Critical care in children has advanced significantly over the years. Along with that improvement comes a variety of issues that occur after recovery.

Children are constantly developing. They develop in four major areas. The acronym for that is PIES. This represents physical, intellectual, emotional, and social growth. All of these areas have shown negative impacts after intensive care for critical medical issues in children.

The result has been a systematic approach to minimize these negative impacts. It also has an acronym. It is called the ABCDEF Bundle.

The letter A stands for pain management. Children who are critically ill are usually in pain. There are three major components to pain management. First of all, there must be a method of ASSESSING how much pain the patient has. Secondly, there needs to be ACTIONS to prevent pain when possible. Then, if pain exists, there needs to be adequate treatment of it. The treatment is covered under the C portion of the bundle.

The B stands for BREATHING. Most critically ill patients have breathing issues. Many need to be put on a ventilator to support breathing. Managing oxygen levels and pressure levels is important. Criteria for removing the ventilator and giving a trial of spontaneous breathing are important components for removing the breathing apparatus.

The C relates to CHOICE of pain treatment and sedation. This relies on the assessment of the pain level in the first place. Children on ventilators are all sedated to stop them from fighting against the machine. However, when the ventilator is discontinued, there is an ongoing need to treat pain. There are a variety of medications used. Sometimes these include opioid related medications. Care must be taken to reduce symptoms of withdrawal from those medications.

The D means DELIRIUM. Most patients in an ICU have issues with alertness. It tends to occur in about 80 percent of that group. This is one of the major contributors to the post-treatment impact on PIES. That is especially true of the intellectual and emotional components.

The E refers to EARLY Mobility. Being laid up in a hospital bed with a breathing tube interferes significantly with the physical component of PIES. We have learned that the earlier this area is addressed, the better the outcomes for the patient. Many children will need to continue therapy long after hospital discharge.

The F is related to FAMILY engagement. Family involvement helps with early mobility (P in PIES). It decreases delirium (I in PIES). It reduces stress (E in PIES). It improves mental health social interactions (S in PIES). Therefore, it affects all significant areas.

Critical care used to focus only on the acute issues. We now know that there are also long term issues that can affect every part of a child’s development.