You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Does Pediatric Mechanical Ventilation Affect Neurocognitive Function?

  • Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 4/8/2022
  • Valid for credit through: 4/8/2023
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, pediatricians, pediatric critical care specialists and nurses, nurse practitioners, and other members of the healthcare team who treat and manage children with a history of severe illness.

The goal of this activity is for learners to be better able to understand the long-term effects of mechanical ventilation during early childhood.

Upon completion of this activity, participants will:

  • Assess variables associated with neurologic complications after pediatric intensive care unit admission
  • Evaluate neurocognitive outcomes of children who underwent mechanical ventilation at an early age
  • Outline implications for the healthcare team


Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.

News Author

  • Batya Swift Yasgur, MA, LSW

    Freelance writer, Medscape


    Disclosure: Batya Swift Yasgur, MA, LSW, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Lisa Simani, APRN, MS, ACNP, has disclosed no relevant financial relationships.

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Does Pediatric Mechanical Ventilation Affect Neurocognitive Function?

Authors: News Author: Batya Swift Yasgur, MA, LSW; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/8/2022

Valid for credit through: 4/8/2023


Clinical Context

Previous research has suggested that approximately 30% of patients discharged from the pediatric intensive care unit (PICU) suffer subsequent neurologic and functional morbidity, and that this effect may be more pronounced among young children. Shein and colleagues assessed the prevalence of neurologic morbidity among previously admitted children admitted to the PICU between the ages of 0 and 2 years; their results were published in the December 2017 issue of Pediatric Critical Care Medicine.[1]

A total of 3751 children had data at hospital discharge after bronchiolitis, and 9516 were followed at subsequent hospitalizations for evidence of neurologic complications or disability: 18.6% of children had a neurologic complication or disability at discharge, and the rate of these outcomes at subsequent hospitalization was 11.6%. The application of mechanical ventilation was significantly associated with a higher risk for neurologic complications or disability in the short- and long-term, but children's age at admission, sex, and race/ethnicity were not.

The current study expands on this previous research by focusing on the neurologic outcomes of children admitted to the PICU with respiratory failure.

Study Synopsis and Perspective

Children who survive an episode of acute respiratory failure that requires invasive mechanical ventilation may be at risk for slightly lower long-term neurocognitive function, new research suggests.

Investigators found lower IQs in children without previous neurocognitive problems who survived PICU admission for acute respiratory failure compared with their biological siblings.

Although this magnitude of difference was small on average, more than twice as many patients than siblings had an IQ of 85 or lower, and children hospitalized at the youngest ages did worse than their siblings.

"Children surviving acute respiratory failure may benefit from routine evaluation of neurocognitive function after hospital discharge and may require serial evaluation to identify deficits that emerge over the course of child's continued development to facilitate early intervention to prevent disability and optimize school performance," study investigator R. Scott Watson, MD, MPH, professor of pediatrics, University of Washington School of Medicine, Seattle, told Medscape Medical News.

The study was published online March 1 in JAMA.[2]

Unknown Long-term Effects

"Approximately 23 700 US children undergo invasive mechanical ventilation for acute respiratory failure annually, with unknown long-term effects on neurocognitive function," the authors write.

"With improvements in pediatric critical care over the past several decades, critical illness-associated mortality has improved dramatically, [but] as survivorship has increased, we are starting to learn that many patients and their families suffer from long-term morbidity associated with the illness and its treatment," said Dr Watson, who is the associate division chief, Pediatric Critical Care Medicine, Seattle Children's Hospital, Center for Child Health, Behavior, and Development.

Animal studies "have found that some sedative medications commonly used to keep children safe during mechanical ventilation may have detrimental neurologic effects, particularly in the developing brain," Dr Watson added.

To gain a better understanding of this potential association, the researchers turned to a subset of participants in the previously conducted Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial of pediatric patients receiving mechanical ventilation for acute respiratory failure.

For the current study (RESTORE-Cognition), multiple domains of neurocognitive function were assessed 3 to 8 years after hospital discharge in trial patients who did not have a history of neurocognitive dysfunction, as well as matched, healthy siblings.

To be included in the study, the children had to be 8 years old or younger at trial enrollment, have a Pediatric Cerebral Performance Category (PCPC) score of 1 (normal) before PICU admission, and have no worse than moderate neurocognitive dysfunction at PICU discharge.

Siblings of enrolled patients were required to be between 4 and 16 years old at the time of neurocognitive testing, have a PCPC score of 1, have the same biological parents as the patient, and live with the patient.

The primary outcome was IQ, estimated by the age-appropriate Vocabulary and Block Design subtests of the Wechsler Intelligence Scale. Secondary outcomes included attention, processing speed, learning and memory, visuospatial skills, motor skills, language, and executive function. Enough time was allowed after hospitalization "for transient deficits to resolve and longer-lasting neurocognitive sequelae to manifest."

"Uncertain" Clinical Importance

Of the 121 sibling pairs (67% non-Hispanic White, 47% from families in which 1 or both parents worked full-time), 116 were included in the primary outcome analysis, and 66 to 119 were included in analyses of secondary outcomes.

Patients had been in the PICU at a median (IQR) age of 1.0 (0.2-3.2) years and had received a median of 5.5 (3.1-7.7) days of invasive mechanical ventilation.

The median age at testing for patients and matched siblings was 6.6 (IQR, 5.4-9.1) and 8.4 (IQR, 7.0-10.2) years, respectively. Interviews with parents and testing of patients were conducted a median of 3.8 (IQR, 3.2-5.2) and 5.2 (IQR, 4.3-6.1) years, respectively, after hospitalization.

The most common etiologies of respiratory failure were bronchiolitis and asthma and pneumonia (44% and 37%, respectively). Beyond respiratory failure, most patients (72%) also had experienced multiple organ dysfunction syndrome.

Patients had a lower mean estimated IQ compared with the matched siblings (101.5 vs 104.3; mean difference, −2.8 [95% confidence interval (CI), −5.4 to −0.2]), and more patients than siblings had an estimated IQ of 5 or less but not of 70 or less.

Patients also had significantly lower scores on nonverbal memory, visuospatial skills, and fine motor control (mean differences, −0.9 [95% CI, −1.6 to −0.3], −0.9 [95% CI, −1.8 to −0.1], and −3.1 [95% CI, −4.9 to −1.4], respectively) compared with matched siblings. They also had significantly higher scores on processing speed (mean difference, 4.4 [95% CI, 0.2-8.5]). There were no significant differences in the other secondary outcomes.

Differences in scores between patients and siblings varied significantly by age at hospitalization in several tests--for example, Block Design scores in patients were lower than those of siblings for patients hospitalized at younger than 1 year vs those hospitalized between ages 4 and 8 years.

"When adjusting for patient age at PICU admission, patient age at testing, sibling age at testing, and duration between hospital discharge and testing, the difference in estimated IQ between patients and siblings remained statistically significantly different," the authors note.

The investigators point out several limitations, including the fact that "little is known about sibling outcomes after critical illness, nor about whether parenting of siblings or child development differs based on birth order or on relationship between patient critical illness and the birth of siblings.... If siblings also incur negative effects related to the critical illness, differences between critically ill children and the control siblings would be blunted."

Despite the statistical significance of the difference between the patients and the matched controls, ultimately, the magnitude of the difference was "small and of uncertain clinical importance," the authors conclude.

Filling a Research Gap

Commenting on the findings for Medscape Medical News, Alexandre T. Rotta, MD, professor of pediatrics and chief of the Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, said the study "addresses an important yet vastly understudied gap: long-term neurocognitive morbidity in children exposed to critical care."

Dr Rotta, who is also a coauthor of an accompanying editorial, noted that the fact that the "vast majority of children with an IQ significantly lower than their siblings were under the age of 4 years suggests that the developing immature brain may be particularly susceptible to the effects of critical illness and therapies required to treat it."[3]

The study "underscores the need to include assessments of long-term morbidity as part of any future trial evaluating interventions in pediatric critical care," he added.

The study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development for RESTORE-Cognition and by grants for the RESTORE trial from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research, National Institutes of Health. Dr Watson and coauthors have disclosed no relevant financial relationships. Dr Rotta has received personal fees from Vapotherm Inc for lecturing and development of educational materials and from Breas US for participation in a scientific advisory board, as well as royalties from Elsevier for editorial work outside the submitted work. His coauthor has disclosed no relevant financial relationships.

JAMA. Published online March 1, 2022.

Study Highlights

  • Study participants were younger than 8 years of age when admitted to the PICU for respiratory distress requiring intubation. All participants entered the PICU with normal neurocognitive function and were discharged with no more than moderate neurocognitive disability.
  • Patients who experienced cardiac arrest, who had previous neurocognitive dysfunction, or who had hospital readmission that included mechanical ventilation were excluded from the current study.
  • Patients were compared with siblings who lived with the patient. Siblings had to be 4 to 16 years of age at the time of cognitive testing and have normal neurocognitive function at study enrollment.
  • Patients and siblings underwent a thorough neurocognitive evaluation when they were at least 4 years of age. The main study outcome was the age-adjusted Vocabulary and Block Design subtests of the Wechsler Intelligence Scale, which correlates well with the full-scale IQ. Researchers also compared performance of patients and siblings on specific neurocognitive tests.
  • Study analysis was adjusted to account for patient disease severity variables.
  • 116 patient-sibling pairs provided data for study analysis. Two-thirds of the cohort was White, and most families were middle or upper class. Patients were tested at a mean age of 6.6 years compared with a mean age of 8.4 years for siblings.
  • Patients were tested at a mean of 5.2 years after hospitalization. The median age at PICU admission was 1.0 years. A total of 81% of the patients were admitted for bronchiolitis/asthma or pneumonia. The median duration of mechanical ventilation was 5.5 days.
  • The mean IQ scores in the patient and sibling groups were 101.5 and 104.3, respectively, a slight difference that was statistically significant; 17% of patients had an IQ score that was at least 15% lower than their siblings, and 8% had a score that was at least 15 points higher. A total of 16% of patients had an IQ score of 85 or less compared with 7% of siblings.
  • The difference in IQ scores was similar in analyses based on patients' age at admission and patient/sibling age at testing.
  • Patients who scored particularly low in IQ testing tended to be younger at the time of their PICU admission, but variables such as diagnosis at admission and duration of mechanical ventilation did not affect IQ results.
  • Regarding specific tests, patients performed worse than siblings on tests for nonverbal memory, visuospatial skills, and fine motor control. However, patients had superior results compared with siblings for processing speed.
  • There was no difference between patients and siblings for attention, verbal memory, expressive language, and executive function.

Clinical Implications

  • A study of previously healthy children admitted to the PICU with bronchiolitis found that 18.6% of children had a neurologic complication or disability at discharge, and the rate of these outcomes at subsequent hospitalization was 11.6%. The only significant risk factor for neurologic complication or disability was mechanical ventilation.
  • The current study finds a small IQ deficit in comparing children who were intubated in the PICU compared with their siblings. Results were mixed with regard to deficits in specific cognitive domains.
  • Implications for the healthcare team: The healthcare team should be aware that mechanical ventilation in young children may be associated with later neurocognitive deficits, although the practical effect on children's function remains uncertain.


Earn Credit

  • Print