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Background Rapidly progressive interstitial lung disease presents as a severe complication of juvenile dermatomyositis, particularly when associated with anti-melanoma differentiation-associated gene 5. We report a pediatric case that underscores the necessity for clinicians to maintain a high index of suspicion for early identification and management. Case presentation A previously healthy 7-year-old White girl presented with a 6-week history of generalized weakness, fever, joint pain, and abdominal pain. Initial examination revealed hypoxia, tachypnea, and hepatosplenomegaly. Laboratory tests were marked by thrombocytopenia, lymphopenia, elevated liver enzymes, high ferritin, high triglyceride, elevated muscle enzymes, and increased soluble IL-2 receptor, suggesting macrophage activation syndrome that was and managed with dexamethasone 5 mg/kg/m 2 twice daily. There were no pathogenic skin features of juvenile dermatomyositis, except for nailfold capillary dropout. Initial cell counts revealed that her white blood cell count was 2.87 × 10 9 /L, hemoglobin was 105 g/L, platelet was 90 × 10 9 /L, and ferritin was 2000.6 μg/L and antinuclear and anti-Ro52 antibodies were positive. She was noted to have peripheral muscle weakness. Her clinical course was marked by progressive respiratory failure requiring mechanical ventilation with imaging revealing diffuse alveolar ground-glass opacities. The infectious work up was negative for bacterial, fungal, and viral ethologies including Epstein–Barr virus; hepatitis A virus, hepatitis B, hepatitis C, and hepatitis E viruses; parvovirus B19; cytomegalovirus; herpes simplex virus 1 and 2; and human herpesvirus 6. With the interstitial lung disease picture, pulse doses of intravenous methylprednisolone and intravenous immunoglobulin were initiated. She developed a significant air leak that was managed with bilateral chest tubes. Her significant hypoxemia required cannulation to veno-venous extracorporeal membrane oxygenation. The diagnosis of anti-melanoma differentiation-associated gene 5 antibody-associated juvenile dermatomyositis was confirmed by antibody testing. Additional immunomodulatory therapy was utilized during the treatment course with no noted improvement. She was not a candidate for lung transplantation, and in the face of additional organ dysfunction, life-sustaining therapies were withdrawn on day 32 of intensive care unit admission. Conclusions This case demonstrates the diagnostic and therapeutic challenges in patients with rapidly progressive interstitial lung disease in the context of anti-melanoma differentiation-associated gene 5 associated juvenile dermatomyositis, who may not present with overt muscle and cutaneous features of juvenile dermatomyositis and whose lung disease can progress very rapidly. A high index of suspicion among clinicians is critical, and expedited diagnostic serology may assist with earlier diagnosis and initiation of therapy. Extracorporeal membrane oxygenation can be utilized as a bridge to diagnosis in the setting of severe refractory hypoxemic respiratory failure. However, despite aggressive treatment, the prognosis remains challenging.

BackgroundViral respiratory tract infections (vRTIs) are a leading cause of paediatric hospitalisation and healthcare utilisation. Existing syndromic surveillance tools, including the WHO Severe Acute Respiratory Infection definition, demonstrate limited diagnostic accuracy in children whose symptom profiles vary widely. This study aimed to develop a machine learning (ML) model to predict microbiologically confirmed vRTIs in hospitalised children and to evaluate performance across age groups and viral pathogens.MethodsWe conducted a retrospective cross-sectional study of 2050 paediatric patients (<18 years) admitted with acute respiratory infections to two tertiary paediatric hospitals in Canada. Predictors included age, sex, hospital transfer status, chronic comorbidity status and 22 presenting symptoms. The primary outcome was microbiologically confirmed vRTI, determined by multiplex PCR or rapid antigen testing. Six ML algorithms were trained and the best-performing model, identified by area under the receiver operating characteristic curve (auROC), was tested on age subgroups, viral pathogens and sites.ResultsAmong 2050 patients (median (IQR) age 2.4 (0.8–5.2) years), 1831 (89.3%) tested positive, most commonly for respiratory syncytial virus (RSV) (38.7%) and enterovirus/rhinovirus (32.8%). Logistic regression with L2 regularisation demonstrated the best performance (auROC, 0.754; 95% CI 0.697 to 0.808; sensitivity, 69.2%; specificity, 69.9%), with greatest performance among children <1 year (auROC, 0.763) and RSV cases (auROC, 0.727).ConclusionsAn ML-based logistic regression model using admission data accurately predicted paediatric vRTIs, outperforming traditional syndromic surveillance definitions, especially among infants <1 year. By integrating ML models into hospital electronic medical records, healthcare systems can achieve enhanced respiratory virus surveillance, faster outbreak detection, greater diagnostic efficiency and improved pandemic preparedness.

Background Nutrition and fluid balance are core components of supportive care in paediatric critical illness, yet their interaction remains poorly defined. We examined the relationship between fluid balance trajectories and nutritional delivery during the first week of paediatric intensive care. Methods We performed a retrospective cohort study of mechanically ventilated children (0–18 years) admitted for ≥ 24 h to a tertiary PICU between 2019 and 2024 who received furosemide. Patients with diagnoses requiring disease-specific fluid strategies were excluded. Fluid balance was calculated in 12-hour intervals and cumulatively. Nutritional delivery from enteral and parenteral sources was expressed as a percentage of predicted energy expenditure (DPEE). The primary outcome was cumulative nutritional delivery at ICU discharge or day 7, comparing patients with negative versus neutral/positive cumulative fluid balance. Multivariable linear regression adjusted for age, illness severity, vasoactive support, mechanical ventilation duration, and ICU length of stay. Results Among 511 included patients (median age 42 months), nutritional support increased progressively, with > 75% receiving nutrition by 72 h and > 90% by day 7; enteral feeding predominated. Fluid balance was initially positive, transitioning toward neutrality and negative balance after approximately 72 h. As cumulative fluid balance declined, cumulative nutritional delivery increased. In adjusted analyses, negative cumulative fluid balance was independently associated with a 50% reduction in delivered energy compared with neutral or positive balance ( p  = 0.002). Younger age was associated with lower nutritional delivery, while longer ICU stay was associated with modest increases. Conclusions During early paediatric critical illness, fluid balance and nutritional delivery follow interdependent trajectories. Strategies aimed at achieving negative fluid balance are associated with substantially reduced energy delivery, independent of illness severity. These findings identify fluid and nutrition management as linked, modifiable targets and support integrated approaches to optimize supportive care in critically ill children.

The utilization of noninvasive ventilation (NIV) in pediatric intensive care units (PICUs), to support children with respiratory failure and avoid endotracheal intubation, has increased. Current guidelines recommend initiating enteral nutrition (EN) within the first 24–48 h post admission. This practice remains variable among PICUs due to perceptions of a lack of safety data and the potential increase in respiratory and gastric complications. The objective of this retrospective study was to evaluate the association between EN and development of extraintestinal complications in children 0–18 years of age on NIV for acute respiratory failure. Of 332 patients supported with NIV, 249 (75%) were enterally fed within the first 48 h of admission. Respiratory complications occurred in 132 (40%) of the total cohort and predominantly in non-enterally fed patients (60/83, 72% vs. 72/249, 29%; p < 0.01), and they occurred earlier during ICU admission (0 vs. 2 days; p < 0.01). The majority of complications were changes in the fraction of inspired oxygen (220/290, 76%). In the multivariate evaluation, children on bilevel positive airway pressure (BiPAP) (23/132, 17% vs. 96/200, 48%; odds ratio [OR] = 5.3; p < 0.01), receiving a higher fraction of inspired oxygen (FiO2) (0.42 vs. 0.35; OR = 6; p = 0.03), and with lower oxygen saturation (SpO2) (91% vs. 97%; OR = 0.8; p < 0.01) were more likely to develop a complication. Time to discharge from the intensive care unit (ICU) was longer for patients with complications (11 vs. 3 days; OR = 1.12; p < 0.01). The large majority of patients requiring NIV can be enterally fed without an increase in respiratory complications after an initial period of ICU stabilization.

Energy expenditure in critically ill children is a key determinant for nutritional caloric delivery in critically ill children. However, its methods of measurement are poorly available, and its prediction is unreliable and imprecise with currently available methodology. This thesis seeks to better understand patient and clinical factors related to energy expenditure to improve its prediction. In the first study, we conducted a systematic review to determine the patient and clinical factors associated with energy expenditure in critically ill patients. We described the limitations of currently available data and identified important factors that are not included in current prediction formulae of the critically ill. In the second study, we conducted a retrospective study at two Canadian centers to describe some predictors of energy expenditure in this population and estimate their magnitude of effect. We were able to describe some factors of interest in critically ill children, identify factors that were not evaluated in sufficient numbers, and determine new predictors associated with energy expenditure not previously described in paediatric ICU. In the third study, we aimed to establish a prospective cohort of critically ill children with indirect calorimetry measurements and clinical data to support the development and initial validation of an equation that predicts energy expenditure. This thesis achieved its intended aims and the work provides the foundation for the development of an energy expenditure equation that is reliable, valid, accessible, and widely applied in critically ill children.

Background: Total energy expenditure (TEE) is the total energy expended by an individual to sustain life, activities, and growth. TEE is formed by four components: resting energy expenditure (REE), activity energy expenditure (AEE), growth-related energy expenditure (GEE), and the thermic effect of feeding (TEF). Some energy expenditure (EE) components may change throughout childhood and cannot be reliably estimated using prediction formulae. Objective: To summarize measured TEE components as reported in the literature in healthy and critically ill children. Methods: We searched MEDLINE, EMBASE, and CINAHL for studies published between 1946 and 7 September 2023. The primary outcome was energy expenditure. Included studies were published in English and measured one or more of TEE, AEE, GEE, and TEF with Indirect Calorimetry or Doubly Labeled Water in participants between 1 month and 18 years of age. We excluded studies reporting only REE or using predictive equations. Following abstraction, reported values were converted into kcal/kg/day or kcal/day as possible. Weighted mean values were calculated using median or means of EE measurements. Results: We found 138 studies, 8163 patients, and 16,636 eligible measurements. The median (IQR) study sample size was 20 (12, 35) patients. TEE was the most evaluated component. The median (IQR) TEE in infants was 73.1 (67.0, 76.5), in children 78.0 (66.0, 81.3), and in adolescents was 44.2 (41.8, 51.9) kcal/kg/day. Very few studies reported on GEE and TEF. Conclusions: This is one of the first studies that summarizes components of total energy expenditure in different pediatric age groups in healthy and critically ill children. Growth- and feeding-associated energy expenditure are poorly reported in healthy children, while all components of TEE (except REE) are poorly reported in critically ill children.

Abstract Background Asthma exacerbations triggered by acute respiratory infections (ARIs) are a major cause of hospitalizations in children. There were large reductions in asthma admission during the SARS-CoV2 pandemic. Following the relaxation of public health interventions, there was a resurgence in admissions for ARIs. The effect of this rebound in ARIs on asthma management practices and outcomes is not well understood. Objectives To describe sociodemographic characteristics, etiology, management, and clinical outcomes of children and youth under the age of 18 years admitted to a tertiary care paediatric hospital with an acute asthma exacerbation from July 1, 2022 to Dec 31, 2022. Design/Methods An observational cohort study of children and youth less than 18 years, hospitalized with an acute asthma exacerbation from July 1, 2022 to Dec 31, 2022 at a single large Canadian children’s hospital. This was a subgroup analysis of the READAPT-Kids study cohort (Clinical chaRacteristics and outcomEs of hospitAlized children with Acute resPiratory infecTions.) Cases were identified using ICD-10-CA codes, then manually screened for inclusion. Detailed clinical and demographic information was extracted. Results Among 551 patients hospitalized with an ARI, 29.2% (n=161) were diagnosed with an asthma exacerbation. 99 were male (61.5%) with a median age of 3.8 years (IQR 2.2-6.3). 41.3% (n=64) had a previously documented asthma history, and of those, only 16.9% were taking any form of asthma therapy at admission. In hospital, 91.4% were given systemic corticosteroids, 86.5% had at least 1 viral pathogen identified, 72.2% had a chest x ray, 42.1% received antibiotics, and 23.7% had high flow nasal cannula oxygen outside of the paediatric intensive care (PICU). 22.4% (n=36), were admitted to the PICU, and 3.7% required invasive mechanical ventilation, there were no patient deaths. Median length of stay was 2.6 days (IQR 1.7–4.6 days). At discharge, 79.5% were prescribed regular inhaled corticosteroid therapy. Conclusion Asthma admissions accounted for a significant proportion of children hospitalized with ARIs in the post-pandemic era, with one fifth requiring transfer to PICU. CXR and antibiotic usage were high. Over 80% of those with a previous diagnosis of asthma were not taking inhaled corticosteroids at the time of admission.

Abstract Background Respiratory syncytial virus (RSV) is one of the most common acute respiratory infections (ARI) in infants and young children. After the relaxation of COVID-19 pandemic restrictions, children’s hospitals worldwide experienced unprecedented volumes and severity in presentation of children admitted with ARIs, such as RSV. It is unknown whether the increase in volumes was also associated with changes in the typical demographic, severity and outcomes of patients with RSV infections. Objectives To describe sociodemographic characteristics, clinical presentation, management including diagnosis and disposition and clinical outcomes of children under the age of 18 years admitted to tertiary care paediatric hospital with RSV-associated ARI. Design/Methods Observational cohort of children and adolescents aged 0-18 years admitted to two large Canadian children’s hospitals between July 1, 2022 - December 31, 2022, who had microbiological evidence of RSV infection. Detailed clinical and demographic information were extracted, including admission and discharge diagnoses, diagnostic tests, viral and bacterial testing, interventions, and respiratory settings. Clinical outcomes and complications were collected, including length of hospital admission, paediatric intensive care unit (PICU) admission, need for invasive mechanical ventilation, disposition, and death. Results There were 455 patients admitted with an RSV infection, of which a third (35.0%, n=146) were transfers from other hospitals. Cases were 41.0% male and the median age was 1.22 years (interquartile range [IQR] 0.19-3.06). Nearly two-thirds of patients (62.0%, n=284) were younger than 2 years of age, 8.6% had a history of prematurity. One third (31.0%, n=142) of patients had at least one documented comorbid condition, the most common diagnosis was asthma (6.6%). In addition to RSV, 3.5% (n=16) of patients had a simultaneous bacterial pathogen identified. Most patients (73%, n=330) were only RSV positive, while 24% (n=109) had two pathogens identified. One quarter (25.9%) were admitted to the PICU. The median length of hospital stay was 3 days (IQR 2.00-5.00) and for those admitted to the PICU, nearly two thirds of patients (63.0%, n=75) were admitted for less than 4 days. 0 patients died. The most common discharge diagnosis in 61.0% of patients (n=279) was bronchiolitis. There were 56 patients (12.3%) who had an unscheduled return visit to the ED within 30 days of discharge with 23.0% (n=13) requiring readmission to the hospital. Conclusion There continues to be a substantial volume of hospitalizations secondary to RSV infection, predominantly in those <2 years of age, with a prominent diagnosis of bronchiolitis. A quarter of patients had notable severity requiring PICU admission.