IMPORTANCE After initial resuscitation, critically ill children may accumulate fluid and develop fluid overload. Accruing evidence suggests that fluid overload contributes to greater complexity of care and worse outcomes. OBJECTIVE To describe the methods to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children. DATA SOURCES Systematic search of MEDLINE, EMBASE, Cochrane Library, trial registries, and selected gray literature from inception to March 2017. STUDY SELECTION Studies of children admitted to pediatric intensive care units that described fluid balance or fluid overload and reported outcomes of interest were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS All stages were conducted independently by 2 reviewers. Data extracted included study characteristics, population, fluid metrics, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. Narrative description of fluid assessment methods and fluid overload definitions was done. When feasible, pooled analyses were performed using random-effects models. MAIN OUTCOMES AND MEASURES Mortality was the primary outcome. Secondary outcomes included treatment intensity, organ failure, and resource use. RESULTS A total of 44 studies (7507 children) were included in this systematic review and meta-analysis. Of those, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case-control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The proportion of children with fluid overload varied by case mix and fluid overload definition (median, 33%; range, 10%-83%). Fluid overload, however defined, was associated with increased in-hospital mortality (17 studies [n = 2853]; odds ratio [OR], 4.34 [95% CI, 3.01-6.26]; I 2 = 61%). Survivors had lower percentage fluid overload than nonsurvivors (22 studies [n = 2848]; mean difference, −5.62 [95% CI, −7.28 to −3.97]; I 2 = 76%). After adjustment for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage fluid overload (11 studies [n = 3200]; adjusted OR, 1.06 [95% CI, 1.03-1.10]; I 2 = 66%). Fluid overload was associated with increased risk for prolonged mechanical ventilation (>48 hours) (3 studies [n = 631]; OR, 2.14 [95% CI, 1.25-3.66]; I 2 = 0%) and acute kidney injury (7 studies [n = 1833]; OR, 2.36 [95% CI, 1.27-4.38]; I 2 = 78%). CONCLUSIONS AND RELEVANCE Fluid overload is common and is associated with substantial morbidity and mortality in critically ill children. Additional research should now ideally focus on interventions aimed to mitigate the potential for harm associated with fluid overload.

Disclosure: The authors declare no conflict of interest. 1. Research is needed to focus on evaluating the validity and outcome associations of different methods of defining baseline SCr in neonates, which consider the physiological changes occurring in SCr in early neonatal life 2. Research is needed to develop SCr-based neonatal AKI definitions by studying newborn infants at varying gestational and postnatal ages, from the first few weeks of life, compared with older age groups 3. Studies evaluating neonatal AKI and long-term outcomes should be powered to evaluate the association between at least stage 2 AKI and outcomes Use of urine output change as a criterion for defining AKI in newborn infants 4. Research is needed to further evaluate urine output-defined AKI in neonatal AKI studies, including comparison with SCr-AKI definition and outcome associations 5. Research is needed to define "volume overload" or "change in volume status/balance" by evaluating and comparing studies that precisely measured urine output and incorporating the findings in the definition of neonatal AKI 6. Urine output and/or volume overload-based neonatal AKI definitions need to be evaluated in neonates of varying gestational and postnatal ages, comparing the first week of life with later periods Use of other serum and urine biomarkers for a neonatal AKI definition 7. Future studies need to evaluate novel AKI biomarkers in neonates for AKI diagnosis and prediction of short-and long-term neonatal outcomes 8. Studies are needed to elucidate neonatal clinical and physiologic factors that affect AKI biomarker concentrations independent of renal function

Objective: To investigate whether the significant and substantive findings from a previous study of youth mental health literacy (MHL) could be replicated using the same methods in another population. Method:We examined the impact of a curriculum resource, the Mental Health and High School Curriculum Guide (The Guide), taught by usual classroom teachers on students' knowledge and attitudes related to mental health and mental illness in Canadian secondary schools. Survey data were collected before, immediately after, and 2 months after implementation of The Guide by teachers in usual classroom teaching. We conducted paired-sample t tests and calculated the Cohen d value to determine outcomes and impact of the curriculum resource application. Results:One hundred fourteen students were matched for analysis of knowledge data and 112 students were matched for analysis of attitude data at pre-intervention, postintervention, and 2-month follow-up time periods. Following classroom exposure to the curriculum resource, students' knowledge scores increased significantly and substantively, compared with baseline (P < 0.001, d = 1.11), and this was maintained at 2-month follow-up (P < 0.001, d = 0.91). Similar findings for attitude improvement were found (P < 0.001, d = 0.66), and this improvement was maintained at 2-month follow-up (P < 0.001, d = 0.52). Conclusions:These findings corroborate those from a previous study conducted in a different location. Taken together these results suggest a simple but effective approach to improving MHL in young people by embedding a classroom resource, delivered by usual classroom teachers in usual school settings.

Earlier, better prediction of severe AKI has the potential to improve AKI associated patient outcomes. Compared to isolated, context-free changes in SCr, renal angina risk assessment improved accuracy for prediction of severe AKI in critically ill children and young adults.