Recipe for Disaster: Homemade Formula Leading to Severe Complications in 2 Infants.

Families and physicians alike benefit from the advances and ease of the Internet. Similarly, both can be unaware of harmful misinformation circulating the Web. In this article, we describe the presentation of 2 unrelated infants, within 1 week of each other, with vitamin D deficiency rickets and severe extraskeletal manifestations of hypocalcemia, including seizures and cardiac arrest, from homemade, vegan formula found through Pinterest (San Francisco, CA). Despite good parental intentions this formula did not meet macronutrient and micronutrient standards, particularly regarding vitamin D, phosphorus, and calcium content, and led to rare, life-threatening complications in both cases. Before presentation, both patients followed appropriately with their pediatrician and discussed feeding in detail, although neither family disclosed the use of homemade formula. Pediatricians must be aware of these dangerous homemade alternative formulas, consider the manner and depth of their feeding history questioning, and continue to counsel against homemade formula to prevent further harm to children.

Application of Telemedicine Technology to Facilitate Diagnosis of Pediatric Postintensive Care Syndrome.

Background: Postintensive care syndrome (PICS) is well-defined in the adult literature but has not received much attention in pediatrics. Introduction: We sought to use a telemedicine platform for the characterization of PICS by creating a convenient and effective virtual follow-up clinic. Materials and Methods: Prospective single-center study in a pediatric intensive care unit (ICU) of patients aged 4-17 years who underwent any invasive procedures while admitted to the ICU. Parents completed the Weiss Functional Impairment Rating Scale (WFIRS) based on baseline behaviors before ICU admission, with the scale readministered at 1 week, 1 month, and 3 months postdischarge via secure telehealth platform. Patients with a WFIRS baseline raw score of 10 or an interval increase of 2 were referred to psychiatry for evaluation and treatment. Results: Fifty patients were enrolled. Risk factors for PICS included number of procedural interventions, length of pediatric ICU stay, number of specialty consults, sex, race, and duration of sedation/airway instrumentation. In univariate analysis, age appeared to be the only statistically significant factor associated with the development of PICS. Variables associated with a higher change in WFIRS score showed a statistically significant correlation with the number of procedures completed, the number of specialists involved, and the need for a psychiatric referral. Only 34% of total telemedicine follow-ups were completed. Discussion: There is an association between age and the development of PICS and between change in WFIRS score and number of procedures, specialist involved, and psychiatric referral. Conclusions: The use of telemedicine did not result in an improved follow-up rate when compared to outpatient clinic studies.

Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence.

We report a fatal tracheoinnominate artery fistula (TIF) in a 13-year-old female patient with long-term tracheostomy tube dependence due to chronic respiratory failure. Thirteen years after placement of her tracheostomy tube, the patient experienced two separate episodes of sentinel bleeding prior to a fatal hemorrhagic event. Diagnostic evaluation after the sentinel events was mostly nonconclusive. This case highlights the risk of TIF in pediatric age group, even years after initial tracheostomy tube placement, and the need for a high index of suspicion for TIF when children present with unexplained tracheal bleeding.

The Effect of Telemedicine on Resource Utilization and Hospital Disposition in Critically Ill Pediatric Transport Patients.

PURPOSE: Pediatric transport teams rely on communication to report patient data to medical command officers, who create care plans and determine disposition. Common destinations are the emergency department (ED), pediatric intensive care unit (PICU), or regular inpatient care area (RIPCA). Telephone report does not result in complete understanding of the patient's condition. Further workup in the ED is often required. Telemedicine allows the patient to be directly seen; parents to be interviewed; and laboratory studies, radiographs, and vital signs to be reviewed. We hypothesized that telemedicine would improve understanding of the patient and result in more accurate disposition. DESIGN: Patients within our hospital from 2012 to 2013 were compared with patients transported using our telemedicine program from April 2014 to April 2015. RESULTS: From 2012 to 2013, a total of 4,662 transports were performed. Of these, 4,067 were inbound transports, 2,302 of these patients were sent to ED (56.6%), 1,062 were sent to RIPCA (26%), and 431 were sent to PICU (10.6%). Over a year-long period of telemedicine implementation, 212 patients used telemedicine and were analyzed. ED utilization decreased to 27% (p < 0.0001), PICU increased to 34.4% (p < 0.0001), and RIPCA rates remained the same at 28% (p = 0.203). Of ED dispositions, 58.6% were admitted to RIPCA for further care, 13.7% to PICU for escalation of care, and 24.1% were discharged. Of RIPCA dispositions, 10% had rapid responses; 0 had code blues. Of PICU dispositions, 90.4% had care escalation; 9.6% were observed in the PICU without escalation. CONCLUSION: Telemedicine use in transported pediatric patients can positively alter disposition patterns.

The Impact of Multiple Viral Respiratory Infections on Outcomes for Critically Ill Children.

OBJECTIVE: Advances in molecular diagnosis have led to increased testing for single and multiviral respiratory infection in routine clinical practice. This study compares outcomes between single and multiviral respiratory infections in children younger than 5 years old admitted to the PICU with respiratory failure. DESIGN: Retrospective, single-center, cohort study. SETTING: Tertiary-care, freestanding children's hospital. PATIENTS: Children younger than 5 years old admitted to the PICU with respiratory failure and positive respiratory molecular panel. Children with comorbidity or history of similar infections were excluded. After exclusions, the children were divided into single or multiviral groups. Their demographics and PICU outcomes were compared and analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred seventy-seven children with respiratory failure tested positive on respiratory panel, out of which 432 had single and 45 had multiple viruses. Children with multiple viruses had a longer PICU stay (4.5 d) compared with the single viral group (3 d; p < 0.002). Multiviral infections were associated with higher utilization of central line (odds ratio, 2.4; 95% CI, 1.3-4.6; p = 0.008) but not with the need of invasive ventilation requirement or cardiovascular dysfunction. Further analysis among invasively ventilated patients showed multiviral infections resulted in higher association of prolonged ventilation (> 7 d) (odds ratio, 3.4; 95% CI, 1.2-9.4; p = 0.01) and bacterial lower respiratory tract infection confirmed by quantitative bronchoalveolar lavage (odds ratio, 2.1; 95% CI, 1.1-11.2; p = 0.03). Infections with human rhinovirus/Enterovirus, Adenovirus, parainfluenza, and influenza formed a significantly larger proportions of cases (p = 0.00089) as multiviral infections compared with individual infections. CONCLUSIONS: Multiviral infections were associated with longer PICU stay, with prolonged mechanical ventilation, with bacterial lower respiratory infections, and with central line requirement. Certain common viruses resulted in higher percentages of PICU admission as multiviral infections.

Use of Telehealth in Pediatric Palliative Care.

OBJECTIVES: Pediatric subspecialty care, including multidisciplinary palliative care, tends to be located in urban academic centers or children's hospitals. Telehealth provides the opportunity to care for patients who would otherwise not be able to access services. We present cases wherein telehealth was used to provide counseling services to patients who would not have been able to receive this service. METHODS: We discuss cases of telehealth use for patient and family counseling in the setting of palliative care and bereavement follow-up. Patients who live a great distance from the hospital with limited access to services were followed by a hospital-based pediatric palliative care team. Patients and families gave feedback after use of telehealth for counseling services. RESULTS: Counseling through telehealth by our hospital-based palliative care social worker was successful for all parties involved: patient, family, and social worker. CONCLUSIONS: Telehealth helps relieve disparity in access to services and care, which is particularly problematic in pediatrics and mental health. For the patients in this case series, it was an effective modality to receive counseling services and meet needs that otherwise would not have been addressed.

A More Rapid, Rapid Response.

OBJECTIVES: Critical care physicians' standard for arrival to a rapid response team activation is 10 minutes or less at this institution. This study proposes that a FaceTime (Apple, Cupertino, CA) video call between the staff at the bedside and the critical care physician will allow the implementation of potentially life-saving therapies earlier than the current average response (4.5 min). DESIGN: Prospective cohort study. SETTING: Freestanding, tertiary-care children's hospital. PATIENTS: Pediatric patients ages 0-17. INTERVENTIONS: Six units were chosen as matched pairs. In the telemedicine units, after notification of an rapid response team, the critical care intensivist established a FaceTime video call with the nurse at the bedside and gathered history, visually assessed the patient, and suggested interventions. Simultaneously, the rapid response nurse, respiratory therapist, and fellow were dispatched to respond to the bedside. After the video call, the intensivist also reported to the bedside. The control units followed the standard rapid response team protocol: the intensivist physically responded to the bedside. Differences in response time, number of interventions, Pediatric Early Warning System scores, and disposition were measured, and the PICU course of those transferred was evaluated. MEASUREMENTS AND MAIN RESULTS: The telemedicine group's average time to establish FaceTime interface was 2.6 minutes and arrival at bedside was 3.7 minutes. The control group average arrival time was 3.6 minutes. The difference between FaceTime interface and physical arrival in the control group was statistically significant (p = 0.012). Physical arrival times between the telemedicine and control groups remained consistent. Fifty-eight percent of the telemedicine patients and 73% of the control patients were admitted to the PICU (p = 0.13). Of patients transferred to the PICU, there was no difference in rate of intubation, initiation of bilevel positive airway pressure, central line placement, or vasopressors. The study group averaged 1.4 interventions and a Pediatric Early Warning Signs score of 3.6. The control group averaged 1.9 interventions and a Pediatric Early Warning Signs score of 3.1 (p = not significant). CONCLUSION: FaceTime allowed the intensivist to become involved earlier and provide immediate guidance to the inpatient care teams. However, it did not clinically alter the patient course. Further study is necessary.

An unusual case of button battery-induced traumatic tracheoesophageal fistula.

BACKGROUND: Much of pediatric medicine is focused on prevention of disease and injury. Although accidental ingestions of various household chemicals and medicines are well described and the treatment is supported by local poison control hotlines, the ingestion of button batteries by children is less publicized, and the dangers are less understood by both parents and health care providers. METHODS: We describe a case report of a 17-month-old girl with no significant medical history who presented with respiratory distress, cough, and fever and subsequently was discovered to have ingested a button battery. RESULTS: The formation of a traumatic tracheoesophageal fistula required intensive management that escalated to cardiopulmonary bypass and eventual pericardial patch closure of the tracheal defect after the failure of conventional mechanical ventilation. CONCLUSIONS: Esophageal button battery impaction places the patient at high risk for full-thickness damage to the esophagus and tracheal structures with fistula formation in as little as a few hours. The key to successful therapy is prompt diagnosis and removal, but in nonverbal pediatric patients, this often is not achievable. Because of the complications associated with this disease (tracheoesophageal fistula) and subsequent difficulties associated with oxygenation and ventilation, these patients should be managed at an institution with the skilled capability of providing cardiopulmonary bypass quickly as a potentially lifesaving therapy.

Empyema necessitatis in an infant: a rare surgical disease.

Empyema necessitatis is a rare complication of empyema and is more commonly reported in adults. It is characterized by purulence in the pleural space extending into the overlying soft tissues. We report a rare case in an otherwise healthy 3-month-old girl who presented with right chest wall swelling and was subsequently found to have methicillin-resistant Staphylococcus aureus empyema necessitatis requiring thoracotomy with decortication.

Intussusception in a child with respiratory syncytial virus: a new association.

Intussusception is known to be associated with childhood viral illnesses. Respiratory syncytial virus (RSV) has not, to our knowledge, been previously reported in association with intussusception. We report a case of a 4-month-old boy admitted with RSV bronchiolitis, who subsequently developed an intussusception during the hospital course, necessitating laparotomy and resection.