Outcomes for Children Receiving Noninvasive Ventilation as the First-Line Mode of Mechanical Ventilation at Intensive Care Admission: A Propensity Score-Matched Cohort Study.

OBJECTIVES: To compare outcomes of children receiving noninvasive ventilation with those receiving invasive ventilation as first-line mode of mechanical ventilation following unplanned intensive care admission. DESIGN: Propensity score-matched cohort study analyzing data prospectively collected by the Pediatric Intensive Care Audit Network over 8 years (2007-2014). SETTING: Thirty-one PICUs in the United Kingdom and Ireland; twenty-one of whom submitted Pediatric Critical Care Minimum Dataset data for the entire study period. PATIENTS: Children consecutively admitted to study PICUs. Planned admissions following surgery, unplanned admissions from other hospitals, those on chronic ventilation, and those who did not receive mechanical ventilation on the day of PICU admission were excluded. INTERVENTIONS: Use of noninvasive ventilation, rather than invasive ventilation, as the first-line mode of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: PICU mortality, length of ventilation, length of PICU stay, and ventilator-free days at day 28. During the study period, there were 151,128 PICU admissions. A total of 15,144 admissions (10%) were eligible for analysis once predefined exclusion criteria were applied: 4,804 (31.7%) received "noninvasive ventilation first," whereas 10,221 (67.5%) received "invasive ventilation first"; 119 (0.8%) admissions could not be classified. Admitting PICU site explained 6.5% of the variation in first-line mechanical ventilation group (95% CI, 2.0-19.0%). In propensity score-matched analyses, receiving noninvasive ventilation first was associated with a significant reduction in mortality by 3.1% (95% CI, 1.7-4.6%), length of ventilation by 1.6 days (95% CI, 1.0-2.3), and length of PICU stay by 2.1 days (95% CI, 1.3-3.0), as well as an increase in ventilator-free days at day 28 by 3.7 days (95% CI, 3.1-4.3). CONCLUSIONS: Use of noninvasive ventilation as first-line mode of mechanical ventilation in critically ill children admitted to PICU in an unplanned fashion may be associated with significant clinical benefits. Further high-quality evidence regarding optimal patient selection and timing of initiation of noninvasive ventilation could lead to less variability in clinical care between institutions and improved patient outcomes

How many children and young people with life-limiting conditions are clinically unstable? A national data linkage study

Objective: To determine the clinical stage (stable, unstable, deteriorating or dying) for children and young people (CYP) aged 0-25 years in Scotland with lifelimiting conditions (LLCs). Design: National cohort of CYP with LLCs using linked routinely collected healthcare data. Setting: Scotland. Patients: 20 436 CYP identified as having LLCs and resident in Scotland between 1 April 2009 and 31 March 2014. Main outcome: Clinical stage based on emergency inpatient and intensive care unit admissions and date of death. Results: Over 2200 CYP with LLCs in Scotland were unstable, deteriorating or dying in each year. Compared with 1-year-olds to 5-year-olds, children under 1 year of age had the highest risk of instability (OR 6.4, 95% CI 5.7 to 7.1); all older age groups had lower risk. Girls were more likely to be unstable than boys (OR 1.15, 95% CI 1.06 to 1.24). CYP of South Asian (OR 1.61, 95% CI 1.28 to 2.01), Black (OR 1.58, 95% CI 1.04 to 2.41) and Other (OR 1.33, 95% CI 1.02 to 1.74) ethnicity were more likely to experience instability than White CYP. Deprivation was not a significant predictor of instability. Compared with congenital abnormalities, CYP with most other primary diagnoses had a higher risk of instability; only CYP with a primary perinatal diagnosis had significantly lower risk (OR 0.23, 95% CI 0.19 to 0.29). Conclusions: The large number of CYP with LLCs who are unstable, deteriorating or dying may benefit from input from specialist paediatric palliative care. The age group under 1 and CYP of South Asian, Black and Other ethnicities should be priority groups

Birthweight and childhood wheezing disorders: a systematic review and meta-analysis

BACKGROUND: Previous observational studies have claimed that birthweight and childhood wheezing disorders are associated although the results remained inconsistent. One systematic review and two systematic reviews that included meta-analyses reported inconsistent results. We aimed to conduct a systematic review and meta-analysis to investigate this. METHODS: An online search of published papers linking childhood asthma and wheezing disorders with birthweight up to February 2014 was carried out using EMBASE and Medline medical research databases. Summary odds ratios (OR) were estimated using random-effects models. Sub-group meta-analyses were performed to assess the robustness of risk associations and between-study heterogeneity. RESULTS: A total of 37 studies comprising 1,712,737 participants were included in our meta-analysis. The unadjusted summary ORs for risk of childhood wheezing disorders associated with low birthweight (4.0kg) as compared to the 2.5-4.0kg birthweight group was 1.02 (95% CI: 0.99 to 1.04, P=0.13). There was substantial heterogeneity in the unadjusted low birthweight risk estimates which was not accounted for by predefined study characteristics. There was no significant heterogeneity in the high birthweight risk estimates. There was some evidence of funnel plot asymmetry and small study effects in the low birthweight (2.5kg versus ≥2.5kg and <2.5kg versus 2.5-4.0kg) odds ratio estimates. CONCLUSION: Our results suggest that low birth (<2.5kg) is an independent risk factor for wheezing disorders during childhood and adolescence although there was substantial heterogeneity among the risk estimates. However, we found no significant association of high birthweight with wheezing disorders

Selecting children for head CT following head injury

OBJECTIVE: Indicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield. DESIGN: Cross-sectional study. SETTING: Hospital inpatient units: England, Wales, Northern Ireland and the Channel Islands. PATIENTS: Children (3 years were much more likely to have CT than those <3 years (OR 2.35 (95% CI 2.08 to 2.65)). CONCLUSION: Compliance with guidelines and diagnostic yield was variable across age groups, the type of hospital and region where children were admitted. With this pattern of clinical practice the risks of both missing intracranial injury and overuse of CT are considerable

Development of two socioeconomic indices for Saudi Arabia

Background: Health and socioeconomic status (SES) are linked in studies worldwide. Measures of SES exist for many countries, however not for Saudi Arabia (SA). We describe two indices of area-based SES for SA. Methods: Routine census data has been used to construct two indices of SES at the geographically-delimited administrative region of Governorates in SA (n = 118). The data used included indicators of educational status, employment status, car and material ownership. A continuous measure of SES was constructed using exploratory factor analysis (EFA) and a categorical measure of SES using latent class analysis (LCA). Both indices were mapped by Governorates. Results: The EFA identified three factors: The first explained 51.58% of the common variance within the interrelated factors, the second 15.14%, and the third 14.26%. These proportions were used in the formulation of the standard index. The scores were fixed to range from 100 for the affluent Governorate and 0 for the deprived. The LCA found a 4 class model as the best model fit. Class 1 was termed "affluent" and included 11.01% of Governorates, class 2 "upper middle class" (44.91%), class 3 "lower middle class" (33.05%) and class 4 "deprived" (11.01%). The populated urbanised Governorates were found to be the most affluent whereas the smaller rural Governorates were the most deprived. Conclusion: This is the first description of measures of SES in SA at a geographical level. Two measures have been successfully constructed and mapped. The maps show similar patterns suggesting validity. Both indices support the common perception of SES in SA

Effects of birthweight and growth on childhood wheezing disorders: findings from the Born in Bradford Cohort.

Objectives To examine the effects of birth weight and childhood growth on childhood wheezing disorders. We hypothesised that low birth weight and fast growth during early age would increase the risk of wheezing disorders. Setting Observational secondary analysis of data from the Born in Bradford cohort. Participants All children who were born at the Bradford Royal Infirmary hospital between March 2007 and December 2010 were eligible for the study. A total of 13 734 and 1598 children participated in the analyses of the effects of birth weight and growth on wheezing disorders, respectively. Primary and secondary outcome measures Wheezing disorders diagnosis (diagnosed as asthma or had wheezing symptom) during the ages of 0–7 years were the primary outcome measures. Diagnosis of asthma and occurrence of wheezing during the same period were secondary outcome measures. Birth weight was classified as normal (2.5–4.0 kg), low (4.0 kg). Growth mixture models were used to drive growth pattern outcomes which were classified as ‘normal’, ‘fast’ and ‘slow’ growth based on their velocities between birth and 36 months. Results The adjusted relative risks (RRs) of wheezing disorders diagnosis for the low and high birthweight children were 1.29 (95% CI 1.12 to 1.50; p=0.001) and 0.91 (95% CI 0.79 to 1.04; p=0.17), respectively. The adjusted RRs of wheezing disorders diagnosis were 1.30 (95% CI 0.56 to 3.06; p=0.54) and 0.60 (95% CI 0.16 to 2.18; p=0.44), respectively, for the ‘fast’ and ‘slow’ growth as compared with the ‘normal’ growth. Conclusions Low birth weight is associated with an increased risk of wheezing disorders; however, there is a weak evidence that suggests high birthweight children have a reduced risk in this birth cohort. Low birth weight coupled with a slower growth until 3 months and a sharp growth between 3 and 12 months has an increased risk of wheezing disorders diagnosi

Comparison of ethnic group classification using naming analysis and routinely collected data: application to cancer incidence trends in children and young people

Objective: Inpatient Hospital Episode Statistics (HES) ethnicity data are available but not always collected and data quality can be unreliable. This may have implications when assessing outcomes by ethnicity. An alternative method for assigning ethnicity is using naming algorithms. We investigate if the association between ethnicity and cancer incidence varied dependent upon how ethnic group was assigned. Design: Population-based cancer registry cohort study Setting: Yorkshire, UK Participants: Cancer registrations from 1998-2009 in children and young people (0-29 years) from a specialist cancer register in Yorkshire, UK (N=3998) were linked to inpatient HES data to obtain recorded ethnicity. Patient?s names, recorded in the cancer register, were matched to an ethnic group using the naming algorithm software Onomap. Each source of ethnicity was categorised as White, South Asian (SA) or Other and a further two indicators were defined based on the combined ethnicities of HES and Onomap, one prioritising HES results, the other prioritising Onomap. Outcomes: Incidence rate ratios (IRR) between ethnic groups were compared using Poisson regression for all cancers combined, leukaemia, lymphoma and central nervous system (CNS) tumours. Results: Depending on the indicator used, 7.1% to 8.6% of the study population were classified as SA. For all cancers there were no statistically significant differences between White and SA groups using any indicator, however for lymphomas significant differences were only evident using one of the ?Combined? indicators (IRR=1.36 (95%CI 1.08, 1.71)) and for CNS tumours incidence was lower using three of the four indicators. For the other ethnic group the IRR for all cancers ranged from 0.78 (0.65, 0.94) to 1.41 (1.23, 1.62). Conclusions: Using different methods of assigning ethnicity can result in different estimates of ethnic variation in cancer incidence. Combining ethnicity from multiple sources results in a more complete estimate of ethnicity than the use of one single source