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  • 1
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    Scoring Systems for Organ Dysfunction and Multiple Organ Dysfunction: The PODIUM Consensus Conference
    American Academy of Pediatrics (AAP) ; 2022
    In:  Pediatrics Vol. 149, No. Supplement_1 ( 2022-01-01), p. S23-S31
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 149, No. Supplement_1 ( 2022-01-01), p. S23-S31
    Abstract: Multiple scores exist to characterize organ dysfunction in children. OBJECTIVE To review the literature on multiple organ dysfunction (MOD) scoring systems to estimate severity of illness and to characterize the performance characteristics of currently used scoring tools and clinical assessments for organ dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020. STUDY SELECTION Studies were included if they evaluated critically ill children with MOD, evaluated the performance characteristics of scoring tools for MOD, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. DATA EXTRACTION Data were abstracted into a standard data extraction form by a task force member. RESULTS Of 1152 unique abstracts screened, 156 full text studies were assessed including a total of 54 eligible studies. The most commonly reported scores were the Pediatric Logistic Organ Dysfunction Score (PELOD), pediatric Sequential Organ Failure Assessment score (pSOFA), Pediatric Index of Mortality (PIM), PRISM, and counts of organ dysfunction using the International Pediatric Sepsis Definition Consensus Conference. Cut-offs for specific organ dysfunction criteria, diagnostic elements included, and use of counts versus weighting varied substantially. LIMITATIONS While scores demonstrated an increase in mortality associated with the severity and number of organ dysfunctions, the performance ranged widely. CONCLUSIONS The multitude of scores on organ dysfunction to assess severity of illness indicates a need for unified and data-driven organ dysfunction criteria, derived and validated in large, heterogenous international databases of critically ill children.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2021-052888D
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2022
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  • 2
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    A National Approach to Pediatric Sepsis Surveillance
    American Academy of Pediatrics (AAP) ; 2019
    In:  Pediatrics Vol. 144, No. 6 ( 2019-12-01)
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 144, No. 6 ( 2019-12-01)
    Abstract: Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of age-dependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2019-1790
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2019
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  • 3
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    Refining the Pediatric Multiple Organ Dysfunction Syndrome
    American Academy of Pediatrics (AAP) ; 2022
    In:  Pediatrics Vol. 149, No. Supplement_1 ( 2022-01-01), p. S13-S22
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 149, No. Supplement_1 ( 2022-01-01), p. S13-S22
    Abstract: Since its introduction into the medical literature in the 1970s, the term multiple organ dysfunction syndrome (or some variant) has been applied broadly to any patient with & gt;1 concurrent organ dysfunction. However, the epidemiology, mechanisms, time course, and outcomes among children with multiple organ dysfunction vary substantially. We posit that the term pediatric multiple organ dysfunction syndrome (or MODS) should be reserved for patients with a systemic pathologic state resulting from a common mechanism (or mechanisms) that affects numerous organ systems simultaneously. In contrast, children in whom organ injuries are attributable to distinct mechanisms should be considered to have additive organ system dysfunctions but not the syndrome of MODS. Although such differentiation may not always be possible with current scientific knowledge, we make the case for how attempts to differentiate multiple organ dysfunction from other states of additive organ dysfunctions can help to evolve clinical and research priorities in diagnosis, monitoring, and therapy from largely organ-specific to more holistic strategies.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2021-052888C
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2022
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  • 4
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    Improving Vancomycin Stewardship in Critically Ill Children
    American Academy of Pediatrics (AAP) ; 2022
    In:  Pediatrics Vol. 149, No. 4 ( 2022-04-01)
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 149, No. 4 ( 2022-04-01)
    Abstract: Inappropriate vancomycin use is common in children’s hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU. METHODS We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction. RESULTS Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin. CONCLUSION Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2021-052165
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2022
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  • 5
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    Frequency of and Risk Factors Associated With Hospital Readmission After Sepsis
    American Academy of Pediatrics (AAP) ; 2023
    In:  Pediatrics Vol. 152, No. 1 ( 2023-07-01)
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 152, No. 1 ( 2023-07-01)
    Abstract: Although children who survive sepsis are at risk for readmission, identification of patient-level variables associated with readmission has been limited by administrative datasets. We determined frequency and cause of readmission within 90 days of discharge and identified patient-level variables associated with readmission using a large, electronic health record-based registry. METHODS This retrospective observational study included 3464 patients treated for sepsis or septic shock between January 2011 and December 2018 who survived to discharge at a single academic children’s hospital. We determined frequency and cause of readmission through 90 days post-discharge and identified patient-level variables associated with readmission. Readmission was defined as inpatient treatment within 90 days post-discharge from a prior sepsis hospitalization. Outcomes were frequency of and reasons for 7-, 30-, and 90-day (primary) readmission. Patient variables were tested for independent associations with readmission using multivariable logistic regression. RESULTS Following index sepsis hospitalization, frequency of readmission at 7, 30, and 90 days was 7% (95% confidence interval 6%–8%), 20% (18%–21%), and 33% (31%–34%). Variables independently associated with 90-day readmission were age ≤ 1 year, chronic comorbid conditions, lower hemoglobin and higher blood urea nitrogen at sepsis recognition, and persistently low white blood cell count ≤ 2 thous/µL. These variables explained only a small proportion of overall risk (pseudo-R2 range 0.05–0.13) and had moderate predictive validity (area under the receiver operating curve range 0.67–0.72) for readmission. CONCLUSIONS Children who survive sepsis were frequently readmitted, most often for infections. Risk for readmission was only partly indicated by patient-level variables.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2022-060819
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2023
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  • 6
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    Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary
    American Academy of Pediatrics (AAP) ; 2022
    In:  Pediatrics Vol. 149, No. Supplement_1 ( 2022-01-01), p. S1-S12
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 149, No. Supplement_1 ( 2022-01-01), p. S1-S12
    Abstract: Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2021-052888B
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2022
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  • 7
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    Perinatal Predictors of Atopic Dermatitis Occurring in the First Six Months of Life
    American Academy of Pediatrics (AAP) ; 2004
    In:  Pediatrics Vol. 113, No. 3 ( 2004-03-01), p. 468-474
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 113, No. 3 ( 2004-03-01), p. 468-474
    Abstract: Objective. Previous studies of predictors of atopic dermatitis have had limited sample size, small numbers of variables, or retrospective data collection. The purpose of this prospective study was to investigate several perinatal predictors of atopic dermatitis occurring in the first 6 months of life. Design. We report findings from 1005 mothers and their infants participating in Project Viva, a US cohort study of pregnant women and their offspring. The main outcome measure was maternal report of a provider’s diagnosis of eczema or atopic dermatitis in the first 6 months of life. We used multiple logistic regression models to assess the associations between several simultaneous predictors and incidence of atopic dermatitis. Results. Cumulative incidence of atopic dermatitis in the first 6 months of life was 17.1%. Compared with infants born to white mothers, the adjusted odds ratio (OR) for risk of atopic dermatitis among infants born to black mothers was 2.41 (95% confidence interval [CI]: 1.47, 3.94) and was 2.58 among infants born to Asian mothers (95% CI: 1.27, 5.24). Male infants had an OR of 1.76 (95% CI: 1.24, 2.51). Increased gestational age at birth was a predictor (OR: 1.14; 95% CI: 1.02, 1.27, for each 1-week increment), but birth weight for gestational age was not. Infants born to mothers with a history of eczema had an OR of 2.67 (95% CI: 1.74, 4.10); paternal history of eczema also was predictive, although maternal atopic history was more predictive than paternal history. Several other perinatal, social, feeding, and environmental variables were not related to risk of atopic dermatitis. Conclusions. Black and Asian race/ethnicity, male gender, higher gestational age at birth, and family history of atopy, particularly maternal history of eczema, were associated with increased risk of atopic dermatitis in the first 6 months of life. These findings suggest that genetic and pre- and perinatal influences are important in the early presentation of this condition.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.113.3.468
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2004
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  • 8
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    Forced Expiratory Volume in 1 Second Percentage Improves the Classification of Severity Among Children With Asthma
    American Academy of Pediatrics (AAP) ; 2006
    In:  Pediatrics Vol. 118, No. 2 ( 2006-08-01), p. e347-e355
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 118, No. 2 ( 2006-08-01), p. e347-e355
    Abstract: OBJECTIVE. Spirometry is an important component of the National Asthma Education and Prevention Program guidelines for asthma, yet published data show variable associations between forced expiratory volume in 1 second percentage (FEV1%) predicted, symptoms and health care utilization. The objective of this analysis was to examine the association between FEV1% and future risk of exacerbations among a well-characterized population of children with asthma. METHODS. Using data that are available from the Childhood Asthma Management Program, we examined the relationship between prebronchodilator FEV1% and important clinical outcomes. Multiple observations of FEV1 were available for each patient; multivariate regression analysis, using a general estimating equation approach, was used to control for the correlation between repeated measurements among individuals and potential confounders. FEV1% was categorized into 4 levels and as a continuous variable. Outcomes of interest included mean symptom score (0–3), episode-free days, and asthma-related events (oral steroid use, emergency department visits, and hospitalizations) during the ensuing 4-month period. Our analysis was limited to the placebo group (N = 417). RESULTS. We observed a clear relationship between prebronchodilator FEV1% and important clinical outcomes. In multivariable models that simultaneously controlled for covariates of interest, age at baseline, time, previous event history, and nocturnal awakenings, a significant relationship between FEV1% and asthma symptoms and serious asthma exacerbations (oral steroids, emergency department visits, and hospitalizations) was observed. Compared with children with an FEV1% ≥100%, children with FEV1% 80% to 99%, 60% to 79%, and & lt;60% were 1.3, 1.8, and 4.8, respectively, more likely to have a serious asthma exacerbation during the ensuing 4 months. CONCLUSIONS. In children with mild to moderate asthma, FEV1% predicted is independently associated with future asthma symptoms and health care utilization. Previous asthma-related hospitalizations and nocturnal symptoms also were independently associated with risk for future adverse events. FEV1 is an important component of asthma health status and asthma severity classification.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2005-2962
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2006
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  • 9
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    Cord Blood Cytokines and Acute Lower Respiratory Illnesses in the First Year of Life
    American Academy of Pediatrics (AAP) ; 2007
    In:  Pediatrics Vol. 119, No. 1 ( 2007-01-01), p. e171-e178
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 119, No. 1 ( 2007-01-01), p. e171-e178
    Abstract: OBJECTIVES. Little is known about the relation between cytokine profile at birth and acute lower respiratory illnesses in the first year of life. The purpose of this work was to examine the relation between cytokine secretions by cord blood mononuclear cells and acute lower respiratory illness in a birth cohort of 297 children. METHODS. Cord blood mononuclear cells were isolated, and secretion of interferon-γ, interleukin-13, interleukin-10, and tumor necrosis factor-α at baseline and in response to allergens (Blatella germanica 2 and Dermatophagoides farinae 1) and mitogen (phytohemagglutinin) were quantified using enzyme-linked immunosorbent assay. Acute lower respiratory illness was defined as a parental report of a diagnosis of bronchiolitis, pneumonia, bronchitis, and/or croup by a health care professional in the first year of life. Differences in the levels of cord blood cytokines between children with and without acute lower respiratory illness were examined using 2-sample Wilcoxon tests. Logistic regression models were used to examine the relation between various categories of cord blood cytokines and acute lower respiratory illness. RESULTS. Median levels of interferon-γ secreted by cord blood mononuclear cells in response to Blatella germanica 2 and Dermatophagoides farinae 1 were higher among children without acute lower respiratory illness as compared with children with acute lower respiratory illness. After adjustment for other covariates, the odds of acute lower respiratory illness was reduced among children in the top category (at or more than the median of detectable values) of interferon-γ level, significantly so in response to Blatella germanica 2. CONCLUSIONS. In a cohort of children from the general population, we found that upregulated interferon-γ secretion at birth is associated with reduced risk of acute lower respiratory illness in the first year of life.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2006-0524
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2007
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  • 10
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    Procalcitonin in Young Febrile Infants for the Detection of Serious Bacterial Infections
    American Academy of Pediatrics (AAP) ; 2008
    In:  Pediatrics Vol. 122, No. 4 ( 2008-10-01), p. 701-710
    Details
    In: Pediatrics, American Academy of Pediatrics (AAP), Vol. 122, No. 4 ( 2008-10-01), p. 701-710
    Abstract: OBJECTIVES. The objectives of the study were (1) to study the test performance of procalcitonin for identifying serious bacterial infections in febrile infants ≤90 days of age without an identifiable bacterial source and (2) to determine an optimal cutoff value to identify infants at low risk for serious bacterial infections. METHODS. A prospective observational study was performed with febrile infants ≤90 days of age presenting to an urban, pediatric, emergency department. Serum procalcitonin levels were measured by using an automated high-sensitivity assay. An optimal procalcitonin cutoff value was selected to maximize sensitivity and negative predictive value for the detection of serious bacterial infections. Infants were classified as having definite, possible, or no serious bacterial infections. RESULTS. A total of 234 infants (median age: 51 days) were studied. Thirty infants (12.8%) had definite serious bacterial infections (bacteremia: n = 4; bacteremia with urinary tract infections: n = 2; urinary tract infections: n = 24), and 12 infants (5.1%) had possible serious bacterial infections (pneumonia: n = 5; urinary tract infections: n = 7). Mean procalcitonin levels for definite serious bacterial infections (2.21 ± 3.9 ng/mL) and definite plus possible serious bacterial infections (2.48 ± 4.6 ng/mL) were significantly higher than that for no serious bacterial infection (0.38 ± 1.0 ng/mL). The area under the receiver operating characteristic curve was 0.82 for definite serious bacterial infections and 0.76 for definite and possible serious bacterial infections. For identifying definite and possible serious bacterial infections, a cutoff value of 0.12 ng/mL had sensitivity of 95.2%, specificity of 25.5%, negative predictive value of 96.1%, and negative likelihood ratio of 0.19; all cases of bacteremia were identified accurately with this cutoff value. CONCLUSIONS. Procalcitonin has favorable test characteristics for detecting serious bacterial infections in young febrile infants. Procalcitonin measurements performed especially well in detecting the most serious occult infections.
    Type of Medium: Online Resource
    ISSN: 0031-4005 , 1098-4275
    URL: Article
    DOI: 10.1542/peds.2007-3503
    Language: English
    Publisher: American Academy of Pediatrics (AAP)
    Publication Date: 2008
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