Assuntos
Insuficiência de Múltiplos Órgãos/terapia , Pediatria/normas , Sepse/terapia , Choque Séptico/terapia , Adolescente , Anti-Infecciosos/uso terapêutico , Criança , Cuidados Críticos/normas , Hidratação/métodos , Hemodinâmica , Humanos , Lactente , Insuficiência de Múltiplos Órgãos/etiologia , Projetos de Pesquisa , Sepse/complicações , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVES: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS: The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS: A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
Assuntos
Insuficiência de Múltiplos Órgãos/terapia , Pediatria/normas , Sepse/terapia , Choque Séptico/terapia , Adolescente , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Medicina Baseada em Evidências , Hidratação/métodos , Hemodinâmica , Humanos , Lactente , Recém-Nascido , Ácido Láctico/sangue , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/etiologia , Respiração Artificial/métodos , Ressuscitação/métodos , Sepse/complicações , Sepse/diagnóstico , Choque Séptico/diagnóstico , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVES: To examine how infant and maternal factors, hospital factors, and neighborhood-level factors impact or modify racial/ethnic disparities in human milk intake at hospital discharge among very low birth weight infants. STUDY DESIGN: We studied 14 422 infants from 119 California Perinatal Quality Care Collaborative neonatal intensive care units born from 2008 to 2011. Maternal addresses were linked to 2010 census tract data, representing neighborhoods. We tested for associations with receiving no human milk at discharge, using multilevel cross-classified models. RESULTS: Compared with non-Hispanic whites, the adjusted odds of no human milk at discharge was higher among non-Hispanic blacks (aOR 1.33 [1.16-1.53]) and lower among Hispanics (aOR 0.83 [0.74-0.93]). Compared with infants of more educated white mothers, infants of less educated white, black, and Asian mothers had higher odds of no human milk at discharge, and infants of Hispanic mothers of all educational levels had similar odds as infants of more educated white mothers. Country of birth and neighborhood socioeconomic was also associated with disparities in human milk intake at discharge. CONCLUSIONS: Non-Hispanic blacks had the highest and Hispanic infants the lowest odds of no human milk at discharge. Maternal education and country of birth were the biggest drivers of disparities in human milk intake, suggesting the need for targeted approaches of breastfeeding support.
Assuntos
Aleitamento Materno/etnologia , Etnicidade , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Leite Humano , Grupos Raciais , Adulto , California/epidemiologia , Feminino , Humanos , Recém-Nascido , Masculino , Alta do Paciente/tendências , Gravidez , Estudos RetrospectivosRESUMO
INTRODUCTION: Cigarette smoking is a major environmental risk factor for many diseases, including chronic obstructive pulmonary disease (COPD). There are shared genetic influences on cigarette smoking and COPD. Genetic risk factors for cigarette smoking in cohorts enriched for COPD are largely unknown. METHODS: We performed genome-wide association analyses for average cigarettes per day (CPD) across the Genetic Epidemiology of COPD (COPDGene) non-Hispanic white (NHW) (n = 6659) and African American (AA) (n = 3260), GenKOLS (the Genetics of Chronic Obstructive Lung Disease) (n = 1671), and ECLIPSE (the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) (n = 1942) cohorts. In addition, we performed exome array association analyses across the COPDGene NHW and AA cohorts. We considered analyses across the entire cohort and stratified by COPD case-control status. RESULTS: We identified genome-wide significant associations for CPD on chromosome 15q25 across all cohorts (lowest p = 1.78 × 10-15), except in the COPDGene AA cohort alone. Previously reported associations on chromosome 19 had suggestive and directionally consistent associations (RAB4, p = 1.95 × 10-6; CYP2A7, p = 7.50 × 10-5; CYP2B6, p = 4.04 × 10-4). When we stratified by COPD case-control status, single nucleotide polymorphisms on chromosome 15q25 were nominally associated with both NHW COPD cases (ß = 0.11, p = 5.58 × 10-4) and controls (ß = 0.12, p = 3.86 × 10-5) For the gene-based exome array association analysis of rare variants, there were no exome-wide significant associations. For these previously replicated associations, the most significant results were among COPDGene NHW subjects for CYP2A7 (p = 5.2 × 10-4). CONCLUSIONS: In a large genome-wide association study of both common variants and a gene-based association of rare coding variants in ever-smokers, we found genome-wide significant associations on chromosome 15q25 with CPD for common variants, but not for rare coding variants. These results were directionally consistent among COPD cases and controls. IMPLICATIONS: We examined both common and rare coding variants associated with CPD in a large population of heavy smokers with and without COPD of NHW and AA descent. We replicated genome-wide significant associations on chromosome 15q25 with CPD for common variants among NHW subjects, but not for rare variants. We demonstrated for the first time that common variants on chromosome 15q25 associated with CPD are similar among COPD cases and controls. Previously reported associations on chromosome 19 showed suggestive and directionally consistent associations among common variants (RAB4, CYP2A7, and CYP2B6) and for rare variants (CYP2A7) among COPDGene NHW subjects. Although the genetic effect sizes for these single nucleotide polymorphisms on chromosome 15q25 are modest, we show that this creates a substantial smoking burden over the lifetime of a smoker.
Assuntos
Etnicidade/genética , Marcadores Genéticos , Predisposição Genética para Doença , Polimorfismo de Nucleotídeo Único , Doença Pulmonar Obstrutiva Crônica/etiologia , Fumantes/estatística & dados numéricos , Fumar/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Hidrocarboneto de Aril Hidroxilases/genética , Estudos de Casos e Controles , Citocromo P-450 CYP2B6/genética , Família 2 do Citocromo P450/genética , Europa (Continente)/epidemiologia , Feminino , Estudo de Associação Genômica Ampla/métodos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/patologia , Fumar/efeitos adversos , Fumar/epidemiologia , Estados Unidos/epidemiologia , Proteínas rab4 de Ligação ao GTP/genéticaRESUMO
OBJECTIVE: To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month). STUDY DESIGN: We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects. RESULTS: Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites. CONCLUSIONS: Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.
Assuntos
Aleitamento Materno/etnologia , Disparidades em Assistência à Saúde/etnologia , Leite Humano , Aleitamento Materno/estatística & dados numéricos , Etnicidade , Feminino , Humanos , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal , Estimativa de Kaplan-Meier , Masculino , Massachusetts , Mães/estatística & dados numéricos , Alta do Paciente , Padrões de Prática Médica/estatística & dados numéricosRESUMO
OBJECTIVES: As of July 2013, pediatric resident trainee guidelines in the United States no longer require proficiency in nonneonatal tracheal intubation. We hypothesized that laryngoscopy by pediatric residents has decreased over time, with a more pronounced decrease after this guideline change. DESIGN: Prospective cohort study. SETTING: Twenty-five PICUs at various children's hospitals across the United States. PATIENTS: Tracheal intubations performed in PICUs from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Prospective cohort study in which all primary tracheal intubations occurring in the United States from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children) were analyzed. Participating PICU leaders were also asked to describe their local airway management training for residents. Resident participation trends over time, stratified by presence of a Pediatric Critical Care Medicine fellowship and airway training curriculum for residents, were described. A total of 9,203 tracheal intubations from 25 PICUs were reported. Pediatric residents participated in 16% of tracheal intubations as first laryngoscopists: 14% in PICUs with a Pediatric Critical Care Medicine fellowship and 34% in PICUs without one (p < 0.001). Resident participation decreased significantly over time (3.4% per year; p < 0.001). The decrease was significant in ICUs with a Pediatric Critical Care Medicine fellowship (p < 0.001) but not in ICUs without one (p = 0.73). After adjusting for site-level clustering, patient characteristics, and Pediatric Critical Care Medicine fellowship presence, the Accreditation Council for Graduate Medical Education guideline change was not associated with lower participation by residents (odds ratio, 0.86; 95% CI, 0.59-1.24; p = 0.43). The downward trend of resident participation was similar regardless of the presence of an airway curriculum for residents. CONCLUSION: Laryngoscopy by pediatric residents has substantially decreased over time. This downward trend was not associated with the 2013 Accreditation Council for Graduate Medical Education change in residency requirements.
Assuntos
Unidades de Terapia Intensiva Pediátrica/tendências , Internato e Residência/tendências , Intubação Intratraqueal/tendências , Laringoscopia/educação , Pediatria/educação , Criança , Pré-Escolar , Currículo , Feminino , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal/métodos , Laringoscopia/tendências , Masculino , Pediatria/tendências , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: To determine the extent to which postdischarge feeding behaviors and interactions among caregiver-preterm infant dyads are associated with infant neurodevelopment at 1-year corrected gestational age (CGA). STUDY DESIGN: We studied 119 preterm infants born <34 weeks gestation and <1750 g at birth, and their caregivers, enrolled in the Collaborative Home Infant Monitoring Evaluation with in-person feeding assessments according to the Nursing Child Assessment Feeding Scale (NCAFS) at 39-59 weeks postmenstrual age that completed Bayley Scales of Infant Development, Second Edition testing at 1 year CGA. RESULTS: Mean ± SD gestational age was 29.6 ± 2.4 weeks, and birth weight was 1260 ± 320 g. After adjustment for maternal and infant demographics, gestational age at birth, discharge and birth weight, mode of infant feeding, and caregiver type during the postdischarge NCAFS assessment, overall NCAFS scores were positively associated with higher 1-year CGA Bayley mental developmental index (MDI) scores (for each 1 SD increase in overall NCAFS score, MDI increased by 2.8 [95% CI 0.7, 4.9] points). Among individual NCAFS domains, strongest effects were seen for caregiver responsiveness to infant distress, such that, compared with dyads having domain scores of 11 (highest possible score), the adjusted mean difference in MDI was 8.3 points (95% CI -15.2, -1.4) lower among dyads with scores <9. CONCLUSIONS: Caregiver-preterm infant feeding interaction and caregiver responsiveness to preterm infant feeding distress were associated with preterm infant Bayley MDI at 1-year CGA. Caregiver-infant feeding interaction may represent a modifiable factor to improve the neurodevelopment of at-risk preterm infants.
Assuntos
Desenvolvimento Infantil , Comportamento Alimentar , Cuidado do Lactente , Transtornos do Neurodesenvolvimento/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Masculino , Idade Materna , Fatores de Risco , Adulto JovemRESUMO
OBJECTIVE: To determine the extent to which fetal weight during mid-pregnancy and fetal weight gain from mid-pregnancy to birth predict adiposity and blood pressure (BP) at age 3 years. STUDY DESIGN: Among 438 children in the Project Viva cohort, we estimated fetal weight at 16-20 (median 18) weeks' gestation using ultrasound biometry measures. We analyzed fetal weight gain as change in quartile of weight from the second trimester until birth, and we measured height, weight, subscapular and triceps skinfold thicknesses, and BP at age 3. RESULTS: Mean (SD) estimated weight at 16-20 weeks was 234 (30) g and birth weight was 3518 (420) g. In adjusted models, weight estimated during the second trimester and at birth were associated with higher body mass index (BMI) z-scores at age 3 years (0.32 unit [95% CI, 0.04-0.60 unit] and 0.53 unit [95% CI, 0.24-0.81 unit] for the highest vs lowest quartile of weight). Infants with more rapid fetal weight gain and those who remained large from mid-pregnancy to birth had higher BMI z-scores (0.85 unit [95% CI, 0.30-1.39 unit] and 0.63 unit [95% CI, 0.17-1.09 unit], respectively) at age 3 than did infants who remained small during fetal life. We did not find associations between our main predictors and sum or ratio of subscapular and triceps skinfold thicknesses or systolic BP. CONCLUSION: More rapid fetal weight gain and persistently high fetal weight during the second half of gestation predicted higher BMI z-score at age 3 years. The rate of fetal weight gain throughout pregnancy may be important for future risk of adiposity in childhood.
Assuntos
Obesidade/diagnóstico , Biometria , Peso ao Nascer , Pressão Sanguínea , Índice de Massa Corporal , Peso Corporal , Pré-Escolar , Estudos de Coortes , Feminino , Peso Fetal , Humanos , Recém-Nascido , Masculino , Análise Multivariada , Obesidade/etiologia , Gravidez , Ultrassonografia Pré-Natal/métodos , Aumento de PesoRESUMO
OBJECTIVE: To determine the extent to which known prenatal and perinatal predictors of childhood obesity also predict weight gain in early infancy. STUDY DESIGN: We studied 690 infants participating in the prospective cohort Project Viva. We measured length and weight at birth and at 6 months. Using multivariable linear regression, we examined relationships of selected maternal and infant factors with change in weight-for-length z-score (WFL-z) from 0 to 6 months. RESULTS: Mean (standard deviation) change in WFL-z from 0 to 6 months was 0.23 (1.11), which translates to 4500 grams gained from birth to 6 months of life in an infant with average birth weight and length. After adjustment for confounding variables and birth weight-for-gestational age z-score (-0.28 [95% confidence interval, -0.37, -0.19] per unit), cord blood leptin (-0.40 [95%confidence interval, -0.61, -0.19] per 10 ng/mL), and gestational diabetes -0.50 [95%confidence interval, -0.88, -0.11] versus normal glucose tolerance)were each associated with slower gain in WFL-z from 0 to 6 months. CONCLUSIONS: Higher neonatal leptin and gestational diabetes predicted slower weight gain in the first 6 months of life. The hormonal milieu of the intrauterine environment may determine growth patterns in early infancy and thus later obesity.