Parental Distress during Separation from Their Critically Ill Child

BACKGROUND AND AIM: A child's critical illness is a stressful event for the entire family, causing significant emotional distress among parents and changes to family functioning. Family-centered care (FCC) has been endorsed by major professional organizations. The SARS-CoV-2 pandemic has abruptly caused modifications in visitation policies of PICUs in many countries. We hypothesized that caregivers with no or severely restricted access to PICUs would demonstrate elevated psychological distress compared to those who had limitless access to PICU. METHOD(S): Sociodemographics variables, levels of psychological distress, family functioning and ability to cope with stressful events were collected with an online survey in a group of caregivers (N=43) after their child hospitalization. A Pediatric Risk of Mortality-II (PRISM-II) score was calculated at child admission. Ratings of psychological distress were compared between caregivers with no/severely restricted (NA) and with limitless access (LA) to PICUs. All data were analyzed in the context of the Generalized Linear Model (GLZM). RESULT(S): Levels of depression, anxiety and the global severity index of psychological distress were significantly higher in NA with respect to LA (respectively LR chi2=9.885, p=0.001, LR chi2=5.54 p=0.08, LR chi2=6.928 p=0.008), correcting for gender, age, PRISM-II levels and personal ability to cope with stressful events. No significant effect of family functioning scores or other sociodemographic variables was found. CONCLUSION(S): Restrictions imposed to visitation policies in PICU during the pandemic negatively impacted on families' psychological well-being. A balance between safety of patients, families and health care professionals and meeting the needs of families is of utmost importance.

Lung Ultrasound Patterns in Multisystem Inflammatory Syndrome in Children (Mis-C): Characteristics and Prognostic Value

BACKGROUND AND AIM: Following Covid-19 infection, children can develop an hyperinflammatory state termed Multisystem Inflammatory Syndrome in Children (MIS-C). Lung Ultrasound (LUS) features of COVID-19 in children have been described but data describing the LUS findings of MIS-C are limited. Aim of this retrospective observational study conducted between March, 1st, and December 31st, 2020, at a tertiary pediatric hospital in Milano, is to describe LUS patterns in patients with MIS-C and to verify correlation with illness severity. Secondary objective is to evaluate concordance of LUS with Chest X-Ray (CXR). METHOD(S): Clinical and laboratory data were collected for all patients (age 0-18 years) admitted with MIS-C, as well as LUS and CXR patterns at admission. PICU admission, need for respiratory support and inotrope administration, hospital and PICU length of stay were considered as outcomes and evaluated in the different LUS patterns. Agreement between LUS and CXR evaluation was assessed with Cohen' k. RESULT(S): 38 children were enrolled;24 had a LUS examination upon admission. LUS pattern of subpleural consolidations < or > 1 cm with or without pleural effusion were associated with worse Left Ventricular Ejection Fraction at admission and need for inotropes. Subpleural consolidations < 1 cm were also associated with PICU length of stay. Agreement of CXR with LUS for consolidations and effusion was slight. CONCLUSION(S): LUS pattern of subpleural consolidations and consolidations with or without pleural effusion are predictors of disease severity;under this aspect, LUS can be used at admission to stratify risk of severe disease.

Changes in Bronchiolitis Picu Admissions in Italy: The Effect of Covid-19

BACKGROUND AND AIM: Bronchiolitis is the most common lower respiratory illness in young children, mostly caused by Respiratory Syncitial Virus (RSV);PICU admission for respiratory support is required in some cases. The recent Covid-19 pandemic has altered dynamics of viral transmission in the community. We aim to describe if there has been a modification in the number and characteristics of patients admitted to Italian PICUs between the pre-pandemic and post-pandemic period. METHOD(S): Multicenter retrospective observational study based on the national electronic web-based national registry of the Italian Network of PICU Study Group (TIPNet). PICU admissions due to bronchiolitis were compared from 2017 to 2022, considering the seasonal peak periods (October, 1st to April, 30th). RESULT(S): 918 patients have been admitted due to bronchiolitis to Italian PICUs in the above mentioned years. Cumulative yearly admissions are reported in Figure 1. The winter season of 2020-2021 reported a significantly lower number of admissions. RSV was consistently the reported cause in most cases throughout the years except in season 2020-2021, when it was never reported. In the 2020-2021 season, enterovirus was reported in 23% of cases. Covid-19 as cause of bronchiolitis was reported in one case in 2020- 21 and 2 cases in 2021-22. CONCLUSION(S): Covid-19 pandemic, due to possibly multiple factors, has changed the panorama of PICU admissions due to bronchiolitis in Italy. Although research is still ongoing, it seems that Covid itself is not a cause of severe bronchiolitis requiring respiratory support. (Figure Presented).

Acute cardiac compromission in patients with MIS-C

Background and Aim: Multisystem inflammatory syndrome in chil-dren (MIS-C) is a late manifestation of SARS-CoV-2 infection. Cardiac involvement is common and presents as ventricular dys-function, shock, and coronary anomalies. The aim of the study is evaluate the influence of cardiac disfunction on clinical presen-tations and outcomes in a single center. Method(s): A retrospective study on patients diagnosed with MIS-C and referred to Buzzi Children's Hospital in Milan from November 2020 to February 2021. Patients were treated with intravenous immunoglobulins, corticosteroids and anti-throm-botic prophylaxis, in respect to our approved multidisciplinary protocol. According to the admission cardiac left ventricular ejec-tion fraction (LVEF), the patients were divided into group A (LVEF lt;45%) and group B (LVEF >=45%). Result(s): We collected 32 consecutive patients. Group A included 10 patients (9M/1F, aged 13 years [IQR 5-15]), and group B included 22 patients (15M/7M, aged 9 years [IQR 7-13]). At the presentation, significant differences were observed among shock (group A 6/10 vs group B 2/22, plt;0.01), gastrointestinal involvement (9/10 vs 11/22, p = 0.04) and duration of fever (5.3 vs 6.9 days, p = 0.02). All patients in group A required inten-sive care hospitalization (10/10 vs 12/22, p = 0.01). Interestingly, despite good cardiac function, two patients in group B presented with shock, probably due to vasoplegic/distributive cardiocircula-tory impairment secondary to the inflammatory state. Among biochemistry parameters, leukocytes, neutrophils, and CRP were significantly worse in group A (p = 0.001, p = 0.001 and p = 0.008, respectively). Pathological level of troponin T and NTproBNP were detected in all patients in group A and also in 33% and 77% of group B;with statistically significant higher median values in group A (Troponin T 72 [40-243] ng/L vs 22 [8-49] ng/L, p = 0.01;NTproBNP 14825 [11340-17810] ng/L vs 5921 [1114-11243] ng/L, p = 0.01). In group A, mitral regurgitation was more frequent (plt;0.01) and one patient had transient left main coronary dilation (Boston z-score +2.39). At the discharge, cardiac function normalized in all patients. Total length of hospital stay and cardiac recovery time were not statistically different between groups. Conclusion(s): If correctly diagnosed and early treated, all the MIS-C patients completely recovered, regardless of the initial cardiac involvement.

Impact of COVID-19 Pandemic on Pediatric Intensive Care Unit (PICU) Visiting Policies: A Worldwide Survey

The purpose of this study was to evaluate pediatric intensive care unit (PICU) visiting policies around the world and how the coronavirus disease 2019 (COVID- 19) pandemic has affected these policies, due to concerns relating to a viral transmission. A webbased international survey was designed and disseminated through social networks, emails, or directmessages. Two hundred forty- one answers were received. Fromthese, 26 were excluded (13 due tomissing location and 13 duplicated answers), resulting in a final number of 215 answers. Europe accounted for 35% of responses (n = 77), South America 22.4% (n = 49), North America 19% (n = 41), Asia 16.5% (n = 36), Central America 2.7% (n = 6), Oceania, and Africa 2.2% each (n = 5 each). Before the pandemic, reported admission/visiting policies already varied between continents. Family time schedules remained similar to the pre-pandemic period in half of European, Central, and South American units and have changed in 60% of Asian, African, North American, and Oceanian units. Access to PICUs has been granted for patients and caregivers tested negative for severe acute respiratory syndrome coronavirus 2 (SARS COV-2) in only part of studied PICUs. Isolation precautions for the visitors were intensified at the onset of the pandemic. Changes in visiting policies were observed in most PICUs worldwide during the COVID- 19 pandemic, with some PICUs prohibiting any visitation by families. These changes can decrease possibilities of parental participation in emotional support and reduction of sedation needs, early mobility, and shared decision- making process and impact negatively both children and parental well- being and even patients' outcomes.

Non-thyroidal illness syndrome and SARS-CoV-2-associated multisystem inflammatory syndrome in children.

PURPOSE: COVID-19 disease may result in a severe multisystem inflammatory syndrome in children (MIS-C), which in turn may alter thyroid function (TF). We assessed TF in MIS-C, evaluating its impact on disease severity. METHODS: We retrospectively considered children admitted with MIS-C to a single pediatric hospital in Milan (November 2019-January 2021). Non-thyroidal illness syndrome (NTIS) was defined as any abnormality in TF tests (FT3, FT4, TSH) in the presence of critical illness and absence of a pre-existing hormonal abnormality. We devised a disease severity score by combining severity scores for each organ involved. Glucose and lipid profiles were also considered. A principal component analysis (PCA) was performed, to characterize the mutual association patterns between TF and disease severity. RESULTS: Of 26 (19 M/7F) patients, median age 10.7 (IQR 5.8-13.3) years, 23 (88.4%) presented with NTIS. A low FT3 level was noted in 15/23 (65.3%), while the other subjects had varying combinations of hormone abnormalities (8/23, 34.7%). Mutually correlated variables related to organ damage and inflammation were represented in the first dimension (PC1) of the PCA. FT3, FT4 and total cholesterol were positively correlated and characterized the second axis (PC2). The third axis (PC3) was characterized by the association of triglycerides, TyG index and HDL cholesterol. TF appeared to be related to lipemic and peripheral insulin resistance profiles. A possible association between catabolic components and severity score was also noted. CONCLUSIONS: A low FT3 level is common among MIS-C. TF may be useful to define the impact of MIS-C on children's health and help delineate long term follow-up management and prognosis.

Live-tweeting the discovery of the new multisystem inflammatory syndrome in children (MIS-C)

INTRODUCTION: In April 2020, the COVID-19 pandemic saw a rise in the number of children with a multi-system hyperinflammatory disease with myocardial involvement and characteristics of toxic shock syndrome, Kawasaki Disease Shock Syndrome, atypical Kawasaki disease. Clinicians turned to social media to discuss what they were seeing and several names for this new syndrome were used, including Paediatric Multisystem Inflammatory Syndrome - Temporally Associated with SARSCoV- 2 and MIS-C. The use of these different names and hashtags may have affected the discussion and ability to share information. Our goal was to examine the real-time conversation on Twitter related to the discovery of this new syndrome. METHODS: We examined conversations occurring on Twitter in the pediatric critical care (PCC) community by examining hashtags associated with #PedsICU. Symplur Signals was used to identify the MIS-C related hashtags. We examined the digital footprint containing those hashtags including stakeholders, frequency of use, and the most commonly tweeted links. RESULTS: Between April 1st and July 21st 2020, there were 50,628 tweets by 13,411 users in the #PedsICU dataset resulting in 128,609,673 impressions. Thirteen new hashtags were identified related to MIS-C in 3664 tweets by 1391 users;#PIMSTS and #MISC were the most commonly used in 3085 (84%) of these tweets. Although #PIMSTS was promoted more in the UK and #MISC in the US, there were no significant differences in usage by country. Of the users tweeting with these MIS-C related hashtags, 39% were healthcare providers, 23% were physicians, and 6% were healthcare organizations. The five most commonly shared links were shared 248 times and included links to research articles, government guidelines, news articles, and a review blog. Peaks of usage of these hashtags coincided with the publication of research articles. CONCLUSIONS: New hashtags like #PIMSTS and #MISC have been used in the PCC community to focus and disseminate contents related to a novel pediatric syndrome related to COVID19. The evolving definitions and names used for this new entity are converging, but early confusion in names may have hampered discussion on Twitter and curation of reliable content.