Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children

Background This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (>1 month and <18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain. Methods A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study. Results The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1–8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is sug-gested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN. Conclusion Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.

Chinese guidelines for the diagnosis and treatment of hand, foot and mouth disease (2018 edition)

Background Hand, foot, and mouth disease (HFMD) is a common infectious disease in childhood caused by an enterovirus (EV), and which is principally seen in children under 5 years of age. To promote diagnostic awareness and effective treat-ments, to further standardize and strengthen the clinical management and to reduce the mortality of HFMD, the guidelines for diagnosis and treatment have been developed. Methods National Health Commission of China assembled an expert committee for a revision of the guidelines. The com-mittee included 33 members who are specialized in diagnosis and treatment of HFMD. Results Early recognition of severe cases is utmost important in diagnosis and treatment of patients with HFMD. The key to diagnosis and treatment of severe cases lies in the timely and accurate recognition of stages 2 and 3 of HFMD, in order to stop progression to stage 4. Clinicians should particularly pay attention to those EV-A71 cases in children aged less than 3 years, and those with disease duration less than 3 days. The following indicators should alert the clinician of possible deterioration and impending critical disease: (1) persistent hyperthermia;(2) involvement of nervous system;(3) worsening respiratory rate and rhythm;(4) circulatory dysfunction;(5) elevated peripheral WBC count;(6) elevated blood glucose and (7) elevated blood lactic acid. For treatment, most mild cases can be treated as outpatients. Patients should be isolated to avoid cross-infection. Intense treatment modalities should be given for those severe cases. Conclusion The guidelines can provide systematic guidance on the diagnosis and management of HFMD.

Occurrence of early epilepsy in children with traumatic brain injury:a retrospective study

Background Early post-traumatic seizures(EPTS)refer to epileptic seizures occurring within one week after brain injury.This study aimed to define the risk factors of EPTS and the protective factors that could prevent its occurrence.Methods This is a single-center retrospective study in the PICU,Beijing Children's Hospital.Patients diagnosed with traumatic brain injury(TBI),admitted with and without EPTS between January 2016 and December 2020 were included in the study.Results We included 108 patients diagnosed with TBI.The overall EPTS incidence was 33.98%(35/108).The correlation between EPTS and depressed fractures is positive(P=0.023).Positive correlations between EPTS and intracranial hemorrhage and subarachnoid hemorrhage had been established(P=0.011 and P=0.004,respectively).The detection rates of EPTS in the electroencephalogram(EEG)monitoring was 80.00%.There was a significant difference in the EEG monitoring rate between the two groups(P=0.041).Forty-one(37.86%,41/108)post-neurosurgical patients were treated with prophylactic antiepileptic drugs(AEDs),and eight(19.51%,8/41)still had seizures.No statistical significance was noted between the two groups in terms of prophylactic AEDs use(P=0.519).Logistic regression analysis revealed that open craniocerebral injury and fever on admission were risk factors for EPTS,whereas,surgical intervention and use of hypertonic saline were associated with not developing EPTS.Conclusions Breakthrough EPTS occurred after severe TBI in 33.98%of pediatric cases in our cohort.This is a higher seizure incidence than that reported previously.Patients with fever on admission and open craniocerebral injuries are more likely to develop EPTS.

Molecular characteristics and antimicrobial susceptibility of Staphylococcus aureus among children with respiratory tract infections in southwest China

Background The molecular characteristics and antimicrobial susceptibility of Staphylococcus aureus (S.aureus) in general pediatric wards and county-level hospitals were rarely reported in China.Methods Staphylococcus aureus was isolated from children hospitalized with respiratory tract infection (RTI) in Zhongjiang and Youyang counties in 2015.All isolates were typed by multilocus sequence,staphylococcal protein A,accessory gene regulator (agr),and staphylococcal cassette chromosome mec [SCCmec,for methicillin-resistant S.aureus (MRSA) only].Polymerase chain reaction was used to screen 21 super-antigen (SAg) genes and panton-valentine leukocidin (pvl).Antimicrobial susceptibility testing was performed by E test.Results A total of 2136 children were enrolled.Overall,125 (5.9%) children carried S.aureus,among which MRSA accounted for 42.4%.ST59-SCCmec type Ⅳ-t437-agr group Ⅰ (58.5%) was the most prevalent genotype in MRSA,and ST188-t189-agr group Ⅰ (22.2%) was the top genotype in methicillin-sensitive S.aureus (MSSA).The pvl carriage rate in MRSA and MSSA was 15.1% and 9.7%,respectively (P =0.4112).About 96.8% of S.aureus isolates were positive for at least one SAg gene.The most common SAg gene profile in the dominant ST59 clone was seb-sek-seq (42.8%).All S.aureus isolates were resistant to penicillin and erythromycin (minimum inhibitory concentration 90 was > 32 and 256 mg/L to penicillin and erythromycin,respectively),but usually susceptible to other tested non-β-lactam antimicrobials.Conclusions Staphylococcus aureus and MRSA were detected with a high frequency in children with RTI in county-level hospitals of China.ST59-SCCmec type Ⅳ-t437-agr group Ⅰ was the dominant MRSA clone.The S.aureus isolates exhibited high resistance to penicillin and erythromycin.

Effect of zinc supplementation on infants with severe pneumonia

Background:Pneumonia is a common respiratory infectious disease in infancy.Previous work shows controversial results on the benefit of zinc supplementation in patients with pneumonia.We conducted this study to investigate serum zinc status amongst infants with severe pneumonia and the clinical impact that zinc supplementation has on those patients with low serum zinc levels.Methods:This study design was a non-blinded prospective randomized controlled trial.The study is approved by the Ethics Committees of Beijing Children's Hospital.A total of 96 infants diagnosed with severe pneumonia and hospitalized in the pediatric intensive care unit between November 2011 and January 2012 were enrolled.Enrolled patients were divided into low serum zinc and normal serum zinc group.The low serum zinc group was randomized into treatment and control groups.Only the treatment group received zinc supplementation within 48-72 hours after hospitalization.Results:The prevalence of zinc defi ciency on admission was 76.0%.The low zinc level was most apparent in infants between 1 and 3 months of age.The serum zinc level increased in the zinc treatment group and returned to a normal level(median,53.20μmol/L)on day 12±2.There was no statistical difference in the pediatric critic illness score,lung injury score,length of hospital stay,and duration of mechanical ventilation between the zinc treatment group and control group.Conclusions:Zinc deficiency is common in infants with severe pneumonia.Normalization of zinc levels with zinc supplementation did not improve clinical outcomes of infants with pneumonia.

Applications of mPCR testing reduced initial antibiotic use and duration of mechanical ventilation in virus-infected children with severe community-acquired pneumonia admitted to the PICU

Community-acquired pneumonia(CAP)remains the leading cause of morbidity and mortality among children worldwide.It is critical for these patients to select and timely initiate appropriate empirical antimicrobial therapy against the causative pathogens[1].However,conventional pathogen-detecting methods,such as culture and serology,have no prospect of altering empiric therapy owing to their time delay in obtaining results and to their lower detection rates[2].Recent advances in molecular diagnostic assays,such as multiplex polymerase chain reaction PCR(mPCR)methods,have been used to detect multiple pathogens in CAP simultaneously within two hours and have dramatically improved the ability to diagnose respiratory pathogens[3].However,whether this molecular diagnosis method can reduce the use of antibiotics and can improve prognosis in severe CAP children,especially those less than 5 years old,remains to be explored.

Comparison between hospital- and community-acquired septic shockin children: a single-center retrospective cohort study

Background We explored the differences in baseline characteristics, pathogens, complications, outcomes, and risk factorsbetween children with hospital-acquired septic shock (HASS) and community-acquired septic shock (CASS) in the pediatricintensive care unit (PICU).Methods This retrospective study enrolled children with septic shock at the PICU of Beijing Children’s Hospital from January1, 2016, to December 31, 2019. The patients were followed up until 28 days after shock or death and were divided intothe HASS and CASS group. Logistic regression analysis was used to identify risk factors for mortality.Results A total of 298 children were enrolled. Among them, 65.9% (n = 91) of HASS patients had hematologic/oncologicdiseases, mainly with Gram-negative bacterial bloodstream infections (47.3%). Additionally, 67.7% (n = 207) of CASSpatients had no obvious underlying disease, and most experienced Gram-positive bacterial infections (30.9%) of the respiratoryor central nervous system. The 28-day mortality was 62.6% and 32.7% in the HASS and CASS groups, respectively(P < 0.001). Platelet [odds ratio (OR) = 0.996, 95% confidence interval (CI) = 0.992–1.000, P = 0.028], positive pathogendetection (OR = 3.557, 95% CI = 1.307–9.684, P = 0.013), and multiple organ dysfunction syndrome (OR = 10.953, 95%CI = 1.974–60.775, P = 0.006) were risk factors for 28-day mortality in HASS patients. Lactate (OR = 1.104, 95% CI = 1.022–1.192, P = 0.012) and mechanical ventilation (OR = 8.114, 95% CI = 1.806–36.465, P = 0.006) were risk factors for 28-daymortality in patients with CASS.Conclusions The underlying diseases, pathogens, complications, prognosis, and mortality rates varied widely between theHASS and CASS groups. The predictors of 28-day mortality were different between HASS and CASS pediatric patientswith septic shock.

Clinical and molecular characteristics of Staphylococcus aureus isolated from Chinese children:association among the agr groups and genotypes,virulence genes and disease types

Background This study was aimed to investigate the clinical and molecular epidemiology of Staphylococcus aureus(S.aureus)isolated from Chinese children and determine the possible relationship among the accessory gene regulator(agr)groups and genotypes,as well as among the virulence genes and disease types.Methods S.aureus strains were isolated from Beijing Children's Hospital between October 2017 and October 2019.The isolates and 19 virulence genes were characterized using multi-locus sequence typing,staphylococcal protein A(spa),staphylococcal cassette chromosome mec,and agr typing.Results A total of 191 non-repetitive S.aureus clinical isolates were divided into 33 sequence types(STs),18 clonal com-plexes(CCs),and 59 spa types.ST59(39.8%),t437(37.7%),and agrⅠ(84.8%)were the predominant types.CC59,CC25,CC22,CC951,CC8,and CC398 belonged to agrⅠ.CC5 and CC15 were assigned to agrⅡ,and CC30 was characterized as agrⅢ.CC121 was classified under agrⅣ.The eta,etb,and bbp genes were more prevalent in agrⅣ(P<0.001 for each),while tst was more prevalent in agr groupⅢcompared to the other groups(P<0.001).Nearly all isolates that harbored lukS/F-PV belonged to agrⅠ(P=0.005).However,the correlation between disease types and agr groups was not significant(P>0.05).Conclusions An association among the agr groups and genotypes,as well as specific toxin genes,was observed among the S.aureus strains isolated from Chinese children.However,a statistical correlation was not found among the agr groups and disease types.

Identification of hemolytic activity and hemolytic genes of Methicillin-resistant Staphylococcus aureus isolated from Chinese children

To the Editor:Methicillin-resistant Staphylococcus aureus(MRSA)are a group of gram-positive bacteria that cause a wide range of diseases in children.[1]Surveillance of MRSA is particularly important since certain clones have spread over wide geographical regions.The MRSA clones that have spread in North China over the past decade include ST59-SCCmecIVa-t437,ST59-SCCmecV-t437,and ST239-SCCmecIII-t030.

Global Pediatric Pulmonology Alliance recommendation to strengthen prevention of pediatric seasonal influenza under COVID-19 pandemic

The World Health Organization(WHO)announced COVID-19 as a global pandemic in March of 2020[1].The COVID-19 pandemic may persist for a long period of time.Global prevention and control becomes a complex and challenging task,and such efforts should be sustained.Although general measures,such as social distancing,face masks,respiratory hygiene and hand sanitization,will bear fruits for decreasing spread of other respiratory illnesses including influenza,the specific prevention through vaccination is a key focus especially in the upcoming winter and spring seasons[2].