumors diagnosed in the fetus, since there was no case of pregnancy interruption Objective: To assess morbidity and mortality in the perinatal period and at long term in fetuses diagnosed with cardiac tumor. Our secondary objective was to assess the evaluating factors of perinatal and postnatal results. Methods: This was a retrospective cohort study with 74 pregnant women with an echocardiographic diagnosis of fetal cardiac tumor at two referral centers between May 1991 and November 2021. A descriptive analysis was performed, and data were expressed as absolute (n) and relative (%) frequencies, median and interquartile range. Fisher's exact test was used to evaluate the association of echocardiographic characteristics and clinical manifestations with perinatal and postnatal results. Global survival was calculated using the Kaplan-Meier method and the curves were compared by the log-rank test. The time of follow-up, calculated in months, corresponded to the time elapsed from hospital discharge to current status (survived/ censoring or death). The level of significance was set at 5% (p<0.05). Results: Rhabdomyoma is the most common type of cardiac tumor (85%), with a high morbidity (79.3%) and overall mortality of 17.4%. The presence of fetal hydrops was a predictor of death. Conclusion: The presence of fetal hydrops had an impact on mortality, and hence is an important factor in counselling and determining the prognosis. Most deaths occurred before hospital discharge.

BackgroundPediatric acute liver failure (PALF) is a clinical diagnosis in which previously asymptomatic children exhibit a rapid loss of liver function.ObjectivesTo describe the clinical and nutrition conditions at admission and during hospitalization in patients with PALF who underwent liver transplantation (LT) at a referral center and establish a possible association between nutrition status and prognosis in this population.MethodsA prospective study was conducted on children underwent LT because of PALF. Nutrition assessment was performed at admission and repeated weekly until hospital discharge, and their relationships with clinical outcomes were tested.ResultsThe study population consisted of 23 patients with a median age of 60 months and, in most cases, the etiology of acute liver failure (ALF) was indeterminate (69.6%). The majority of the patients were well nourished according to the z score body mass index-for-age (82.6%) and z arm circumference-for-age (zAC/A) (82.6%). A decline in nutrition status was observed in 47.6% of the patients, as indicated by a decrease in zAC. Clinical and nutrition improvement was demonstrated by the progressive increase in zAC, serum albumin levels, and phase angle (PA) values and by the reduction in C-reactive protein levels. There was no statistically significant relationship between nutrition status and clinical outcomes.ConclusionMost children and adolescents with ALF presented adequate nutrition status at the time of LT, and some patients worsened their nutrition status during hospitalization, suggesting that post-LT is a period of high nutrition risk, and early nutrition therapy (NT) must be a priority in these patients.

IMPORTANCE Neurological manifestations during acute SARS-CoV-2-related multisystem inflammatory syndrome in children (MIS-C) are common in hospitalized patients younger than 18 years and may increase risk of new neurocognitive or functional morbidity. OBJECTIVE To assess the association of severe neurological manifestations during a SARS-CoV-2-related hospital admission with new neurocognitive or functional morbidities at discharge. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study from 46 centers in 10 countries included patients younger than 18 years who were hospitalized for acute SARS-CoV-2 or MIS-C between January 2, 2020, and July 31, 2021. EXPOSURE Severe neurological manifestations, which included acute encephalopathy, seizures or status epilepticus, meningitis or encephalitis, sympathetic storming or dysautonomia, cardiac arrest, coma, delirium, and stroke. MAIN OUTCOMES AND MEASURES The primary outcome was new neurocognitive (based on the Pediatric Cerebral Performance Category scale) and/or functional (based on the Functional Status Scale) morbidity at hospital discharge. Multivariable logistic regression analyses were performed to examine the association of severe neurological manifestations with new morbidity in each SARS-CoV-2-related condition. RESULTS Overall, 3568 patients younger than 18 years (median age, 8 years [IQR, 1-14 years]; 54.3% male) were included in this study. Most (2980 [83.5%]) had acute SARS-CoV-2; the remainder (588 [16.5%]) had MIS-C. Among the patients with acute SARS-CoV-2, 536 (18.0%) had a severe neurological manifestation during hospitalization, as did 146 patients with MIS-C (24.8%). Among survivors with acute SARS-CoV-2, those with severe neurological manifestations were more likely to have new neurocognitive or functional morbidity at hospital discharge compared with those without severe neurological manifestations (27.7% [n = 142] vs 14.6% [n = 356]; P < .001). For survivors with MIS-C, 28.0% (n = 39) with severe neurological manifestations had new neurocognitive and/or functional morbidity at hospital discharge compared with 15.5% (n = 68) of those without severe neurological manifestations (P = .002). When adjusting for risk factors in those with severe neurological manifestations, both patients with acute SARS-CoV-2 (odds ratio, 1.85 [95% CI, 1.27-2.70]; P = .001) and those with MIS-C (odds ratio, 2.18 [95% CI, 1.22-3.89]; P = .009) had higher odds of having new neurocognitive and/or functional morbidity at hospital discharge. CONCLUSION AND RELEVANCE The results of this study suggest that children and adolescents with acute SARS-CoV-2 or MIS-C and severe neurological manifestations may be at high risk for long-term impairment and may benefit from screening and early intervention to assist recovery.

Resumo Fundamento: Seguimento de coorte retrospectiva de 30 anos que se aproxima da história natural dos tumores cardíacos diagnosticados no feto uma vez que nenhum caso foi submetido à interrupção da gestação. Objetivo: Avaliar a morbidade e mortalidade perinatal e em longo prazo em fetos com diagnóstico de tumor cardíaco. Como objetivo secundário avaliar os fatores que influenciaram os resultados perinatais e pós-natais. Método: Estudo de coorte retrospectiva envolvendo 74 gestantes com diagnóstico ecocardiográfico fetal de tumor cardíaco acompanhadas em dois serviços de referência no período de maio de 1991 a novembro de 2021. Foi realizada análise descritiva dos dados por meio de frequências absolutas (n) e relativas (%), mediana e intervalos interquartis. Para avaliar a associação entre as características ecocardiográficas e as manifestações clínicas com os resultados perinatais e pós-natais, foi aplicado o teste exato de Fisher. O cálculo da sobrevida global foi realizado pelo método de Kaplan-Meier e a comparação de curvas pelo teste de log-rank. O tempo de seguimento, calculado em meses, foi definido a partir da data de alta do hospital à data do status atual (vivo/censura ou óbito). O nível de significância considerado foi de 5% (p<0,05). Resultados: o rabdomioma é o tipo mais frequente (85%) de tumor cardíaco; apresenta alta morbidade (79,3%) e mortalidade geral de 17,4%; a presença de hidropisia fetal preditiva de óbito. Conclusão: A presença de hidropisia fetal teve impacto na mortalidade, sendo fator importante para aconselhamento e estabelecimento de prognóstico. A maioria dos óbitos ocorrem antes da alta hospitalar.

OBJECTIVE:To assess a comparative analysis of the ROX index, Wood-Downes-Ferrés score (WDF), p-ROXI, and the SpO2/FiO2 ratio as predictors of high-flow nasal cannula (HFNC) failure in children hospitalized for bronchiolitis. METHODS:Data were extracted from the clinical trial "Comparison between HFNC and NIV in children with acute respiratory failure caused by bronchiolitis" conducted at a tertiary Brazilian hospital (Emergency Department and PICU). The inclusion criteria were children under 2 years of age admitted for bronchiolitis who developed mild to moderate respiratory distress and were eligible for HFNC therapy. Performance was determined by ROC and AUC metrics to define the best sensitivity and specificity for each variable. Children were evaluated at 0 h, 2 h, 6 h, 12 h, 24 h, 48 h, 72 h and 96 h after HFNC therapy initiation. RESULTS:A total of 126 patients were recruited for this analysis. The median age was 3 months. Ninety-one percent of the patients had an identified viral agent, with RSV being the most common (65%). Twenty-three percent (29/126) of patients experienced failed HFNC therapy and required mechanical ventilation. The best cutoff points at 12 hours were 4.5 for WDF (AUC = 0.83, 0.74-0.92), 8.8 for ROX (AUC = 0.7, 0.54-0.84), 1.45 for p-ROXI (AUC = 0.56, 0.38-0-74), and 269 for SpO2/FiO2 (AUC = 0.64, 0.48-0.74). The scores and indices were also correlated with the PICU and hospital LOS. CONCLUSIONS:The ROX index and WDF were the most accurate scores for assessing HFNC failure considering 12-hour cutoff points. TRIAL REGISTRATION NUMBER:U1111-1262-1740; RBR-104z966s. Date of registration: 03/01/2023.

Introdução: As ações de erro médico têm sido uma tendência nas últimas décadas. A busca pela reparação do dano causado proporcionou aos tribunais e aos advogados uma área de atuação onde é necessária a junção do conhecimento médico e jurídico para se determinar um julgamento eficaz. Objetivo: Analisar os processos cíveis de erro médico na área de pediatria e os parâmetros judiciais de indenização. Material e métodos: Análise retrospectiva de 60 perícias médicas na faixa etária pediátrica realizadas no Instituto de Criminologia do Estado de São Paulo (IMESC) no período de abril de 2009 a fevereiro de 2014 e a sentença judicial em primeira instância. Resultados: A maioria das perícias foi indireta – óbito (65%). Nexo causal ocorreu em 27 perícias (45%). Das 27 perícias com nexo causal, uma o magistrado foi discordante do laudo pericial e não determinou erro médico. Das 26 perícias com nexo causal a sentença foi concordante ou parcialmente concordante. Todas as ações solicitaram dano moral (100%). 41 ações solicitaram dano material e somente em 3 dano estético. Dano moral foi dado em todas as sentenças variando de 9 a 691 salários mínimos, com média de 159 salários mínimos. Conclusão: O valor arbitrado pelo juiz teve grande variação.