Characteristics and predictors of outcomes of critically Ill children with SARS-CoV-2 infection - the PICU experience

Abstract Objective To describe the clinical characteristics, laboratory parameters, treatment, and predictors of an unfavorable outcome of critically ill children with SARS-CoV-2 infection. Method This was a prospective observational study performed in a pediatric intensive care unit (PICU) of a tertiary care COVID referral hospital among critically ill children in the age group 1 month - 12 years admitted due to SARS-CoV-2 infection from June to December 2020. Demographic, clinical profile, pSOFA and PRISM III scores, laboratory parameters, treatment, and outcomes of the patients were recorded. Children who had a prolonged PICU stay (>14 days) or died were compared with those who were discharged from PICU within 14 days to assess predictors of unfavorable outcomes. Results PICU admission rate among hospitalized SARS-CoV-2 infected children was 22.1% (92/416). Infants comprised the majority of the ICU population. Invasive mechanical ventilation and inotropic support were required for 28.3% and 37% of patients, respectively. Remdesivir, IVIg, and steroids were administered to 15.2%, 26.1%, and 54.3% of the subjects, respectively. The mortality rate was 7.6 %. MIS-C patients were older, less comorbid, and required less ventilator support but more inotrope support than acute severe COVID-19 patients. Predictors of unfavorable outcomes were age < 1 year, fever duration > 5 days, respiratory distress, shock, comorbidity, elevated CRP (> 50 mg/L), procalcitonin (> 6 ng/L), D-dimer (> 6 µg/L) and arterial lactate (> 2 mmol/L). Conclusion Critically ill children with unfavorable outcomes were predominantly infants, comorbid, prolonged fever, respiratory distress, shock and elevated inflammatory markers, D-dimer and lactate. These factors may be useful for watchful monitoring and early intervention.

Role of lung ultrasound patterns in monitoring coronavirus disease 2019 pneumonia and acute respiratory distress syndrome in children.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, lung ultrasonography (US) has been gaining importance in pediatric intensive care and emergency settings for the screening, diagnosis, and monitoring of pulmonary pathology. PURPOSE: To describe the pattern of lung US changes in patients with COVID-19 pneumonia and its potential role in monitoring ventilated patients. METHODS: This prospective observational study included children aged 1 month to 12 years with a confirmed diagnosis of COVID-19. Lung US was performed using a high-frequency linear probe (5-12 MHz) in all children with moderate/severe respiratory symptoms within 24 hours of admission and then daily until the patient required oxygen therapy. Lung involvement severity was assessed using lung US scores, while lung aeration improvement or deterioration was measured using lung ultrasound reaeration scores (LUSReS). RESULTS: Of 85 children with moderate to severe disease, 54 with pulmonary disease were included. Of them, 50 (92.5%) had an interstitial pattern, followed by pleural line abnormalities in 44 (81.5%), reduced or absent lung sliding in 31 (57.4%), and consolidation in 28 (51.8%). A significantly higher lung US score (median, 18; interquartile range [IQR], 11-22) was observed in ventilated versus nonventilated patients (median, 9; IQR, 6-11). LUSReS improvement after positive end-expiratory pressure titration was positively correlated with improved dynamic lung compliance and oxygenation indices and negatively correlated with the requirement for driving pressure. Successful weaning could be predicted with 100% specificity if loss of LUSReS ≤ 5. CONCLUSION: Interstitial syndrome, fragmented pleural line, and subpleural microconsolidation were the most prevalent lung US findings in children with COVID-19 pneumonia. Thus, lung US may have the ability to monitor changes in lung aeration caused by mechanical ventilation and predict its successful weaning in children with COVID-19.

Clinical Characteristics of Children With SARS-CoV-2 Infection During the Third Wave of the Pandemic: Single Center Experience.

OBJECTIVE: To evaluate pulmonary functions in children with transfusion-dependent thalassemia, and its reversal (lung dysfunction) using intensive intravenous chelation with desferrioxamine (DFO) (4 weeks). METHODS: This descriptive study enrolled 77 children with transfusion-dependent thalassemia. Pulmonary function test (PFT) and iron load (serum ferritin (SF) and T2* MRI of heart and liver) were done. PFT included spirometry, total lung capacity (TLC) by helium dilution test and diffusion capacity by carbon monoxide (DLCO). Follow-up PFT was available for 13 children with moderate to severe lung dysfunction given intravenous DFO. RESULTS: 50 (68.8%) patients had lung dysfunction, most commonly diffusional impairment (48; 96%), and reduced TLC (11; 22%); and none had obstructive pattern. 9 (81.8%) patients with restrictive defect had moderate to severely deranged DLCO. PFT and T2* MRI values were inversely correlated with serum ferritin. Among 13 patients receiving intensive chelation for 4 weeks, significant improvement was noticed in forced expiratory volume in one minute/ forced vital capacity ratio (DFEV1/FVC) (P=0.009), DDLCO (P=0.006) and DSF (P=0.01). CONCLUSIONS: Pulmonary dysfunction is common in children with multi-transfused thalassemia, and routine screening by PFT needs to be part of the management guidelines.

Characteristics and predictors of outcomes of critically Ill children with SARS-CoV-2 infection - the PICU experience.

OBJECTIVE: To describe the clinical characteristics, laboratory parameters, treatment, and predictors of an unfavorable outcome of critically ill children with SARS-CoV-2 infection. METHOD: This was a prospective observational study performed in a pediatric intensive care unit (PICU) of a tertiary care COVID referral hospital among critically ill children in the age group 1 month - 12 years admitted due to SARS-CoV-2 infection from June to December 2020. Demographic, clinical profile, pSOFA and PRISM III scores, laboratory parameters, treatment, and outcomes of the patients were recorded. Children who had a prolonged PICU stay (>14 days) or died were compared with those who were discharged from PICU within 14 days to assess predictors of unfavorable outcomes. RESULTS: PICU admission rate among hospitalized SARS-CoV-2 infected children was 22.1% (92/416). Infants comprised the majority of the ICU population. Invasive mechanical ventilation and inotropic support were required for 28.3% and 37% of patients, respectively. Remdesivir, IVIg, and steroids were administered to 15.2%, 26.1%, and 54.3% of the subjects, respectively. The mortality rate was 7.6 %. MIS-C patients were older, less comorbid, and required less ventilator support but more inotrope support than acute severe COVID-19 patients. Predictors of unfavorable outcomes were age < 1 year, fever duration > 5 days, respiratory distress, shock, comorbidity, elevated CRP (> 50 mg/L), procalcitonin (> 6 ng/L), D-dimer (> 6 µg/L) and arterial lactate (> 2 mmol/L). CONCLUSION: Critically ill children with unfavorable outcomes were predominantly infants, comorbid, prolonged fever, respiratory distress, shock and elevated inflammatory markers, D-dimer and lactate. These factors may be useful for watchful monitoring and early intervention.

Role of cooked green banana in home management of acute diarrhea in under-5 children.

BACKGROUND: Acute diarrhea is an important contributor to under-5 mortality. Green banana is traditionally used as a home-based remedy for diarrhea. OBJECTIVES: To identify the effect of green banana on duration, recovery and prevention of severe dehydration in under-5 children with acute watery diarrhea with no/some dehydration. METHODS: This study was conducted in the rural field practice area of a tertiary care center between January 2020 and December 2021 in under-5 children presenting with acute diarrhea with no/some dehydration. One hundred fifty-three children were divided into group A (received cooked green banana supplementation along with standard management) and group B (received only standard management). Duration of diarrhea, proportion of children recovered, requirement of hospitalization, development of persistent diarrhea and number of diarrheal episodes in 1 year follow-up period were compared between two groups. RESULTS: Green banana supplementation was significantly associated with reduction in duration [median (interquartile range)-4 (1.5) day versus 5.5 (1) day, P < 0.001] of diarrhea, less hospitalization (9.2% versus 22.1%, P = 0.03) and early recovery, both at day 3 (17.1% versus 3.9%, P = 0.007) and day 7 (90.8% versus 77.9%, P = 0.03). Green banana also protected children from the development of persistent diarrhea (7.9% versus 19.5%, P = 0.04). It also reduced future episodes of diarrhea by 40.5%. CONCLUSION: Green banana supplementation could be a promising adjunct therapy in acute diarrhea and thereby it might reduce under-5 mortality.

Acute diarrhea is the second leading cause of under-5 mortality excluding neonatal causes in India where green banana has traditionally been used as a home-based remedy for diarrhea since ancient days. Some of the previous literatures have found promising results of green banana supplementation in prolonged diarrhea, dysentery and hospital management of acute diarrhea but none have considered it in the home management of diarrhea and have not reviewed its role on duration, recovery and prevention of severe dehydration in under-5 children with acute watery diarrhea with no/some dehydration. These issues along with the possible role of green banana in preventing future episodes of diarrhea have been addressed in our study. One hundred fifty-three under-5 children presenting with acute diarrhea with no/some dehydration were studied over 2 years dividing into group A (received cooked green banana supplementation along with standard management) and group B (received only standard management). Green banana supplementation was significantly associated with reduction in duration of diarrhea, less hospitalization and early recovery, lesser incidences of development of persistent diarrhea, and it also significantly reduced the future episodes of diarrhea. Hence, green banana could be a promising adjunct therapy in acute diarrhea and might reduce under-5 mortality.

Effect of Music on Outcomes of Birth Asphyxia: A Randomized Controlled Trial.

INTRODUCTION: Birth asphyxia may cause neuro-developmental impairment in the affected newborns especially those who had hypoxic-ischemic encephalopathy. Music therapy has been observed to help in reducing pain and stress in newborns and improve neurodevelopmental outcome. OBJECTIVES: The objective of this study is to determine the effects of music therapy on the outcomes of birth asphyxia. METHODS: A randomized controlled trial involving 3095 newborns born between January 2013 and August 2019 with birth asphyxia was conducted in the neonatal intensive care unit of Burdwan Medical College. They were distributed in two groups-A (received music therapy along with coventional management) and B (only received conventional management), using computer-generated randomization. Pain score was assessed during any painful procedure and the neurodevelopmental outcome was measured at 3rd, 6th, 12th, 18th and 24th months. p < 0.01 was considered statistically significant. RESULTS: A total of 3095 newborns were included with a mean gestation of 34.3 ± 2.1 weeks and 56.7% of them were male. Mean hospital stay, oxygen dependency, requirement of mechanical ventilation and incidence of apnea were significantly lesser among newborns of group A. Newborns of group B showed a significantly higher mean pain score, whereas newborns in Group A exhibited significantly greater mental and motor neurodevelopmental quotients. CONCLUSIONS: Music therapy was observed to help in reducing hospital stay, oxygen dependency, incidences of apnea, pain during procedures and also resulted in better neurodevelopmental outcome. However, before generalizing the findings, further multi-centric research should be undertaken.

Effect of Virgin Coconut Oil Application on the Skin of Preterm Newborns: A Randomized Controlled Trial.

BACKGROUND: Preterm constitutes a major part of neonatal mortality, particularly in India. Due to dermal immaturity, preterm neonates are susceptible to various complications like infection, hypothermia, etc. Emollient application is a traditional practice in our subcontinent. AIMS: To find out the efficacy of coconut oil application for skin maturity, prevention of sepsis, hypothermia and apnea, its effect on long-term neurodevelopment and adverse effect of it, if any. MATERIAL AND METHODS: A randomized controlled trial was conducted in the rural field practice area of Department of Community Medicine, Burdwan Medical College from March 2014 to August 2018. Preterm born in the study period was divided into Group A (received virgin coconut oil application) and Group B (received body massage without any application). Neonatal skin condition was assessed on 7th, 14th, 21st and 28th day of life. Neurodevelopmental status was assessed on 3rd, 6th and 12th months. RESULTS: A total of 2294 preterm were included in the study. Groups A and B consisted of 1146 and 1148 preterm infants, consecutively. Mean gestational age of the study population was 31.9 ± 3.4 weeks and 50.4% were male. Mean weight loss in first few days was less in group A but mean weight gain per day was higher in group B. Lesser incidences of hypothermia and apnea, and better skin maturity and neurodevelopmental outcome were noted in group A. No significant adverse effect was noted with coconut oil application. CONCLUSION: Use of coconut oil helps in dermal maturity and better neurodevelopmental outcome. Further studies are warranted for universal recommendation.

Neurological manifestations in children with dengue fever: an Indian perspective.

Ours was a descriptive observational cross-sectional study carried out in a tertiary care hospital in eastern India over a period of one year to study the profile of neurological involvement in paediatric dengue patients. Of 71 laboratory-confirmed cases, 20 (28.17%) had neurological involvement. Common forms observed were acute encephalopathy (40%), encephalitis (30%), pure motor weakness (15%), transverse myelitis (5%), acute disseminated encephalomyelitis (5%) and Guillain-Barré syndrome (5%). The dengue IgM antibody could be detected in the cerebrospinal fluid of only two patients with encephalitis. Neurological involvement was present in all four patients who died during the study period (two-tailed P value = 0.005).