The decision to close small ventricular septal defect is still controversial. Previous study showed that ventricular dysfunction in adulthood is correlated with small perimembranous ventricular septal defect. N terminal pro B-type natriuretic peptide (NT-proBNP) is a neurohormone secreted primarily from the ventricles in response to increased left and right ventricular pressure and volume load. The left ventricular end-diastolic pressure will reflect ventricular performance. This study aimed to evaluate the correlation between left ventricular end-diastolic pressure and the NT-proBNP in children with small perimembranous ventricular septal defect.

Level of NT-proBNP in 41 patients with small perimembranous ventricular septal defect was measured before transcatheter closure procedure. We also measured the left ventricular end-diastolic pressure in each patients during catheterisation. We investigated the value of NT-proBNP in patients with small perimembranous ventricular septal defect and its correlation with the level of left ventricular end-diastolic pressure

We found positive correlation between NT-proBNP and left ventricular end-diastolic pressure (r = 0.278, p = 0.046). The median of NT-proBNP at left ventricular end-diastolic pressure < 10 was lower than at left ventricular end-diastolic pressure ≥ 10 (0.87 ng/ml versus 1.83 ng/ml, p = 0.023). The results of the NT-proBNP diagnostic test for predicting left ventricular end-diastolic pressure ≥ 10 using Receiver Operating Characteristic (ROC) analysis showed the area under the curve value of 0.715 (95% CI: 0.546–0.849). The cut-off value >0.99 ng/ml of NT-proBNP has 75.0% sensitivity and 72.2% specifity.

Level of NT-proBNP higher than 0.99 ng/ml was correlated significantly with left ventricular end-diastolic pressure ≥10 in children with small perimembranous ventricular septal defect.

Research and clinical expertise have emphasized the mental health needs of parents and caregivers of medically complex children. Evidence-based interventions are available for adult mental health, including those designed specifically for caregivers caring for children with a variety of health-care needs. This paper describes practical and legal considerations of 3 possible pathways for psychologists to address the needs of caregivers within pediatric hospital settings.

Literature regarding the mental health needs of caregivers of children with medical conditions, evidence-based interventions, and pediatric subspecialty psychosocial guidelines was reviewed. Relevant legal and ethical obligations for psychologists were also summarized.

The mental health needs of caregivers of medically complex children are often high, yet programmatic, institutional, legal, and ethical barriers can limit access to appropriate care.

Integration of screening and treatment of caregivers’ mental health within the pediatric hospital setting is one pathway to addressing caregivers’ needs. The development of programs for caregiver mental health screening and treatment within pediatric hospital settings will enhance the well-being of children and families and reduce legal and ethical risks for pediatric psychologists. Consultation with institutional compliance, legal/risk, and medical records departments and the creation of electronic medical records for the caregiver may be useful and practical opportunities for integration.

The majority of pediatric medications are dosed according to weight and therefore accurate weight assessment is essential. However, this can be difficult in the unpredictable and peripatetic prehospital care setting, and medication errors are common. The Handtevy method and the Broselow tape are two systems designed to guide Emergency Medical Services (EMS) providers in both pediatric patient weight estimation and medication dosing. The accuracy of the Handtevy method of weight estimation as practiced in the field by EMS has not been previously examined.

The primary objective of this study was to examine the field performance of the Handtevy method and the Broselow tape with respect to prehospital patient weight estimation.

This was a retrospective chart review of trauma and non-trauma patients transported by EMS to the emergency department (ED) of a quaternary care children’s hospital from January 1, 2021 through June 30, 2021. Demographic data, ED visit information, prehospital weight estimation, and medication dosing were collected and analyzed. Scale-based weight from the ED was used as the standard for comparison.

A total of 509 patients <13 years of age were included in this study. The EMS providers using the Broselow method estimated patient weight to within +/-10% of ED scale weight in 51.3% of patients. When using the Handtevy method, the EMS providers estimated patient weight to within +/-10% of ED scale weight in 43.7% of patients. When comparing the Handtevy versus Broselow method of prehospital weight estimation, there was no significant association between method and categorized weight discrepancy (over, under, or accurate estimates – defined as within 10% of ED scale weight; P = .25) or percent weight discrepancy (P = .75). On average, prehospital weight estimation was 6.33% lower than ED weight with use of the Handtevy method and 6.94% lower with use of the Broselow method.

This study demonstrated no statistically significant difference between the use of the Handtevy or Broselow methods with respect to prehospital weight estimation. While further research is necessary, these results suggest similar field performance of the Broselow and Handtevy methods.

Balance deficits are heterogeneous among children with Developmental Coordination Disorder (DCD). Balance performance depends on different balance domains, each associated with specific underlying neurological systems. In DCD, any of these domains can be affected, but the control mechanisms are poorly understood. The mirror neuron system (MNS) seems to play a key-role in DCD-related deficits. To understand the role of MNS as a control mechanism underlying the balance deficits, simultaneous registration of cortical MNS activity while performing balance tasks is imperative. Therefore, a protocol for combining real-time registration of cortical MNS activity during functional balance tasks in children with DCD, CP and TD is introduced. Methods: Children with DCD, CP and TD (n=108) aged 5-10yr perform preselected tasks of the Kids-BESTest, representing specific balance domains (mixed design): leaning with eyes closed (stability limits/verticality), single-leg-stance, alternate stair touching (anticipatory balance), in-place response, compensatory stepping backward (reactive balance) and walking over obstacles (gait stability). Simultaneously, functional Near-Infrared Spectroscopy (fNIRS) monitors cortical activity involving the MNS: premotor, inferior and superior parietal cortex and supplementary motor area. An 8-8-optode bundle, making 22 channels, targets this region of interest. Outcome measures are: (de)oxygenated hemoglobin concentration changes per task per channel. Results: In this ongoing research, the protocol was already feasible in 19 children (7.52±1.19). Conclusion: Simultaneous registration of cortical MNS activity (fNIRS) and Kids-BESTest scores will help increase the understanding of the control mechanisms underlying the heterogeneous balance problems in DCD. Consequently, first steps are made to confirm whether DCD shows deviant or delayed development.

No significant relationships.

Pediatric epilepsy is a debilitating disease that impacts not only children with epilpsy but also persons arround them. It is often considered as a source of anxiety for family caregivers.

Assess the level of anxiety in caregivers of children with epilepsy and to identify factors related to it.

We conducted a cross-sectional, descriptive and analytical study between July and October 2020. It included caregivers of children with epilepsy hospitalized in the pediatric neurology department of Sfax. We used the STAI-Y scale to assess the level of state anxiety (STAI-AE).

Forty four womens participated in our study. Low socio-economic level was found in 31.8% of cases. The average age of children was 4.9 years. The mean duration of epilepsy was 2.2 years. It was comorbid with an autism spectrum disorder or an intellectual disability in 15.9% of cases. In 70.5% of the cases, the children were dependent on their caregivers in their daily lives. The level of anxiety was moderate in 27.3% and high to very high in 13.6% of them. A higher state-anxiety score was correlated with a longer duration of epilepsy (p=0.033), a lower familial socioeconomic level (p=0.013) and a higher number of children in family (p=0.048).

Pediatric epilepsy is associated with significant level of anxiety in family caregivers. This anxiety increases with the duration of the disease and with the presence of socioeconomic and family difficulties. Thus, psychosocial support for caregivers should be integrated into a global approach of the disease.

No significant relationships.

Inhibition capabilities have been shown to be a strong predictor of social and educational life outcomes (Mischel & Ebbesen, 1970; Shoda et al., 1990). Inhibition capabilities have an enormous impact on attention and impulsivity (Bari & Robbins, 2013). These two executive functions are associated with numerous psychiatric disorders but are not well understood in terms of white matter (WM) connectivity (Puiu et al., 2018). Novel techniques and statistical approaches in neuroimaging bring us closer to a biologically sustained model.

This research aims to: 1) identify WM connections associated with attention/impulsivity performance and 2) characterize the differences in WM microstructure associated with the variation of the performance.

157 children (GESTE cohort, 8-12 years, 27 Dx ADHD, 2 Dx ASD) with b=1500mm2/s, 2mm isotropic dMRI acquisitions were included. Tractography was performed with TractoFlow pipeline (Theaud et al., 2020). Dimensionality reduction of diffusion metrics yielded two components : microstructural complexity (DTI Metrics, AFD & NuFo) and axonal density (AFD_fixel) (Chamberland et al., 2019). Attention/impulsivity were evaluated with the CPT3. Multivariate linear regression was performed in python.

Lower microstructural complexity was associated with poorer attentional performance on regions of the parietal lobe to the occipital gyrus (P-O, p=0.044, R2=0.14, Figure 1.) and the Broadman’s area 8 to area 6 (SF8-SF6, p=0.002, R2=0.12, Figure 1.). Lower axonal density was associated with a less impulsive pattern on SF8-SF6 (p=0.001, R2=0.13, Figure 1.). Results remained significant when removing children with an ADHD or ASD diagnosis.

We identified underlying difference in WM microstructure that may be associated with the variation in attention/impulsivity performance in school-aged children.

No significant relationships.

Prior to the COVID-19 pandemic, our research group initiated a pediatric practice-based randomized trial for the treatment of childhood obesity in rural communities. Approximately 6 weeks into the originally planned 10-week enrollment period, the trial was forced to pause all study activity due to the COVID-19 pandemic. This pause necessitated a substantial revision in recruitment, enrollment, and other study methods in order to complete the trial using virtual procedures. This descriptive paper outlines methods used to recruit, enroll, and manage clinical trial participants with technology to obtain informed consent, obtain height and weight measurements by video, and maintain participant engagement throughout the duration of the trial.

The study team reviewed the IRB records, protocol team meeting minutes and records, and surveyed the site teams to document the impact of the COVID-19 shift to virtual procedures on the study. The IRB approved study changes allowed for flexibility between clinical sites given variations in site resources, which was key to success of the implementation.

All study sites faced a variety of logistical challenges unique to their location yet successfully recruited the required number of patients for the trial. Ultimately, virtual procedures enhanced our ability to establish relationships with participants who were previously beyond our reach, but presented several challenges and required additional resources.

Lessons learned from this study can assist other study groups in navigating challenges, especially when recruiting and implementing studies with rural and underserved populations or during challenging events like the pandemic.

The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on neuropsychological functioning in children with traumatic brain injury (TBI) relative to orthopedic injury (OI).

Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Children completed a battery of neuropsychological measures targeting attention, memory, and executive functions at four timepoints spanning the immediate post-acute period to 18 months post-injury. Children also completed a comparable age-appropriate battery of measures approximately 7 years post-injury. Parents rated children’s dysexecutive behaviors at all timepoints.

Longitudinal mixed models revealed a significant allele status × injury group interaction with a medium effect size for verbal fluency. Cross-sectional models at 7 years post-injury revealed non-significant but medium effect sizes for the allele status x injury group interaction for fluid reasoning and immediate and delayed verbal memory. Post hoc stratified analyses revealed a consistent pattern of poorer neuropsychological functioning in Met carriers relative to Val/Val homozygotes in the TBI group, with small effect sizes; the opposite trend or no appreciable effect was observed in the OI group.

The results suggest a differential effect of the BDNF Val66Met polymorphism on verbal fluency, and possibly fluid reasoning and immediate and delayed verbal memory, in children with early TBI relative to OI. The Met allele—associated with reduced activity-dependent secretion of BDNF—may confer risk for poorer neuropsychological functioning in children with TBI.

Many triage algorithms exist for use in mass-casualty incidents (MCIs) involving pediatric patients. Most of these algorithms have not been validated for reliability across users.

Investigators sought to compare inter-rater reliability (IRR) and agreement among five MCI algorithms used in the pediatric population.

A dataset of 253 pediatric (<14 years of age) trauma activations from a Level I trauma center was used to obtain prehospital information and demographics. Three raters were trained on five MCI triage algorithms: Simple Triage and Rapid Treatment (START) and JumpSTART, as appropriate for age (combined as J-START); Sort Assess Life-Saving Intervention Treatment (SALT); Pediatric Triage Tape (PTT); CareFlight (CF); and Sacco Triage Method (STM). Patient outcomes were collected but not available to raters. Each rater triaged the full set of patients into Green, Yellow, Red, or Black categories with each of the five MCI algorithms. The IRR was reported as weighted kappa scores with 95% confidence intervals (CI). Descriptive statistics were used to describe inter-rater and inter-MCI algorithm agreement.

Of the 253 patients, 247 had complete triage assignments among the five algorithms and were included in the study. The IRR was excellent for a majority of the algorithms; however, J-START and CF had the highest reliability with a kappa 0.94 or higher (0.9-1.0, 95% CI for overall weighted kappa). The greatest variability was in SALT among Green and Yellow patients. Overall, J-START and CF had the highest inter-rater and inter-MCI algorithm agreements.

The IRR was excellent for a majority of the algorithms. The SALT algorithm, which contains subjective components, had the lowest IRR when applied to this dataset of pediatric trauma patients. Both J-START and CF demonstrated the best overall reliability and agreement.

Educational institutions around the world have long been targets of terrorist attacks. Schools, colleges, and universities often lack security measures against intentional threats and may be viewed as relatively easy, soft targets with high potential for mass casualties. The long-term psychosocial impact on children, youth, and survivors of terrorist attacks are significant and recovery remains a challenge. Deliberate attacks on students and children, in particular, can also often gain mass-media attention, provoke significant community unrest, and place a spotlight on the local government’s inability to protect the vulnerable. This study is an epidemiological examination of all terrorism-related events targeting educational institutions from 1970-2019.

Data collection was performed using a retrospective search through the Global Terrorism Database (GTD). The database was searched using the internal search functions for all events that occurred from January 1, 1970 - December 31, 2019. “Educational institutions” as a primary target type was selected for the purpose of this study and events were further sub-classified by country and attack type. All classifications were pre-determined by the GTD.

The GTD listed 4,520 attacks against educational institutions, recording 3,732 deaths and 9,920 wounded. This accounted for 2.7% of all terrorist attacks (total 168,003 attacks against all target types). There has been a downtrend in attacks since the 2014 peak when 344 attacks were recorded that year. Pakistan recorded the most attacks with 969 events, followed by Afghanistan (369), India (311), and Iraq (279). The most common attack types included bombing/explosions (2290), facility/infrastructure attacks (636), armed assaults (628), hostage takings (kidnappings [415]), assassinations (357), unarmed assaults (72), unknown (67), hostage takings (barricade incidents [46]), and hijackings (9).

Eight hundred seventy-three of the 4,520 attacks were recorded against teachers, professors, and instructors and 486 attacks were recorded against “other personnel” such as security and non-teaching staff.

Terrorist attacks on educational institutions are rare but significant target types. In total, 41.2% of attacks on educational institutions occurred in South Asia, followed by 18.9% in the Middle East and North Africa. Western Europe and North America accounted for 3.9% and 3.6%, respectively. Educational institutions around the world should evaluate their risks and put in place appropriate hardening measures as well as preparedness and recovery plans to intentional threats.

To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries.

Retrospective cohort study utilizing the Premier Healthcare database (PHD).

Inpatient and hospital-based outpatient elective surgical discharges.

Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results.

In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries.

Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10–17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10–17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116).

These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.

In a mass-casualty incident (MCI) involving children, there is a need to apply accurate triage tools in order to help those who require important care, and at the same time, to avoid unnecessary use of resources. Thus, it is discussed which would be the best triage device to use in these situations. One of the most used is a modification of Simple Triage and Rapid Treatment, JumpSTART, whose performative quality this review focuses on.

This review sought to compare the performance parameters of JumpSTART with other triage algorithms used in pediatric disaster victims.

This systematic review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and registered with the PROSPERO database of systematic reviews with the number CRD42021258415. The last update of the search in the databases was on August 12, 2021 and resulted in six documents to be analyzed. The inclusion criteria included the peer-reviewed academic papers in English, Portuguese, Spanish, and Italian languages, and the databases used were PubMed, Scopus, MEDLINE/Bireme (Virtual Library of Health), Web of Science, and CINAHL, which executes the query on the topic, keywords, or abstracts. Also to be included, documents that were available with full-text access through CAPES, Google, or Google Scholar. Books, non-academic research, and content in languages other than the presented ones were represented as exclusion criteria. The Joanna Briggs Institute (JBI) checklists were used to evaluate the methodological quality of the retrieved studies. The results were presented through narrative synthesis. This review was not funded.

Of the collected publications, five articles were used to carry out this review, with the addition of an extra article captured by citation tracking. The findings from the obtained results were that JumpSTART was the preferred tool and presented the fastest speed of use. Only one of the five studies that dealt with accuracy showed JumpSTART as the most accurate algorithm, while three of the other four showed its inferiority in most aspects. In one study, no significant difference was observed amongst the chosen protocols.

There is insufficient evidence to validate JumpSTART as a universal triage tool, given the disparities in the results obtained from the comparisons. No tool performed satisfactorily well, therefore there is an urgent need to create a reliable algorithm.

The paediatric post-cardiac catheterisation Wrap (Wrap), an innovative medical safety device, swaddles young paediatric patients in a supine position aiding in immobilisation post-cardiac catheterisation. This pilot study investigated the feasibility and safety of using the Wrap on young paediatric patients during their bed rest period following cardiac catheterisation with femoral access.

Boston Children’s Hospital Cardiac Catheterization Lab.

20 patients, ages 1–5 years and weighing 3–25 kg.

Investigator-developed tools used to collect data included the Demographic and Outcome Measures Data Tool, the Parent/Caregiver Satisfaction, and Provider Ease of Use tools. They measured:

1. 1. The feasibility of using the Wrap

2. 2. Wrap ease of use from the nurse providers’ perspective

3. 3. Parent satisfaction related to the Wrap

4. 4. Frequency of Wrap non-bleeding-related adverse events

5. 5. Frequency of rebleeding at femoral groin access sites

The Wrap was feasible and safe; increased nurse provider satisfaction by allowing visualisation of the groin access sites while minimising the need for hands-on care; and increased parent satisfaction by allowing parents to hold and provide comfort while their child was on bed rest.

The Wrap is a safe alternative to the current practice of swaddling with a bath blanket. Further studies are warranted to assess the Wrap’s effectiveness in reducing the incidence of rebleeding events in the post-cardiac catheterisation period and explore clinical use outside of the Cardiac Catheterization Lab.

To assess the effect of individual compared to clinic-level feedback on guideline-concordant care for 3 acute respiratory tract infections (ARTIs) among family medicine clinicians caring for pediatric patients.

Cluster randomized controlled trial with a 22-month baseline, 26-month intervention period, and 12-month postintervention period.

In total, 26 family medicine practices (39 clinics) caring for pediatric patients in Virginia, North Carolina, and South Carolina were selected based upon performance on guideline-concordance for 3 ARTIs, stratified by practice size. These were randomly allocated to a control group (17 clinics in 13 practices) or to an intervention group (22 clinics in 13 practices).

All clinicians received an education session and baseline then monthly clinic-level rates for guideline-concordant antibiotic prescribing for ARTIs: upper respiratory tract infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). For the intervention group only, individual clinician performance was provided.

Both intervention and control groups demonstrated improvement from baseline, but the intervention group had significantly greater improvement compared with the control group: URI (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.37–1.92; P < 0.01); ABS (OR, 1.45; 95% CI, 1.11–1.88; P < 0.01); and AOM (OR, 1.59; 95% CI, 1.24–2.03; P < 0.01). The intervention group also showed significantly greater reduction in broad-spectrum antibiotic prescribing percentage (BSAP%): odds ratio 0.80, 95% CI 0.74-0.87, P < 0.01. During the postintervention year, gains were maintained in the intervention group for each ARTI and for URI and AOM in the control group.

Monthly individual peer feedback is superior to clinic-level only feedback in family medicine clinics for 3 pediatric ARTIs and for BSAP% reduction.

ClinicalTrials.gov identifier: NCT04588376, Improving Antibiotic Prescribing for Pediatric Respiratory Infection by Family Physicians with Peer Comparison.

To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP).

Cross-sectional study.

Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP).

Antimicrobial stewardship leaders from the above institutions.

An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals.

Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%).

Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.