Ranking Future Outcomes Most Important to Parents of Children with Bronchopulmonary Dysplasia.

2023

113455

05/2023

1097-6833

OBJECTIVE: To assess which potential future outcomes are most important to parents of children with bronchopulmonary dysplasia (BPD), a disease that affects future respiratory, medical, and developmental outcomes for children born preterm.

STUDY DESIGN: We recruited parents from two children's hospitals' neonatal follow-up clinics and elicited their importance rating for 20 different potential future outcomes associated with BPD. These outcomes were identified and selected through a literature review and discussions with panels of parents and clinician stakeholders, via a discrete choice experiment.

RESULTS: One hundred and five parents participated. Overall, parents ranked "Will my child be more vulnerable to other problems because of having lung disease?" as the most important outcome, with other respiratory health related outcomes also highly ranked. Outcomes related to child development and effects on the family were among the lowest ranked. Individually, parents rated outcomes differently, resulting in a broad distribution of importance scores for many of the outcomes.

CONCLUSIONS: The overall rankings suggest that parents prioritize future outcomes related to physical health and safety. Notably, for guiding research, some top-rated outcomes are not traditionally measured in outcome studies. For guiding individual counseling, the broad distribution of importance scores for many outcomes highlights the extent to which parents differ in their prioritization of outcomes.

10.1016/j.jpeds.2023.113455

J Pediatr

37172804

Respiratory Outcomes for Ventilator-Dependent Children With Bronchopulmonary Dysplasia.

2023

05/2023

1098-4275

OBJECTIVES: To describe outpatient respiratory outcomes and center-level variability among children with severe bronchopulmonary dysplasia (BPD) who require tracheostomy and long-term mechanical ventilation.

METHODS: Retrospective cohort of subjects with severe BPD, born between 2016 and 2021, who received tracheostomy and were discharged on home ventilator support from 12 tertiary care centers participating in the BPD Collaborative Outpatient Registry. Timing of key respiratory events including time to tracheostomy placement, initial hospital discharge, first outpatient clinic visit, liberation from the ventilator, and decannulation were assessed using Kaplan-Meier analysis. Differences between centers for the timing of events were assessed via log-rank tests.

RESULTS: There were 155 patients who met inclusion criteria. Median age at the time of the study was 32 months. The median age of tracheostomy placement was 5 months (48 weeks' postmenstrual age). The median ages of hospital discharge and first respiratory clinic visit were 10 months and 11 months of age, respectively. During the study period, 64% of the subjects were liberated from the ventilator at a median age of 27 months and 32% were decannulated at a median age of 49 months. The median ages for all key events differed significantly by center (P ≤ .001 for all events).

CONCLUSIONS: There is wide variability in the outpatient respiratory outcomes of ventilator-dependent infants and children with severe BPD. Further studies are needed to identify the factors that contribute to variability in practice among the different BPD outpatient centers, which may include inpatient practices.

10.1542/peds.2022-060651

Pediatrics

37122061

Daycare Attendance is Linked to Increased Risk of Respiratory Morbidities in Children Born Preterm with Bronchopulmonary Dysplasia.

2022

22-28.e1

10/2022

1097-6833

OBJECTIVES: To test the hypothesis that daycare attendance among children with bronchopulmonary dysplasia (BPD) is associated with increased chronic respiratory symptoms and/or greater health care use for respiratory illnesses during the first 3 years of life.

STUDY DESIGN: Daycare attendance and clinical outcomes were obtained via standardized instruments for 341 subjects recruited from 9 BPD specialty clinics in the US. All subjects were former infants born preterm (<34 weeks) with BPD (71% severe) requiring outpatient follow-up between 0 and 3 years of age. Mixed logistic regression models were used to test for associations.

RESULTS: Children with BPD attending daycare were more likely to have emergency department visits and systemic steroid usage. Children in daycare up to 3 years of age also were more likely to report trouble breathing, having activity limitations, and using rescue medications when compared with children not in daycare. More severe manifestations were found in children attending daycare between 6 and 12 months of chronological age.

CONCLUSIONS: In this study, children born preterm with BPD who attend daycare were more likely to visit the emergency department, use systemic steroids, and have chronic respiratory symptoms compared with children not in daycare, indicating that daycare may be a potential modifiable risk factor to minimize respiratory morbidities in children with BPD during the preschool years.

10.1016/j.jpeds.2022.06.037

J Pediatr

35803300

Factors associated with discontinuation of pulmonary vasodilator therapy in children with bronchopulmonary dysplasia-associated pulmonary hypertension.

2022

1246-1254

06/2022

1476-5543

OBJECTIVE: To evaluate factors associated with discontinuation of pulmonary vasodilator therapy in bronchopulmonary dysplasia-related pulmonary hypertension (BPD-PH).

STUDY DESIGN: Retrospective study of neonatal, echocardiographic, and cardiac catheterization data in 121 infants with BPD-PH discharged on pulmonary vasodilator therapy from 2009-2020 and followed into childhood.

RESULT: After median 4.4 years, medications were discontinued in 58%. Those in whom medications were discontinued had fewer days of invasive support, less severe BPD, lower incidence of PDA closure or cardiac catheterization, and higher incidence of fundoplication or tracheostomy decannulation (p < 0.05). On multivariable analysis, likelihood of medication discontinuation was lower with longer period of invasive respiratory support [HR 0.95 (CI:0.91-0.99), p = 0.01] and worse RV dilation on pre-discharge echocardiogram [HR 0.13 (CI:0.03-0.70), p = 0.017]. In those with tracheostomy, likelihood of medication discontinuation was higher with decannulation [HR 10.78 (CI:1.98-58.59), p < 0.001].

CONCLUSION: In BPD-PH, childhood discontinuation of pulmonary vasodilator therapy is associated with markers of disease severity.

10.1038/s41372-022-01421-6

J Perinatol

35676536

Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants.

2021

CD012778

2021 11 30

1469-493X

<p><strong>BACKGROUND: </strong>Preterm infants are at risk of lung atelectasis due to various anatomical and physiological immaturities, placing them at high risk of respiratory failure and associated harms. Nasal continuous positive airway pressure (CPAP) is a positive pressure applied to the airways via the nares. It helps prevent atelectasis and supports adequate gas exchange in spontaneously breathing infants. Nasal CPAP is used in the care of preterm infants around the world. Despite its common use, the appropriate pressure levels to apply during nasal CPAP use remain uncertain.</p>

<p><strong>OBJECTIVES: </strong>To assess the effects of 'low' (≤ 5 cm HO) versus 'moderate-high' (&gt; 5 cm HO) initial nasal CPAP pressure levels in preterm&nbsp;infants receiving CPAP either: 1) for initial respiratory support after birth and neonatal resuscitation or 2) following mechanical ventilation and endotracheal extubation.</p>

<p><strong>SEARCH METHODS: </strong>We ran a comprehensive search on 6 November 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials.</p>

<p><strong>SELECTION CRITERIA: </strong>We included RCTs, quasi-RCTs, cluster-RCTs and cross-over RCTs randomizing preterm infants of gestational age &lt; 37 weeks or birth weight &lt; 2500 grams within the first 28 days of life to different nasal CPAP levels.</p>

<p><strong>DATA COLLECTION AND ANALYSIS: </strong>We used the standard methods of Cochrane Neonatal to collect and analyze data. We used the GRADE approach to assess the certainty of the evidence for the prespecified primary outcomes.</p>

<p><strong>MAIN RESULTS: </strong>Eleven trials met inclusion criteria of the review. Four trials were parallel-group RCTs reporting our prespecified primary or secondary outcomes. Two trials randomized 316 infants to low versus moderate-high nasal CPAP for initial respiratory support, and two trials randomized 117 infants to low versus moderate-high nasal CPAP following endotracheal extubation. The remaining seven studies were cross-over trials reporting short-term physiological outcomes. The most common potential sources of bias were absent or unclear blinding of personnel and assessors and uncertain selective reporting. Nasal CPAP for initial respiratory support after birth and neonatal resuscitation None of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months. The remaining five outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.56 to 1.85; 1 trial, 271 participants); mortality by hospital discharge (RR 1.04, 95% CI 0.51 to 2.12; 1 trial, 271 participants); BPD at 28 days of age (RR 1.10, 95% CI 0.56 to 2.17; 1 trial, 271 participants); BPD at 36 weeks' PMA (RR 0.80, 95% CI 0.25 to 2.57; 1 trial, 271 participants), and treatment failure or need for mechanical ventilation (RR 1.00, 95% CI 0.63 to 1.57; 1 trial, 271 participants). We assessed the certainty of the evidence as very low for all five outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. Nasal CPAP following mechanical ventilation and endotracheal extubation One of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. On the basis of these data, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcome of treatment failure or need for mechanical ventilation (RR 1.52, 95% CI 0.92 to 2.50; 2 trials, 117 participants; I = 17%; risk difference 0.15, 95% CI -0.02 to 0.32; number needed to treat for an additional beneficial outcome 7, 95% CI -50 to 3). We assessed the certainty of the evidence as very low due to risk of bias, inconsistency across the studies, and imprecise effect estimates. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months or BPD at 28 days of age. The remaining three outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants); mortality by hospital discharge (RR 2.94, 95% CI 0.12 to 70.30; 1 trial, 93 participants), and BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants). We assessed the certainty of the evidence as very low for all three outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates.&nbsp; AUTHORS' CONCLUSIONS: There are insufficient data from randomized trials to guide nasal CPAP level selection in preterm infants, whether provided as initial respiratory support or following extubation from invasive mechanical ventilation. We are uncertain as to whether low or moderate-high nasal CPAP levels improve morbidity and mortality in preterm infants. Well-designed trials evaluating this important aspect of a commonly used neonatal therapy are needed.</p>

10.1002/14651858.CD012778.pub2

Cochrane Database Syst Rev

34847243

Home Pulse Oximetry after Discharge from a Quaternary-Care Children's Hospital: Prescriber Patterns and Perspectives.

2021

2021 Oct 11

1099-0496

<p><strong>INTRODUCTION: </strong>Pulse oximetry monitoring is prescribed to children receiving home oxygen for chronic medical conditions associated with hypoxemia. Although home pediatric pulse oximetry is supported by national organizations, there are a lack of guidelines outlining indications and prescribing parameters.</p>

<p><strong>METHODS: </strong>A mixed-methods analysis of pediatric home pulse oximetry orders prescribed through the institutional home health care provider at a large US children's hospital 6/2018-7/2019 were retrospectively reviewed to determine prescribed alarm parameter limits and recommended interventions. Semi-structured qualitative interviews with pediatric providers managing patients receiving home oxygen and pulse oximetry were conducted to identify opportunities to improve home pulse oximetry prescribing practices. Interviews were analyzed using a modified content analysis approach to identify recurring themes.</p>

<p><strong>RESULTS: </strong>368 children received home pulse oximetry orders. Orders were most frequently prescribed on non-cardiac medical floors (32%). Attending physicians were the most frequent ordering providers (52%). Frequency of use was prescribed in 96% of orders, however just 70% were provided with specific instructions for interventions when alarms occurred. Provider role and clinical setting were significantly associated with the presence of a care plan. Provider interviews identified opportunities for improvement with the device, management of alarm parameter limits, and access to home monitor data.</p>

<p><strong>DISCUSSION: </strong>This study demonstrated significant variability in home pulse oximetry prescribing practices. Provider interviews highlighted the importance of the provider-patient relationship and areas for improvement. There is an opportunity to create standardized guidelines that optimize the use of home monitoring devices for patients, families, and pulmonary providers. This article is protected by copyright. All rights reserved.</p>

10.1002/ppul.25722

Pediatr Pulmonol

34633759

Positive end-expiratory pressure for preterm infants requiring conventional mechanical ventilation for respiratory distress syndrome or bronchopulmonary dysplasia.

2019

CD004500

2019 Feb 26

1469-493X

<p><strong>BACKGROUND: </strong>Conventional mechanical ventilation (CMV) is a common therapy for neonatal respiratory failure. While CMV facilitates gas exchange, it may simultaneously injure the lungs. Positive end-expiratory pressure (PEEP) has received less attention than other ventilation parameters when considering this benefit-risk balance. While an appropriate PEEP level may result in clinical benefits, both inappropriately low or high levels may cause harm. An appropriate PEEP level may also be best achieved by an individualized approach.</p>

<p><strong>OBJECTIVES: </strong>1. To compare the effects of PEEP levels in preterm infants requiring CMV for respiratory distress syndrome (RDS). We compare both: zero end-expiratory pressure (ZEEP) (0 cm HO) versus any PEEP and low (&lt; 5 cm HO) vs high (≥ 5 cm HO) PEEP.2. To compare the effects of PEEP levels in preterm infants requiring CMV for bronchopulmonary dysplasia (BPD). We compare both: ZEEP (0 cm HO) vs any PEEP and low (&lt; 5 cm HO) versus high (≥ 5 cm HO) PEEP.3. To compare the effects of different methods for individualizing PEEP to an optimal level in preterm newborn infants requiring CMV for RDS.</p>

<p><strong>SEARCH METHODS: </strong>We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials, MEDLINE via PubMed, Embase, and CINAHL to 14 February 2018. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.</p>

<p><strong>SELECTION CRITERIA: </strong>We included all randomized or quasi-randomized controlled trials studying preterm infants born at less than 37 weeks' gestational age, requiring CMV and undergoing randomization to either different PEEP levels (RDS or BPD); or, two or more alternative methods for individualizing PEEP levels (RDS only). We included cross-over trials but limited outcomes to those from the first cross-over period.</p>

<p><strong>DATA COLLECTION AND ANALYSIS: </strong>We performed data collection and analysis according to the recommendations of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of evidence for prespecified key clinically relevant outcomes.</p>

<p><strong>MAIN RESULTS: </strong>Four trials met the inclusion criteria. Two cross-over trials with 28 participants compared different PEEP levels in infants with RDS. Meta-analysis was limited to short-term measures of pulmonary gas exchange and showed no differences between low and high PEEP.We identified no trials comparing PEEP levels in infants with BPD.Two trials enrolling 44 participants compared different methods for individualizing PEEP in infants with RDS. Both trials compared an oxygenation-guided lung-recruitment maneuver (LRM) with gradual PEEP level titrations for individualizing PEEP to routine care (control). Meta-analysis showed no difference between LRM and control on mortality by hospital discharge (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.17 to 5.77); there was no statistically significant difference on BPD, with an effect estimate favoring LRM (RR 0.25, 95% CI 0.03 to 2.07); and a statistically significant difference favoring LRM for the outcome of duration of ventilatory support (mean difference -1.06 days, 95% CI -1.85 to -0.26; moderate heterogeneity, I = 67%). Short-term oxygenation measures also favored LRM. We graded the quality of the evidence as low for all key outcomes due to risk of bias and imprecision of the effect estimates.</p>

<p><strong>AUTHORS' CONCLUSIONS: </strong>There continues to be insufficient evidence to guide PEEP level selection for preterm infants on CMV for RDS or BPD. Low-quality data suggests that selecting PEEP levels through the application of an oxygenation-guided LRM may result in clinical benefit. Well-conducted randomized trials, particularly to further evaluate the potential benefits of oxygenation-guided LRMs, are needed.</p>

10.1002/14651858.CD004500.pub3

Cochrane Database Syst Rev

30820939

Ocular manifestations of candidemia in children.

2013

84-6

2013 Jan

1532-0987

<p>Among 254 patients with candidemia who had a dilated retinal examination, 8 patients (3.2%) were diagnosed with ocular disease resulting in retinal detachment in 2 patients and globe rupture in 1 patient. This study found that ocular candidiasis is an uncommon but serious sight-threatening complication in pediatric patients with candidemia.</p>

10.1097/INF.0b013e31826f547c

Pediatr. Infect. Dis. J.

23241990

Barriers to the Use of PPE to Prevent Pertussis Exposures in a Pediatric Primary Care Network.

2015

49-56

03/2015

2048-7207

<p><strong>BACKGROUND: </strong>The resurgence of pertussis is contributing to mounting healthcare worker (HCW) exposures, especially within pediatric outpatient settings. Infection prevention and control (IPC) guidelines for ambulatory sites exist, but are not uniformly implemented. Our aim was to identify facilitators and barriers to the use of IPC practices to prevent pertussis transmission in ambulatory pediatric settings.</p>

<p><strong>METHODS: </strong>HCWs at 18 of 25 (72%) clinics in a pediatric ambulatory network completed a theory-based questionnaire about pertussis and personal protective equipment (PPE). The questionnaire contained randomly distributed versions of two vignettes to create an experimental design assessing barriers to PPE use.</p>

<p><strong>RESULTS: </strong>Three hundred forty-three of 467 (73%) HCWs completed the survey: 234 (68%) clinical and 109 (32%) nonclinical. Seventy-one percent of clinical HCWs reported wearing PPE when caring for a patient with suspected pertussis; only 27% used PPE for patients with any respiratory symptoms. Among clinical HCWs, reported PPE use when caring for patients with suspected pertussis was independently associated with attitudes toward PPE (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.8, 16.6), knowledge and skills (OR 4.6, 95% CI 1.4, 15.2), and lack of perceived barriers (OR 3.2, 95% CI 1.3, 7.9). HCWs who did not perceive PPE use as a norm were less likely to report using PPE (OR 0.2, 95% CI 0.1, 0.6) or distributing masks to patients with cough (OR 0.02, 95% CI 0.00, 0.2). Reported PPE use was not influenced by perceived infection risk or mask accessibility.</p>

<p><strong>CONCLUSION: </strong>Our results identified barriers to PPE use and targets for education to prevent pertussis transmission in ambulatory pediatric settings.</p>

10.1093/jpids/piu033

J Pediatric Infect Dis Soc

26407357

Variability in the diagnosis and treatment of group a streptococcal pharyngitis by primary care pediatricians.

2014

S79-85

2014 Oct

1559-6834

<p><strong>OBJECTIVE: </strong>To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study.</p>

<p><strong>SETTING: </strong>All encounters to 25 pediatric primary care practices sharing an electronic health record.</p>

<p><strong>METHODS: </strong>Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation.</p>

<p><strong>RESULTS: </strong>Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P &lt; .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing.</p>

<p><strong>CONCLUSIONS: </strong>Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.</p>

10.1086/677820

Infect Control Hosp Epidemiol

25222902