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Sribnick EA, Warner T, Hall MW. Granulocyte- Macrophage Colony-Stimulating Factor Reverses Immunosuppression Acutely Following a Traumatic Brain Injury and Hemorrhage Polytrauma in a Juvenile Male Rat Model. J Neurotrauma 2024. [PMID: 38623766 DOI: 10.1089/neu.2023.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Traumatic brain injury (TBI) is a common cause of morbidity and mortality in children. We have previously shown that TBI with a concurrent extracranial injury reliably leads to post-injury suppression of the innate and adaptive immune systems. In patients with post-injury immune suppression, if immune function could be preserved, this might represent a therapeutic opportunity. As such, we examined, in an animal injury model, whether systemic administration of granulocyte macrophage colony-stimulating factor (GM-CSF) could reverse post-injury immune suppression and whether treatment was associated with neuroinflammation or functional deficit. Prepubescent male rats were injured using a controlled cortical impact model and then subjected to removal of 25% blood volume (TBI/H). Sham animals underwent surgery without injury induction, and the treatment groups were sham and injured animals treated with either saline vehicle or 50 μg/kg GM-CSF. GM-CSF was administered following injury and then daily until sacrifice at post-injury day (PID) 7. Immune function was measured by assessing tumor necrosis factor-α (TNF-α) levels in whole blood and spleen following ex vivo stimulation with pokeweed mitogen (PWM). Brain samples were assessed by multiplex enzyme-linked immunosorbent assay (ELISA) for cytokine levels and by immunohistochemistry for microglia and astrocyte proliferation. Neuronal cell count was examined using cresyl violet staining. Motor coordination was evaluated using the Rotarod performance test. Treatment with GM-CSF was associated with a significantly increased response to PWM in both whole blood and spleen. GM-CSF in injured animals did not lead to increases in levels of pro-inflammatory cytokines in brain samples but was associated with significant increases in counted astrocytes. Finally, while injured animals treated with saline showed a significant impairment on behavioral testing, injured animals treated with GM-CSF performed similarly to uninjured animals. GM-CSF treatment in animals with combined injury led to increased systemic immune cell response in whole blood and spleen in the acute phase following injury. Improved immune response was not associated with elevated pro-inflammatory cytokine levels in the brain or functional impairment.
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Affiliation(s)
- Eric A Sribnick
- Department of Surgery, Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Clinical and Translation Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Timothy Warner
- Center for Clinical and Translation Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark W Hall
- Center for Clinical and Translation Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, Division of Critical Care, Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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Rowan CM, LaBere B, Young CC, Zambrano LD, Newhams MM, Kucukak S, McNamara ER, Mack EH, Fitzgerald JC, Irby K, Maddux AB, Schuster JE, Kong M, Dapul H, Schwartz SP, Bembea MM, Loftis LL, Kolmar AR, Babbitt CJ, Nofziger RA, Hall MW, Gertz SJ, Cvijanovich NZ, Zinter MS, Halasa NB, Bradford TT, McLaughlin GE, Singh AR, Hobbs CV, Wellnitz K, Staat MA, Coates BM, Crandall HR, Maamari M, Havlin KM, Schwarz AJ, Carroll CL, Levy ER, Moffitt KL, Campbell AP, Randolph AG, Chou J. Pre-existing Immunocompromising Conditions and Outcomes of Acute COVID-19 Patients Admitted for Pediatric Intensive Care. Clin Infect Dis 2024:ciae133. [PMID: 38465976 DOI: 10.1093/cid/ciae133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/24/2024] [Accepted: 03/07/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND We aimed to determine if pre-existing immunocompromising conditions (ICCs) were associated with the presentation or outcome of patients with acute coronavirus disease 2019 (COVID-19) admitted for pediatric intensive care. METHODS 55 hospitals in 30 U.S. states reported cases through the Overcoming COVID-19 public health surveillance registry. Patients <21 years admitted March 12, 2020-December 30, 2021 to the pediatric intensive care unit (PICU) or high acuity unit for acute COVID-19 were included. RESULTS Of 1,274 patients, 105 (8.2%) had an ICC including 33 (31.4%) hematologic malignancies, 24 (22.9%) primary immunodeficiencies and disorders of hematopoietic cells, 19 (18.1%) nonmalignant organ failure with solid organ transplantation, 16 (15.2%) solid tumors and 13 (12.4%) autoimmune disorders. Patients with ICCs were older, had more underlying renal conditions, and had lower white blood cell and platelet counts than those without ICCs, but had similar clinical disease severity upon admission. In-hospital mortality from COVID-19 was higher (11.4% vs. 4.6%, p = 0.005) and hospitalization was longer (p = 0.01) in patients with ICCs. New major morbidities upon discharge were not different between those with and without ICC (10.5% vs 13.9%, p = 0.40). In patients with ICC, bacterial co-infection was more common in those with life-threatening COVID-19. CONCLUSIONS In this national case series of patients <21 years of age with acute COVID-19 admitted for intensive care, existence of a prior ICCs were associated with worse clinical outcomes. Reassuringly, most patients with ICCs hospitalized in the PICU for severe acute COVID-19 survived and were discharged home without new severe morbidities.
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Affiliation(s)
- Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Brenna LaBere
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Pulmonology, Section of Allergy-Immunology, Phoenix Children's Hospital, Phoenix, AZ
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Laura D Zambrano
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Elizabeth R McNamara
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital at NYU Langone, New York, NY
| | - Stephanie P Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura L Loftis
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Amanda R Kolmar
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Christopher J Babbitt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Miller Children's and Women's Hospital of Long Beach, Long Beach, CA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Matt S Zinter
- Department of Pediatrics, Divisions of Critical Care Medicine and Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, San Francisco, CA
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Tamara T Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Charlotte V Hobbs
- Department of Pediatrics, Division of Infectious Diseases; Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hillary R Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center Dallas, TX
| | - Kevin M Havlin
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Louisville, and Norton Children's Hospital, Louisville, KY
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Health Orange County (CHOC), Orange, CA
| | | | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Kristin L Moffitt
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA
| | - Angela P Campbell
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, MA
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:665-674. [PMID: 38245889 PMCID: PMC10900966 DOI: 10.1001/jama.2024.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Importance Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective To update and evaluate criteria for sepsis and septic shock in children. Evidence Review The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.
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Affiliation(s)
- Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew C. Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Canada
- University of Ottawa, Ontario, Canada
| | - Mark W. Hall
- Division of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paolo Biban
- Pediatric Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- University of Liverpool, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Divisions of Critical Care Medicine and Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Idris Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - Cláudio Flauzino de Oliveira
- AMIB–Associação de Medicina Intensiva Brasileira, São Paulo, Brazil
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
| | - Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - David Inwald
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California, San Diego School of Medicine, La Jolla
| | - Juan Camilo Jaramillo-Bustamante
- PICU Hospital General de Medellín “Luz Castro de Gutiérrez” and Hospital Pablo Tobón Uribe, Medellín, Colombia
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
- Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mark J. Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Suchitra Ranjit
- Pediatric Intensive Care Unit, Apollo Children’s Hospital, Chennai, India
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Halden F. Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Emergency Department, Children’s Hospital Colorado, Aurora
| | - Daniela Carla de Souza
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Universitario of the University of São Paulo, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Sírio Libanês, São Paulo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, Canada and Walimu, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jerry J. Zimmerman
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - L. Nelson Sanchez-Pinto
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Critical Care, and Department of Preventive Medicine, Division of Health & Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
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Horvat CM, Hamilton MF, Hall MW, McGuire JK, Mink RB. Child Health Needs and the Pediatric Critical Care Medicine Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678G. [PMID: 38300003 DOI: 10.1542/peds.2023-063678g] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
This article, focused on the current and future pediatric critical care medicine (PCCM) workforce, is part of a supplement in Pediatrics anticipating the future supply of the pediatric subspecialty workforce. It draws on information available in the literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the American Board of Pediatrics Foundation in collaboration with the Carolina Workforce Research Center at the University of North Carolina at Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling and Analysis Ltd. A brief history of the field of PCCM is provided, followed by an in-depth examination of the current PCCM workforce and a subsequent evaluation of workforce forecasts from 2020 to 2040. Under baseline conditions, the PCCM workforce is expected to increase by 105% during the forecasted period, more than any other pediatric subspecialty. Forecasts are modeled under a variety of multifactorial conditions meant to simulate the effects of changes to the supply of PCCM subspecialists, with only modest changes observed. Future PCCM workforce demand is unclear, although some suggest an oversupply may exist and that market forces may correct this. The findings generate important questions regarding the future state of the PCCM workforce and should be used to guide trainees considering a PCCM career, subspecialty leaders responsible for hosting training programs, staffing ICUs, and governing bodies that oversee training program accreditation and subspecialist certification.
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Affiliation(s)
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | | | - Richard B Mink
- The Lundquist Institute for Biomedical Innovation at Harbor, University of California Los Angeles Medical Center, Torrance, California
- David Geffen School of Medicine at UCLA, Torrance, CA
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5
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Atreya MR, Banerjee S, Lautz AJ, Alder MN, Varisco BM, Wong HR, Muszynski JA, Hall MW, Sanchez-Pinto LN, Kamaleswaran R. Machine learning-driven identification of the gene-expression signature associated with a persistent multiple organ dysfunction trajectory in critical illness. EBioMedicine 2024; 99:104938. [PMID: 38142638 PMCID: PMC10788426 DOI: 10.1016/j.ebiom.2023.104938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) disproportionately drives morbidity and mortality among critically ill patients. However, we lack a comprehensive understanding of its pathobiology. Identification of genes associated with a persistent MODS trajectory may shed light on underlying biology and allow for accurate prediction of those at-risk. METHODS Secondary analyses of publicly available gene-expression datasets. Supervised machine learning (ML) was used to identify a parsimonious set of genes associated with a persistent MODS trajectory in a training set of pediatric septic shock. We optimized model parameters and tested risk-prediction capabilities in independent validation and test datasets, respectively. We compared model performance relative to an established gene-set predictive of sepsis mortality. FINDINGS Patients with a persistent MODS trajectory had 568 differentially expressed genes and characterized by a dysregulated innate immune response. Supervised ML identified 111 genes associated with the outcome of interest on repeated cross-validation, with an AUROC of 0.87 (95% CI: 0.85-0.88) in the training set. The optimized model, limited to 20 genes, achieved AUROCs ranging from 0.74 to 0.79 in the validation and test sets to predict those with persistent MODS, regardless of host age and cause of organ dysfunction. Our classifier demonstrated reproducibility in identifying those with persistent MODS in comparison with a published gene-set predictive of sepsis mortality. INTERPRETATION We demonstrate the utility of supervised ML driven identification of the genes associated with persistent MODS. Pending validation in enriched cohorts with a high burden of organ dysfunction, such an approach may inform targeted delivery of interventions among at-risk patients. FUNDING H.R.W.'s NIHR35GM126943 award supported the work detailed in this manuscript. Upon his death, the award was transferred to M.N.A. M.R.A., N.S.P, and R.K were supported by NIHR21GM151703. R.K. was supported by R01GM139967.
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Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA.
| | - Shayantan Banerjee
- Department of Biotechnology, Bhupat and Jyoti Mehta School of Biosciences, Indian Institute of Technology Madras, Chennai, 600 036, India
| | - Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Matthew N Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, 43205, OH, USA; Department of Pediatrics, Ohio State University, Columbus, 43205, OH, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, 43205, OH, USA; Department of Pediatrics, Ohio State University, Columbus, 43205, OH, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, 60611, IL, USA; Department of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, 60611, IL, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, 30322, GA, United States; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, 30322, GA, United States
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6
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Osborne CM, Langelier C, Kamm J, Williamson K, Ambroggio L, Reeder RW, Locandro C, Kirk Harris J, Wagner BD, Maddux AB, Caldera S, Lyden A, Soesanto V, Simões EAF, Leroue MK, Carpenter TC, Hall MW, Zuppa AF, Carcillo JA, Meert KL, Pollack MM, McQuillen PS, Notterman DA, DeRisi J, Mourani PM. Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection. Pediatr Crit Care Med 2024; 25:e1-e11. [PMID: 37732845 PMCID: PMC10756702 DOI: 10.1097/pcc.0000000000003336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs). DESIGN This is an analysis of of a seven-center prospective cohort study. SETTING Seven PICUs within academic children's hospitals in the United States. PATIENTS Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours. INTERVENTIONS We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement. MEASUREMENTS AND MAIN RESULTS Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001). CONCLUSIONS Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.
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Affiliation(s)
- Christina M Osborne
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Charles Langelier
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, CA
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Lilliam Ambroggio
- Department of Epidemiology, University of Colorado School of Medicine, Aurora, CO
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - J Kirk Harris
- Department of Pediatrics, Section of Pulmonary Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO
| | - Eric A F Simões
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew K Leroue
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Todd C Carpenter
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| | - Athena F Zuppa
- Anesthesiology and Critical Care, Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joseph A Carcillo
- Department of Anesthesia and Critical Care Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kathleen L Meert
- Department of Pediatrics, Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Murray M Pollack
- Department of Pediatrics, Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | | | | | - Peter M Mourani
- Department of Pediatrics, Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR
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7
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Leland SB, Staffa SJ, Newhams MM, Khemani RG, Marshall JC, Young CC, Maddux AB, Hall MW, Weiss SL, Schwarz AJ, Coates BM, Sanders RC, Kong M, Thomas NJ, Nofziger RA, Cullimore ML, Halasa NB, Loftis LL, Cvijanovich NZ, Schuster JE, Flori H, Gertz SJ, Hume JR, Olson SM, Patel MM, Zurakowski D, Randolph AG. The Modified Clinical Progression Scale for Pediatric Patients: Evaluation as a Severity Metric and Outcome Measure in Severe Acute Viral Respiratory Illness. Pediatr Crit Care Med 2023; 24:998-1009. [PMID: 37539964 PMCID: PMC10688559 DOI: 10.1097/pcc.0000000000003331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To develop, evaluate, and explore the use of a pediatric ordinal score as a potential clinical trial outcome metric in children hospitalized with acute hypoxic respiratory failure caused by viral respiratory infections. DESIGN We modified the World Health Organization Clinical Progression Scale for pediatric patients (CPS-Ped) and assigned CPS-Ped at admission, days 2-4, 7, and 14. We identified predictors of clinical improvement (day 14 CPS-Ped ≤ 2 or a three-point decrease) using competing risks regression and compared clinical improvement to hospital length of stay (LOS) and ventilator-free days. We estimated sample sizes (80% power) to detect a 15% clinical improvement. SETTING North American pediatric hospitals. PATIENTS Three cohorts of pediatric patients with acute hypoxic respiratory failure receiving intensive care: two influenza (pediatric intensive care influenza [PICFLU], n = 263, 31 sites; PICFLU vaccine effectiveness [PICFLU-VE], n = 143, 17 sites) and one COVID-19 ( n = 237, 47 sites). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive mechanical ventilation rates were 71.4%, 32.9%, and 37.1% for PICFLU, PICFLU-VE, and COVID-19 with less than 5% mortality for all three cohorts. Maximum CPS-Ped (0 = home at respiratory baseline to 8 = death) was positively associated with hospital LOS ( p < 0.001, all cohorts). Across the three cohorts, many patients' CPS-Ped worsened after admission (39%, 18%, and 49%), with some patients progressing to invasive mechanical ventilation or death (19%, 11%, and 17%). Despite this, greater than 76% of patients across cohorts clinically improved by day 14. Estimated sample sizes per group using CPS-Ped to detect a percentage increase in clinical improvement were feasible (influenza 15%, n = 142; 10%, n = 225; COVID-19, 15% n = 208) compared with mortality ( n > 21,000, all), and ventilator-free days (influenza 15%, n = 167). CONCLUSIONS The CPS-Ped can be used to describe the time course of illness and threshold for clinical improvement in hospitalized children and adolescents with acute respiratory failure from viral infections. This outcome measure could feasibly be used in clinical trials to evaluate in-hospital recovery.
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Affiliation(s)
- Shannon B Leland
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - John C Marshall
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County (CHOC), Orange, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Heidi Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, MI
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Samantha M Olson
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - Manish M Patel
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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8
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Sanchez-Pinto LN, Bennett TD, Stroup EK, Luo Y, Atreya M, Bubeck Wardenburg J, Chong G, Geva A, Faustino EVS, Farris RW, Hall MW, Rogerson C, Shah SS, Weiss SL, Khemani RG. Derivation, Validation, and Clinical Relevance of a Pediatric Sepsis Phenotype With Persistent Hypoxemia, Encephalopathy, and Shock. Pediatr Crit Care Med 2023; 24:795-806. [PMID: 37272946 PMCID: PMC10540758 DOI: 10.1097/pcc.0000000000003292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Untangling the heterogeneity of sepsis in children and identifying clinically relevant phenotypes could lead to the development of targeted therapies. Our aim was to analyze the organ dysfunction trajectories of children with sepsis-associated multiple organ dysfunction syndrome (MODS) to identify reproducible and clinically relevant sepsis phenotypes and determine if they are associated with heterogeneity of treatment effect (HTE) to common therapies. DESIGN Multicenter observational cohort study. SETTING Thirteen PICUs in the United States. PATIENTS Patients admitted with suspected infections to the PICU between 2012 and 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used subgraph-augmented nonnegative matrix factorization to identify candidate trajectory-based phenotypes based on the type, severity, and progression of organ dysfunction in the first 72 hours. We analyzed the candidate phenotypes to determine reproducibility as well as prognostic, therapeutic, and biological relevance. Overall, 38,732 children had suspected infection, of which 15,246 (39.4%) had sepsis-associated MODS with an in-hospital mortality of 10.1%. We identified an organ dysfunction trajectory-based phenotype (which we termed persistent hypoxemia, encephalopathy, and shock) that was highly reproducible, had features of systemic inflammation and coagulopathy, and was independently associated with higher mortality. In a propensity score-matched analysis, patients with persistent hypoxemia, encephalopathy, and shock phenotype appeared to have HTE and benefit from adjuvant therapy with hydrocortisone and albumin. When compared with other high-risk clinical syndromes, the persistent hypoxemia, encephalopathy, and shock phenotype only overlapped with 50%-60% of patients with septic shock, moderate-to-severe pediatric acute respiratory distress syndrome, or those in the top tier of organ dysfunction burden, suggesting that it represents a nonsynonymous clinical phenotype of sepsis-associated MODS. CONCLUSIONS We derived and validated the persistent hypoxemia, encephalopathy, and shock phenotype, which is highly reproducible, clinically relevant, and associated with HTE to common adjuvant therapies in children with sepsis.
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Affiliation(s)
- L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tellen D Bennett
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Emily K Stroup
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mihir Atreya
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Grace Chong
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Alon Geva
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | | | - Reid W Farris
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA
| | - Mark W Hall
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH
| | - Colin Rogerson
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Sareen S Shah
- Department of Pediatrics, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, Los Angeles, CA
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9
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Cheung C, Kernan KF, Berg RA, Zuppa AF, Notterman DA, Pollack MM, Wessel D, Meert KL, Hall MW, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Banks RK, Reeder RW, Holubkov R, Carcillo JA, Fink EL. Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study. Pediatr Crit Care Med 2023; 24:840-848. [PMID: 37314247 PMCID: PMC10719421 DOI: 10.1097/pcc.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure. DESIGN Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS). SETTING Nine tertiary care PICUs in the United States. PATIENTS Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC. CONCLUSIONS One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.
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Affiliation(s)
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F. Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Rick E. Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
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10
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Chang JC, Young CC, Muscal E, Sexson Tejtel SK, Newhams MM, Kucukak S, Crandall H, Maddux AB, Rowan CM, Halasa NB, Harvey HA, Hobbs CV, Hall MW, Kong M, Aguiar CL, Schuster JE, Fitzgerald JC, Singh AR, Wellnitz K, Nofziger RA, Cvijanovich NZ, Mack EH, Schwarz AJ, Heidemann SM, Newburger JW, Zambrano LD, Campbell AP, Patel MM, Randolph AG, Son MBF. Variation in Early Anakinra Use and Short-Term Outcomes in Multisystem Inflammatory Syndrome in Children. Arthritis Rheumatol 2023; 75:1466-1476. [PMID: 36908050 PMCID: PMC10495537 DOI: 10.1002/art.42495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/03/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Evidence regarding effectiveness of interleukin-1 receptor antagonism in multisystem inflammatory syndrome in children (MIS-C) is lacking. We characterized variation in initial treatment with anakinra and evaluated cardiovascular outcomes associated with adding anakinra to standard initial therapy. METHODS We conducted a retrospective cohort study of MIS-C cases in a US surveillance registry from November 2020 to December 2021. Day 0 was the first calendar day of immunomodulatory treatment. Factors associated with initial anakinra use (days 0-1) were identified. We compared cases in patients ages 2-20 years receiving intravenous immunoglobulin (IVIG) and glucocorticoids versus anakinra plus IVIG and/or glucocorticoids on days 0-1, using inverse probability weighting to balance disease severity. Primary outcomes were vasopressor requirement on day 3 and impaired left ventricular ejection fraction on days 3-4. The secondary outcome was 50% reduction in C-reactive protein on day 3. RESULTS Among 1,516 MIS-C cases at 44 sites, 193 (13%) patients received anakinra alone or with other immunomodulators as initial treatment (range 0-74% by site). Site accounted for 59% of residual variance in anakinra use. After balancing disease severity, initial treatment with anakinra plus IVIG and/or glucocorticoids (n = 121) versus IVIG plus glucocorticoids (n = 389) was not associated with significant differences in vasopressor requirement (25.6% versus 20.1%, respectively; risk ratio [RR] 1.27 [95% confidence interval (95% CI) 0.88-1.84]), ventricular dysfunction (33.7% versus 25.7%, respectively; RR 1.31 [95% CI 0.98-1.75]), or C-reactive protein reduction. CONCLUSION We identified substantial variation in initial anakinra use in a real-world population of children with MIS-C, but no average short-term improvement in cardiovascular outcomes associated with early addition of anakinra to IVIG and/or glucocorticoids compared to IVIG and glucocorticoids alone.
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Affiliation(s)
- Joyce C Chang
- Division of Immunology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Eyal Muscal
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Sara K Sexson Tejtel
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine and Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Helen A Harvey
- Department of Critical Care Medicine, Rady Children's Hospital-San Diego, San Diego, California
| | - Charlotte V Hobbs
- Division of Infectious Disease, Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Cassyanne L Aguiar
- Department of Pediatric Rheumatology, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County, Orange, California
| | - Sabrina M Heidemann
- Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, and Departments of Pediatrics and Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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11
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Novak T, Crawford JC, Hahn G, Hall MW, Thair SA, Newhams MM, Chou J, Mourani PM, Tarquinio KM, Markovitz B, Loftis LL, Weiss SL, Higgerson R, Schwarz AJ, Pinto NP, Thomas NJ, Gedeit RG, Sanders RC, Mahapatra S, Coates BM, Cvijanovich NZ, Ackerman KG, Tellez DW, McQuillen P, Kurachek SC, Shein SL, Lange C, Thomas PG, Randolph AG. Transcriptomic profiles of multiple organ dysfunction syndrome phenotypes in pediatric critical influenza. Front Immunol 2023; 14:1220028. [PMID: 37533854 PMCID: PMC10390830 DOI: 10.3389/fimmu.2023.1220028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/19/2023] [Indexed: 08/04/2023] Open
Abstract
Background Influenza virus is responsible for a large global burden of disease, especially in children. Multiple Organ Dysfunction Syndrome (MODS) is a life-threatening and fatal complication of severe influenza infection. Methods We measured RNA expression of 469 biologically plausible candidate genes in children admitted to North American pediatric intensive care units with severe influenza virus infection with and without MODS. Whole blood samples from 191 influenza-infected children (median age 6.4 years, IQR: 2.2, 11) were collected a median of 27 hours following admission; for 45 children a second blood sample was collected approximately seven days later. Extracted RNA was hybridized to NanoString mRNA probes, counts normalized, and analyzed using linear models controlling for age and bacterial co-infections (FDR q<0.05). Results Comparing pediatric samples collected near admission, children with Prolonged MODS for ≥7 days (n=38; 9 deaths) had significant upregulation of nine mRNA transcripts associated with neutrophil degranulation (RETN, TCN1, OLFM4, MMP8, LCN2, BPI, LTF, S100A12, GUSB) compared to those who recovered more rapidly from MODS (n=27). These neutrophil transcripts present in early samples predicted Prolonged MODS or death when compared to patients who recovered, however in paired longitudinal samples, they were not differentially expressed over time. Instead, five genes involved in protein metabolism and/or adaptive immunity signaling pathways (RPL3, MRPL3, HLA-DMB, EEF1G, CD8A) were associated with MODS recovery within a week. Conclusion Thus, early increased expression of neutrophil degranulation genes indicated worse clinical outcomes in children with influenza infection, consistent with reports in adult cohorts with influenza, sepsis, and acute respiratory distress syndrome.
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Affiliation(s)
- Tanya Novak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
- Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
- National Institute of Allergy and Infectious Diseases (NIAID), Centers of Excellence for Influenza Research and Response (CEIRR), Center for Influenza Disease and Emergence Response (CIDER), Athens, GA, United States
| | - Jeremy Chase Crawford
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
- National Institute of Allergy and Infectious Diseases (NIAID), Centers of Excellence for Influenza Research and Response (CEIRR), St. Jude Children's Research Hospital, Memphis, TN, United States
- Department of Immunology, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Georg Hahn
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Simone A. Thair
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Margaret M. Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
- National Institute of Allergy and Infectious Diseases (NIAID), Centers of Excellence for Influenza Research and Response (CEIRR), Center for Influenza Disease and Emergence Response (CIDER), Athens, GA, United States
| | - Janet Chou
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, AR, United States
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Barry Markovitz
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, United States
| | - Laura L. Loftis
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Scott L. Weiss
- Nemours Children’s Hospital Delaware, Critical Care Medicine, Wilmington, DE, United States
| | - Renee Higgerson
- Pediatric Critical Care Medicine, St. David’s Children’s Hospital, Austin, TX, United States
| | - Adam J. Schwarz
- Department of Pediatrics, Children’s Hospital of Orange County, Orange, CA, United States
| | - Neethi P. Pinto
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Neal J. Thomas
- Department of Pediatrics, Penn State Health Children’s Hospital, Penn State University College of Medicine, Hershey, PA, United States
| | - Rainer G. Gedeit
- Pediatric Critical Care, Milwaukee Hospital-Children’s Wisconsin, Milwaukee, WI, United States
| | - Ronald C. Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, AR, United States
| | - Sidharth Mahapatra
- Pediatric Critical Care Medicine, Children’s Hospital & Medical Center Omaha, University of Nebraska Medical Center, Omaha, NE, United States
| | - Bria M. Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Natalie Z. Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital, Oakland, CA, United States
| | - Kate G. Ackerman
- Department of Pediatrics, University of Rochester/UR Medicine Golisano Children’s Hospital, Rochester, NY, United States
| | - David W. Tellez
- Pediatric Critical Care Medicine, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Patrick McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Stephen C. Kurachek
- Department of Critical Care, Children’s Specialty Center, Children’s Minnesota, Minneapolis, MN, United States
| | - Steven L. Shein
- Division of Pediatric Critical Care Medicine, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, United States
| | - Christoph Lange
- Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Paul G. Thomas
- National Institute of Allergy and Infectious Diseases (NIAID), Centers of Excellence for Influenza Research and Response (CEIRR), St. Jude Children's Research Hospital, Memphis, TN, United States
- Department of Immunology, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, United States
- Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
- National Institute of Allergy and Infectious Diseases (NIAID), Centers of Excellence for Influenza Research and Response (CEIRR), Center for Influenza Disease and Emergence Response (CIDER), Athens, GA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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12
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Bembea MM, Loftis LL, Thiagarajan RR, Young CC, McCadden TP, Newhams MM, Kucukak S, Mack EH, Fitzgerald JC, Rowan CM, Maddux AB, Kolmar AR, Irby K, Heidemann S, Schwartz SP, Kong M, Crandall H, Havlin KM, Singh AR, Schuster JE, Hall MW, Wellnitz KA, Maamari M, Gaspers MG, Nofziger RA, Lim PPC, Carroll RW, Coronado Munoz A, Bradford TT, Cullimore ML, Halasa NB, McLaughlin GE, Pannaraj PS, Cvijanovich NZ, Zinter MS, Coates BM, Horwitz SM, Hobbs CV, Dapul H, Graciano AL, Butler AD, Patel MM, Zambrano LD, Campbell AP, Randolph AG. Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs. Pediatr Crit Care Med 2023; 24:356-371. [PMID: 36995097 PMCID: PMC10153593 DOI: 10.1097/pcc.0000000000003212] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) has been used successfully to support adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiac or respiratory failure refractory to conventional therapies. Comprehensive reports of children and adolescents with SARS-CoV-2-related ECMO support for conditions, including multisystem inflammatory syndrome in children (MIS-C) and acute COVID-19, are needed. DESIGN Case series of patients from the Overcoming COVID-19 public health surveillance registry. SETTING Sixty-three hospitals in 32 U.S. states reporting to the registry between March 15, 2020, and December 31, 2021. PATIENTS Patients less than 21 years admitted to the ICU meeting Centers for Disease Control criteria for MIS-C or acute COVID-19. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The final cohort included 2,733 patients with MIS-C ( n = 1,530; 37 [2.4%] requiring ECMO) or acute COVID-19 ( n = 1,203; 71 [5.9%] requiring ECMO). ECMO patients in both groups were older than those without ECMO support (MIS-C median 15.4 vs 9.9 yr; acute COVID-19 median 15.3 vs 13.6 yr). The body mass index percentile was similar in the MIS-C ECMO versus no ECMO groups (89.9 vs 85.8; p = 0.22) but higher in the COVID-19 ECMO versus no ECMO groups (98.3 vs 96.5; p = 0.03). Patients on ECMO with MIS-C versus COVID-19 were supported more often with venoarterial ECMO (92% vs 41%) for primary cardiac indications (87% vs 23%), had ECMO initiated earlier (median 1 vs 5 d from hospitalization), shorter ECMO courses (median 3.9 vs 14 d), shorter hospital length of stay (median 20 vs 52 d), lower in-hospital mortality (27% vs 37%), and less major morbidity at discharge in survivors (new tracheostomy, oxygen or mechanical ventilation need or neurologic deficit; 0% vs 11%, 0% vs 20%, and 8% vs 15%, respectively). Most patients with MIS-C requiring ECMO support (87%) were admitted during the pre-Delta (variant B.1.617.2) period, while most patients with acute COVID-19 requiring ECMO support (70%) were admitted during the Delta variant period. CONCLUSIONS ECMO support for SARS-CoV-2-related critical illness was uncommon, but type, initiation, and duration of ECMO use in MIS-C and acute COVID-19 were markedly different. Like pre-pandemic pediatric ECMO cohorts, most patients survived to hospital discharge.
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Affiliation(s)
- Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura L Loftis
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Timothy P McCadden
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Amanda R Kolmar
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Sabrina Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit, MI
| | - Stephanie P Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Kevin M Havlin
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Louisville, and Norton Children's Hospital, Louisville, KY
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Kari A Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Health Medical Center, Dallas, TX
| | - Mary G Gaspers
- Department of Pediatrics and Banner Children's at Diamond Children's Medical Center, University of Arizona, Tucson, AZ
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Peter Paul C Lim
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Ryan W Carroll
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA
| | - Alvaro Coronado Munoz
- Pediatric Critical Care Division, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX
| | - Tamara T Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Pia S Pannaraj
- Division of Infectious Diseases, Children's Hospital Los Angeles and Departments of Pediatrics and Molecular Microbiology and Immunology, University of Southern California, Los Angeles, CA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Matt S Zinter
- Department of Pediatrics, Divisions of Critical Care Medicine and Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, San Francisco, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Steven M Horwitz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Charlotte V Hobbs
- Department of Pediatrics, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS
| | - Heda Dapul
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, NY
| | - Ana Lia Graciano
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Andrew D Butler
- Division of Pediatric Critical Care, St. Christopher's Hospital for Children, Philadelphia, PA
| | - Manish M Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura D Zambrano
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Angela P Campbell
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, MA
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13
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Maddux AB, Grunwell JR, Newhams MM, Chen SR, Olson SM, Halasa NB, Weiss SL, Coates BM, Schuster JE, Hall MW, Nofziger RA, Flori HR, Gertz SJ, Kong M, Sanders RC, Irby K, Hume JR, Cullimore ML, Shein SL, Thomas NJ, Miller K, Patel M, Fitzpatrick AM, Phipatanakul W, Randolph AG. Association of Asthma With Treatments and Outcomes in Children With Critical Influenza. J Allergy Clin Immunol Pract 2023; 11:836-843.e3. [PMID: 36379408 PMCID: PMC10006305 DOI: 10.1016/j.jaip.2022.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Hospitalization for severe influenza infection in childhood may result in postdischarge sequelae. OBJECTIVE To evaluate inpatient management and postdischarge sequelae in children with critical respiratory illness owing to influenza with or without preexisting asthma. METHODS This was a prospective, observational multicenter study of children (aged 8 months to 17 years) admitted to a pediatric intensive care or high-acuity unit (in November 2019 to April 2020) for influenza. Results were stratified by preexisting asthma. Prehospital status, hospital treatments, and outcomes were collected. Surveys at approximately 90 days after discharge evaluated postdischarge health resource use, functional status, and respiratory symptoms. RESULTS A total of 165 children had influenza: 56 with preexisting asthma (33.9%) and 109 without it (66.1%; 41.1% and 39.4%, respectively, were fully vaccinated against influenza). Fifteen patients with preexisting asthma (26.7%) and 34 without it (31.1%) were intubated. More patients with versus without preexisting asthma received pharmacologic asthma treatments during hospitalization (76.7% vs 28.4%). Of 136 patients with 90-day survey data (82.4%; 46 with preexisting asthma [33.8%] and 90 without it [66.1%]), a similar proportion had an emergency department/urgent care visit (4.3% vs 6.6%) or hospital readmission (8.6% vs 3.3%) for a respiratory condition. Patients with preexisting asthma more frequently experienced asthma symptoms (78.2% vs 3.3%) and had respiratory specialist visits (52% vs 20%) after discharge. Of 109 patients without preexisting asthma, 10 reported receiving a new diagnosis of asthma (11.1%). CONCLUSIONS Respiratory health resource use and symptoms are important postdischarge outcomes after influenza critical illness in children with and without preexisting asthma. Less than half of children were vaccinated for influenza, a tool that could mitigate critical illness and its sequelae.
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Affiliation(s)
- Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Sabrina R Chen
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Samantha M Olson
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control of Prevention, Atlanta, Ga
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Jennifer E Schuster
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Miss
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Mich
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Ark
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Ark
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minn
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Neb
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, Pa
| | - Kristen Miller
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
| | - Manish Patel
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control of Prevention, Atlanta, Ga
| | - Anne M Fitzpatrick
- Children's Healthcare of Atlanta, Division of Pulmonology, Cystic Fibrosis, and Sleep Medicine, Atlanta, Ga
| | - Wanda Phipatanakul
- Department of Pediatrics, Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass; Department of Anaesthesia, Harvard Medical School, Boston, Mass.
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14
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Moffitt KL, Nakamura MM, Young CC, Newhams MM, Halasa NB, Reed JN, Fitzgerald JC, Spinella PC, Soma VL, Walker TC, Loftis LL, Maddux AB, Kong M, Rowan CM, Hobbs CV, Schuster JE, Riggs BJ, McLaughlin GE, Michelson KN, Hall MW, Babbitt CJ, Cvijanovich NZ, Zinter MS, Maamari M, Schwarz AJ, Singh AR, Flori HR, Gertz SJ, Staat MA, Giuliano JS, Hymes SR, Clouser KN, McGuire J, Carroll CL, Thomas NJ, Levy ER, Randolph AG. Community-Onset Bacterial Coinfection in Children Critically Ill With Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Open Forum Infect Dis 2023; 10:ofad122. [PMID: 36968962 PMCID: PMC10034750 DOI: 10.1093/ofid/ofad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Background Community-onset bacterial coinfection in adults hospitalized with coronavirus disease 2019 (COVID-19) is reportedly uncommon, though empiric antibiotic use has been high. However, data regarding empiric antibiotic use and bacterial coinfection in children with critical illness from COVID-19 are scarce. Methods We evaluated children and adolescents aged <19 years admitted to a pediatric intensive care or high-acuity unit for COVID-19 between March and December 2020. Based on qualifying microbiology results from the first 3 days of admission, we adjudicated whether patients had community-onset bacterial coinfection. We compared demographic and clinical characteristics of those who did and did not (1) receive antibiotics and (2) have bacterial coinfection early in admission. Using Poisson regression models, we assessed factors associated with these outcomes. Results Of the 532 patients, 63.3% received empiric antibiotics, but only 7.1% had bacterial coinfection, and only 3.0% had respiratory bacterial coinfection. In multivariable analyses, empiric antibiotics were more likely to be prescribed for immunocompromised patients (adjusted relative risk [aRR], 1.34 [95% confidence interval {CI}, 1.01-1.79]), those requiring any respiratory support except mechanical ventilation (aRR, 1.41 [95% CI, 1.05-1.90]), or those requiring invasive mechanical ventilation (aRR, 1.83 [95% CI, 1.36-2.47]) (compared with no respiratory support). The presence of a pulmonary comorbidity other than asthma (aRR, 2.31 [95% CI, 1.15-4.62]) was associated with bacterial coinfection. Conclusions Community-onset bacterial coinfection in children with critical COVID-19 is infrequent, but empiric antibiotics are commonly prescribed. These findings inform antimicrobial use and support rapid de-escalation when evaluation shows coinfection is unlikely.
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Affiliation(s)
- Kristin L Moffitt
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mari M Nakamura
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Antimicrobial Stewardship Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Nelson Reed
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Vijaya L Soma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
| | - Tracie C Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital, Chapel Hill, North Carolina, USA
| | - Laura L Loftis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Charlotte V Hobbs
- Department of Pediatrics, Division of Disease, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
| | - Becky J Riggs
- Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kelly N Michelson
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | | | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, University of California, San Francisco Benioff Children’s Hospital,Oakland, California, USA
| | - Matt S Zinter
- School of Medicine, Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children’s Health Medical Center Dallas, Dallas, Texas, USA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children’s Hospital Orange County, Orange, California, USA
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan, USA
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - John S Giuliano
- Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saul R Hymes
- Division of Pediatric Infectious Diseases, Stony Brook Children's Hospital, Renaissance School of Medicine, Stony Brook, New York, USA
| | - Katharine N Clouser
- Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - John McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital and the University of Washington, Seattle, Washington, USA
| | | | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrienne G Randolph
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
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15
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Halasa NB, Spieker AJ, Young CC, Olson SM, Newhams MM, Amarin JZ, Moffitt KL, Nakamura MM, Levy ER, Soma VL, Talj R, Weiss SL, Fitzgerald JC, Mack EH, Maddux AB, Schuster JE, Coates BM, Hall MW, Schwartz SP, Schwarz AJ, Kong M, Spinella PC, Loftis LL, McLaughlin GE, Hobbs CV, Rowan CM, Bembea MM, Nofziger RA, Babbitt CJ, Bowens C, Flori HR, Gertz SJ, Zinter MS, Giuliano JS, Hume JR, Cvijanovich NZ, Singh AR, Crandall HA, Thomas NJ, Cullimore ML, Patel MM, Randolph AG. Life-Threatening Complications of Influenza vs Coronavirus Disease 2019 (COVID-19) in US Children. Clin Infect Dis 2023; 76:e280-e290. [PMID: 35717646 PMCID: PMC9384330 DOI: 10.1093/cid/ciac477] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/06/2022] [Accepted: 06/08/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical differences between critical illness from influenza infection vs coronavirus disease 2019 (COVID-19) have not been well characterized in pediatric patients. METHODS We compared demographics, clinical characteristics, and outcomes of US children (aged 8 months to 17 years) admitted to the intensive care or high-acuity unit with influenza or COVID-19. Using mixed-effects models, we assessed the odds of death or requiring life support for influenza vs COVID-19 after adjustment for age, sex, race and Hispanic origin, and underlying conditions including obesity. RESULTS Children with influenza (n = 179) were younger than those with COVID-19 (n = 381; median, 5.2 years vs 13.8 years), less likely to be non-Hispanic Black (14.5% vs 27.6%) or Hispanic (24.0% vs 36.2%), and less likely to have ≥1 underlying condition (66.4% vs 78.5%) or be obese (21.4% vs 42.2%), and a shorter hospital stay (median, 5 days vs 7 days). They were similarly likely to require invasive mechanical ventilation (both 30.2%), vasopressor support (19.6% and 19.9%), or extracorporeal membrane oxygenation (2.2% and 2.9%). Four children with influenza (2.2%) and 11 children with COVID-19 (2.9%) died. The odds of death or requiring life support in children with influenza vs COVID-19 were similar (adjusted odds ratio, 1.30; 95% confidence interval, .78-2.15; P = .32). CONCLUSIONS Despite differences in demographics and clinical characteristics of children with influenza or COVID-19, the frequency of life-threatening complications was similar. Our findings highlight the importance of implementing prevention measures to reduce transmission and disease severity of influenza and COVID-19.
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Affiliation(s)
- Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Samantha M Olson
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Justin Z Amarin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kristin L Moffitt
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mari M Nakamura
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA,Antimicrobial Stewardship Program, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijaya L Soma
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children’s Hospital, New York, New York, USA
| | - Rana Talj
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
| | - Bria M Coates
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Stephanie P Schwartz
- Department of Pediatrics, Division of Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County (CHOC), Orange, California, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St. Louis, Missouri, USA
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Charlotte V Hobbs
- Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children’s Hospital, Akron, Ohio, USA
| | | | - Cindy Bowens
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children’s Medical Center, Dallas, Texas, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children’s Hospital and University of Michigan, Ann Arbor, Michigan, USA
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Matt S Zinter
- Department of Pediatrics, Division of Critical Care, University of California–San Francisco, San Francisco, California, USA
| | - John S Giuliano
- Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, University of California–San Francisco Benioff Children’s Hospital Oakland, Oakland, California, USA
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Hillary A Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children’s Hospital, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children’s Hospital and Medical Center, Omaha, Nebraska, USA
| | | | - Adrienne G Randolph
- Correspondence: Adrienne G. Randolph, Boston Children’s Hospital, 300 Longwood Avenue Bader 634, Boston, MA, USA 02115 ()
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16
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Ross CE, Burns JP, Grossestreuer AV, Bhattarai P, McKiernan CA, Franks JD, Lehmann S, Sorcher JL, Sharron MP, Wai K, Al-Wahab H, Boukas K, Hall MW, Ru G, Sen AI, Rajasekhar HR, Kleinman LC, McGuire JK, Arrington AS, Munoz-Rivas F, Osborne CM, Shekerdemian LS. Trends in Disease Severity Among Critically Ill Children With Severe Acute Respiratory Syndrome Coronavirus 2: A Retrospective Multicenter Cohort Study in the United States. Pediatr Crit Care Med 2023; 24:25-33. [PMID: 36516349 PMCID: PMC9798852 DOI: 10.1097/pcc.0000000000003105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe trends in critical illness from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children over the course of the COVID-19 pandemic. We hypothesized that PICU admission rates were higher in the Omicron period compared with the original outbreak but that fewer patients needed endotracheal intubation. DESIGN Retrospective cohort study. SETTING This study took place in nine U.S. PICUs over 3 weeks in January 2022 (Omicron period) compared with 3 weeks in March 2020 (original period). PATIENTS Patients less than or equal to 21 years old who screened positive for SARS-CoV-2 infection by polymerase chain reaction or hospital-based rapid antigen test and were admitted to a PICU or intermediate care unit were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 267 patients (239 Omicron and 28 original) were reviewed. Forty-five patients in the Omicron cohort had incidental SARS-CoV-2 and were excluded from analysis. The Omicron cohort patients were younger compared with the original cohort patients (median [interquartile range], 6 yr [1.3-13.3 yr] vs 14 yr [8.3-17.3 yr]; p = 0.001). The Omicron period, compared with the original period, was associated with an average increase in COVID-19-related PICU admissions of 13 patients per institution (95% CI, 6-36; p = 0.008), which represents a seven-fold increase in the absolute number admissions. We failed to identify an association between cohort period (Omicron vs original) and odds of intubation (odds ratio, 0.7; 95% CI, 0.3-1.7). However, we cannot exclude the possibility of up to 70% reduction in intubation. CONCLUSIONS COVID-19-related PICU admissions were seven times higher in the Omicron wave compared with the original outbreak. We could not exclude the possibility of up to 70% reduction in use of intubation in the Omicron versus original epoch, which may represent differences in PICU/hospital admission policy in the later period, or pattern of disease, or possibly the impact of vaccination.
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Affiliation(s)
- Catherine E Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey P Burns
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Anne V Grossestreuer
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Pallav Bhattarai
- Division of Pediatric Critical Care, Department of Pediatrics, Baystate Children's Hospital, UMass Chan Medical School Baystate, Springfield, MA
| | - Christine A McKiernan
- Division of Pediatric Critical Care, Department of Pediatrics, Baystate Children's Hospital, UMass Chan Medical School Baystate, Springfield, MA
| | - Jennifer D Franks
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
- College of the Holy Cross, Worcester, MA
| | | | - Jill L Sorcher
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matthew P Sharron
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Kitman Wai
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Haitham Al-Wahab
- Division of Critical Care Medicine, Department of Pediatrics, Children's Memorial Hermann Hospital, The University of Texas Health Science Center at Houston, Houston, TX
| | - Konstantinos Boukas
- Division of Critical Care Medicine, Department of Pediatrics, Children's Memorial Hermann Hospital, The University of Texas Health Science Center at Houston, Houston, TX
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - George Ru
- Division of Pediatric Critical Care and Hospitalist Medicine, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Anita I Sen
- Division of Pediatric Critical Care and Hospitalist Medicine, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Hariprem R Rajasekhar
- Division of Pediatric Critical Care, Department of Pediatrics, Bristol-Myers Squibb Children's Hospital, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Lawrence C Kleinman
- Division of Population Health, Quality, and Implementation Science, Department of Pediatrics, Bristol-Myers Squibb Children's Hospital, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - John K McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Amy S Arrington
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Flor Munoz-Rivas
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Christopher M Osborne
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lara S Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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17
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LaRovere KL, Poussaint TY, Young CC, Newhams MM, Kucukak S, Irby K, Kong M, Schwartz SP, Walker TC, Bembea MM, Wellnitz K, Havlin KM, Cvijanovich NZ, Hall MW, Fitzgerald JC, Schuster JE, Hobbs CV, Halasa NB, Singh AR, Mack EH, Bradford TT, Gertz SJ, Schwarz AJ, Typpo KV, Loftis LL, Giuliano JS, Horwitz SM, Biagas KV, Clouser KN, Rowan CM, Maddux AB, Soma VL, Babbitt CJ, Aguiar CL, Kolmar AR, Heidemann SM, Harvey H, Zambrano LD, Campbell AP, Randolph AG. Changes in Distribution of Severe Neurologic Involvement in US Pediatric Inpatients With COVID-19 or Multisystem Inflammatory Syndrome in Children in 2021 vs 2020. JAMA Neurol 2023; 80:91-98. [PMID: 36342679 PMCID: PMC9641594 DOI: 10.1001/jamaneurol.2022.3881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022]
Abstract
Importance In 2020 during the COVID-19 pandemic, neurologic involvement was common in children and adolescents hospitalized in the United States for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related complications. Objective To provide an update on the spectrum of SARS-CoV-2-related neurologic involvement among children and adolescents in 2021. Design, Setting, and Participants Case series investigation of patients reported to public health surveillance hospitalized with SARS-CoV-2-related illness between December 15, 2020, and December 31, 2021, in 55 US hospitals in 31 states with follow-up at hospital discharge. A total of 2253 patients were enrolled during the investigation period. Patients suspected of having multisystem inflammatory syndrome in children (MIS-C) who did not meet criteria (n = 85) were excluded. Patients (<21 years) with positive SARS-CoV-2 test results (reverse transcriptase-polymerase chain reaction and/or antibody) meeting criteria for MIS-C or acute COVID-19 were included in the analysis. Exposure SARS-CoV-2 infection. Main Outcomes and Measures Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening neurologic involvement was adjudicated by experts based on clinical and/or neuroradiological features. Type and severity of neurologic involvement, laboratory and imaging data, vaccination status, and hospital discharge outcomes (death or survival with new neurologic deficits). Results Of 2168 patients included (58% male; median age, 10.3 years), 1435 (66%) met criteria for MIS-C, and 476 (22%) had documented neurologic involvement. Patients with neurologic involvement vs without were older (median age, 12 vs 10 years) and more frequently had underlying neurologic disorders (107 of 476 [22%] vs 240 of 1692 [14%]). Among those with neurologic involvement, 42 (9%) developed acute SARS-CoV-2-related life-threatening conditions, including central nervous system infection/demyelination (n = 23; 15 with possible/confirmed encephalitis, 6 meningitis, 1 transverse myelitis, 1 nonhemorrhagic leukoencephalopathy), stroke (n = 11), severe encephalopathy (n = 5), acute fulminant cerebral edema (n = 2), and Guillain-Barré syndrome (n = 1). Ten of 42 (24%) survived with new neurologic deficits at discharge and 8 (19%) died. Among patients with life-threatening neurologic conditions, 15 of 16 vaccine-eligible patients (94%) were unvaccinated. Conclusions and Relevance SARS-CoV-2-related neurologic involvement persisted in US children and adolescents hospitalized for COVID-19 or MIS-C in 2021 and was again mostly transient. Central nervous system infection/demyelination accounted for a higher proportion of life-threatening conditions, and most vaccine-eligible patients were unvaccinated. COVID-19 vaccination may prevent some SARS-CoV-2-related neurologic complications and merits further study.
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Affiliation(s)
- Kerri L. LaRovere
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Tina Y. Poussaint
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Cameron C. Young
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Margaret M. Newhams
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Suden Kucukak
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Stephanie P. Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital, Chapel Hill
| | - Tracie C. Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital, Chapel Hill
| | - Melania M. Bembea
- Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City
| | - Kevin M. Havlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children’s Hospital, Louisville, Kentucky
| | - Natalie Z. Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital, Oakland, California
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Charlotte V. Hobbs
- Division of Infectious Diseases, Departments of Pediatrics and Microbiology, University of Mississippi Medical Center, Jackson
| | - Natasha B. Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center, New York Medical College, Valhalla
| | - Elizabeth H. Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Tamara T. Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center, Children’s Hospital of New Orleans, New Orleans
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, New Jersey
| | - Adam J. Schwarz
- Division of Critical Care Medicine, Children’s Health Orange County (CHOC), Orange, California
| | - Katri V. Typpo
- Department of Pediatrics and Banner Children’s at Diamond Children’s Medical Center, University of Arizona, Tucson
| | - Laura L. Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Houston
| | - John S. Giuliano
- Division of Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Steven M. Horwitz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Katherine V. Biagas
- Department of Pediatrics, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Katharine N. Clouser
- Department of Pediatrics, Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack, New Jersey
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Aline B. Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Vijaya L. Soma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | | | - Cassyanne L. Aguiar
- Division of Pediatric Rheumatology, Department of Pediatrics, Eastern Virginia Medical School, Children’s Hospital of The King’s Daughters, Norfolk
| | - Amanda R. Kolmar
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sabrina M. Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit
| | - Helen Harvey
- Division of Pediatric Critical Care, Rady Children’s Hospital, San Diego, California
| | - Laura D. Zambrano
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Angela P. Campbell
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adrienne G. Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
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18
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Lee S, Zhang Y, Newhams M, Novak T, Thomas PG, Mourani PM, Hall MW, Loftis LL, Cvijanovich NZ, Tarquinio KM, Schwarz AJ, Weiss SL, Thomas NJ, Markovitz B, Cullimore ML, Sanders RC, Zinter MS, Sullivan JE, Halasa NB, Bembea MM, Giuliano JS, Typpo KV, Nofziger RA, Shein SL, Kong M, Coates BM, Weiss ST, Lange C, Su HC, Randolph AG. DDX58 Is Associated With Susceptibility to Severe Influenza Virus Infection in Children and Adolescents. J Infect Dis 2022; 226:2030-2036. [PMID: 35986912 PMCID: PMC10205622 DOI: 10.1093/infdis/jiac350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Seasonal influenza virus infection causes a range of disease severity, including lower respiratory tract infection with respiratory failure. We evaluated the association of common variants in interferon (IFN) regulatory genes with susceptibility to critical influenza infection in children. METHODS We performed targeted sequencing of 69 influenza-associated candidate genes in 348 children from 24 US centers admitted to the intensive care unit with influenza infection and lacking risk factors for severe influenza infection (PICFlu cohort, 59.4% male). As controls, whole genome sequencing from 675 children with asthma (CAMP cohort, 62.5% male) was compared. We assessed functional relevance using PICFlu whole blood gene expression levels for the gene and calculated IFN gene signature score. RESULTS Common variants in DDX58, encoding the retinoic acid-inducible gene I (RIG-I) receptor, demonstrated association above or around the Bonferroni-corrected threshold (synonymous variant rs3205166; intronic variant rs4487862). The intronic single-nucleotide polymorphism rs4487862 minor allele was associated with decreased DDX58 expression and IFN signature (P < .05 and P = .0009, respectively) which provided evidence supporting the genetic variants' impact on RIG-I and IFN immunity. CONCLUSIONS We provide evidence associating common gene variants in DDX58 with susceptibility to severe influenza infection in children. RIG-I may be essential for preventing life-threatening influenza-associated disease.
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Affiliation(s)
- Sanghun Lee
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- Department of Medical Consilience, Graduate School, Dankook University, Yongin-si, South Korea
| | - Yu Zhang
- Laboratory of Clinical Immunology and Microbiology, Intramural Research Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Tanya Novak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul G Thomas
- Department of Immunology, St Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, California, USA
| | - Keiko M Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Adam J Schwarz
- Department of Pediatrics, Children’s Hospital of Orange County, Orange, California, USA
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children’s Hospital, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Barry Markovitz
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - Matt S Zinter
- Divisions of Critical Care Medicine and Allergy, Immunology, and Bone Marrow Transplant, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Janice E Sullivan
- Division of Pediatric Critical Care, University of Louisville School of Medicine and Norton Children’s Hospital, Louisville, Kentucky, USA
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John S Giuliano
- Division of Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Katri V Typpo
- Department of Pediatrics, Steele Children’s Research Center, University of Arizona, Tucson, Arizona, USA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio, USA
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott T Weiss
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Lange
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Helen C Su
- Laboratory of Clinical Immunology and Microbiology, Intramural Research Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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19
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Zambrano LD, Ly KN, Link-Gelles R, Newhams MM, Akande M, Wu MJ, Feldstein LR, Tarquinio KM, Sahni LC, Riggs BJ, Singh AR, Fitzgerald JC, Schuster JE, Giuliano JS, Englund JA, Hume JR, Hall MW, Osborne CM, Doymaz S, Rowan CM, Babbitt CJ, Clouser KN, Horwitz SM, Chou J, Patel MM, Hobbs C, Randolph AG, Campbell AP. Investigating Health Disparities Associated With Multisystem Inflammatory Syndrome in Children After SARS-CoV-2 Infection. Pediatr Infect Dis J 2022; 41:891-898. [PMID: 36102740 PMCID: PMC9555608 DOI: 10.1097/inf.0000000000003689] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a postinfectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related complication that has disproportionately affected racial/ethnic minority children. We conducted a pilot study to investigate risk factors for MIS-C aiming to understand MIS-C disparities. METHODS This case-control study included MIS-C cases and SARS-CoV-2-positive outpatient controls less than 18 years old frequency-matched 4:1 to cases by age group and site. Patients hospitalized with MIS-C were admitted between March 16 and October 2, 2020, across 17 pediatric hospitals. We evaluated race, ethnicity, social vulnerability index (SVI), insurance status, weight-for-age and underlying medical conditions as risk factors using mixed effects multivariable logistic regression. RESULTS We compared 241 MIS-C cases with 817 outpatient SARS-CoV-2-positive at-risk controls. Cases and controls had similar sex, age and U.S. census region distribution. MIS-C patients were more frequently previously healthy, non-Hispanic Black, residing in higher SVI areas, and in the 95th percentile or higher for weight-for-age. In the multivariable analysis, the likelihood of MIS-C was higher among non-Hispanic Black children [adjusted odds ratio (aOR): 2.07; 95% CI: 1.23-3.48]. Additionally, SVI in the 2nd and 3rd tertiles (aOR: 1.88; 95% CI: 1.18-2.97 and aOR: 2.03; 95% CI: 1.19-3.47, respectively) were independent factors along with being previously healthy (aOR: 1.64; 95% CI: 1.18-2.28). CONCLUSIONS In this study, non-Hispanic Black children were more likely to develop MIS-C after adjustment for sociodemographic factors, underlying medical conditions, and weight-for-age. Investigation of the potential contribution of immunologic, environmental, and other factors is warranted.
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Affiliation(s)
- Laura D. Zambrano
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kathleen N. Ly
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ruth Link-Gelles
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Margaret M. Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Manzilat Akande
- Department of Pediatrics-Section of Critical Care, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Michael J. Wu
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Leora R. Feldstein
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Leila C. Sahni
- Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Immunization Project, Houston, Texas
| | - Becky J. Riggs
- Department of Anesthesiology and Critical Care Medicine; Division of Pediatric Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - John S. Giuliano
- Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut
| | - Janet A. Englund
- Department of Pediatrics, School of Medicine, Seattle Children’s Research Institute, University of Washington, Seattle, Washington
| | - Janet R. Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Christina M. Osborne
- Department of Pediatrics, Sections of Critical Care Medicine and Infectious Diseases, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Christopher J. Babbitt
- Division of Pediatric Critical Care Medicine, Miller Children’s and Women’s Hospital of Long Beach, Long Beach, California
| | - Katharine N. Clouser
- Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Steven M. Horwitz
- Department of Pediatrics, Division of Critical Care, Bristol-Myers Squibb Children’s Hospital, New Brunswick, New Jersey
| | - Janet Chou
- Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Departments of
| | - Manish M. Patel
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Charlotte Hobbs
- Pediatrics
- Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Departments of
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Angela P. Campbell
- From the COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
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20
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Salud D, Reeder RW, Banks RK, Meert KL, Berg RA, Zuppa A, Newth CJ, Hall MW, Quasney M, Sapru A, Carcillo JA, McQuillen PS, Mourani PM, Varni JW, Zimmerman JJ. Association of Pathogen Type With Outcomes of Children Encountering Community-Acquired Pediatric Septic Shock. Pediatr Crit Care Med 2022; 23:635-645. [PMID: 35687094 PMCID: PMC9529775 DOI: 10.1097/pcc.0000000000003001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the association of pathogen type with mortality, functional status, and health-related quality of life (HRQL) among children at hospital discharge/1 month following hospitalization for septic shock. DESIGN Secondary database analysis of a prospective, descriptive cohort investigation. SETTING Twelve academic PICUs in the United States. PATIENTS Critically ill children, 1 month to 18 years old, enrolled from 2013 to 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Association of clinical outcomes with pathogen type was assessed for all patients and separately for surviving patients enrolled in the primary Life After Pediatric Sepsis Evaluation (LAPSE) investigation. For this secondary analysis, we predicted that age would be associated with pathogen type and outcomes, and accordingly, it was incorporated as a confounding variable in primary analyses. Among 389 children enrolled with septic shock, at 1 month/hospital discharge, we observed no statistically significant differences in relation to pathogen types for the composite outcome mortality or substantial new functional morbidity: no causative organism identified (27% [28/103]), pure viral infections (26% [24/91]), pure bacterial/fungal infections (25% [31/125]), and bacterial/fungal+viral coinfections (33% [23/70]). Similarly, we observed no statistically significant differences in relation to pathogen types for the composite outcome, mortality, or persistent serious deterioration of HRQL: no causative organism identified (43% [44/103]), pure viral infections (33% [30/91]), pure bacterial/fungal infections (46% [57/125]), and bacterial/fungal+viral coinfections (43% [30/70]). However, we did identify statistically significant associations between pathogen type and the outcome ventilator-free days ( p = 0.0083) and PICU-free days (0.0238). CONCLUSIONS This secondary analysis of the LAPSE database identified no statistically significant association of pathogen type with composite mortality and morbidity outcomes. However, pathogen type may be associated with PICU resources employed to treat sepsis organ dysfunction. Ultimately, pediatric septic shock was frequently associated with adverse patient-centered, clinically meaningful outcomes regardless of infectious disease pathogen type.
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Affiliation(s)
- Derek Salud
- Touro College of Osteopathic Medicine, New York, NY
| | | | | | - Kathleen L Meert
- Children’s Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI
| | - Robert A Berg
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Athena Zuppa
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Mark W Hall
- Nationwide Children’s Hospital, Columbus, OH
| | - Michael Quasney
- CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A Carcillo
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | | | | | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
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21
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Britto C, Mohorianu I, Yeung T, Cheung E, Novak T, Hall MW, Mourani PM, Weiss SL, Thomas NJ, Markovitz B, Randolph AG, Moffitt KL. Host respiratory transcriptome signature associated with poor outcome in children with influenza-Staphylococcus aureus pneumonia. J Infect Dis 2022; 226:1286-1294. [PMID: 35899844 DOI: 10.1093/infdis/jiac325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/25/2022] [Indexed: 11/14/2022] Open
Abstract
Respiratory coinfection of influenza with Staphylococcus aureus often causes severe disease; methicillin resistant S. aureus (MRSA) coinfection is frequently fatal. Understanding disease pathogenesis may inform therapies. We aimed to identify host and pathogen transcriptomic (mRNA) signatures from the respiratory compartment of patients with influenza-S. aureus coinfection (ISAC) critical illness that predict worse outcomes. mRNA extracted from endotracheal aspirates was evaluated for S. aureus and host transcriptomic biosignatures. Influenza-MRSA outcomes were worse, but of 190 S. aureus virulence-associated genes, 6 were differentially expressed between MRSA- versus methicillin-susceptible S. aureus coinfected patients and none discriminated outcome. Host gene expression in ISAC patients was compared to influenza infection alone. Patients with poor clinical outcomes (death or prolonged multi-organ dysfunction) had relatively reduced expression of interferons and down-regulation of interferon gamma-induced immune cell chemoattractants CXCL10 and CXCL11. In influenza-S. aureus respiratory coinfection, airway host but not pathogen gene expression profiles predicted worse clinical outcomes.
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Affiliation(s)
- Carl Britto
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Oxford Vaccine Group, Department of Paediatrics, University of Oxford, UK.,Division of Infectious Disease, St. John's Research Institute, Bengaluru, India
| | - Irina Mohorianu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, UK.,Wellcome-MRC Cambridge, Stem Cell Institute, University of Cambridge, UK
| | - Tracy Yeung
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Elaine Cheung
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Tanya Novak
- Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Peter M Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA, USA
| | - Barry Markovitz
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Adrienne G Randolph
- Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesia, Harvard Medical School, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kristin L Moffitt
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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22
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Ames SG, Banks RK, Zinter MS, Fink EL, McQuillen PS, Hall MW, Zuppa A, Meert KL, Mourani PM, Carcillo JA, Carpenter T, Pollack MM, Berg RA, Mareboina M, Holubkov R, Dean JM, Notterman DA, Sapru A. Assessment of Patient Health-Related Quality of Life and Functional Outcomes in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2022; 23:e319-e328. [PMID: 35452018 DOI: 10.1097/pcc.0000000000002959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe health-related quality of life (HRQL) and functional outcomes in pediatric acute respiratory distress syndrome (ARDS) and to determine risk factors associated with poor outcome defined as death or severe reduction in HRQL at 28 days or ICU discharge. DESIGN Prospective multisite cohort-outcome study conducted between 2019 and 2020. SETTING Eight academic PICUs in the United States. PATIENTS Children with ARDS based on standard criteria. INTERVENTIONS Patient characteristics and illness severity were collected during PICU admission. Parent proxy-report measurements were obtained at baseline, day 28/ICU discharge, month 3, and month 9, utilizing Pediatric Quality of Life Inventory and Functional Status Scale (FSS). A composite outcome evaluated using univariate and multivariate analysis was death or severe reduction in HRQL (>25% reduction in the Pediatric Quality of Life Inventory at day 28/ICU discharge. MEASUREMENTS AND MAIN RESULTS This study enrolled 122 patients with a median age of 3 years (interquartile range, 1-12 yr). Common etiologies of ARDS included pneumonia ( n = 63; 52%) and sepsis ( n = 27; 22%). At day 28/ICU discharge, half (50/95; 53%) of surviving patients with follow-up data reported a greater than 10% decrease in HRQL from baseline, and approximately one-third of participants ( n = 19/61; 31%) reported a greater than 10% decrease in HRQL at 9 months. Trends in FSS were similar. Of 104 patients with data, 47 patients (45%) died or reported a severe decrease of greater than 25% in HRQL at day 28/ICU discharge. Older age was associated with an increased risk of death or severe reduction in HRQL (odds ratio, 1.08; CI, 1.01-1.16). CONCLUSIONS Children with ARDS are at risk for deterioration in HRQL and FSS that persists up to 9 months after ARDS. Almost half of children with ARDS experience a poor outcome including death or severe reduction in HRQL at day 28/ICU discharge.
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Affiliation(s)
| | | | - Matt S Zinter
- Benioff Children's Hospital, University of California-San Francisco, San Francisco, CA
| | - Ericka L Fink
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Benioff Children's Hospital, University of California-San Francisco, San Francisco, CA
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Joseph A Carcillo
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Manvita Mareboina
- Mattel Children's Hospital, University of California-Los Angeles, Los Angeles, CA
| | | | | | | | - Anil Sapru
- Mattel Children's Hospital, University of California-Los Angeles, Los Angeles, CA
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23
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Schuster JE, Halasa NB, Nakamura M, Levy ER, Fitzgerald JC, Young CC, Newhams MM, Bourgeois F, Staat MA, Hobbs CV, Dapul H, Feldstein LR, Jackson AM, Mack EH, Walker TC, Maddux AB, Spinella PC, Loftis LL, Kong M, Rowan CM, Bembea MM, McLaughlin GE, Hall MW, Babbitt CJ, Maamari M, Zinter MS, Cvijanovich NZ, Michelson KN, Gertz SJ, Carroll CL, Thomas NJ, Giuliano JS, Singh AR, Hymes SR, Schwarz AJ, McGuire JK, Nofziger RA, Flori HR, Clouser KN, Wellnitz K, Cullimore ML, Hume JR, Patel M, Randolph AG. A Description of COVID-19-Directed Therapy in Children Admitted to US Intensive Care Units 2020. J Pediatric Infect Dis Soc 2022; 11:191-198. [PMID: 35022779 PMCID: PMC8807297 DOI: 10.1093/jpids/piab123] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is unclear how acute coronavirus disease 2019 (COVID-19)-directed therapies are used in children with life-threatening COVID-19 in US hospitals. We described characteristics of children hospitalized in the intensive care unit or step-down unit (ICU/SDU) who received COVID-19-directed therapies and the specific therapies administered. METHODS Between March 15, 2020 and December 27, 2020, children <18 years of age in the ICU/SDU with acute COVID-19 at 48 pediatric hospitals in the United States were identified. Demographics, laboratory values, and clinical course were compared in children who did and did not receive COVID-19-directed therapies. Trends in COVID-19-directed therapies over time were evaluated. RESULTS Of 424 children in the ICU/SDU, 235 (55%) received COVID-19-directed therapies. Children who received COVID-19-directed therapies were older than those who did not receive COVID-19-directed therapies (13.3 [5.6-16.2] vs 9.8 [0.65-15.9] years), more had underlying medical conditions (188 [80%] vs 104 [55%]; difference = 25% [95% CI: 16% to 34%]), more received respiratory support (206 [88%] vs 71 [38%]; difference = 50% [95% CI: 34% to 56%]), and more died (8 [3.4%] vs 0). Of the 235 children receiving COVID-19-directed therapies, 172 (73%) received systemic steroids and 150 (64%) received remdesivir, with rising remdesivir use over the study period (14% in March/April to 57% November/December). CONCLUSION Despite the lack of pediatric data evaluating treatments for COVID-19 in critically ill children, more than half of children requiring intensive or high acuity care received COVID-19-directed therapies.
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Affiliation(s)
- Jennifer E Schuster
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri, USA
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mari Nakamura
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Antimicrobial Stewardship Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Florence Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Charlotte V Hobbs
- Division of Disease, Departments of Pediatrics and Microbiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine and Hassenfeld Children’s Hospital, New York, New York, USA
| | - Leora R Feldstein
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ashley M Jackson
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tracie C Walker
- Department of Pediatrics, Division of Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St. Louis, Missouri, USA
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Christopher J Babbitt
- Division of Pediatric Critical Care, Department of Pediatrics, Miller Children’s and Women’s Hospital of Long Beach, Long Beach, California, USA
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children’s Health Medical Center, Dallas, Texas, USA
| | - Matt S Zinter
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, California, USA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, California, USA
| | - Kelly N Michelson
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Christopher L Carroll
- Division of Critical Care, Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children’s Hospital, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - John S Giuliano
- Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Saul R Hymes
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stony Brook Children’s Hospital, Stony Brook, New York, USA
| | - Adam J Schwarz
- Division of Critical Care Medicine, CHOC Children’s Hospital, Orange, California, USA
| | - John K McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital and the University of Washington, Seattle, Washington, USA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children’s Hospital, Akron, Ohio, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children’s Hospital and University of Michigan, Ann Arbor, Michigan, USA
| | - Katharine N Clouser
- Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children’s Hospital and Medical Center, Omaha, Nebraska, USA
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Manish Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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24
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Yates AR, Berger JT, Reeder RW, Banks R, Mourani PM, Berg RA, Carcillo JA, Carpenter T, Hall MW, Meert KL, McQuillen PS, Pollack MM, Sapru A, Notterman DA, Holubkov R, Dean JM, Wessel DL. Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients. Pediatr Crit Care Med 2022; 23:245-254. [PMID: 35200229 PMCID: PMC9058189 DOI: 10.1097/pcc.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery. DESIGN Observational cohort study. SETTING PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals. PATIENTS Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days. CONCLUSIONS Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.
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Affiliation(s)
- Andrew R. Yates
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | | | | | | | - Peter M. Mourani
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Robert A. Berg
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Todd Carpenter
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark W. Hall
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Kathleen L. Meert
- Children’s Hospital of Michigan, Detroit, Michigan; Central Michigan University, Mt. Pleasant, MI
| | | | | | - Anil Sapru
- Mattel Children’s Hospital, Los Angeles, CA
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25
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Hobbs CV, Woodworth K, Young CC, Jackson AM, Newhams MM, Dapul H, Maamari M, Hall MW, Maddux AB, Singh AR, Schuster JE, Rowan CM, Fitzgerald JC, Irby K, Kong M, Mack EH, Staat MA, Cvijanovich NZ, Bembea MM, Coates BM, Halasa NB, Walker TC, McLaughlin GE, Babbitt CJ, Nofziger RA, Loftis LL, Bradford TT, Campbell AP, Patel MM, Randolph AG. Frequency, Characteristics and Complications of COVID-19 in Hospitalized Infants. Pediatr Infect Dis J 2022; 41:e81-e86. [PMID: 34955519 PMCID: PMC8828316 DOI: 10.1097/inf.0000000000003435] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies of severe acute respiratory syndrome coronavirus 2 infection in infants have incompletely characterized factors associated with severe illness or focused on infants born to mothers with coronavirus disease 2019 (COVID-19). Here we highlight demographics, clinical characteristics and laboratory values that differ between infants with and without severe acute COVID-19. METHODS Active surveillance was performed by the Overcoming COVID-19 network to identify children and adolescents with severe acute respiratory syndrome coronavirus 2-related illness hospitalized at 62 sites in 31 states from March 15 to December 27, 2020. We analyzed patients >7 days to <1 year old hospitalized with symptomatic acute COVID-19. RESULTS We report 232 infants >7 days to <1 year of age hospitalized with acute symptomatic COVID-19 from 37 US hospitals in our cohort from March 15 to December 27, 2020. Among 630 cases of severe COVID-19 in patients >7 days to <18 years old, 128 (20.3%) were infants. In infants with severe illness from the entire study period, the median age was 2 months, 66% were from racial and ethnic minority groups, 66% were previously healthy, 73% had respiratory complications, 13% received mechanical ventilation and <1% died. CONCLUSIONS Infants accounted for over a fifth of children <18 years of age hospitalized for severe acute COVID-19, commonly manifesting with respiratory symptoms and complications. Although most infants hospitalized with COVID-19 did not suffer significant complications, longer term outcomes remain unclear. Notably, 75% of infants with severe disease were <6 months of age in this cohort study period, which predated maternal COVID-19 vaccination, underscoring the importance of maternal vaccination for COVID-19 in protecting the mother and infant.
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Affiliation(s)
- Charlotte V. Hobbs
- From the Department of Pediatrics, Division of Disease, Microbiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Kate Woodworth
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cameron C. Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Ashley M. Jackson
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Margaret M. Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Heda Dapul
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children’s Hospital, New York, New York
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children’s Medical Center Dallas, Texas
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth H. Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mary A. Staat
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Natalie Z. Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital Oakland, California
| | - Melania M. Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bria M. Coates
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Natasha B. Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tracie C. Walker
- Department of Pediatrics, Division of Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gwenn E. McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Christopher J. Babbitt
- Division of Pediatric Critical Care, Department of Pediatrics, Miller Children’s and Women’s Hospital of Long Beach, Long Beach, California
| | - Ryan A. Nofziger
- Division of Critical Care Medicine, Akron Children’s Hospital, Akron, Ohio
| | - Laura L. Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas
| | - Tamara T. Bradford
- Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children’s Hospital of New Orleans, New Orleans, Louisiana
| | - Angela P. Campbell
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manish M. Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adrienne G. Randolph
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children’s Hospital, New York, New York
- Department of Anaesthesia
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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26
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Gillespie SL, Christian LM, Mackos AR, Nolan TS, Gondwe KW, Anderson CM, Hall MW, Williams KP, Slavich GM. Lifetime stressor exposure, systemic inflammation during pregnancy, and preterm birth among Black American women. Brain Behav Immun 2022; 101:266-274. [PMID: 35031400 PMCID: PMC8885874 DOI: 10.1016/j.bbi.2022.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 01/07/2023] Open
Abstract
Although Black American mothers and infants are at higher risk for morbidity and mortality than their White counterparts, the biological mechanisms underlying these phenomena remain largely unknown. To investigate the role that lifetime stressor exposure, perceived stressor severity, and systemic inflammatory markers might play, we studied how these factors were interrelated in 92 pregnant Black American women. We also compared inflammatory marker levels for women who did versus did not go on to give birth preterm. During the early third trimester, women completed the Stress and Adversity Inventory for Adults to assess the stressors they experienced over their lifetime. Women also provided blood samples for plasma interleukin (IL)-6, IL-8, IL-1β, and tumor necrosis factor (TNF)-α quantification. Preterm births were identified by medical record review. Controlling for relevant covariates, there were significant positive associations between average levels of both overall and acute perceived stressor severity and plasma IL-1β levels. Controlling for perceived stress at assessment and exposure to racial discrimination did not affect these results. Mediation models revealed that exposure to more chronic stressors was related to higher plasma IL-1β levels, as mediated by higher average levels of overall perceived stressor severity. Exposure to fewer acute stressors was related to higher plasma IL-1β levels, as mediated by higher average levels of acute perceived stressor severity. Finally, women who went on to give birth preterm had higher levels of plasma IL-6. These data thus highlight the potential importance of assessing and addressing lifetime stressor exposure among mothers before and during maternal-infant care.
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Affiliation(s)
- Shannon L. Gillespie
- College of Nursing, The Ohio State University, Columbus, OH, USA,Please address correspondence to Shannon L. Gillespie, 358 Newton Hall, 1585 Neil Avenue, Columbus, OH, USA; 1-614-292-4589 Office;
| | - Lisa M. Christian
- Department of Psychiatry and Behavioral Health, College of Medicine, The Ohio State University, Columbus, OH, USA,Institute for Behavioral Medicine Research, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Amy R. Mackos
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Timiya S. Nolan
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Kaboni W. Gondwe
- College of Nursing, University of Wisconsin, Milwaukee, WI, USA,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA,Department of Nursing Research & Evidence-based Practice, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | | | - Mark W. Hall
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA,Research Institute, Nationwide Children’s Hospital, Columbus, OH, USA
| | | | - George M. Slavich
- Cousins Center for Psychoneuroimmunology and Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, CA, USA
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27
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Tsitsiklis A, Osborne CM, Kamm J, Williamson K, Kalantar K, Dudas G, Caldera S, Lyden A, Tan M, Neff N, Soesanto V, Harris JK, Ambroggio L, Maddux AB, Carpenter TC, Reeder RW, Locandro C, Simões EAF, Leroue MK, Hall MW, Zuppa AF, Carcillo J, Meert KL, Sapru A, Pollack MM, McQuillen PS, Notterman DA, Dean JM, Zinter MS, Wagner BD, DeRisi JL, Mourani PM, Langelier CR. Lower respiratory tract infections in children requiring mechanical ventilation: a multicentre prospective surveillance study incorporating airway metagenomics. The Lancet Microbe 2022; 3:e284-e293. [PMID: 35544065 PMCID: PMC9446282 DOI: 10.1016/s2666-5247(21)00304-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alexandra Tsitsiklis
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Christina M Osborne
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | | | - Gytis Dudas
- Gothenburg Global Biodiversity Centre, Gothenburg, Sweden
| | - Saharai Caldera
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | | | - Norma Neff
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Todd C Carpenter
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chris Locandro
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric A F Simões
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew K Leroue
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Mark W Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Anil Sapru
- Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital and George Washington School of Medicine and Health Services, Washington, DC, USA
| | - Patrick S McQuillen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Matt S Zinter
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Charles R Langelier
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA.
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28
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Notterman DA, Colville G, Meert KL. Post-Traumatic Growth in Parents following Their Child's Death in a Pediatric Intensive Care Unit. J Palliat Med 2022; 25:265-273. [PMID: 34612728 PMCID: PMC8861930 DOI: 10.1089/jpm.2021.0290] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Although bereaved parents suffer greatly, some may experience positive change referred to as post-traumatic growth. Objective: Explore the extent to which parents perceive post-traumatic growth after their child's death in a pediatric intensive care unit (PICU), and associated factors. Design: Longitudinal parent survey conducted 6 and 13 months after a child's death. Surveys included the Post-traumatic Growth Inventory-Short Form (PTGI-SF), a 10-item measure with range of 0-50 where higher scores indicate more post-traumatic growth. Surveys also included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a single item on perceived overall health, and sociodemographics. Setting/Subjects: One hundred fifty-seven parents of 104 children who died in 1 of 8 PICUs affiliated with the U.S. Collaborative Pediatric Critical Care Research Network. Results: Of participating parents, 62.4% were female, 71.6% White, 82.7% married, and 89.2% had at least a high school education. Mean PTGI-SF scores were 27.5 ± 12.52 (range 5-50) at 6 months and 28.6 ± 11.52 (range 2-49) at 13 months (p = 0.181). On multivariate modeling, higher education (compared with those not completing high school) and higher 6-month ICG scores (reflecting more complicated grief symptoms) were associated with lower 13-month PTGI-SF scores (p = 0.005 and 0.033, respectively). Conclusion: Parents bereaved by their child's PICU death perceive a moderate degree of post-traumatic growth in the first 13 months after the death however variability is wide. Education level and complicated grief symptoms may influence parents' perception of post-traumatic growth.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Murray M. Pollack
- Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Peter M. Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, California, USA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Daniel A. Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Gillian Colville
- St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA.,Department of Pediatrics, Central Michigan University, Mt. Pleasant, Michigan, USA.,Address correspondence to: Kathleen L. Meert, MD, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201, USA
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29
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Farhat MH, Shadley JD, Halligan NL, Hall MW, Popova AP, Quasney MW, Dahmer MK. Differences in the Genomic Profiles of Immunoparalyzed and Nonimmunoparalyzed Children With Sepsis: A Pilot Study. Pediatr Crit Care Med 2022; 23:79-88. [PMID: 35119428 PMCID: PMC10993860 DOI: 10.1097/pcc.0000000000002860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Sepsis-induced immunoparalysis represents a pathologic downregulation of leukocyte function shown to be associated with adverse outcomes, although its mechanisms remain poorly understood. Our goal was to compare genome-wide gene expression profiles of immunoparalyzed and nonimmunoparalyzed children with sepsis to identify genes and pathways associated with immunoparalysis. DESIGN Prospective observational study. PATIENTS Twenty-six children with lower respiratory tract infection meeting criteria for sepsis, severe sepsis, or septic shock admitted to the PICU. SETTING Two tertiary care PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Innate immune function was assayed ex vivo by measuring release of tumor necrosis factor-α from whole blood after incubation with lipopolysaccharide for 4 hours. Immunoparalysis was defined as a tumor necrosis factor-α production capacity less than 200 pg/mL. Ten of the 26 children were immunoparalyzed. There were 17 significant differentially expressed genes when comparing genome-wide gene expression profiles of immunoparalyzed and nonimmunoparalyzed children (false discovery rate < 0.05). Nine genes showed increased expression in immunoparalyzed children (+1.5- to +8.8-fold change). Several of these dampen the immune system. Eight showed decreased expression in immunoparalyzed children (-1.7- to -3.9-fold change), several of which are involved in early regulation and activation of immune function. Functional annotation clustering using differentially expressed genes with p value of less than 0.05 showed three clusters related to immunity with significant enrichment scores (2.2-4.5); the most significant gene ontology terms in these clusters were antigen processing and presentation and negative regulation of interleukin-6 production. Network analysis identified potential protein interactions that may be involved in the development of immunoparalysis in children. CONCLUSIONS In this exploratory analysis, immunoparalyzed children with sepsis showed increased expression of genes that dampen the immune system and decreased expression of genes involved in regulation and activation of the immune system. Analysis also implicated other proteins as potentially having as yet unidentified roles in the development of immunoparalysis.
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Affiliation(s)
- Mohamed Hani Farhat
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Jeffery D. Shadley
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Nadine L.N. Halligan
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Antonia P. Popova
- Division of Pulmonology, Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Michael W. Quasney
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Mary K. Dahmer
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
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30
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Abstract
Central nervous system trauma is a common cause of morbidity and mortality. Additionally, these injuries frequently occur in younger individuals, leading to lifetime expenses for patients and caregivers and the loss of opportunity for society. Despite this prevalence and multiple attempts to design a neuroprotectant, clinical trials for a pharmacological agent for the treatment of traumatic brain injury (TBI) or spinal cord injury (SCI) have provided disappointing results. Improvements in outcome from these disease processes in the past decades have been largely due to improvements in supportive care. Among the many challenges facing patients and caregivers following neurotrauma, posttraumatic nosocomial infection is a significant and potentially reversible risk factor. Multiple animal and clinical studies have provided evidence of posttraumatic systemic immune suppression, and injuries involving the CNS may be even more prone, leading to a higher risk for in-hospital infections following neurotrauma. Patients who have experienced neurotrauma with nosocomial infection have poorer recovery and higher risks of long-term morbidity and in-hospital mortality than patients without infection. As such, the etiology and reversal of postneurotrauma immune suppression is an important topic. There are multiple possible etiologies for these posttraumatic changes including the release of damage-associated molecular patterns, the activation of immunosuppressive myeloid-derived suppressor cells, and sympathetic nervous system activation. Postinjury systemic immunosuppression, particularly following neurotrauma, provides a challenge for clinicians but also an opportunity for improvement in outcome. In this review, the authors sought to outline the evidence of postinjury systemic immune suppression in both animal models and clinical research of TBI, TBI polytrauma, and SCI.
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Affiliation(s)
- Eric A Sribnick
- 1Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus.,2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus
| | - Phillip G Popovich
- 3Department of Neuroscience.,4Center for Brain and Spinal Cord Repair.,5Belford Center for Spinal Cord Injury, and.,6Medical Scientist Training Program, The Ohio State University, College of Medicine, Columbus; and
| | - Mark W Hall
- 2The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus.,7Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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31
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Olson SM, Newhams MM, Halasa NB, Feldstein LR, Novak T, Weiss SL, Coates BM, Schuster JE, Schwarz AJ, Maddux AB, Hall MW, Nofziger RA, Flori HR, Gertz SJ, Kong M, Sanders RC, Irby K, Hume JR, Cullimore ML, Shein SL, Thomas NJ, Stewart LS, Barnes JR, Patel MM, Randolph AG. Vaccine Effectiveness Against Life-Threatening Influenza Illness in US Children. Clin Infect Dis 2022; 75:230-238. [PMID: 35024795 DOI: 10.1093/cid/ciab931] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Predominance of 2 antigenically drifted influenza viruses during the 2019-2020 season offered an opportunity to assess vaccine effectiveness against life-threatening pediatric influenza disease from vaccine-mismatched viruses in the United States. METHODS We enrolled children aged <18 years admitted to the intensive care unit with acute respiratory infection across 17 hospitals. Respiratory specimens were tested using reverse-transcription polymerase chain reaction for influenza viruses and sequenced. Using a test-negative design, we estimated vaccine effectiveness comparing odds of vaccination in test-positive case patients vs test-negative controls, stratifying by age, virus type, and severity. Life-threating influenza included death or invasive mechanical ventilation, vasopressors, cardiopulmonary resuscitation, dialysis, or extracorporeal membrane oxygenation. RESULTS We enrolled 159 critically ill influenza case-patients (70% ≤8 years; 51% A/H1N1pdm09 and 25% B-Victoria viruses) and 132 controls (69% were aged ≤8 years). Among 56 sequenced A/H1N1pdm09 viruses, 29 (52%) were vaccine-mismatched (A/H1N1pdm09/5A+156K) and 23 (41%) were vaccine-matched (A/H1N1pdm09/5A+187A,189E). Among sequenced B-lineage viruses, majority (30 of 31) were vaccine-mismatched. Effectiveness against critical influenza was 63% (95% confidence interval [CI], 38% to 78%) and similar by age. Effectiveness was 75% (95% CI, 49% to 88%) against life-threatening influenza vs 57% (95% CI, 24% to 76%) against non-life-threating influenza. Effectiveness was 78% (95% CI, 41% to 92%) against matched A(H1N1)pdm09 viruses, 47% (95% CI, -21% to 77%) against mismatched A(H1N1)pdm09 viruses, and 75% (95% CI, 37% to 90%) against mismatched B-Victoria viruses. CONCLUSIONS During a season when vaccine-mismatched influenza viruses predominated, vaccination was associated with a reduced risk of critical and life-threatening influenza illness in children.
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Affiliation(s)
- Samantha M Olson
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leora R Feldstein
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tanya Novak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Adam J Schwarz
- Department of Pediatrics, Children's Hospital of Orange County, Orange, California, USA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan, USA
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Laura S Stewart
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John R Barnes
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Manish M Patel
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Hall MW, Carcillo JA, Cornell T. Immune System Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S91-S98. [PMID: 34970674 PMCID: PMC9166150 DOI: 10.1542/peds.2021-052888n] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Immune system dysfunction is poorly represented in pediatric organ dysfunction definitions. OBJECTIVE To evaluate evidence for criteria that define immune system dysfunction in critically ill children and associations with adverse outcomes and develop consensus criteria for the diagnosis of immune system dysfunction in critically ill children. DATA SOURCES We conducted electronic searches of PubMed and Embase from January 1992 to January 2020, using medical subject heading terms and text words to define immune system dysfunction and outcomes of interest. STUDY SELECTION Studies of critically ill children with an abnormality in leukocyte numbers or function that is currently measurable in the clinical laboratory in which researchers assessed patient-centered outcomes were included. Studies of adults or premature infants, animal studies, reviews and commentaries, case series (≤10 subjects), and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from eligible studies into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS We identified the following criteria for immune system dysfunction: (1) peripheral absolute neutrophil count <500 cells/μL, (2) peripheral absolute lymphocyte count <1000 cells/μL, (3) reduction in CD4+ lymphocyte count or percentage of total lymphocytes below age-specific thresholds, (4) monocyte HLA-DR expression <30%, or (5) reduction in ex vivo whole blood lipopolysaccharide-induced TNFα production capacity below manufacturer-provided thresholds. LIMITATIONS Many measures of immune system function are currently limited to the research environment. CONCLUSIONS We present consensus criteria for the diagnosis of immune system dysfunction in critically ill children.
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Affiliation(s)
- Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, College of Medicine, The Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh and Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Timothy Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children’s Hospital Stanford, Palo Alto, California
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Muszynski JA, Banks R, Reeder RW, Hall MW, Berg RA, Zuppa A, Shanley TP, Cornell TT, Newth CJL, Pollack MM, Wessel D, Doctor A, Lin JC, Harrison RE, Meert KL, Dean JM, Holubkov R, Carcillo JA. Outcomes Associated With Early RBC Transfusion in Pediatric Severe Sepsis: A Propensity-Adjusted Multicenter Cohort Study. Shock 2022; 57:88-94. [PMID: 34628452 PMCID: PMC8678199 DOI: 10.1097/shk.0000000000001863] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about the epidemiology of and outcomes related to red blood cell (RBC) transfusion in septic children across multiple centers. We performed propensity-adjusted secondary analyses of the Biomarker Phenotyping of Pediatric Sepsis and Multiple Organ Failure (PHENOMS) study to test the hypothesis that early RBC transfusion is associated with fewer organ failure-free days in pediatric severe sepsis. METHODS Four hundred one children were enrolled in the parent study. Children were excluded from these analyses if they received extracorporeal membrane oxygenation (n = 22) or died (n = 1) before sepsis day 2. Propensity-adjusted analyses compared children who received RBC transfusion on or before sepsis day 2 (early RBC transfusion) with those who did not. Logistic regression was used to model the propensity to receive early RBC transfusion. A weighted cohort was constructed using stabilized inverse probability of treatment weights. Variables in the weighted cohort with absolute standardized differences >0.15 were added to final multivariable models. RESULTS Fifty percent of children received at least one RBC transfusion. The majority (68%) of first transfusions were on or before sepsis day 2. Early RBC transfusion was not independently associated with organ failure-free (-0.34 [95%CI: -2, 1.3] days) or PICU-free days (-0.63 [-2.3, 1.1]), but was associated with the secondary outcome of higher mortality (aOR 2.9 [1.1, 7.9]). CONCLUSIONS RBC transfusion is common in pediatric severe sepsis and may be associated with adverse outcomes. Future studies are needed to clarify these associations, to understand patient-specific transfusion risks, and to develop more precise transfusion strategies.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P Shanley
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Timothy T Cornell
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Allan Doctor
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - John C Lin
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - Rick E Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Kernan KF, Ghaloul-Gonzalez L, Vockley J, Lamb J, Hollingshead D, Chandran U, Sethi R, Park HJ, Berg RA, Wessel D, Pollack MM, Meert KL, Hall MW, Newth CJL, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Prevalence of Pathogenic and Potentially Pathogenic Inborn Error of Immunity Associated Variants in Children with Severe Sepsis. J Clin Immunol 2022; 42:350-364. [PMID: 34973142 PMCID: PMC8720168 DOI: 10.1007/s10875-021-01183-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Purpose Our understanding of inborn errors of immunity is increasing; however, their contribution to pediatric sepsis is unknown. Methods We used whole-exome sequencing (WES) to characterize variants in genes related to monogenic immunologic disorders in 330 children admitted to intensive care for severe sepsis. We defined candidate variants as rare variants classified as pathogenic or potentially pathogenic in QIAGEN’s Human Gene Mutation Database or novel null variants in a disease-consistent inheritance pattern. We investigated variant correlation with infection and inflammatory phenotype. Results More than one in two children overall and three of four African American children had immunodeficiency-associated variants. Children with variants had increased odds of isolating a blood or urinary pathogen (blood: OR 2.82, 95% CI: 1.12–7.10, p = 0.023, urine: OR: 8.23, 95% CI: 1.06–64.11, p = 0.016) and demonstrating increased inflammation with hyperferritinemia (ferritin \documentclass[12pt]{minimal}
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\begin{document}$$\ge 500$$\end{document}≥500 ng/mL, OR: 2.16, 95% CI: 1.28–3.66, p = 0.004), lymphopenia (lymphocyte count < 1000/µL, OR: 1.66, 95% CI: 1.06 – 2.60, p = 0.027), thrombocytopenia (platelet count < 150,000/µL, OR: 1.76, 95% CI: 1.12–2.76, p = 0.013), and CRP greater than 10 mg/dl (OR: 1.71, 95% CI: 1.10–2.68, p = 0.017). They also had increased odds of requiring extracorporeal membrane oxygenation (ECMO, OR: 4.19, 95% CI: 1.21–14.5, p = 0.019). Conclusion Herein, we describe the genetic findings in this severe pediatric sepsis cohort and their microbiologic and immunologic significance, providing evidence for the phenotypic effect of these variants and rationale for screening children with life-threatening infections for potential inborn errors of immunity. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-021-01183-4.
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Affiliation(s)
- Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Janette Lamb
- Genomics Core Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Uma Chandran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahil Sethi
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Department of Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen L Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher J L Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
- Division of Pediatric Critical Care Medicine, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, MD, Baltimore, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University, CA, Palo Alto, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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Snyder A, Jedreski K, Fitch J, Wijeratne S, Wetzel A, Hensley J, Flowers M, Bline K, Hall MW, Muszynski JA. Transcriptomic Profiles in Children With Septic Shock With or Without Immunoparalysis. Front Immunol 2021; 12:733834. [PMID: 34659221 PMCID: PMC8517409 DOI: 10.3389/fimmu.2021.733834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/14/2021] [Indexed: 12/29/2022] Open
Abstract
Background Severe innate immune suppression, termed immunoparalysis, is associated with increased risks of nosocomial infection and mortality in children with septic shock. Currently, immunoparalysis cannot be clinically diagnosed in children, and mechanisms remain unclear. Transcriptomic studies identify subsets of septic children with downregulation of genes within adaptive immune pathways, but assays of immune function have not been performed as part of these studies, and little is known about transcriptomic profiles of children with immunoparalysis. Methods We performed a nested case-control study to identify differences in RNA expression patterns between children with septic shock with immunoparalysis (defined as lipopolysaccharide (LPS)-induced tumor necrosis factor (TNF)α response < 200 pg/ml) vs those with normal LPS-induced TNFα response. Children were enrolled within 48 hours of the onset of septic shock and divided into two groups based on LPS-induced TNFα response. RNA was extracted from whole blood for RNAseq, differential expression analyses using DESeq2 software, and pathway analyses using Ingenuity Pathway Analysis. Results 32 children were included in analyses. Comparing those with immunoparalysis (n =19) to those with normal TNFα response (n = 13), 2,303 transcripts were differentially expressed with absolute value fold change ≥ 1.5 and false discovery rate ≤ 0.05. The majority of downregulated pathways in children with immunoparalysis were pathways that involved interactions between innate and adaptive immune cells necessary for cell-mediated immunity, crosstalk between dendritic cells and natural killer cells, and natural killer cell signaling pathways. Upregulated pathways included those involved in humoral immunity (T helper cell type 2), corticotropin signaling, platelet activation (GP6 signaling), and leukocyte migration and extravasation. Conclusions Our study suggests that gene expression data might be useful to identify children with immunoparalysis and identifies several key differentially regulated pathways involved in both innate and adaptive immunity. Our ongoing work in this area aims to dissect interactions between innate and adaptive immunity in septic children and to more fully elucidate patient-specific immunologic pathophysiology to guide individualized immunotherapeutic targets.
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Affiliation(s)
- Andrew Snyder
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Kathleen Jedreski
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - James Fitch
- Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Saranga Wijeratne
- Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Amy Wetzel
- Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Josey Hensley
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Margaret Flowers
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Katherine Bline
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Mark W Hall
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jennifer A Muszynski
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
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36
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Mertz C, Glowinski R, Cohen SH, Mertz S, Ye F, Hall MW, Peeples ME, King T, Wang H, Leber AL, Sanchez PJ, Ramilo O, Mejias A. SARS-CoV-2 RNAemia and clinical outcomes in children with COVID-19. J Infect Dis 2021; 225:208-213. [PMID: 34618885 DOI: 10.1093/infdis/jiab491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/23/2021] [Indexed: 01/08/2023] Open
Abstract
The burden of COVID-19 in children represents a fraction of cases worldwide, yet a subset of those infected are at risk for severe disease. We measured plasma SARS-CoV-2 RNA in a cohort of 103 children hospitalized with COVID-19 with diverse clinical manifestations. SARS-CoV-2 RNAemia was detected in 27 (26%) of these children, lasted for a median of 6 [2-9] days, and it was associated with higher rates of oxygen administration, admission to the intensive care unit, and longer hospitalization.
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Affiliation(s)
- C Mertz
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - R Glowinski
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - S H Cohen
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - S Mertz
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - F Ye
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - M W Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - M E Peeples
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - T King
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA
| | - H Wang
- Department of Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - A L Leber
- Department of Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - P J Sanchez
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital , and The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, Division of Neonatology, Columbus, OH, USA.,Division of Infectious Diseases, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - O Ramilo
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Infectious Diseases, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - A Mejias
- Center for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, and The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Infectious Diseases, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
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Geva A, Patel MM, Newhams MM, Young CC, Son MBF, Kong M, Maddux AB, Hall MW, Riggs BJ, Singh AR, Giuliano JS, Hobbs CV, Loftis LL, McLaughlin GE, Schwartz SP, Schuster JE, Babbitt CJ, Halasa NB, Gertz SJ, Doymaz S, Hume JR, Bradford TT, Irby K, Carroll CL, McGuire JK, Tarquinio KM, Rowan CM, Mack EH, Cvijanovich NZ, Fitzgerald JC, Spinella PC, Staat MA, Clouser KN, Soma VL, Dapul H, Maamari M, Bowens C, Havlin KM, Mourani PM, Heidemann SM, Horwitz SM, Feldstein LR, Tenforde MW, Newburger JW, Mandl KD, Randolph AG. Data-driven clustering identifies features distinguishing multisystem inflammatory syndrome from acute COVID-19 in children and adolescents. EClinicalMedicine 2021; 40:101112. [PMID: 34485878 PMCID: PMC8405351 DOI: 10.1016/j.eclinm.2021.101112] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) consensus criteria were designed for maximal sensitivity and therefore capture patients with acute COVID-19 pneumonia. METHODS We performed unsupervised clustering on data from 1,526 patients (684 labeled MIS-C by clinicians) <21 years old hospitalized with COVID-19-related illness admitted between 15 March 2020 and 31 December 2020. We compared prevalence of assigned MIS-C labels and clinical features among clusters, followed by recursive feature elimination to identify characteristics of potentially misclassified MIS-C-labeled patients. FINDINGS Of 94 clinical features tested, 46 were retained for clustering. Cluster 1 patients (N = 498; 92% labeled MIS-C) were mostly previously healthy (71%), with mean age 7·2 ± 0·4 years, predominant cardiovascular (77%) and/or mucocutaneous (82%) involvement, high inflammatory biomarkers, and mostly SARS-CoV-2 PCR negative (60%). Cluster 2 patients (N = 445; 27% labeled MIS-C) frequently had pre-existing conditions (79%, with 39% respiratory), were similarly 7·4 ± 2·1 years old, and commonly had chest radiograph infiltrates (79%) and positive PCR testing (90%). Cluster 3 patients (N = 583; 19% labeled MIS-C) were younger (2·8 ± 2·0 y), PCR positive (86%), with less inflammation. Radiographic findings of pulmonary infiltrates and positive SARS-CoV-2 PCR accurately distinguished cluster 2 MIS-C labeled patients from cluster 1 patients. INTERPRETATION Using a data driven, unsupervised approach, we identified features that cluster patients into a group with high likelihood of having MIS-C. Other features identified a cluster of patients more likely to have acute severe COVID-19 pulmonary disease, and patients in this cluster labeled by clinicians as MIS-C may be misclassified. These data driven phenotypes may help refine the diagnosis of MIS-C.
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Affiliation(s)
- Alon Geva
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston,
These authors contributed equally to this work. A complete list of members and affiliations is provided in the Supplementary Appendix. MA, USA - Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Manish M. Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Margaret M. Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston,
These authors contributed equally to this work. A complete list of members and affiliations is provided in the Supplementary Appendix. MA, USA
| | - Cameron C. Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston,
These authors contributed equally to this work. A complete list of members and affiliations is provided in the Supplementary Appendix. MA, USA
| | - Mary Beth F. Son
- Department of Pediatrics, Division of Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Becky J. Riggs
- Department of Anesthesiology and Critical Care Medicine; Division of Pediatric Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - John S. Giuliano
- Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, CT, USA
| | - Charlotte V. Hobbs
- Department of Pediatrics, Division of Disease; Microbiology; University of Mississippi Medical Center, Jackson, MS, USA
| | - Laura L. Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Gwenn E. McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephanie P. Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC, USA
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | | | - Natasha B. Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Janet R. Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Tamara T. Bradford
- Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR, USA
| | | | - John K. McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Elizabeth H. Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Philip C. Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Mary A. Staat
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katharine N. Clouser
- Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Vijaya L. Soma
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, NY, USA
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, NY, USA
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Health Medical Center Dallas, TX, USA
| | - Cindy Bowens
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Louisville, and Norton Children's Hospital, Louisville, KY, USA
| | - Kevin M. Havlin
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit, MI, USA
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Sabrina M. Heidemann
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit, MI, USA
| | - Steven M. Horwitz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Leora R. Feldstein
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mark W. Tenforde
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth D. Mandl
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
- Departments of Biomedical Informatics and Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston,
These authors contributed equally to this work. A complete list of members and affiliations is provided in the Supplementary Appendix. MA, USA - Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA, USA
- Corresponding author at: Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Bader 634, 300 Longwood Avenue, Boston, MA 02115, USA.
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38
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Bline KE, Hall MW. Immune Function in Critically Ill Septic Children. Pathogens 2021; 10:1239. [PMID: 34684188 PMCID: PMC8539782 DOI: 10.3390/pathogens10101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 11/19/2022] Open
Abstract
The inflammatory response in pediatric sepsis is highly dynamic and includes both pro- and anti-inflammatory elements that involve the innate and adaptive immune systems. While the pro-inflammatory response is responsible for the initial clinical signs and symptoms of sepsis, a concurrent compensatory anti-inflammatory response often results in an occult, but highly clinically relevant, form of acquired immunodeficiency. When severe, this is termed "immunoparalysis" and is associated with increased risks for nosocomial infection, prolonged organ dysfunction, and death. This review focuses on the pathophysiology and clinical implications of both over- and under-active immune function in septic children. Host-, disease-, and treatment-specific risk factors for immunoparalysis are reviewed along with immune phenotype-specific approaches for immunomodulation in pediatric sepsis which are currently the subject of clinical trials.
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Affiliation(s)
- Katherine Elizabeth Bline
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH 43205, USA;
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39
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Diaz-Diaz A, Bunsow E, Garcia-Maurino C, Moore-Clingenpeel M, Naples J, Juergensen A, Mertz S, Wang H, Leber AL, Gern J, Hall MW, Cohen DM, Ramilo O, Mejias A. Nasopharyngeal Codetection of H. influenzae and S. pneumoniae and Respiratory Syncytial Virus Disease Outcomes in Children. J Infect Dis 2021; 225:912-923. [PMID: 34543409 DOI: 10.1093/infdis/jiab481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of nasopharyngeal bacteria on RSV disease has been underestimated. We measured the frequency and quantitative detection of potentially pathogenic bacteria in the upper respiratory tract of infants with RSV infection over seven respiratory seasons, and their impact on clinical outcomes. METHODS Children <2 years old with mild (outpatients; n=115) or severe (inpatients; n=566) RSV infection, and matched healthy controls (n=161) were prospectively enrolled. Nasopharyngeal samples were obtained for RSV, S. pneumoniae, S. aureus, M. catarrhalis, and H. influenzae detection and quantitation by PCR. Multivariable models were constructed to identify variables predictive of severe disease. RESULTS S. pneumoniae, H. influenzae, and M. catarrhalis, but not S. aureus, were detected more frequently in RSV-infected children (84%) than healthy controls (46%; p<0.001). Detection of S. pneumoniae and/or H. influenzae was associated with fever, more frequent antibiotic treatment, worse radiologic findings, and higher neutrophil counts (p<0.01). In adjusted analyses S. pneumoniae/H. influenzae co-detection was associated with greater odds (OR; 95% CI) of hospitalization (2.25 [1.07-4.74), higher disease severity scores (1.93 [1.14-3.26]), prolonged oxygen administration (2.23 [1.01-4.91]), and longer hospitalization (2.53 [1.33-4.79]). CONCLUSIONS Nasopharyngeal co-detection of S. pneumoniae and H. influenzae in infants with RSV infection is associated with increased disease severity.
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Affiliation(s)
- Alejandro Diaz-Diaz
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital-The Ohio State University College of Medicine, Columbus, OH, USA
| | - Eleonora Bunsow
- Center for Vaccines & Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Cristina Garcia-Maurino
- Center for Vaccines & Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Melissa Moore-Clingenpeel
- Biostatistics Resource Core, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeffrey Naples
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alexis Juergensen
- Center for Vaccines & Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Sara Mertz
- Center for Vaccines & Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Huanyu Wang
- Department of Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amy L Leber
- Department of Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - James Gern
- Department of Pediatrics. University of Wisconsin, School of Medicine and Public Health. Madison WI, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel M Cohen
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Octavio Ramilo
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital-The Ohio State University College of Medicine, Columbus, OH, USA.,Center for Vaccines & Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital-The Ohio State University College of Medicine, Columbus, OH, USA.,Center for Vaccines & Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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40
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Burd RS, Jensen AR, VanBuren JM, Richards R, Holubkov R, Pollack MM, Berg RA, Carcillo JA, Carpenter TC, Dean JM, Gaines B, Hall MW, McQuillen PS, Meert KL, Mourani PM, Nance ML, Yates AR. Factors Associated With Functional Impairment After Pediatric Injury. JAMA Surg 2021; 156:e212058. [PMID: 34076684 DOI: 10.1001/jamasurg.2021.2058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown. Objective To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers. Design, Setting, and Participants This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020. Exposure At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5). Main Outcomes and Measures New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites. Results This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge. Conclusions and Relevance In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC
| | - Aaron R Jensen
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Barbara Gaines
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit.,Central Michigan University, Mt Pleasant
| | - Peter M Mourani
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock
| | - Michael L Nance
- Division of Pediatric Trauma, Department of Surgery, College of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
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41
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Siems A, Banks R, Holubkov R, Meert KL, Bauerfeld C, Beyda D, Berg RA, Bulut Y, Burd RS, Carcillo J, Dean JM, Gradidge E, Hall MW, McQuillen PS, Mourani PM, Newth CJL, Notterman DA, Priestley MA, Sapru A, Wessel DL, Yates AR, Zuppa AF, Pollack MM. Structured Chart Review: Assessment of a Structured Chart Review Methodology. Hosp Pediatr 2021; 10:61-69. [PMID: 31879317 DOI: 10.1542/hpeds.2019-0225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability. METHODS A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability. RESULTS The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories. CONCLUSIONS A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.
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Affiliation(s)
- Ashley Siems
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Russell Banks
- School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Kathleen L Meert
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - Christian Bauerfeld
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Beyda
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yonca Bulut
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - Randall S Burd
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Joseph Carcillo
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - J Michael Dean
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Eleanor Gradidge
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- University of California, San Francisco and University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Peter M Mourani
- University of Colorado and Children's Hospital of Colorado, Denver, Colorado
| | - Christopher J L Newth
- Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California; and
| | | | | | - Anil Sapru
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - David L Wessel
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | | | - Athena F Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Murray M Pollack
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia;
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42
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Son MBF, Murray N, Friedman K, Young CC, Newhams MM, Feldstein LR, Loftis LL, Tarquinio KM, Singh AR, Heidemann SM, Soma VL, Riggs BJ, Fitzgerald JC, Kong M, Doymaz S, Giuliano JS, Keenaghan MA, Hume JR, Hobbs CV, Schuster JE, Clouser KN, Hall MW, Smith LS, Horwitz SM, Schwartz SP, Irby K, Bradford TT, Maddux AB, Babbitt CJ, Rowan CM, McLaughlin GE, Yager PH, Maamari M, Mack EH, Carroll CL, Montgomery VL, Halasa NB, Cvijanovich NZ, Coates BM, Rose CE, Newburger JW, Patel MM, Randolph AG. Multisystem Inflammatory Syndrome in Children - Initial Therapy and Outcomes. N Engl J Med 2021; 385:23-34. [PMID: 34133855 PMCID: PMC8220972 DOI: 10.1056/nejmoa2102605] [Citation(s) in RCA: 222] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The assessment of real-world effectiveness of immunomodulatory medications for multisystem inflammatory syndrome in children (MIS-C) may guide therapy. METHODS We analyzed surveillance data on inpatients younger than 21 years of age who had MIS-C and were admitted to 1 of 58 U.S. hospitals between March 15 and October 31, 2020. The effectiveness of initial immunomodulatory therapy (day 0, indicating the first day any such therapy for MIS-C was given) with intravenous immune globulin (IVIG) plus glucocorticoids, as compared with IVIG alone, was evaluated with propensity-score matching and inverse probability weighting, with adjustment for baseline MIS-C severity and demographic characteristics. The primary outcome was cardiovascular dysfunction (a composite of left ventricular dysfunction or shock resulting in the use of vasopressors) on or after day 2. Secondary outcomes included the components of the primary outcome, the receipt of adjunctive treatment (glucocorticoids in patients not already receiving glucocorticoids on day 0, a biologic, or a second dose of IVIG) on or after day 1, and persistent or recurrent fever on or after day 2. RESULTS A total of 518 patients with MIS-C (median age, 8.7 years) received at least one immunomodulatory therapy; 75% had been previously healthy, and 9 died. In the propensity-score-matched analysis, initial treatment with IVIG plus glucocorticoids (103 patients) was associated with a lower risk of cardiovascular dysfunction on or after day 2 than IVIG alone (103 patients) (17% vs. 31%; risk ratio, 0.56; 95% confidence interval [CI], 0.34 to 0.94). The risks of the components of the composite outcome were also lower among those who received IVIG plus glucocorticoids: left ventricular dysfunction occurred in 8% and 17% of the patients, respectively (risk ratio, 0.46; 95% CI, 0.19 to 1.15), and shock resulting in vasopressor use in 13% and 24% (risk ratio, 0.54; 95% CI, 0.29 to 1.00). The use of adjunctive therapy was lower among patients who received IVIG plus glucocorticoids than among those who received IVIG alone (34% vs. 70%; risk ratio, 0.49; 95% CI, 0.36 to 0.65), but the risk of fever was unaffected (31% and 40%, respectively; risk ratio, 0.78; 95% CI, 0.53 to 1.13). The inverse-probability-weighted analysis confirmed the results of the propensity-score-matched analysis. CONCLUSIONS Among children and adolescents with MIS-C, initial treatment with IVIG plus glucocorticoids was associated with a lower risk of new or persistent cardiovascular dysfunction than IVIG alone. (Funded by the Centers for Disease Control and Prevention.).
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Affiliation(s)
- Mary Beth F Son
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Nancy Murray
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Kevin Friedman
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Cameron C Young
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Margaret M Newhams
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Leora R Feldstein
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Laura L Loftis
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Keiko M Tarquinio
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Aalok R Singh
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Sabrina M Heidemann
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Vijaya L Soma
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Becky J Riggs
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Julie C Fitzgerald
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Michele Kong
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Sule Doymaz
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - John S Giuliano
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Michael A Keenaghan
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Janet R Hume
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Charlotte V Hobbs
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Jennifer E Schuster
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Katharine N Clouser
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Mark W Hall
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Lincoln S Smith
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Steven M Horwitz
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Stephanie P Schwartz
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Katherine Irby
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Tamara T Bradford
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Aline B Maddux
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Christopher J Babbitt
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Courtney M Rowan
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Gwenn E McLaughlin
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Phoebe H Yager
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Mia Maamari
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Elizabeth H Mack
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Christopher L Carroll
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Vicki L Montgomery
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Natasha B Halasa
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Natalie Z Cvijanovich
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Bria M Coates
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Charles E Rose
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Jane W Newburger
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Manish M Patel
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
| | - Adrienne G Randolph
- From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.)
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LaRovere KL, Riggs BJ, Poussaint TY, Young CC, Newhams MM, Maamari M, Walker TC, Singh AR, Dapul H, Hobbs CV, McLaughlin GE, Son MBF, Maddux AB, Clouser KN, Rowan CM, McGuire JK, Fitzgerald JC, Gertz SJ, Shein SL, Munoz AC, Thomas NJ, Irby K, Levy ER, Staat MA, Tenforde MW, Feldstein LR, Halasa NB, Giuliano JS, Hall MW, Kong M, Carroll CL, Schuster JE, Doymaz S, Loftis LL, Tarquinio KM, Babbitt CJ, Nofziger RA, Kleinman LC, Keenaghan MA, Cvijanovich NZ, Spinella PC, Hume JR, Wellnitz K, Mack EH, Michelson KN, Flori HR, Patel MM, Randolph AG. Neurologic Involvement in Children and Adolescents Hospitalized in the United States for COVID-19 or Multisystem Inflammatory Syndrome. JAMA Neurol 2021; 78:536-547. [PMID: 33666649 DOI: 10.1001/jamaneurol.2021.0504] [Citation(s) in RCA: 240] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The spectrum of neurologic involvement in children and adolescents is unclear. Objective To understand the range and severity of neurologic involvement among children and adolescents associated with COVID-19. Setting, Design, and Participants Case series of patients (age <21 years) hospitalized between March 15, 2020, and December 15, 2020, with positive severe acute respiratory syndrome coronavirus 2 test result (reverse transcriptase-polymerase chain reaction and/or antibody) at 61 US hospitals in the Overcoming COVID-19 public health registry, including 616 (36%) meeting criteria for multisystem inflammatory syndrome in children. Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening involvement was adjudicated by experts based on clinical and/or neuroradiologic features. Exposures Severe acute respiratory syndrome coronavirus 2. Main Outcomes and Measures Type and severity of neurologic involvement, laboratory and imaging data, and outcomes (death or survival with new neurologic deficits) at hospital discharge. Results Of 1695 patients (909 [54%] male; median [interquartile range] age, 9.1 [2.4-15.3] years), 365 (22%) from 52 sites had documented neurologic involvement. Patients with neurologic involvement were more likely to have underlying neurologic disorders (81 of 365 [22%]) compared with those without (113 of 1330 [8%]), but a similar number were previously healthy (195 [53%] vs 723 [54%]) and met criteria for multisystem inflammatory syndrome in children (126 [35%] vs 490 [37%]). Among those with neurologic involvement, 322 (88%) had transient symptoms and survived, and 43 (12%) developed life-threatening conditions clinically adjudicated to be associated with COVID-19, including severe encephalopathy (n = 15; 5 with splenial lesions), stroke (n = 12), central nervous system infection/demyelination (n = 8), Guillain-Barré syndrome/variants (n = 4), and acute fulminant cerebral edema (n = 4). Compared with those without life-threatening conditions (n = 322), those with life-threatening neurologic conditions had higher neutrophil-to-lymphocyte ratios (median, 12.2 vs 4.4) and higher reported frequency of D-dimer greater than 3 μg/mL fibrinogen equivalent units (21 [49%] vs 72 [22%]). Of 43 patients who developed COVID-19-related life-threatening neurologic involvement, 17 survivors (40%) had new neurologic deficits at hospital discharge, and 11 patients (26%) died. Conclusions and Relevance In this study, many children and adolescents hospitalized for COVID-19 or multisystem inflammatory syndrome in children had neurologic involvement, mostly transient symptoms. A range of life-threatening and fatal neurologic conditions associated with COVID-19 infrequently occurred. Effects on long-term neurodevelopmental outcomes are unknown.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Becky J Riggs
- Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tina Y Poussaint
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cameron C Young
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Margaret M Newhams
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mia Maamari
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children's Health Medical Center Dallas
| | - Tracie C Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Charlotte V Hobbs
- Division of Infectious Diseases, Department of Pediatrics, Department of Microbiology, University of Mississippi Medical Center, Jackson
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Mary Beth F Son
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Aline B Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Katharine N Clouser
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, New Jersey
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - John K McGuire
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Alvaro Coronado Munoz
- Pediatric Critical Care Division, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock
| | - Emily R Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark W Tenforde
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Leora R Feldstein
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John S Giuliano
- Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | | | - Jennifer E Schuster
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University, Brooklyn
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston
| | - Keiko M Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | - Lawrence C Kleinman
- Division of Population Health, Quality, and Implementation Sciences (PopQuIS), Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Michael A Keenaghan
- Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital, Brooklyn, New York
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, University of California, San Francisco, Benioff Children's Hospital, Oakland
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Kelly N Michelson
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor
| | - Manish M Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. The Association between Therapeutic Alliance and Parental Health Outcomes following a Child's Death in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2021; 12:3-11. [PMID: 36742250 PMCID: PMC9894698 DOI: 10.1055/s-0041-1727179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/20/2021] [Indexed: 02/07/2023] Open
Abstract
Therapeutic alliance reflects the strength and quality of the physician-patient/family relationship. We investigated the association between therapeutic alliance and bereaved parents' mental health and perceived overall health following their child's death in a pediatric intensive care unit (PICU). Bereaved parents were surveyed 6 months after their child's death in a PICU affiliated with the Collaborative Pediatric Critical Care Research Network. Parents were evaluated for complicated grief, depression, and post-traumatic stress using the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire (PHQ-8), and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), respectively. Overall health was evaluated using a single item. Therapeutic alliance between parents and their deceased child's PICU physicians was assessed using the Human Connection scale (HCS). Two hundred and thirty-five parents of 158 deceased children completed surveys. Mean ICG score was 34.4 ± 14.9 with 142 (60.4%) parents screening positive for complicated grief. Mean PHQ-8 score was 9.1 ± 6.2 with 102 (43.4%) screening positive for at least moderate depression. Mean SPRINT score was 14.6 ± 8.2 with 122 (51.9%) screening positive for post-traumatic stress disorder. Overall health was perceived as fair for 47 (20.0%) parents and poor for 10 (4.3%). Using multivariable modeling, higher HCS score (greater therapeutic alliance) was significantly associated with lower (better) ICG score (-0.23, 95% CI -0.42, -0.04, p = 0.018). HCS score was not significantly associated with PHQ-8, SPRINT, or overall health scores. We conclude that bereaved parents experience a high level of adverse mental health symptoms including complicated grief, depression, and post-traumatic stress symptoms. Greater therapeutic alliance with PICU physicians may lessen symptoms of complicated grief during bereavement.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Murray M. Pollack
- Department of Pediatrics, Children's National Hospital, Washington, United States
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, United States
| | - Peter M. Mourani
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Colorado, United States
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, California, United States
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pennsylvania, United States
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | | | - Daniel A. Notterman
- Department of Molecular Biology, Princeton University, New Jersey, United States
| | - Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, Michigan, United States,Address for correspondence Kathleen L. Meert, MD Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan3901 Beaubien, Detroit, MI 48201United States
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. Complicated Grief, Depression and Post-Traumatic Stress Symptoms Among Bereaved Parents following their Child's Death in the Pediatric Intensive Care Unit: A Follow-Up Study. Am J Hosp Palliat Care 2021; 39:228-236. [PMID: 33949217 PMCID: PMC10184266 DOI: 10.1177/10499091211015913] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Parents often suffer reduced mental health after their child's death; however, the trajectory and risk factors are not well described. OBJECTIVE Describe the change in complicated grief, depression, and post-traumatic stress symptoms among parents between 6 and 13 months after their child's death in a pediatric intensive care unit (PICU), and factors associated with 13-month symptoms. METHODS Parents whose children died in 1 of 8 PICUs affiliated with the Collaborative Pediatric Critical Care Research Network completed surveys 6 and 13 months after their child's death. Surveys included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). Parents provided sociodemographics. Charts were reviewed for child characteristics. RESULTS One-hundred and fifty seven parents of 104 deceased children completed surveys at both time points. Mental health symptoms declined over time (mean (SD)): ICG (33.8 (15.4) vs. 30.5 (15.2), p < 0.001), PHQ-8 (9.0 (6.4) vs. 7.3 (5.8), p < 0.001), and SPRINT (14.1 (8.3) vs. 12.0 (8.2), p < 0.001). After controlling for 6-month scores, higher 13-month ICG was independently associated with sudden unexpected death; higher PHQ-8 with Black race, insecure attachment style, and sudden unexpected death; and higher SPRINT with having a high school level of education (compared to college degree or higher). CONCLUSION Mental health symptoms improve among parents during the first 13 months after their child's death; however, symptoms persist for many. Black parents and those whose children die suddenly may be high risk for poor adjustment during bereavement.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA)
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA)
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, Washington DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI, USA
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Meert KL, Reeder RW, Maddux AB, Banks R, Berg RA, Newth CJ, Hall MW, Quasney M, Carcillo JA, McQuillen PS, Mourani PM, Chima RS, Holubkov R, Sorenson S, McGalliard J, Dean JM, Zimmerman JJ. Health-Related Quality of Life After Community-Acquired Septic Shock in Children With Preexisting Severe Developmental Disabilities. Pediatr Crit Care Med 2021; 22:e302-e313. [PMID: 33156209 PMCID: PMC8099927 DOI: 10.1097/pcc.0000000000002606] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To serially evaluate health-related quality of life during the first year after community-acquired septic shock in children with preexisting severe developmental disabilities and explore factors associated with health-related quality of life changes in these children. DESIGN Secondary analysis of the Life after Pediatric Sepsis Evaluation investigation. SETTING Twelve academic PICU in the United States. PATIENTS Children greater than or equal to 1 month and less than 18 years old identified by their family caregiver (e.g., parent/guardian) as having severe developmental disability prior to septic shock. INTERVENTIONS Family caregivers completed the Stein-Jessop Functional Status II-R Short Form as a measure of their child's health-related quality of life at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Stein-Jessop Functional Status II-R Short Form scores were linearly transformed to a 0-100 scale, with higher scores indicating better health-related quality of life. MEASUREMENTS AND MAIN RESULTS Of 392 Life after Pediatric Sepsis Evaluation participants, 137 were identified by their caregiver as having a severe developmental disability. Sixteen children (11.6%) with severe disability died during the 12 months following septic shock. Among 121 survivors, Stein-Jessop Functional Status II-R Short Form scores declined from preadmission baseline to day 7 (70.7 ± 16.1 vs 55.6 ± 19.2; p < 0.001). Stein-Jessop Functional Status II-R Short Form scores remained below baseline through month 12 (59.1 ± 21.0, p < 0.001 vs baseline). After adjusting for baseline Stein-Jessop Functional Status II-R Short Form, the caregiver being a single parent/guardian was associated with lower month 3 Stein-Jessop Functional Status II-R Short Form scores (p = 0.041). No other baseline child or caregiver characteristic, or critical illness-related factors were significantly associated with month 3 Stein-Jessop Functional Status II-R Short Form scores. CONCLUSIONS Health-related quality of life among children with severe developmental disability remains, on average, below baseline during the first year following community-acquired septic shock. Children with severe disability and septic shock that are in single parent families are at increased risk. Clinical awareness of the potential for decline in health-related quality of life among disabled children is essential to prevent this adverse outcome from being missed.
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Affiliation(s)
- Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aline B. Maddux
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J. Newth
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Michael Quasney
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M. Mourani
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Ranjit S. Chima
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Samuel Sorenson
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Julie McGalliard
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle Research Institute, Seattle, WA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. Therapeutic Alliance Between Bereaved Parents and Physicians in the PICU. Pediatr Crit Care Med 2021; 22:e243-e252. [PMID: 33044415 PMCID: PMC8016694 DOI: 10.1097/pcc.0000000000002585] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Therapeutic alliance is the collaborative bond that develops between patients/families and healthcare providers. Our objective is to determine the extent of therapeutic alliance bereaved parents perceive to have occurred with their child's physicians during their child's PICU stay, and associated factors. DESIGN Multicenter observational study. SETTING Eight children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Parents greater than or equal to 18 years old whose child died in a PICU (including cardiac ICU). INTERVENTIONS Bereaved parents completed the Human Connection Scale, a 16-item measure of therapeutic alliance, 6 months after their child's death. Human Connection Scale scores range from 16 to 64 with higher scores indicating greater alliance. Parents provided sociodemographic data, and medical records were reviewed for the child's clinical characteristics. MEASUREMENTS AND MAIN RESULTS Two-hundred and thirty-three parents of 157 deceased children responded to the Human Connection Scale with greater than or equal to 80% item completion. Among parents, 146 (62.7%) were female, 155 (66.5%) were White and 46 (19.7%) were Black, 175 (75.1%) were married, and 209 (89.7%) had at least a high-school education. Among children, median age at the time of death was 5.9 years (interquartile range, 0.64-13.9 yr) and 114 (72.6%) died after limitation or withdrawal of life support. Mean Human Connection Scale score was 51.4 ± 11.1 for all parents, 52.6 ± 9.0 for White parents, and 47.0 ± 13.7 for Black parents. In multivariable modeling predicting Human Connection Scale scores, race was the only parent or child characteristic in the final model. Human Connection Scale scores were significantly different (-4.56; 95% CI, -8.53 to -0.6; p = 0.025) between the Black and White parents with items about trust, care, and honest communication showing the greatest mean difference. CONCLUSIONS Among parents bereaved in the PICU, therapeutic alliance with physicians is moderately high. Future research should identify strategies to strengthen therapeutic alliance with Black parents and examine the role of alliance on bereaved parents' health outcomes.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington DC
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M. Mourani
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI
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Mourani PM, Sontag MK, Williamson KM, Harris JK, Reeder R, Locandro C, Carpenter TC, Maddux AB, Ziegler K, Simões EAF, Osborne CM, Ambroggio L, Leroue MK, Robertson CE, Langelier C, DeRisi JL, Kamm J, Hall MW, Zuppa AF, Carcillo J, Meert K, Sapru A, Pollack MM, McQuillen P, Notterman DA, Dean JM, Wagner BD. Temporal airway microbiome changes related to ventilator-associated pneumonia in children. Eur Respir J 2021; 57:13993003.01829-2020. [PMID: 33008935 DOI: 10.1183/13993003.01829-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
We sought to determine whether temporal changes in the lower airway microbiome are associated with ventilator-associated pneumonia (VAP) in children.Using a multicentre prospective study of children aged 31 days to 18 years requiring mechanical ventilation support for >72 h, daily tracheal aspirates were collected and analysed by sequencing of the 16S rRNA gene. VAP was assessed using 2008 Centers for Disease Control and Prevention paediatric criteria. The association between microbial factors and VAP was evaluated using joint longitudinal time-to-event modelling, matched case-control comparisons and unsupervised clustering.Out of 366 eligible subjects, 66 (15%) developed VAP at a median of 5 (interquartile range 3-5) days post intubation. At intubation, there was no difference in total bacterial load (TBL), but Shannon diversity and the relative abundance of Streptococcus, Lactobacillales and Prevotella were lower for VAP subjects versus non-VAP subjects. However, higher TBL on each sequential day was associated with a lower hazard (hazard ratio 0.39, 95% CI 0.23-0.64) for developing VAP, but sequential values of diversity were not associated with VAP. Similar findings were observed from the matched analysis and unsupervised clustering. The most common dominant VAP pathogens included Prevotella species (19%), Pseudomonas aeruginosa (14%) and Streptococcus mitis/pneumoniae (10%). Mycoplasma and Ureaplasma were also identified as dominant organisms in several subjects.In mechanically ventilated children, changes over time in microbial factors were marginally associated with VAP risk, although these changes were not suitable for predicting VAP in individual patients. These findings suggest that focusing exclusively on pathogen burden may not adequately inform VAP diagnosis.
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Affiliation(s)
- Peter M Mourani
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Marci K Sontag
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Kayla M Williamson
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron Reeder
- Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Todd C Carpenter
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Katherine Ziegler
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Eric A F Simões
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Christina M Osborne
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Matthew K Leroue
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles E Robertson
- Medicine, Division of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles Langelier
- Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA.,Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Joseph L DeRisi
- Chan Zuckerberg Biohub, San Francisco, CA, USA.,Dept of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Mark W Hall
- Dept of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Kathleen Meert
- Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Anil Sapru
- Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Pediatrics, Children's National Medical Center and George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Patrick McQuillen
- Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Brandie D Wagner
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
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Feldstein LR, Tenforde MW, Friedman KG, Newhams M, Rose EB, Dapul H, Soma VL, Maddux AB, Mourani PM, Bowens C, Maamari M, Hall MW, Riggs BJ, Giuliano JS, Singh AR, Li S, Kong M, Schuster JE, McLaughlin GE, Schwartz SP, Walker TC, Loftis LL, Hobbs CV, Halasa NB, Doymaz S, Babbitt CJ, Hume JR, Gertz SJ, Irby K, Clouser KN, Cvijanovich NZ, Bradford TT, Smith LS, Heidemann SM, Zackai SP, Wellnitz K, Nofziger RA, Horwitz SM, Carroll RW, Rowan CM, Tarquinio KM, Mack EH, Fitzgerald JC, Coates BM, Jackson AM, Young CC, Son MBF, Patel MM, Newburger JW, Randolph AG. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA 2021; 325:1074-1087. [PMID: 33625505 PMCID: PMC7905703 DOI: 10.1001/jama.2021.2091] [Citation(s) in RCA: 526] [Impact Index Per Article: 175.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Refinement of criteria for multisystem inflammatory syndrome in children (MIS-C) may inform efforts to improve health outcomes. OBJECTIVE To compare clinical characteristics and outcomes of children and adolescents with MIS-C vs those with severe coronavirus disease 2019 (COVID-19). SETTING, DESIGN, AND PARTICIPANTS Case series of 1116 patients aged younger than 21 years hospitalized between March 15 and October 31, 2020, at 66 US hospitals in 31 states. Final date of follow-up was January 5, 2021. Patients with MIS-C had fever, inflammation, multisystem involvement, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody test results or recent exposure with no alternate diagnosis. Patients with COVID-19 had positive RT-PCR test results and severe organ system involvement. EXPOSURE SARS-CoV-2. MAIN OUTCOMES AND MEASURES Presenting symptoms, organ system complications, laboratory biomarkers, interventions, and clinical outcomes. Multivariable regression was used to compute adjusted risk ratios (aRRs) of factors associated with MIS-C vs COVID-19. RESULTS Of 1116 patients (median age, 9.7 years; 45% female), 539 (48%) were diagnosed with MIS-C and 577 (52%) with COVID-19. Compared with patients with COVID-19, patients with MIS-C were more likely to be 6 to 12 years old (40.8% vs 19.4%; absolute risk difference [RD], 21.4% [95% CI, 16.1%-26.7%]; aRR, 1.51 [95% CI, 1.33-1.72] vs 0-5 years) and non-Hispanic Black (32.3% vs 21.5%; RD, 10.8% [95% CI, 5.6%-16.0%]; aRR, 1.43 [95% CI, 1.17-1.76] vs White). Compared with patients with COVID-19, patients with MIS-C were more likely to have cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% [95% CI, 42.4%-52.0%]; aRR, 2.99 [95% CI, 2.55-3.50] vs respiratory involvement), cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% [95% CI, 4.7%-10.6%]; aRR, 2.49 [95% CI, 2.05-3.02] vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% [95% CI, 2.3%-7.3%]; aRR, 2.29 [95% CI, 1.84-2.85] vs respiratory involvement). Patients with MIS-C had higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7, P < .001), higher C-reactive protein level (median, 152 mg/L vs 33 mg/L; P < .001), and lower platelet count (<150 ×103 cells/μL [212/523 {41%} vs 84/486 {17%}, P < .001]). A total of 398 patients (73.8%) with MIS-C and 253 (43.8%) with COVID-19 were admitted to the intensive care unit, and 10 (1.9%) with MIS-C and 8 (1.4%) with COVID-19 died during hospitalization. Among patients with MIS-C with reduced left ventricular systolic function (172/503, 34.2%) and coronary artery aneurysm (57/424, 13.4%), an estimated 91.0% (95% CI, 86.0%-94.7%) and 79.1% (95% CI, 67.1%-89.1%), respectively, normalized within 30 days. CONCLUSIONS AND RELEVANCE This case series of patients with MIS-C and with COVID-19 identified patterns of clinical presentation and organ system involvement. These patterns may help differentiate between MIS-C and COVID-19.
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Affiliation(s)
- Leora R. Feldstein
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Mark W. Tenforde
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Erica Billig Rose
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Vijaya L. Soma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Cindy Bowens
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children’s Medical Center Dallas, Dallas
| | - Mia Maamari
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children’s Medical Center Dallas, Dallas
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Becky J. Riggs
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John S. Giuliano
- Division of Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children’s Hospital, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Gwenn E. McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Stephanie P. Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital
| | - Tracie C. Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital
| | - Laura L. Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Charlotte V. Hobbs
- Division of Infectious Diseases, Department of Pediatrics, Department of Microbiology, University of Mississippi Medical Center, Jackson
| | - Natasha B. Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Christopher J. Babbitt
- Division of Pediatric Critical Care, Miller Children’s and Women’s Hospital of Long Beach, Long Beach, California
| | - Janet R. Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children’s Hospital, Little Rock
| | - Katharine N. Clouser
- Division of Hospital Medicine, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey
| | - Natalie Z. Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, California
| | - Tamara T. Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children’s Hospital of New Orleans, New Orleans
| | - Lincoln S. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Sabrina M. Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit
| | - Sheemon P. Zackai
- Pediatric Critical Care Medicine, Department of Pediatrics, Icahn School of Medicine at the Mount Sinai Kravis Children’s Hospital, New York, New York
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City
| | - Ryan A. Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio
| | - Steven M. Horwitz
- Department of Pediatrics, Division of Critical Care, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ryan W. Carroll
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Elizabeth H. Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Bria M. Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Ashley M. Jackson
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cameron C. Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Manish M. Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
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Wong HR, Reeder RW, Banks R, Berg RA, Meert KL, Hall MW, McQuillen PS, Mourani PM, Chima RS, Sorenson S, Varni JW, McGalliard J, Zimmerman JJ. Biomarkers for Estimating Risk of Hospital Mortality and Long-Term Quality-of-Life Morbidity After Surviving Pediatric Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation Investigation. Pediatr Crit Care Med 2021; 22:8-15. [PMID: 33003178 PMCID: PMC7790971 DOI: 10.1097/pcc.0000000000002572] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Life After Pediatric Sepsis Evaluation investigation recently reported that one-third of children who survive sepsis experience significant health-related quality-of-life impairment compared with baseline at 1 year after hospitalization. Pediatric Sepsis Biomarker Risk Model is a multibiomarker tool for estimating baseline risk of mortality among children with septic shock. We determined if the Pediatric Sepsis Biomarker Risk Model biomarkers have predictive capacity for estimating the risk of hospital mortality and long-term health-related quality-of-life morbidity among children with community-acquired septic shock. DESIGN Secondary analysis. SETTING Twelve academic PICUs. PATIENTS A subset of Life After Pediatric Sepsis Evaluation subjects (n = 173) with available blood samples. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three predefined outcomes from the Life After Pediatric Sepsis Evaluation investigation were evaluated: all-cause hospital mortality (n = 173), and the composite outcome of mortality or persistent, serious deterioration of health-related quality of life (> 25% below baseline) among surviving children at 1 month (n = 125) or 3 months (n = 117). Pediatric Sepsis Biomarker Risk Model had an area under the receiver operating characteristic curve of 0.73 (95% CI, 0.59-0.87; p = 0.002) for estimating the risk of hospital mortality and was independently associated with increased odds of hospital mortality. In multivariable analyses, Pediatric Sepsis Biomarker Risk Model was not independently associated with increased odds of the composite outcome of mortality or deterioration of persistent, serious deterioration health-related quality of life greater than 25% below baseline. A new decision tree using the Pediatric Sepsis Biomarker Risk Model biomarkers had an area under the receiver operating characteristic curve of 0.87 (95% CI, 0.80-0.95) for estimating the risk of persistent, serious deterioration health-related quality of life at 3 months among children who survived septic shock. CONCLUSIONS Pediatric Sepsis Biomarker Risk Model had modest performance for estimating hospital mortality in an external cohort of children with community-acquired septic shock. The Pediatric Sepsis Biomarker Risk Model biomarkers appear to have utility for estimating the risk of persistent, serious deterioration of health-related quality of life up to 3 months after surviving septic shock. These findings suggest an opportunity to develop a clinical tool for early assignment of risk for long-term health-related quality-of-life morbidity among children who survive septic shock.
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Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | - Patrick S McQuillen
- Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | | | - Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Julie McGalliard
- Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Jerry J Zimmerman
- Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
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