Evaluation of Patients Diagnosed with Acute Flaccid Paralysis Followed and Treated in Pediatric İntensive Care: A Multi-Center Study

Evaluation of Patients Diagnosed with Acute Flaccid Paralysis Followed and Treated in Pediatric İntensive Care: A Multi-Center Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Patients Diagnosed with Acute Flaccid Paralysis Followed and Treated in Pediatric İntensive Care: A Multi-Center Study EDIN BOTAN, MERVE BOYRAZ, SERVET YÜCE, EMRAH GÜN, HASAN ÖZEN, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3948249/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Backgroud: Acute Flaccid Paralysis (AFP) is a syndrome characterized by decreased tone (flaccidity), often presenting with respiratory and bulbar system failure, rapid onset, and weakness in the extremities. Methods: From January 1, 2018 to January 1, 2023, the clinical findings, treatment results, intensive care processes and prognoses of 68 children diagnosed with AFP who applied were evaluated retrospectively. Results: The age range of patients was between one month and 18 years, with a mean age of 7.9 ± 4.5 years. Out of the patients, 33 were male (48.5%).The average pediatric intensive care unit (PICU) stay for all AFP patients was 15.4 ± 19.5 days, and the average hospital stay was 23.3 ± 21.1 days. Among all AFP patients, 42 (61.8%) required respiratory support. All patients received intravenous immunoglobulin (IVIG) treatment. Twenty-five out of 43 Guillain-Barré syndrome (GBS) patients, seven out of 11 and transverse myelitis (TM) patients, and 11 out of 14 acute disseminated encephalomyelitis (ADEM) patients received therapeutic plasma exchange (TPE). Among the 14 intubated GBS patients, five received IVIG treatment for two days or less, and nine received IVIG treatment for four days or more. The invasive mechanical ventilation (MV) durations (in days) showed that patients who received IVIG treatment for four days or more had a significantly longer intubation period (p: 0.044). Out of GBS patients, received only IVIG (monotherapy), and received IVIG and TPE (combined) treatment. The combined treatment group had a longer PICU stay (p: 0.001). Conclusion: In our study revealed that combination therapies (IVIG and TPE or steroid and TPE) led to prolonged MV and PICU stay durations compared to monotherapies (IVIG or steroids) in AFP patients. Moreover showed that in intubated GBS cases, administering 2 g/kg/day IVIG for two days significantly reduced the duration of invasive MV. Children Acute Flaccid Paralysis İntravenous immunoglobulin Pediatric intensive care unit Guillain-Barré syndrome What is Known In cases of AFP, combined (IVIG+TPE or steroid+TPE) treatments have been shown to shorten or not alter PICU length of stay or mechanical ventilator time compared to monotherapy (IVIG or steroid). What is New: In our study, combined (IVIG+TPE or steroid+TPE) treatments prolonged the PICU hospital stay or mechanical ventilator time compared to monotherapy (IVIG or steroid), and in addition, 1g/kg/day IVIG for two days, 0.5g/kg/day for four days in intubated GBS patients. The duration of stay in mechanical ventilation was found to be shorter compared to daily IVIG administration. INTRODUCTION Acute Flaccid Paralysis (AFP) is a syndrome characterized by decreased tone (flaccidity), often presenting with respiratory and bulbar system failure, rapid onset, and weakness in the extremities ( 1 ). Acute Flaccid Myelitis (AFM) is a disease similar to polio and most commonly occurs in childhood, predominantly affecting the anterior horn of the spinal cord, leading to weakness in the extremities ( 2 ). Its pathophysiology has been particularly associated with enteroviruses, such as EV-A71 and EV-D68 ( 3 – 4 ). Additionally, various medical conditions, including Guillain-Barré syndrome (GBS), diphtheria, lesions of the anterior horn cells, and myositis, can also manifest as AFP. Other central nervous system pathologies such as spinal epidural hematomas, spinal arteriovenous fistulas, spinal infarctions, neuromyelitis optica, and spinal parasitic infections can also cause AFP ( 5 ). According to the AFM diagnostic criteria proposed by the International AFM Working Group in 2021, a definitive diagnosis of AFP can be established by the combination of abnormal spinal gray matter findings on magnetic resonance imaging (MRI) and pleocytosis in cerebrospinal fluid in the absence of alternative diagnostic factors ( 6 ). Furthermore, the Council of State and Territorial Epidemiologists and the Centers for Disease Control and Prevention define AFM as acute-onset limb weakness primarily associated with gray matter involvement of one or more spinal segments as observed on MRI ( 7 – 8 ). AFM was first recognized in California in 2012 and in Colorado in 2014. Subsequently, it was acknowledged as a global disease with hundreds of reported cases in Europe, Asia, Australia, Africa, North America, and South America ( 9 ). In AFP patients, weakness of respiratory muscles (i.e., oropharyngeal, laryngeal, tongue, retropharyngeal, intercostal, and diaphragmatic muscles) leads to the loss of airway protection, necessitating ventilatory support ( 10 ). Additionally, these patients require cardiovascular evaluation and management due to autonomic instability, making it a medical emergency ( 11 ). After the eradication of polio in many parts of the world ( 12 ), GBS is now among the most common diagnoses in AFP patients ( 13 , 14 ), with up to 30% of patients requiring invasive or non-invasive mechanical ventilation and admission to the pediatric intensive care unit (PICU) ( 15 , 16 ). Intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE) are commonly used treatments for AFP and have been reported to treat up to 92% of GBS patients in the United States ( 17 ). Corticosteroids are recommended as immunosuppressants in the treatment of refractory or severe GBS patients ( 18 ). After GBS, myelitis is also observed in the pediatric age group, with acute disseminated encephalomyelitis (ADEM) and transverse myelitis (TM) being the most common presentations ( 19 ). High-dose corticosteroids, IVIG, or TPE can be used for the treatment of both diseases ( 20 ). In this study, we aimed to review the clinical characteristics and the PICU course of 68 AFP cases to identify prognostic factors in childhood AFP. MATERIALS and METHODS Study Design and Patient Selection A retrospective descriptive study was conducted on patients diagnosed with AFP including those diagnosed with GBS, TM, and ADEM who were admitted to nine tertiary-level pediatric intensive care units (PICUs) in Turkey from January 1, 2018, to January 1, 2023. Exclusion criteria were as follows: postoperative patients, patients with congenital neuromuscular weakness, traumatic head and spinal cord injuries, electrolyte disturbances (such as hypokalemia), or acute poisoning (organophosphates). Patients with encephalitis and weakness related to tumors were also excluded from the study. Ethics declarations Ethics approval The ethical endorsement for the research was obtained from the Van Regional Training and Research Hospital Human Research Ethics Committee (Decision no: 2023/01-10. Date: 01.04.2022). Before the research, all adolescents to be included in the sample and their parents expressed their consent for participation in the research both verbally and in written format via the “informed consent form.” Consent to participate Before the research, all adolescents to be included in the sample and their parents expressed their consent for participation in the research both verbally and in written format via the “informed consent form.” Conflict of interest The authors declare no competing interests. Data Collection and Definition The age, gender, presenting complaints, physical examination findings at admission, history of previous infections, type of infection, presence of bulbar and autonomic dysfunction, cranial nerve involvement, degree of weakness, pattern of paralysis, need for respiratory support, cerebral and spinal MRI findings, duration of PICU stay, and duration of invasive/non-invasive mechanical ventilation (MV) of the patients were collected and compared. Their treatment protocols were also compared; whereas the GBS group received either IVIG alone or IVIG and TPE, the ADEM/TM group received either steroids alone or steroids and TPE. Some GBS patients were administered 1 g/kg/day of IVIG for two days, while others received 0.5 g/kg/day for four days. All patients received steroids at a dose of 30 mg/kg/day (maximum 1000 mg) for five days. The duration of PICU stay (in days) and the duration of invasive MV were evaluated. Patients diagnosed with GBS, TM, and ADEM were compared within their respective groups in terms of the impact of different treatment modalities on prognosis. Records from nine centers were retrospectively reviewed for the study. Autonomic and Bulbar Dysfunction Autonomic dysfunction was classified under this study as including high or low blood pressure, cardiac arrhythmias (asystole, bradycardia, sinus tachycardia, and atrial and ventricular tachyarrhythmias), urinary retention (bladder dysfunction), and sphincter dysfunction. Bulbar dysfunction was classified under this study as including difficulty in swallowing (dysphagia), facial paralysis, ophthalmoplegia, diplopia, dysarthria, speech disorders, and voice changes. Sample Collection in AFP Patients Samples were collected from AFP patients in accordance with the World Health Organization (WHO) guidelines. A minimum of two samples were taken from each case at least 24 hours apart within 14 days of the onset of paralysis. Each sample had a volume of at least 8–10 grams, and the second sample was collected within 72 hours of the first one. Samples were stored and transported under adequate cold chain conditions, without any leakage or drying, and were appropriately documented (21). Stool samples were collected in sufficient quantity and number from AFP-diagnosed patients following the WHO recommendations and were transported appropriately to public health units. Data Analysis Categorical variables were presented as numbers and percentages, while numerical variables were presented as mean ± standard deviation (or median, minimum-maximum). The Pearson chi-square test was used for comparing categorical measurements between groups. Independent sample t-tests were used for the comparison of normally distributed numerical measurements between two groups, and one-way analysis of variance was used for comparisons involving more than two groups with normal distribution. For numerical measurements that did not follow a normal distribution, the Mann-Whitney U test was used for comparisons of two groups, and the Kruskal-Wallis test was used for comparisons involving more than two groups. The IBM SPSS Statistics Version 28.0 package program was used for statistical analysis. The significance level (p) for all tests was set at 0.05. RESULTS Between the years 2018 and 2023, a total of 68 AFP cases were followed in nine tertiary-level PICU centers in Turkey. The age range of patients was between one month and 18 years, with a mean age of 7.9 ± 4.5 years. Out of the patients, 33 were male (48.5%) and 35 were female (51.5%). The patients were diagnosed with 43 cases of GBS (63.2%), 11 cases of TM (16.2%), and 14 cases of ADEM (20.6%). Among the 43 GBS patients, 18 were male (41.9%), 25 were female (58.1%), with a mean age of 7.5 ± 4 years. For the 14 ADEM patients, 10 were male (71.4%), four were female (28.6%), with a mean age of 7.8 ± 5 years. Also in the 11 TM patients, five were male (45.5%), six were female (54.5%), with a mean age of 8.5 ± 5.5 years. The presence of an infection was detected before the onset of AFP symptoms in 39 patients (57.4%), while no infection was detected before the onset of symptoms in 29 patients (42.6%). When GBS, TM, and ADEM patients were evaluated separately, among the 43 GBS patients, 20 (46.5%) had upper respiratory tract infections (URTI), and five (11.6%) had acute gastrointestinal infections (AGI). Among the 11 TM patients, three (27.3%) had URTI, and two (18.2%) had a history of AGI. Additionally, among the 14 ADEM patients, three (21.5%) had AGI, and 10 (71.4%) had a history of URTI (Table 1). Presentation Findings In 67 out of 68 patients (98.5%), extremity weakness was present (GBS: 43/43, TM: 11/11, ADEM: 13/14). Among the 43 GBS patients, 37 (86%) had symmetric weakness, while six patients (14%) had asymmetric weakness. In the TM patients, eight (72.7%) had symmetric weakness, and three (27.3%) had asymmetric weakness. For ADEM patients, six (42.9%) had symmetric weakness, and seven (57.1%) had asymmetric weakness. Overall, symmetric weakness was observed in 51 patients (75%), while asymmetric weakness was present in 16 patients (23.5%), and no muscle weakness was present in one patient (1.5%). Among the 68 AFP patients, 47 (69.1%) had weakness in both the lower and upper extremities, while 19 patients (28%) had weakness only in the lower extremities, and one patient (1.5%) had weakness only in the upper extremities. Among the 43 GBS patients, all of them had weakness in the lower extremities, and 31 patients (72.1%) had weakness in both the lower and upper extremities.In the 11 TM patients, seven (63.6%) had weakness in both the lower and upper extremities, while 10 patients (90.9%) had weakness only in the lower extremities.Fourteen ADEM patients, 13 (92.9%) had weakness in the lower extremities, and 10 (71.5%) had weakness in both the lower and upper extremities (Table 1). Autonomic Dysfunction In eight patients who were younger than two years old, polio virus was not detected in the analysis of their stool, blood, and body fluids. In addition, in patients younger than two years old, bulbar symptoms were evaluated, including swallowing difficulties, facial involvement, and high-pitched crying, apart from urinary retention. Out of the 43 GBS patients, 14 (32.6%) showed signs of autonomic dysfunction. Among them, 10 patients had only sphincter involvement, two patients had sphincter involvement along with changes in blood pressure, and one patient had sphincter involvement along with arrhythmia. Among the 11 TM patients, only five (45.5%) had autonomic dysfunction (sphincter dysfunction). Among the 14 ADEM patients, four (28.6%) showed signs of autonomic dysfunction (two patients had only sphincter dysfunction, and two patients had both sphincter dysfunction and cardiovascular dysfunction). Out of all 68 patients, 29 (42.6%) had bulbar symptoms (GBS: 20/43, ADEM: 6/14, TM: 3/11). Cranial nerve involvement was observed (GBS/ADEM/TM: 11/4/2) in 17 patients (25%). All patients had completed their vaccination schedules according to their age, and no patient in the study was diagnosed with AFP after vaccination. Imaging Findings Brain and spinal MRI were performed for all cases. Central gray matter lesions affecting the spinal cord were observed in all patients. In most cases, lesions affecting a long segment of the cervical and thoracic spine were present (median of 17 segments; range 3–20). Brainstem lesions, mainly occurring in the pons or medulla, were prevalent (42 cases; 61.7%). PICU Process The average PICU stay for all AFP patients was 15.4 ± 19.5 days, and the average hospital stay was 23.3 ± 21.1 days. Specifically, the average PICU stay for GBS/TM/ADEM patients was 13.2 ± 17.3/16.5 ± 24.1/21.4 ± 21.9 days, respectively, and the average hospital stay was 20.3 ± 20.4/24.3 ± 23.9/31.5 ± 20.1 days, respectively. Among all AFP patients, 42 (61.8%) required respiratory support. Specifically, 23 (33.8%) patients were intubated, seven (10.3%) patients received non-invasive MV, and 12 (17.6%) patients were managed with a reservoir mask for oxygen supplementation. Six patients (8.8%) who remained intubated for a long time were unable to be weaned off mechanical ventilation and were discharged with a tracheostomy. Among the 43 GBS patients, 14 were intubated, five received non-invasive MV, and tracheostomy was performed in three patients. Among the 11 TM patients, three were intubated, and tracheostomy was performed in two patients. Among the 14 ADEM patients, six were intubated, two received non-invasive MV, and tracheostomy was performed in one patient (Table 1). Treatment Modalities All patients received IVIG treatment. Twenty-five out of 43 GBS patients (58.1%), seven out of 11 TM patients (63.6%), and 11 out of 14 ADEM patients (78.6%) received TPE. Among the 14 intubated GBS patients, five received IVIG treatment for two days or less, and nine received IVIG treatment for four days or more. The evaluation of treatment durations in terms of prognosis revealed no significant difference in PICU stay (in days) between patients who received IVIG treatment for two days or less and those who received it for four days or more (p: 0.16). However, the evaluation of invasive MV durations (in days) showed that patients who received IVIG treatment for four days or more had a significantly longer intubation period (p: 0.044) (Table 2). Out of 43 GBS patients, 17 received only IVIG (monotherapy), and 26 received IVIG and TPE (combined) treatment. The combined treatment group had a longer PICU stay (p: 0.001) (Table 2). Among the 14 intubated GBS patients, 12 received additional plasmapheresis treatment in addition to IVIG. Six patients received five or fewer sessions of TPE, while six patients received six or more sessions. There was no significant difference in average PICU stay (24.7 ± 19.4 vs. 33.5 ± 32.8 days) or average mechanical ventilation duration (29.3 ± 23.3 vs. 21.8 ± 20.5 days) between these two patient groups (p: 0.93 and p: 0.68, respectively) (Table 2). Among the 14 intubated GBS patients, two received only IVIG, and 12 received IVIG and TPE treatment. Although there was no significant difference in PICU stay (7 ± 8 vs. 29 ± 26) or average duration of invasive MV (3.5 ± 0.7 vs. 25.5 ± 21.3) (p: 0.132 and p: 0.088, respectively), it was observed that PICU and invasive MV durations were considerably longer in the combined treatment group (Table 2). Out of 25 patients diagnosed with ADEM and TM, seven received steroid treatment, 15 received steroid and TPE, and three received only TPE. There was no significant difference in PICU stay between patients who received monotherapy and those who received combined treatment (p: 0.301) (Table 2). In our study, two patients (who were diagnosed solely with ADEM) died. The mortality rate in our study was 2.9%. DISCUSSION AFP is a rare and complex disease that is not fully understood (22). GBS is the most common cause of AFP in children (23). In reported studies GBS is seen in AFP as between 31 and 74% to (24–25). In our study, consistent with the literature, GBS was the most common cause, accounting for 63.2% of cases. GBS has a global distribution and affects all races and ages, including newborns (26). AFP is predominantly a childhood disease, with a median age of 6.3 years. It is more commonly observed in males (27). In our study, the mean age of AFP patients was 7.9 ± 4.5 years, and contrary to the literature, 51.5% were females. In most cases, AFP develops following a post-viral infection. Many affected individuals report a febrile prodromal period with respiratory symptoms preceding the onset of paralysis (28). In our study, more than half of the cases (57.4%) had a history of infection. The neurological condition primarily involves lesions targeting the anterior horn cells of the spinal cord and motor nuclei of the brainstem. Although enteroviruses (especially enterovirus A71) and certain coxsackievirus strains have been implicated, enterovirus D68 has been the dominant virus suspected in biennial AFM outbreaks (29). In our study, all AFP patients underwent spinal and cranial MRI, revealing lesions primarily affecting the central gray matter of the spinal cord. Radiological findings served as supportive evidence in diagnosing AFP. The radiological findings of our patients were consistent with the literature. In patients, weakness in one extremity can range from mild to moderate, progressing to complete paralysis of all extremities and axial and bulbar muscles (30). In our study, weakness in extremities was present in 98.5% of patients. Among them, 69.1% had weakness in both upper and lower extremities, 28% had weakness only in the lower extremities, and 1.5% had weakness only in the upper extremity. A study reported that the most commonly recorded neurological signs of GBS were the absence or decrease of reflexes in over 95% of cases and weakness in one or more extremities (31). Approximately one-third of hospitalized patients with AFP require intubation and ventilation (30). Other studies have indicated that sensory impairment or loss, bulbar paralysis, and other cranial nerve palsies were observed in about a quarter of GBS cases, and respiratory depression was found in one-third of cases. Additionally, in all reported children with TM, lower extremity weakness was present, and half of them had upper extremity involvement, while four cases showed bulbar palsy, and two others had cranial nerve involvement. One-third of cases were admitted to the PICU and required mechanical ventilation (31). In our study, the distribution of extremity weakness and the frequency of autonomic and bulbar dysfunction in both the GBS and TM groups was found to be consistent with the literature. The rate of intubation in AFP patients followed in the PICU was also consistent with the literature. Among intubated AFP cases, GBS was the most common diagnosis (14/23 patients). These findings are in line with the literature. PICU and Treatment Modalities GBS In the management of children and adolescents with GBS, initiation of mechanical ventilation is recommended when initial signs of respiratory fatigue are observed and before clinical decompensation occurs. Additionally, in cases of dysphagia associated with saliva aspiration or inadequate airway clearance, intubation is advised (32). Approximately one-third of pediatric GBS patients require ventilator support due to respiratory muscle paralysis, and about 10% of patients die because of the disease and its complications (33). In our series, respiratory failure progressed rapidly in children with upper limb and cranial nerve involvement. Ventilatory support, both invasive and non-invasive, was provided to 26 (60.4%) patients with respiratory distress. Fourteen (32.5%) patients were managed with invasive mechanical ventilation. The rate of respiratory support was similar to that of the literature. If there is no improvement in respiratory function and/or secretion management after one to two weeks of respiratory therapy, tracheostomy is recommended (32). In our study, we waited for four weeks or more to evaluate the response of patients to current treatments (IVIG and TPE). Tracheostomy was performed on three patients who remained on mechanical ventilation for four weeks or more. Our experience suggests that treatment efficacy requires at least four weeks, and therefore, tracheostomy should take place after the fourth week for optimal results. GBS patients may experience autonomic nervous system involvement in about 25% of cases, often presenting as blood pressure instability, sinus tachycardia, abnormal pupillary reflex, or sweating abnormalities (34). In our study, autonomic dysfunction was observed in 14 (32.5%) patients (10 patients with only sphincter involvement, two patients with sphincter involvement and blood pressure changes, and one patient with sphincter involvement and arrhythmia). Our findings were consistent with the literature. The management of severe GBS (i.e., loss of walking ability without assistance) in children and adolescents is recommended to be treated with IVIG (32). Cochrane Review authors reported that in five studies involving 536 patients, there was no significant difference in the effects on recovery between IVIG and TPE, and the combination of IVIG following TPE did not provide any significant additional benefit during recovery (35). In a multi-center study, no significant difference in effectiveness was reported between TPE, IVIG, and combination (IVIG and TPE) treatments (23). Kesici et al. reported that the zipper method (first TPE, then IVIG) as a new treatment method reduces mortality, accelerates weaning from mechanical ventilation, and shortens hospital stay with excellent results in patients with severe Guillain-Barré syndrome requiring intensive care (36). In our study, we compared the PICU stay durations of patients who received only IVIG (17 patients) with those who received IVIG and TPE (26 patients). The PICU stay duration was found to be significantly longer in the IVIG and TPE group (p: 0.001). Among the 14 intubated GBS patients, although there was a clear difference in PICU stay duration and invasive MV duration between the two groups (with longer duration in the IVIG and TPE group), the p value did not reach significance due to the small sample size (only two intubated patients in the IVIG group). In another study, when comparing the group treated with IVIG to the group not receiving IVIG, it was reported that the number of children requiring endotracheal intubation and mechanical ventilation and the duration of mechanical ventilation were significantly lower in the IVIG-treated group. The author also reported that IVIG treatment significantly improved the outcomes in children with severe GBS, reducing the need for intubation and mechanical ventilation and shortening the duration of stay in the intensive care unit (37). Our study and the literature suggest that the first treatment option for GBS patients should be IVIG, and its early administration can shorten PICU and invasive MV durations. In the absence of systematic dose interval study data, IVIG is usually administered in children as in adults with acute GBS, ie 2 g/kg body weight distributed over 4 to 5 consecutive days as a single course. It has been reported that reducing the IVIG administration time to 2 g/kg in 2 days did not show any improvement effect. In one study, it was reported that there was no significant difference in neurological improvement between two days of 2 g/kg IVIG administration and IVIG administered over five days (38). The potential benefits of IVIG treatment are considered to be greatest when administered in the early stages of the disease. Intravenous steroids and plasma exchange are sometimes used for their potential immunomodulatory effects, but whether the potential harm outweighs the therapeutic benefit has been debated (39). In contrast to the literature, our study found that administering IVIG at 2 g/kg for two days did not change the PICU stay duration compared to administering it over four days, but it shortened the duration of invasive MV. Further studies are needed to investigate the optimal dose intervals. Additionally, our study did not observe a significant difference in PICU and invasive MV durations between patients receiving five or fewer TPE sessions and those receiving six or more TPE sessions. Due to the limited number of studies in the literature, we were unable to make a direct comparison of our data. TM and ADEM Acute demyelinating diseases of the central nervous system include acute disseminated encephalomyelitis (ADEM), multiple sclerosis, TM, myelin oligodendrocyte glycoproteins (MOG) antibody-associated demyelination, and neuromyelitis optical spectrum disorder (40). In our study, we included 25 pediatric patients diagnosed with ADEM and TM. The American Society for Apheresis recommends the use of TPE in acute demyelinating diseases (41). Our study aimed to review the PICU process in pediatric patients with acute demyelinating syndrome attacks who received either steroid or steroid and TPE treatment modalities. In the study, only the duration of PICU stay and of invasive MV in patients who received steroid treatment alone and in those who received steroid and TPE treatment were evaluated. In cases suspected of ADEM, intravenous steroids, such as methylprednisolone, are commonly used (42). This treatment is typically dosed at 30 mg/kg (up to 1000 mg) per day for three to five days. Alternative regimens, such as lower doses of methylprednisolone at 10 mg/kg or dexamethasone at 1–2 mg/kg/day for three to five days, have also been reported (43). In our study, patients diagnosed with ADEM and TM received 30 mg/kg/day (max 1000 mg) of steroids for five days. Subsequently, an oral corticosteroid, such as methylprednisolone, is commonly initiated at a dose of 1–2 mg/kg/day (up to 60 mg per day) and tapered by 5–10 mg per week over four to six weeks (44). Our steroid usage and tapering schedule were consistent with the literature. Following the initiation of intravenous steroids, close monitoring of the patient's clinical condition is necessary to observe any changes in mental status, motor strength, coordination, sensation, and/or vision. Lack of improvement or deterioration may indicate a poor prognosis (41). However, it is important to note that approximately 2% of ADEM cases include acute hemorrhagic leukoencephalitis with a poor prognosis and high mortality (45). ADEM is reported to be more common in children under 10 years of age (46), which is supported by our study as well. Studies have reported that approximately 3% of children with ADEM die as a result of the illness (46). In another study of 27 ADEM cases, three cases (11.1%) resulted in death. The percentage of children requiring invasive mechanical ventilation was 78% (21/27), and none of the patients received plasmapheresis (47). In our study, the mortality rate was found to be higher (2/14, 14.2%) compared to the literature. This may be attributed to the small number of patients diagnosed with ADEM in our study. Additionally, in our study, six out of 14 ADEM cases and three out of 11 TM cases required invasive MV, and the number of intubated cases was lower compared to the literature. There is a lack of studies examining the relationship between treatment planning and PICU length of stay. One important point in our study is that there was no significant difference in PICU length of stay between the two groups receiving steroid and steroid and TPE treatments. However, the relationship between steroid and combined steroid and TPE treatments and the duration of invasive mechanical ventilation could not be investigated due to the insufficient number of intubated cases (six patients with ADEM, and three patients with TM) in our study. Limitation The limitation of this study was mainly the poor quality of data as some data was missing, so they were excluded from the analysis. This study is observational and lacked a control group to evaluate treatments. Because this is a retrospective review and did not rely on a specific protocol, there are missing data. This was handled by marking “unknown” or “not done,” therefore results are based on documented findings. CONCLUSION In our study, primary outcomes revealed that combination therapies (IVIG and TPE or steroid and TPE) led to prolonged MV and PICU stay durations compared to monotherapies (IVIG or steroids). Secondary outcomes showed that in intubated GBS cases, administering 2 g/kg/day IVIG for two days significantly reduced the duration of invasive MV. Especially in GBS cases, early and shorter administration of monotherapy (IVIG) resulted in a positive effect, shortening the length of hospital stay and of invasive MV. Further research is needed to better understand the PICU process in AFP patients. Declarations Funding: The original article received no external funding. Conflicts of interest/Competing interests: The authors have no financial disclosures that would be a potential conflict of interest with the current manuscript. Ethics approval: The approval was obtained from Institutional Review Board. Consent to participate: Approval was obtained from the family of the participants. Consent for publication: Approval was obtained from the family of the participants. Availability of data and material: There is data transparency Code availability: There is not code availability Disclosures: The authors have no financial disclosures that would be a potential conflict of interest with the current manuscript. Authors' contributions Statements: EB: conceptualized and designed the study, analyzed and interpreted data, drafted the manuscript MB,SY,ŞET,HÖ,MH: contributed to study design, analyzed data, contributed to data collection EB,AA,AG,EG: collected data EET,EUB,: collected data AK,SY,KD,MD: collected data ÖÖG,FE,OD: collected data RDY,TK: contributed to drafting of the manuscript TK,RDY: conceptualized and designed the study, contributed to data analysis, contributed to drafting of the manuscript References Adewole A. Evaluation of Ondo State acute flaccid paralysis surveillance system (2009-2013). International Journal of Infectious Diseases. 2016;45:290. 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Solomon T, Willison H. Infectious causes of acute flaccid paralysis. Curr. Opin. Infect. Dis. 2003; 16: 375–81. Ryan MM. Pediatric Guillain-Barre syndrome. Curr. Opin. Pediatr. 2013; 25: 689–93. Yuki, Nobuhiro. Guillain–Barré syndrome and anti-ganglioside antibodies: a clinician-scientist’s journey. Proceedings of the Japan Academy, Series B Phys Biol Sci. 2012: 299-326. van den Berg B, Storm EF, Garssen MJP, Blomkwist-Markens PH, Jacobs BC. Clinical outcome of Guillain-Barré syndrome after prolonged mechanical ventilation. Journal of Neurology, Neurosurgery & Psychiatry. 2018);89: 949-954. Verboon C, Doets AY, Galassi G, et al. Current treatment practice of Guillain-Barré syndrome. Neurology (2019;93 :e59-e76. Eli S. Current therapeutic options in severe Guillain-Barre syndrome. Clinical neuropharmacology 2006;29: 45-51. Krupp LB, Tardieu M, Amato MP, et al. International Pediatric Multiple Sclerosis Study Group criteria for pediatric multiple sclerosis and immune-mediated central nervous system demyelinating disorders: revisions to the2 007 definitions. MultScler 2013;19:1261–1267. Tavasoli A, Tabrizi A. Acute Transverse Miyelitis in Children, Literature Review. Iran J Child Neurol. 2018;12:7-16. WorldHealthOrganization(WHO).WHOrecommendedstandardsforsurveil- lance of selected vaccine — preventable diseases. Vaccines and biologicals. Geneva: WHO; 2003. p. 31–4. Messacar K, Schreiner TL, Van Haren K, et al. Acute flaccid myelitis: A clinical Review of US cases 2012-2015. Ann Neurol. 2016;80: 326-338. Hung PL, Chang WN, Huang LT, et al. A clinical and electrophysiologic survey of childhood Guillain- Barré syndrome. Pediatr Neurol 2004;30:86-91. Olive JM, Castillo C, Castro RG, de Quadros CA. Epidemio- logical study of Guillain–Barré syndrome in children <15 years of age in Latin America. J. Infect. Dis. 1997; 175:160–64. Hart DE, Rojas LA, Rosario JA, Recalde H, Roman GC. Child- hood Guillain–Barré syndrome in Paraguay, 1990 to 1991. Ann. Neurol. 1994; 36: 859–86 Ammache Z, Afifi AK, Brown CK, Kimura J. Childhood Guillain- Barré syndrome: Clinical and electrophysiologic features predictive of outcome. J Child Neurol 2001;16:477-483. Ramsay M, Dunning J, Foulkes S, et al. An increase in reports of acute flaccid paralysis (AFP) in the United Kingdom, 1 January 2018–21 January 2019: early findings. Euro Surveill 2019; 24: 2. McLaren N, Lopez A, Kidd S, et al. Characteristics of patients with acute flaccid myelitis, united states, 2015–2018. Emerg Infect Dis 2020; 26: 212–219. Van Haren K, Ayscue P, Waubant E, et al. Acute flaccid myelitis of unknown etiology in California, 2012-2015. JAMA 2015; 314: 2663–2671. Ayers T, Lopez A, Lee A, et al. Acute flaccid myelitis in the United States: 2015–2017 Pediatrics 2019; 144: e20191619. Morrıs A, Ellıott E, D’souza R, Antony J, Kennett M , Longbottom H. Acute flaccid paralysis in Australian children. J. Paediatr. Child Health. 2003;39, 22–26 Korinthenberg R , Trollmann R , Felderhoff-Müser U , Bernert G , Hackenberg A , Hufnagel M. Diagnosis and treatment of Guillain-Barré Syndrome in childhood and adolescence: An evidence- and consensus-based guideline. Eur J Paediatr Neurol. 2020 Mar;25:5-16. Koul RL, Alfutaisi A. Prospective study of children with Guillain- Barre syndrome. Indian J Pediatr 2008;75:787-790. Sakakibara R, Hattori T, Kuwabara S, Yamanishi T, Yasuda K. Micturitional disturbance in patients with Guillain-Barre syndrome. J Neurol Neurosurg Psychiatr 1997;63:649-653. Hughes, RAC, Swan AV, Doorn PAv. Intravenous immunoglobulin for Guillain- Barre syndrome. Cochrane Database Syst Rev; 2014(9) Kesici S, Tanyıldız M, Yetimakman F, Bayrakci B. A Novel Treatment Strategy for Severe Guillain-Barré Syndrome: Zipper Method. J Child Neurol. 2019 Apr;34:277-283. Sınghı SC, Jayshree M, Sınghı P, Banerjee S, Prabhakar S. Intravenous immunoglobulin in very severe childhood Guillain-Barre syndrome. Annals of Tropical Paediatrics 1999; 19:167± 174 Korinthenberg R,Schessl J,Kirschner J,Monting JS. Intravenouslyadministeredimmunoglobulin in the treatment of childhood Guillain-Barre syndrome: a randomized trial. Pediatrics; 2005;116 :8–14. Hixon AM, Clarke P, Tyler KL. Evaluating treatment efficacy in a mouse model of 36. enterovirus D68-associated paralytic myelitis. J Infect Dis 2017; 216: 1245–1253. Brenton JN, Banwell BL. Therapeutic Approach to the Management of Pediatric Demyelinating Disease: Multiple Sclerosis and Acute Disseminated Encephalomyelitis. Neurotherapeutics. 2016;13:84–95. Padmanabhan A, Connelly-Smith L, Aqui N, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019;34:171–354. Pohl D, Alper G, Van Haren K, et al. Acute disseminated encepha- lomyelitis: updates on an inflammatory CNS syndrome. Neurol- ogy. 2016;87:38-45 Salvador E, Shityakov S, Forster C. Glucocorticoids and endothe- lial cell barrier function. Cell Tissue Res. 2014;355: 597–605. Anlar B, Basaran C, Kose G, et al. Acute disseminated encepha- lomyelitis in children: outcome and prognosis. Neuropediatrics. 2003;34:194–199. Yae Y , Kawano G , Yokochi T , et al . Fulminant acute disseminated encephalomyelitis in children. Brain Dev. 2019 Apr;41:373-377. Tenembaum S, Chitnis T, Ness J and Hahn JS. Acute disseminated encephalomyelitis. Neurology 2007; 68: 23–36. Absoud M, Parslow RC, Wassmer E, et al. Severe acute disseminated encephalomyelitis: a paediatric intensive care population-based study. Multiple Sclerosis Journal 2011 Oct;17:1258-1261 Tables Table 1. Demographic characteristics of patients presenting with AFP GBS (n: 43, 63.2%) ADEM (n: 14, 20.6%) TM (n: 11, 16.2%) Total (n: 68, 100%) Gender Male 18 (41.9%) 10 (71.4%) 5 (45.5%) 33 (48.5%) Female 25 (58.1%) 4 (28.6%) 6 (54.5%) 35 (51.5%) Age (years), mean ± SD 7.5 ± 4.0 7.8 ± 5.0 8.5 ± 5.5 7.9 ± 4.5 Prior Infection Present 25 (58.1%) 13 (92.9%) 5 (45.5%) 43 (63.2%) URTI 20 (46.5%) 10 (71.4%) 3 (27.3%) 33 (48.5%) AGI 5 (11.6%) 3 (21.5%) 2 (18.2%) 10 (14.7) Absent 18 (41.9%) 1 (7.1%) 6 (54.5%) 26 (36.8) Muscle Weakness Present 43 (100%) 13 (92.9%) 11 (100%) 67 (98.5%) Absent 0 (0%) 1 (7.1%) 0 (0%) 1 (1.5%) Type of Weakness Symmetric 37 (86.0%) 6 (42.9%) 8 (72.7%) 51 (75%) Asymmetric 6 (14.0%) 7 (57.1%) 3 (27.3%) 16 (23.5%) Weakness Location Lower limbs 12 (27.9%) 3 (21.5%) 4 (36.4%) 19 (28.0%) Lower and Upper Limbs 31 (72.1%) 10 (71.4%) 7 (63.6%) 47 (69.1) Autonomic Symptoms Present 13 (9.3%) 4 (28.6%) 5 (45.5%) 22 (32.4%) Absent 30 (90.7%) 10 (71.4%) 6 (54.5%) 46 (67.6%) Bulbar Symptoms Present 20 (46.5%) 6 (42.9%) 3 (27.3%) 29 (42.6%) Absent 23 (53.5%) 8 (57.1%) 8 (72.7%) 39 (57.4%) Cranial Involvement Present 11 (25.6%) 4 (28.6%) 2 (18.2%) 17 (25%) Absent 32 (74.4%) 10 (71.4%) 9 (81.8%) 51 (75%) Respiratory Support Present 26 (60.5%) 11 (78.5%) 5 (45.5%) 42 (61.8%) Intubation 14 (32.6%) 6 (42.9%) 3 (27.3%) 23 (33.8%) NIV 5 (11.6%) 2 (14.3%) 0 (0%) 7 (10.3%) Mask 7 (16.3%) 3 (21.5%) 2 (18.2%) 12 (17.6%) Absent 17 (39.5%) 3 (21.5%) 6 (54.5%) 26 (38.2%) Tracheostomy 3 (7.0%) 1 (7.1%) 2 (18.2%) 6 (8.8%) Hospital Stay (days), mean ± SD PICU 13.2 ± 17.3 21.4 ± 21.9 16.5 ± 24.1 15.4 ± 19.5 Total 20.3 ± 20.4 31.5 ± 20.1 24.3 ± 23.9 23.3 ± 21.1 Treatment Modality IVIG 43 (100%) 14 (100%) 11 (100%) 68 (100%) IVIG and TPE 25 (58.1%) 11 (78.5%) 7 (63.6%) 43 (63.2%) Steroids 0 (0 %) 4 (16 %) 3 (12 %) 7 (28 %) Steroids and TPE 0 (0 %) 10 (40 %) 5 (20 %) 15 (60 %) Abbreviations: GBS: Guillain-Barré Syndrome, ADEM: Acute Disseminated Encephalomyelitis, TM: Transverse Myelitis, IVIG: Intravenous Immunoglobulin, TPE: Therapeutic Plasma Exchange (Plasmapheresis), SD: Standard Deviation, URTI: Upper Respiratory Tract Infection, AGI: Acute Gastrointestinal Infection, NIV: Non-Invasive Ventilation, MV: Mechanical Ventilation, PICU: Pediatric Intensive Care Unit. Table 2. Comparison of MV and PICU Length of Stay According To Treatment Modality of GBS, ADEM and TM Patients MV duration (days), mean ± SD p PICU stay duration (days), mean ± SD p IVIG treatment duration (day) Two days and less IVIG Treatment (n: 5) 6.6 ± 4.1 0.044* 12.4 ± 5.8 0.16 Four days and more IVIG Treatment (n: 9) 31.2 ± 21.8 33.4 ± 29.2 All GBS Patients (n: 43) IVIG Treatment Only (n: 17) - 5 ± 3 <0.001* IVIG and TPE Treatment (n: 26) - 19 ± 20 Intubated GBS patients, IVIG + ≤5 or ≥6 sessions TPE IVIG + Five or fewer TPE Treatment sessions (n: 6) 29.3 ± 23.3 0.68 24.7 ± 19.4 0.93 IVIG + Six or more TPE Treatment sessions (n: 6) 21.8 ± 20.5 33.5 ± 32.8 Intubated GBS Patients (n: 14) IVIG Treatment Only (n: 2) 3.5 ± 0.7 0.088 7 ± 8 0.132 IVIG and TPE Treatment (n: 12) 25.5 ± 21.3 29 ± 26 TM and ADEM Patients (n: 25) Steroid Treatment Only (n: 7) - 6 ± 5 0.301 Steroid and TPE Treatment (n: 15) - 26 ± 26 TPE Treatment Only (n: 3) - 16 ± 18 Abbreviations: ADEM: Acute Disseminated Encephalomyelitis, TM: Transverse Myelitis, PICU: Pediatric Intensive Care Unit, TPE: Therapeutic Plasma Exchange (Plasmapheresis), GBS: Guillain-Barré Syndrome, MV: Mechanical Ventilation, IVIG: Intravenous Immunoglobulin, Additional Declarations No competing interests reported. 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11:05:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3948249/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3948249/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51290326,"identity":"2e8cf18a-2407-4be7-b4fb-6c0f5c3368c5","added_by":"auto","created_at":"2024-02-18 20:30:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322408,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3948249/v1/4dabb76f-525f-4e3b-86e4-a032e88464a3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Patients Diagnosed with Acute Flaccid Paralysis Followed and Treated in Pediatric İntensive Care: A Multi-Center Study","fulltext":[{"header":"What is Known","content":"\u003cp\u003eIn cases of AFP, combined (IVIG+TPE or steroid+TPE) treatments have been shown to shorten or not alter PICU length of stay or mechanical ventilator time compared to monotherapy (IVIG or steroid).\u003c/p\u003e\n\u003cp\u003eWhat is New: In our study, combined (IVIG+TPE or steroid+TPE) treatments prolonged the PICU hospital stay or mechanical ventilator time compared to monotherapy (IVIG or steroid), and in addition, 1g/kg/day IVIG for two days, 0.5g/kg/day for four days in intubated GBS patients. The duration of stay in mechanical ventilation was found to be shorter compared to daily IVIG administration.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eAcute Flaccid Paralysis (AFP) is a syndrome characterized by decreased tone (flaccidity), often presenting with respiratory and bulbar system failure, rapid onset, and weakness in the extremities (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Acute Flaccid Myelitis (AFM) is a disease similar to polio and most commonly occurs in childhood, predominantly affecting the anterior horn of the spinal cord, leading to weakness in the extremities (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Its pathophysiology has been particularly associated with enteroviruses, such as EV-A71 and EV-D68 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, various medical conditions, including Guillain-Barr\u0026eacute; syndrome (GBS), diphtheria, lesions of the anterior horn cells, and myositis, can also manifest as AFP. Other central nervous system pathologies such as spinal epidural hematomas, spinal arteriovenous fistulas, spinal infarctions, neuromyelitis optica, and spinal parasitic infections can also cause AFP (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). According to the AFM diagnostic criteria proposed by the International AFM Working Group in 2021, a definitive diagnosis of AFP can be established by the combination of abnormal spinal gray matter findings on magnetic resonance imaging (MRI) and pleocytosis in cerebrospinal fluid in the absence of alternative diagnostic factors (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Furthermore, the Council of State and Territorial Epidemiologists and the Centers for Disease Control and Prevention define AFM as acute-onset limb weakness primarily associated with gray matter involvement of one or more spinal segments as observed on MRI (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). AFM was first recognized in California in 2012 and in Colorado in 2014. Subsequently, it was acknowledged as a global disease with hundreds of reported cases in Europe, Asia, Australia, Africa, North America, and South America (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In AFP patients, weakness of respiratory muscles (i.e., oropharyngeal, laryngeal, tongue, retropharyngeal, intercostal, and diaphragmatic muscles) leads to the loss of airway protection, necessitating ventilatory support (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Additionally, these patients require cardiovascular evaluation and management due to autonomic instability, making it a medical emergency (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). After the eradication of polio in many parts of the world (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), GBS is now among the most common diagnoses in AFP patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), with up to 30% of patients requiring invasive or non-invasive mechanical ventilation and admission to the pediatric intensive care unit (PICU) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE) are commonly used treatments for AFP and have been reported to treat up to 92% of GBS patients in the United States (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Corticosteroids are recommended as immunosuppressants in the treatment of refractory or severe GBS patients (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter GBS, myelitis is also observed in the pediatric age group, with acute disseminated encephalomyelitis (ADEM) and transverse myelitis (TM) being the most common presentations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). High-dose corticosteroids, IVIG, or TPE can be used for the treatment of both diseases (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, we aimed to review the clinical characteristics and the PICU course of 68 AFP cases to identify prognostic factors in childhood AFP.\u003c/p\u003e"},{"header":"MATERIALS and METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Patient Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A retrospective descriptive study was conducted on patients diagnosed with AFP including those diagnosed with GBS, TM, and ADEM who were admitted to nine tertiary-level pediatric intensive care units (PICUs) in Turkey from January 1, 2018, to January 1, 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExclusion criteria were as follows: postoperative patients, patients with congenital neuromuscular weakness, traumatic head and spinal cord injuries, electrolyte disturbances (such as hypokalemia), or acute poisoning (organophosphates). Patients with encephalitis and weakness related to tumors were also excluded from the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics declarations\u003c/p\u003e\n\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eThe ethical endorsement for the research was obtained from the Van Regional Training and Research Hospital Human Research Ethics Committee (Decision no: 2023/01-10. Date: 01.04.2022). Before the research, all adolescents to be included in the sample and their parents expressed their consent for participation in the research both verbally and in written format via the \u0026ldquo;informed consent form.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eConsent to participate\u003c/p\u003e\n\u003cp\u003eBefore the research, all adolescents to be included in the sample and their parents expressed their consent for participation in the research both verbally and in written format via the \u0026ldquo;informed consent form.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eConflict of interest\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Definition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe age, gender, presenting complaints, physical examination findings at admission, history of previous infections, type of infection, presence of bulbar and autonomic dysfunction, cranial nerve involvement, degree of weakness, pattern of paralysis, need for respiratory support, cerebral and spinal MRI findings, duration of PICU stay, and duration of invasive/non-invasive mechanical ventilation (MV) of the patients were collected and compared. Their treatment protocols were also compared; whereas the GBS group received either IVIG alone or IVIG and TPE, the ADEM/TM group received either steroids alone or steroids and TPE. Some GBS patients were administered 1 g/kg/day of IVIG for two days, while others received 0.5 g/kg/day for four days. All patients received steroids at a dose of 30 mg/kg/day (maximum 1000 mg) for five days. The duration of PICU stay (in days) and the duration of invasive MV were evaluated.\u003c/p\u003e\n\u003cp\u003ePatients diagnosed with GBS, TM, and ADEM were compared within their respective groups in terms of the impact of different treatment modalities on prognosis. Records from nine centers were retrospectively reviewed for the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAutonomic and Bulbar Dysfunction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAutonomic dysfunction was classified under this study as including high or low blood pressure, cardiac arrhythmias (asystole, bradycardia, sinus tachycardia, and atrial and ventricular tachyarrhythmias), urinary retention (bladder dysfunction), and sphincter dysfunction.\u003c/p\u003e\n\u003cp\u003eBulbar dysfunction was classified under this study as including difficulty in swallowing (dysphagia), facial paralysis, ophthalmoplegia, diplopia, dysarthria, speech disorders, and voice changes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Collection in AFP Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSamples were collected from AFP patients in accordance with the World Health Organization (WHO) guidelines. A minimum of two samples were taken from each case at least 24 hours apart within 14 days of the onset of paralysis. Each sample had a volume of at least 8\u0026ndash;10 grams, and the second sample was collected within 72 hours of the first one. Samples were stored and transported under adequate cold chain conditions, without any leakage or drying, and were appropriately documented (21).\u003c/p\u003e\n\u003cp\u003eStool samples were collected in sufficient quantity and number from AFP-diagnosed patients following the WHO recommendations and were transported appropriately to public health units.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCategorical variables were presented as numbers and percentages, while numerical variables were presented as mean \u0026plusmn; standard deviation (or median, minimum-maximum). The Pearson chi-square test was used for comparing categorical measurements between groups. Independent sample t-tests were used for the comparison of normally distributed numerical measurements between two groups, and one-way analysis of variance was used for comparisons involving more than two groups with normal distribution. For numerical measurements that did not follow a normal distribution, the Mann-Whitney U test was used for comparisons of two groups, and the Kruskal-Wallis test was used for comparisons involving more than two groups. The IBM SPSS Statistics Version 28.0 package program was used for statistical analysis. The significance level (p) for all tests was set at 0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eBetween the years 2018 and 2023, a total of 68 AFP cases were followed in nine tertiary-level PICU centers in Turkey. The age range of patients was between one month and 18 years, with a mean age of 7.9 \u0026plusmn; 4.5 years. Out of the patients, 33 were male (48.5%) and 35 were female (51.5%). The patients were diagnosed with 43 cases of GBS (63.2%), 11 cases of TM (16.2%), and 14 cases of ADEM (20.6%). \u0026nbsp;Among the 43 GBS patients, 18 were male (41.9%), 25 were female (58.1%), with a mean age of 7.5 \u0026plusmn; 4 years. For the 14 ADEM patients, 10 were male (71.4%), four were female (28.6%), with a mean age of 7.8 \u0026plusmn; 5 years. Also in the 11 TM patients, five were male (45.5%), six were female (54.5%), with a mean age of 8.5 \u0026plusmn; 5.5 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe presence of an infection was detected before the onset of AFP symptoms in 39 patients (57.4%), while no infection was detected before the onset of symptoms in 29 patients (42.6%). When GBS, TM, and ADEM patients were evaluated separately, among the 43 GBS patients, 20 (46.5%) had upper respiratory tract infections (URTI), and five (11.6%) had acute gastrointestinal infections (AGI). Among the 11 TM patients, three (27.3%) had URTI, and two (18.2%) had a history of AGI. Additionally, among the 14 ADEM patients, three (21.5%) had AGI, and 10 (71.4%) had a history of URTI (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresentation Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 67 out of 68 patients (98.5%), extremity weakness was present (GBS: 43/43, TM: 11/11, ADEM: 13/14). Among the 43 GBS patients, 37 (86%) had symmetric weakness, while six patients (14%) had asymmetric weakness. In the TM patients, eight (72.7%) had symmetric weakness, and three (27.3%) had asymmetric weakness. For ADEM patients, six (42.9%) had symmetric weakness, and seven (57.1%) had asymmetric weakness. Overall, symmetric weakness was observed in 51 patients (75%), while asymmetric weakness was present in 16 patients (23.5%), and no muscle weakness was present in one patient (1.5%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 68 AFP patients, 47 (69.1%) had weakness in both the lower and upper extremities, while 19 patients (28%) had weakness only in the lower extremities, and one patient (1.5%) had weakness only in the upper extremities. Among the 43 GBS patients, all of them had weakness in the lower extremities, and 31 patients (72.1%) had weakness in both the lower and upper extremities.In the \u0026nbsp;11 TM patients, seven (63.6%) had weakness in both the lower and upper extremities, while 10 patients (90.9%) had weakness only in the lower extremities.Fourteen ADEM patients, 13 (92.9%) had weakness in the lower extremities, and 10 (71.5%) had weakness in both the lower and upper extremities (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAutonomic Dysfunction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn eight patients who were younger than two years old, polio virus was not detected in the analysis of their stool, blood, and body fluids. In addition, in patients younger than two years old, bulbar symptoms were evaluated, including swallowing difficulties, facial involvement, and high-pitched crying, apart from urinary retention. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of the 43 GBS patients, 14 (32.6%) showed signs of autonomic dysfunction. Among them, 10 patients had only sphincter involvement, two patients had sphincter involvement along with changes in blood pressure, and one patient had sphincter involvement along with arrhythmia. Among the 11 TM patients, only five (45.5%) had autonomic dysfunction (sphincter dysfunction). Among the 14 ADEM patients, four (28.6%) showed signs of autonomic dysfunction (two patients had only sphincter dysfunction, and two patients had both sphincter dysfunction and cardiovascular dysfunction). Out of all 68 patients, 29 (42.6%) had bulbar symptoms (GBS: 20/43, ADEM: 6/14, TM: 3/11). Cranial nerve involvement was observed (GBS/ADEM/TM: 11/4/2) in 17 patients (25%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients had completed their vaccination schedules according to their age, and no patient in the study was diagnosed with AFP after vaccination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBrain and spinal MRI were performed for all cases. Central gray matter lesions affecting the spinal cord were observed in all patients. In most cases, lesions affecting a long segment of the cervical and thoracic spine were present (median of 17 segments; range 3\u0026ndash;20). Brainstem lesions, mainly occurring in the pons or medulla, were prevalent (42 cases; 61.7%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePICU Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe average PICU stay for all AFP patients was 15.4 \u0026plusmn; 19.5 days, and the average hospital stay was 23.3 \u0026plusmn; 21.1 days. Specifically, the average PICU stay for GBS/TM/ADEM patients was 13.2 \u0026plusmn; 17.3/16.5 \u0026plusmn; 24.1/21.4 \u0026plusmn; 21.9 days, respectively, and the average hospital stay was 20.3 \u0026plusmn; 20.4/24.3 \u0026plusmn; 23.9/31.5 \u0026plusmn; 20.1 days, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong all AFP patients, 42 (61.8%) required respiratory support. Specifically, 23 (33.8%) patients were intubated, seven (10.3%) patients received non-invasive MV, and 12 (17.6%) patients were managed with a reservoir mask for oxygen supplementation. Six patients (8.8%) who remained intubated for a long time were unable to be weaned off mechanical ventilation and were discharged with a tracheostomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 43 GBS patients, 14 were intubated, five received non-invasive MV, and tracheostomy was performed in three patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 11 TM patients, three were intubated, and tracheostomy was performed in two patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 14 ADEM patients, six were intubated, two received non-invasive MV, and tracheostomy was performed in one patient (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment Modalities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients received IVIG treatment. Twenty-five out of 43 GBS patients (58.1%), seven out of 11 TM patients (63.6%), and 11 out of 14 ADEM patients (78.6%) received TPE. Among the 14 intubated GBS patients, five received IVIG treatment for two days or less, and nine received IVIG treatment for \u0026nbsp;four days or more. The evaluation of treatment durations in terms of prognosis revealed no significant difference in PICU stay (in days) between patients who received IVIG treatment for two days or less and those who received it for four days or more (p: 0.16). However, the evaluation of invasive MV durations (in days) showed that patients who received IVIG treatment for four days or more had a significantly longer intubation period (p: 0.044) (Table 2).\u003c/p\u003e\n\u003cp\u003eOut of 43 GBS patients, 17 received only IVIG (monotherapy), and 26 received IVIG and TPE (combined) treatment. The combined treatment group had a longer PICU stay (p: 0.001) (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 14 intubated GBS patients, 12 received additional plasmapheresis treatment in addition to IVIG. Six patients received five or fewer sessions of TPE, while six patients received six or more sessions. There was no significant difference in average PICU stay (24.7 \u0026plusmn; 19.4 vs. 33.5 \u0026plusmn; 32.8 days) or average mechanical ventilation duration (29.3 \u0026plusmn; 23.3 vs. 21.8 \u0026plusmn; 20.5 days) between these two patient groups (p: 0.93 and p: 0.68, respectively) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Among the 14 intubated GBS patients, two received only IVIG, and 12 received IVIG and TPE treatment. Although there was no significant difference in PICU stay (7 \u0026plusmn; 8 vs. 29 \u0026plusmn; 26) or average duration of invasive MV (3.5 \u0026plusmn; 0.7 vs. 25.5 \u0026plusmn; 21.3) (p: 0.132 and p: 0.088, respectively), it was observed that PICU and invasive MV durations were considerably longer in the combined treatment group (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut of 25 patients diagnosed with ADEM and TM, seven received steroid treatment, 15 received steroid and TPE, and three received only TPE. There was no significant difference in PICU stay between patients who received monotherapy and those who received combined treatment (p: 0.301) (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, two patients (who were diagnosed solely with ADEM) died. The mortality rate in our study was 2.9%.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAFP is a rare and complex disease that is not fully understood (22). GBS is the most common cause of AFP in children (23). In reported studies GBS is seen in AFP as between 31 and 74% to \u0026nbsp;(24\u0026ndash;25). In our study, consistent with the literature, GBS was the most common cause, accounting for 63.2% of cases. GBS has a global distribution and affects all races and ages, including newborns (26). AFP is predominantly a childhood disease, with a median age of 6.3 years. It is more commonly observed in males (27). In our study, the mean age of AFP patients was 7.9 \u0026plusmn; 4.5 years, and contrary to the literature, 51.5% were females.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn most cases, AFP develops following a post-viral infection. Many affected individuals report a febrile prodromal period with respiratory symptoms preceding the onset of paralysis (28). In our study, more than half of the cases (57.4%) had a history of infection. The neurological condition primarily involves lesions targeting the anterior horn cells of the spinal cord and motor nuclei of the brainstem. Although enteroviruses (especially enterovirus A71) and certain coxsackievirus strains have been implicated, enterovirus D68 has been the dominant virus suspected in biennial AFM outbreaks (29). In our study, all AFP patients underwent spinal and cranial MRI, revealing lesions primarily affecting the central gray matter of the spinal cord. Radiological findings served as supportive evidence in diagnosing AFP. The radiological findings of our patients were consistent with the literature.\u003c/p\u003e\n\u003cp\u003eIn patients, weakness in one extremity can range from mild to moderate, progressing to complete paralysis of all extremities and axial and bulbar muscles (30). In our study, weakness in extremities was present in 98.5% of patients. Among them, 69.1% had weakness in both upper and lower extremities, 28% had weakness only in the lower extremities, and 1.5% had weakness only in the upper extremity. A study reported that the most commonly recorded neurological signs of GBS were the absence or decrease of reflexes in over 95% of cases and weakness in one or more extremities (31). Approximately one-third of hospitalized patients with AFP require intubation and ventilation (30). Other studies have indicated that sensory impairment or loss, bulbar paralysis, and other cranial nerve palsies were observed in about a quarter of GBS cases, and respiratory depression was found in one-third of cases. Additionally, in all reported children with TM, lower extremity weakness was present, and half of them had upper extremity involvement, while four cases showed bulbar palsy, and two others had cranial nerve involvement. One-third of cases were admitted to the PICU and required mechanical ventilation (31). In our study, the distribution of extremity weakness and the frequency of autonomic and bulbar dysfunction in both the GBS and TM groups was found to be consistent with the literature. The rate of intubation in AFP patients followed in the PICU was also consistent with the literature. Among intubated AFP cases, GBS was the most common diagnosis (14/23 patients). These findings are in line with the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePICU and Treatment Modalities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGBS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the management of children and adolescents with GBS, initiation of mechanical ventilation is recommended when initial signs of respiratory fatigue are observed and before clinical decompensation occurs. Additionally, in cases of dysphagia associated with saliva aspiration or inadequate airway clearance, intubation is advised (32). Approximately one-third of pediatric GBS patients require ventilator support due to respiratory muscle paralysis, and about 10% of patients die because of the disease and its complications (33). In our series, respiratory failure progressed rapidly in children with upper limb and cranial nerve involvement. Ventilatory support, both invasive and non-invasive, was provided to 26 (60.4%) patients with respiratory distress. Fourteen (32.5%) patients were managed with invasive mechanical ventilation. The rate of respiratory support was similar to that of the literature.\u003c/p\u003e\n\u003cp\u003eIf there is no improvement in respiratory function and/or secretion management after one to two weeks of respiratory therapy, tracheostomy is recommended (32). In our study, we waited for four weeks or more to evaluate the response of patients to current treatments (IVIG and TPE). Tracheostomy was performed on three patients who remained on mechanical ventilation for four weeks or more. Our experience suggests that treatment efficacy requires at least four weeks, and therefore, tracheostomy should take place after the fourth week for optimal results.\u003c/p\u003e\n\u003cp\u003eGBS patients may experience autonomic nervous system involvement in about 25% of cases, often presenting as blood pressure instability, sinus tachycardia, abnormal pupillary reflex, or sweating abnormalities (34). In our study, autonomic dysfunction was observed in 14 (32.5%) patients (10 patients with only sphincter involvement, two patients with sphincter involvement and blood pressure changes, and one patient with sphincter involvement and arrhythmia). Our findings were consistent with the literature.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe management of severe GBS (i.e., loss of walking ability without assistance) in children and adolescents is recommended to be treated with IVIG (32). Cochrane Review authors reported that in five studies involving 536 patients, there was no significant difference in the effects on recovery between IVIG and TPE, and the combination of IVIG following TPE did not provide any significant additional benefit during recovery (35). In a multi-center study, no significant difference in effectiveness was reported between TPE, IVIG, and combination (IVIG and TPE) treatments (23). Kesici et al. reported that the zipper method (first TPE, then IVIG) as a new treatment method reduces mortality, accelerates weaning from mechanical ventilation, and shortens hospital stay with excellent results in patients with severe Guillain-Barr\u0026eacute; syndrome requiring intensive care (36). In our study, we compared the PICU stay durations of patients who received only IVIG (17 patients) with those who received IVIG and TPE (26 patients). The PICU stay duration was found to be significantly longer in the IVIG and TPE group (p: 0.001). Among the 14 intubated GBS patients, although there was a clear difference in PICU stay duration and invasive MV duration between the two groups (with longer duration in the IVIG and TPE group), the p value did not reach significance due to the small sample size (only two intubated patients in the IVIG group). In another study, when comparing the group treated with IVIG to the group not receiving IVIG, it was reported that the number of children requiring endotracheal intubation and mechanical ventilation and the duration of mechanical ventilation were significantly lower in the IVIG-treated group. The author also reported that IVIG treatment significantly improved the outcomes in children with severe GBS, reducing the need for intubation and mechanical ventilation and shortening the duration of stay in the intensive care unit (37).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study and the literature suggest that the first treatment option for GBS patients should be IVIG, and its early administration can shorten PICU and invasive MV durations. In the absence of systematic dose interval study data, IVIG is usually administered in children as in adults with acute GBS, ie 2 g/kg body weight distributed over 4 to 5 consecutive days as a single course. It has been reported that reducing the IVIG administration time to 2 g/kg in 2 days did not show any improvement effect. In one study, it was reported that there was no significant difference in neurological improvement between two days of 2 g/kg IVIG administration and IVIG administered over five days (38). The potential benefits of IVIG treatment are considered to be greatest when administered in the early stages of the disease. Intravenous steroids and plasma exchange are sometimes used for their potential immunomodulatory effects, but whether the potential harm outweighs the therapeutic benefit has been debated (39). In contrast to the literature, our study found that administering IVIG at 2 g/kg for two days did not change the PICU stay duration compared to administering it over four days, but it shortened the duration of invasive MV. Further studies are needed to investigate the optimal dose intervals. Additionally, our study did not observe a significant difference in PICU and invasive MV durations between patients receiving five or fewer TPE sessions and those receiving six or more TPE sessions. Due to the limited number of studies in the literature, we were unable to make a direct comparison of our data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTM and ADEM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcute demyelinating diseases of the central nervous system include acute disseminated encephalomyelitis (ADEM), multiple sclerosis, TM, myelin oligodendrocyte glycoproteins (MOG) antibody-associated demyelination, and neuromyelitis optical spectrum disorder (40). In our study, we included 25 pediatric patients diagnosed with ADEM and TM. The American Society for Apheresis recommends the use of TPE in acute demyelinating diseases (41). Our study aimed to review the PICU process in pediatric patients with acute demyelinating syndrome attacks who received either steroid or steroid and TPE treatment modalities. In the study, only the duration of PICU stay and of invasive MV in patients who received steroid treatment alone and in those who received steroid and TPE treatment were evaluated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn cases suspected of ADEM, intravenous steroids, such as methylprednisolone, are commonly used (42). This treatment is typically dosed at 30 mg/kg (up to 1000 mg) per day for three to five days. Alternative regimens, such as lower doses of methylprednisolone at 10 mg/kg or dexamethasone at 1\u0026ndash;2 mg/kg/day for three to five days, have also been reported (43). In our study, patients diagnosed with ADEM and TM received 30 mg/kg/day (max 1000 mg) of steroids for five days. Subsequently, an oral corticosteroid, such as methylprednisolone, is commonly initiated at a dose of 1\u0026ndash;2 mg/kg/day (up to 60 mg per day) and tapered by 5\u0026ndash;10 mg per week over four to six weeks (44). Our steroid usage and tapering schedule were consistent with the literature.\u003c/p\u003e\n\u003cp\u003eFollowing the initiation of intravenous steroids, close monitoring of the patient\u0026apos;s clinical condition is necessary to observe any changes in mental status, motor strength, coordination, sensation, and/or vision. Lack of improvement or deterioration may indicate a poor prognosis (41). However, it is important to note that approximately 2% of ADEM cases include acute hemorrhagic leukoencephalitis with a poor prognosis and high mortality (45).\u003c/p\u003e\n\u003cp\u003eADEM is reported to be more common in children under 10 years of age (46), which is supported by our study as well. Studies have reported that approximately 3% of children with ADEM die as a result of the illness (46). In another study of 27 ADEM cases, three cases (11.1%) resulted in death. The percentage of children requiring invasive mechanical ventilation was 78% (21/27), and none of the patients received plasmapheresis (47).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the mortality rate was found to be higher (2/14, 14.2%) compared to the literature. This may be attributed to the small number of patients diagnosed with ADEM in our study. Additionally, in our study, six out of 14 ADEM cases and three out of 11 TM cases required invasive MV, and the number of intubated cases was lower compared to the literature. There is a lack of studies examining the relationship between treatment planning and PICU length of stay. One important point in our study is that there was no significant difference in PICU length of stay between the two groups receiving steroid and steroid and TPE treatments. However, the relationship between steroid and combined steroid and TPE treatments and the duration of invasive mechanical ventilation could not be investigated due to the insufficient number of intubated cases (six patients with ADEM, and three patients with TM) in our study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe limitation of this study was mainly the poor quality of data as some data was missing, so they were excluded from the analysis. This study is observational and lacked a control group to evaluate treatments. Because this is a retrospective review and did not rely on a specific protocol, there are missing data. This was handled by marking \u0026ldquo;unknown\u0026rdquo; or \u0026ldquo;not done,\u0026rdquo; therefore results are based on documented findings.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn our study, primary outcomes revealed that combination therapies (IVIG and TPE or steroid and TPE) led to prolonged MV and PICU stay durations compared to monotherapies (IVIG or steroids). Secondary outcomes showed that in intubated GBS cases, administering 2 g/kg/day IVIG for two days significantly reduced the duration of invasive MV. Especially in GBS cases, early and shorter administration of monotherapy (IVIG) resulted in a positive effect, shortening the length of hospital stay and of invasive MV. Further research is needed to better understand the PICU process in AFP patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding:\u0026nbsp;The original article received no external funding.\u003c/p\u003e\n\u003cp\u003eConflicts of interest/Competing interests:\u0026nbsp;The authors have no financial disclosures that would be a potential conflict of interest with the current manuscript.\u003c/p\u003e\n\u003cp\u003eEthics approval: The approval was obtained from Institutional Review Board.\u003c/p\u003e\n\u003cp\u003eConsent to participate: Approval was obtained from the family of the participants. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: Approval was obtained from the family of the participants. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Availability of data and material: There is data transparency\u003c/p\u003e\n\u003cp\u003eCode availability: There is not code availability \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDisclosures: The authors have no financial disclosures that would be a potential conflict of interest with the current manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions Statements:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEB: conceptualized and designed the study, analyzed and interpreted data, drafted the manuscript MB,SY,ŞET,H\u0026Ouml;,MH: contributed to study design, analyzed data, contributed to data collection \u0026nbsp;EB,AA,AG,EG: collected data EET,EUB,: collected data AK,SY,KD,MD: collected data \u0026Ouml;\u0026Ouml;G,FE,OD: collected data RDY,TK: contributed to drafting of the manuscript \u0026nbsp; TK,RDY: conceptualized and designed the study, contributed to data analysis, contributed to drafting of the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAdewole A. Evaluation of Ondo State acute flaccid paralysis surveillance system (2009-2013). International Journal of Infectious Diseases. 2016;45:290.\u003c/li\u003e\n \u003cli\u003eKnoester M, Helfferich J, Poelman R, et al. Twenty-nine cases of enterovirus-D68-associated acute flaccid myelitis in Europe 2016: a case series and epidemiologic overview. Pediatr Infect Dis J. 2019;38:16-21.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDyda A, Stelzer-Braid S, Adam D, Chughtai AA, MacIntyre CR. The association between acute flaccid myelitis (AFM) and en- terovirus D68 (EV-D68)\u0026mdash;what is the evidence for causation? Euro Surveill. 2018;23:17-00310.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMessacar K, Spence-Davizon E, Osborne C, et al. Clinical char- acteristics of enterovirus A71 neurological disease during an outbreak in children in Colorado, USA, in 2018: an observational cohort study. Lancet Infect Dis. 2020;20:230-239.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMarx A, Glass JD, Sutter RW. Differential diagnosis of acute flaccid paralysis and its role in poliomyelitis surveillance. Epidemiol Rev. 2000;22:298\u0026ndash;316.\u003c/li\u003e\n \u003cli\u003eMurphy OC, Messacar K, Benson L, et al. Acute flaccid myelitis: cause, diagnosis, and management. Lancet. 2020;397:334-346.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCenters for Disease Control and Prevention. Acute Flaccid Myelitis Case Definitions. https://www.cdc.gov/acute-flaccid-myelitis/hcp/case-definition.html. Retrieved July 20, 2018.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCenters for Disease Control and Prevention. Acute Flaccid myelitis. http://www.cdc.gov/acute-flaccid-myelitis/. Retrieved 10/05/2016.\u003c/li\u003e\n \u003cli\u003eMurphy OC, Messacar K, Benson L, Bove R, Carpenter JL, Crawford T. Acute flaccid myelitis: cause, diagnosis, and management (Lancet. 2021 January 23; 397:334\u0026ndash;346.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eShang P\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, Feng J\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, Wu W\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, \u0026nbsp;Zhang\u003csup\u003e\u0026nbsp;\u003c/sup\u003eHL. Intensive Care and Treatment of Severe Guillain\u0026ndash;Barr\u0026eacute; Syndrome. Frontiers in Pharmacology 2021 Apr 27;12: 608130.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Bove R, Rowles W, Carleton M, et al. Unmet needs in the evaluation, treatment, and recovery for 167 children affected by acute flaccid myelitis reported by parents through social media. Pediatr Neurol 2020; 102: 20\u0026ndash;27.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKhuzwayo LS, Kuonza LR, Ngcobo NJ. Evaluating the acute flaccid paralysis surveillance system in South Africa, 2005\u0026ndash;2009 \u0026ndash; An analysis of secondary data. 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Journal of Neurology, Neurosurgery \u0026amp; Psychiatry. 2018);89: 949-954.\u003c/li\u003e\n \u003cli\u003eVerboon\u003csup\u003e\u0026nbsp;\u003c/sup\u003eC, Doets\u003csup\u003e\u0026nbsp;\u003c/sup\u003e AY, Galassi\u003csup\u003e\u0026nbsp;\u003c/sup\u003eG,\u0026nbsp;et al. Current treatment practice of Guillain-Barr\u0026eacute; syndrome.\u0026nbsp;Neurology (2019;93 :e59-e76.\u003c/li\u003e\n \u003cli\u003eEli S. Current therapeutic options in severe Guillain-Barre syndrome.\u0026nbsp;Clinical neuropharmacology\u0026nbsp;2006;29: 45-51.\u003c/li\u003e\n \u003cli\u003eKrupp LB, Tardieu M, Amato MP, et al. International Pediatric Multiple Sclerosis Study Group criteria for pediatric multiple sclerosis and immune-mediated central nervous system demyelinating disorders: revisions to the2 007 definitions. MultScler 2013;19:1261\u0026ndash;1267.\u003c/li\u003e\n \u003cli\u003eTavasoli A, Tabrizi A. Acute Transverse Miyelitis in Children, Literature Review. Iran J Child Neurol. 2018;12:7-16.\u003c/li\u003e\n \u003cli\u003eWorldHealthOrganization(WHO).WHOrecommendedstandardsforsurveil- lance of selected vaccine \u0026mdash; preventable diseases. Vaccines and biologicals. Geneva: WHO; 2003. p. 31\u0026ndash;4.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMessacar K, Schreiner TL, Van Haren K, et al. Acute flaccid myelitis: A clinical Review of US cases 2012-2015. Ann Neurol. 2016;80: 326-338.\u003c/li\u003e\n \u003cli\u003eHung PL, Chang WN, Huang LT, et al. A clinical and electrophysiologic survey of childhood Guillain- Barré syndrome. Pediatr Neurol 2004;30:86-91.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOlive JM, Castillo C, Castro RG, de Quadros CA. Epidemio- logical study of Guillain\u0026ndash;Barré syndrome in children \u0026lt;15 years of age in Latin America. J. Infect. Dis. 1997; 175:160\u0026ndash;64.\u003c/li\u003e\n \u003cli\u003eHart DE, Rojas LA, Rosario JA, Recalde H, Roman GC. Child- hood Guillain\u0026ndash;Barré syndrome in Paraguay, 1990 to 1991. Ann. Neurol. 1994; 36: 859\u0026ndash;86\u003c/li\u003e\n \u003cli\u003eAmmache Z, Afifi AK, Brown CK, Kimura J. Childhood Guillain- Barré syndrome: Clinical and electrophysiologic features predictive of outcome. J Child Neurol 2001;16:477-483.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRamsay M, Dunning J, Foulkes S, et al. An increase in reports of acute flaccid paralysis (AFP) in the United Kingdom, 1 January 2018\u0026ndash;21 January 2019: early findings. Euro Surveill 2019; 24: 2.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMcLaren N, Lopez A, Kidd S, et al. Characteristics of patients with acute flaccid myelitis, united states, 2015\u0026ndash;2018. Emerg Infect Dis 2020; 26: 212\u0026ndash;219.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVan Haren K, Ayscue P, Waubant E, et al. Acute flaccid myelitis of unknown etiology in California, 2012-2015. 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Cochrane Database Syst Rev; 2014(9)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKesici S, Tanyıldız M, Yetimakman F, Bayrakci B.\u0026nbsp;A Novel Treatment Strategy for Severe Guillain-Barr\u0026eacute; Syndrome: Zipper Method.\u0026nbsp;J Child Neurol.\u0026nbsp;2019 Apr;34:277-283.\u003c/li\u003e\n \u003cli\u003eSınghı SC, Jayshree M, Sınghı P, Banerjee S, Prabhakar S. Intravenous immunoglobulin in very severe childhood Guillain-Barre syndrome. Annals of Tropical Paediatrics 1999; 19:167\u0026plusmn; 174\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKorinthenberg R,Schessl J,Kirschner J,Monting JS. Intravenouslyadministeredimmunoglobulin in the treatment of childhood Guillain-Barre syndrome: a randomized trial. Pediatrics; 2005;116 :8\u0026ndash;14.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHixon AM, Clarke P, Tyler KL. Evaluating treatment efficacy in a mouse model of 36. enterovirus D68-associated paralytic myelitis. J Infect Dis 2017; 216: 1245\u0026ndash;1253.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBrenton JN, Banwell BL. Therapeutic Approach to the Management of Pediatric Demyelinating Disease: Multiple Sclerosis and Acute Disseminated Encephalomyelitis. Neurotherapeutics. 2016;13:84\u0026ndash;95.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePadmanabhan A, Connelly-Smith L, Aqui N, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019;34:171\u0026ndash;354.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePohl D, Alper G, Van Haren K, et al. Acute disseminated encepha- lomyelitis: updates on an inflammatory CNS syndrome. Neurol- ogy. 2016;87:38-45\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSalvador E, Shityakov S, Forster C. Glucocorticoids and endothe- lial cell barrier function. Cell Tissue Res. 2014;355: 597\u0026ndash;605.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAnlar B, Basaran C, Kose G, et al. Acute disseminated encepha- lomyelitis in children: outcome and prognosis. Neuropediatrics. 2003;34:194\u0026ndash;199.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYae Y\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, Kawano G\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, Yokochi T\u003csup\u003e\u0026nbsp;\u003c/sup\u003e,\u0026nbsp;et al\u003csup\u003e\u0026nbsp;\u003c/sup\u003e. Fulminant acute disseminated encephalomyelitis in children. Brain Dev. 2019 Apr;41:373-377.\u003c/li\u003e\n \u003cli\u003eTenembaum S, Chitnis T, Ness J and Hahn JS. Acute disseminated encephalomyelitis. Neurology 2007; 68: 23\u0026ndash;36.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAbsoud M, Parslow RC, Wassmer E, et al. Severe acute disseminated encephalomyelitis: a paediatric intensive care population-based study. Multiple Sclerosis Journal 2011 Oct;17:1258-1261\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Demographic characteristics of patients presenting with AFP\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"615\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\" rowspan=\"2\"\u003e\n \u003cp\u003eGBS\u003c/p\u003e\n \u003cp\u003e(n: 43, 63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\" rowspan=\"2\"\u003e\n \u003cp\u003eADEM\u003c/p\u003e\n \u003cp\u003e(n: 14, 20.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\" rowspan=\"2\"\u003e\n \u003cp\u003eTM\u003c/p\u003e\n \u003cp\u003e(n: 11, 16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\" rowspan=\"2\"\u003e\n \u003cp\u003eTotal (n: 68, 100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"31\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"31\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e18 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e10 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e33 (48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e25 (58.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e4 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e35 (51.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00813008130081%\" colspan=\"2\"\u003e\n \u003cp\u003eAge (years), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.121951219512194%\"\u003e\n \u003cp\u003e7.5 \u0026plusmn; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.86178861788618%\"\u003e\n \u003cp\u003e7.8 \u0026plusmn; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.934959349593496%\"\u003e\n \u003cp\u003e8.5 \u0026plusmn; 5.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.073170731707318%\"\u003e\n \u003cp\u003e7.9 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"4\"\u003e\n \u003cp\u003ePrior Infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e25 (58.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e13 (92.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e43 (63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eURTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e20 (46.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e10 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e33 (48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAGI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e3 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e10 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e18 (41.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e26 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eMuscle Weakness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e43 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e13 (92.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e11 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e67 (98.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e1 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eType of Weakness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003eSymmetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e37 (86.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e8 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e51 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAsymmetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e6 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e7 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e16 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eWeakness Location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003eLower limbs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e12 (27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e3 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e4 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e19 (28.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eLower and Upper Limbs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e31 (72.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e10 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e47 (69.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eAutonomic Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e13 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e4 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e22 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e30 (90.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e10 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e46 (67.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eBulbar Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e20 (46.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e29 (42.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e23 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e8 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e8 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e39 (57.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eCranial Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e11 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e4 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e17 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e32 (74.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e10 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e9 (81.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e51 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"5\"\u003e\n \u003cp\u003eRespiratory Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e26 (60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e11 (78.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e5 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e42 (61.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eIntubation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e14 (32.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e3 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e23 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eNIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e5 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e7 (10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eMask\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e7 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e3 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e12 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e17 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e3 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e26 (38.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.00813008130081%\" colspan=\"2\"\u003e\n \u003cp\u003eTracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.121951219512194%\"\u003e\n \u003cp\u003e3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.86178861788618%\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.934959349593496%\"\u003e\n \u003cp\u003e2 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.073170731707318%\"\u003e\n \u003cp\u003e6 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"2\"\u003e\n \u003cp\u003eHospital Stay (days), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003ePICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e13.2 \u0026plusmn; 17.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e21.4 \u0026plusmn; 21.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e16.5 \u0026plusmn; 24.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e15.4 \u0026plusmn; 19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e20.3 \u0026plusmn; 20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e31.5 \u0026plusmn; 20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e24.3 \u0026plusmn; 23.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e23.3 \u0026plusmn; 21.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.233766233766232%\" rowspan=\"4\"\u003e\n \u003cp\u003eTreatment Modality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003eIVIG\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.097402597402597%\"\u003e\n \u003cp\u003e43 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.83116883116883%\"\u003e\n \u003cp\u003e14 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.909090909090908%\"\u003e\n \u003cp\u003e11 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.045454545454547%\"\u003e\n \u003cp\u003e68 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eIVIG and TPE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e25 (58.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e11 (78.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e7 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e43 (63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eSteroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e\u0026nbsp;4 (16 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e3 (12 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e\u0026nbsp;7 (28 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.155038759689923%\"\u003e\n \u003cp\u003eSteroids and TPE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.023255813953487%\"\u003e\n \u003cp\u003e\u0026nbsp;0 (0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48062015503876%\"\u003e\n \u003cp\u003e\u0026nbsp;10 (40 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.992248062015506%\"\u003e\n \u003cp\u003e\u0026nbsp;5 (20 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.348837209302324%\"\u003e\n \u003cp\u003e\u0026nbsp;15 (60 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"16\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: GBS: Guillain-Barr\u0026eacute; Syndrome, ADEM: Acute Disseminated Encephalomyelitis, TM: Transverse Myelitis, IVIG: Intravenous Immunoglobulin, TPE: Therapeutic Plasma Exchange (Plasmapheresis), SD: Standard Deviation, URTI: Upper Respiratory Tract Infection, AGI: Acute Gastrointestinal Infection, NIV: Non-Invasive Ventilation, MV: Mechanical Ventilation, PICU: Pediatric Intensive Care Unit. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Comparison of MV and PICU Length of Stay According To Treatment Modality of GBS, ADEM and TM Patients\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"639\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.592476489028215%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.84012539184953%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.711598746081506%\" valign=\"top\"\u003e\n \u003cp\u003eMV duration (days),\u0026nbsp;mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.836990595611285%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003ePICU stay duration (days),\u0026nbsp;mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.77742946708464%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.592476489028215%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIVIG treatment duration (day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.84012539184953%\"\u003e\n \u003cp\u003eTwo days and less IVIG Treatment (n: 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.711598746081506%\" valign=\"top\"\u003e\n \u003cp\u003e6.6 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.836990595611285%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.044*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\"\u003e\n \u003cp\u003e12.4 \u0026plusmn; 5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.77742946708464%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.20884520884521%\"\u003e\n \u003cp\u003eFour days and more IVIG Treatment (n: 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.764127764127764%\" valign=\"top\"\u003e\n \u003cp\u003e31.2 \u0026plusmn; 21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.027027027027028%\"\u003e\n \u003cp\u003e33.4 \u0026plusmn; 29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.592476489028215%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAll GBS Patients (n: 43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.84012539184953%\"\u003e\n \u003cp\u003eIVIG Treatment Only (n: 17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.711598746081506%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.836990595611285%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\"\u003e\n \u003cp\u003e5 \u0026plusmn; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.77742946708464%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.20884520884521%\"\u003e\n \u003cp\u003eIVIG and TPE Treatment (n: 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.764127764127764%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.027027027027028%\"\u003e\n \u003cp\u003e19 \u0026plusmn; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.592476489028215%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIntubated GBS patients, IVIG +\u0026nbsp;\u0026le;5 or\u0026nbsp;\u0026ge;6 sessions TPE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.84012539184953%\"\u003e\n \u003cp\u003eIVIG + Five or fewer TPE Treatment sessions (n: 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.711598746081506%\" valign=\"top\"\u003e\n \u003cp\u003e29.3 \u0026plusmn; 23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.836990595611285%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\"\u003e\n \u003cp\u003e24.7 \u0026plusmn; 19.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.77742946708464%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.20884520884521%\"\u003e\n \u003cp\u003eIVIG + Six or more TPE Treatment sessions (n: 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.764127764127764%\" valign=\"top\"\u003e\n \u003cp\u003e21.8 \u0026plusmn; 20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.027027027027028%\"\u003e\n \u003cp\u003e33.5 \u0026plusmn; 32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.592476489028215%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIntubated GBS Patients (n: 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.84012539184953%\"\u003e\n \u003cp\u003eIVIG Treatment Only\u003c/p\u003e\n \u003cp\u003e(n: 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.711598746081506%\" valign=\"top\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.836990595611285%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\"\u003e\n \u003cp\u003e7 \u0026plusmn; 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.77742946708464%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.20884520884521%\"\u003e\n \u003cp\u003eIVIG and TPE Treatment (n: 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.764127764127764%\" valign=\"top\"\u003e\n \u003cp\u003e25.5 \u0026plusmn; 21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.027027027027028%\"\u003e\n \u003cp\u003e29 \u0026plusmn; 26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.592476489028215%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eTM and ADEM Patients (n: 25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.84012539184953%\"\u003e\n \u003cp\u003eSteroid Treatment Only (n: 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.711598746081506%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.836990595611285%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\"\u003e\n \u003cp\u003e6 \u0026plusmn; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.77742946708464%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.20884520884521%\"\u003e\n \u003cp\u003eSteroid and TPE Treatment (n: 15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.764127764127764%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.027027027027028%\"\u003e\n \u003cp\u003e26 \u0026plusmn; 26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.20884520884521%\"\u003e\n \u003cp\u003eTPE Treatment Only (n: 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.764127764127764%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.027027027027028%\"\u003e\n \u003cp\u003e16 \u0026plusmn; 18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: ADEM: Acute Disseminated Encephalomyelitis, TM: Transverse Myelitis, PICU: Pediatric Intensive Care Unit, TPE: Therapeutic Plasma Exchange (Plasmapheresis), GBS: Guillain-Barr\u0026eacute; Syndrome, MV: Mechanical Ventilation, IVIG: Intravenous Immunoglobulin,\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Children, Acute Flaccid Paralysis, İntravenous immunoglobulin, Pediatric intensive care unit, Guillain-Barré syndrome","lastPublishedDoi":"10.21203/rs.3.rs-3948249/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3948249/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgroud: \u003c/strong\u003eAcute Flaccid Paralysis (AFP) is a syndrome characterized by decreased tone (flaccidity), often presenting with respiratory and bulbar system failure, rapid onset, and weakness in the extremities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eFrom January 1, 2018 to January 1, 2023, the clinical findings, treatment results, intensive care processes and prognoses of 68 children diagnosed with AFP who applied were evaluated retrospectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe age range of patients was between one month and 18 years, with a mean age of 7.9 ± 4.5 years. Out of the patients, 33 were male (48.5%).The average pediatric intensive care unit (PICU) stay for all AFP patients was 15.4 ± 19.5 days, and the average hospital stay was 23.3 ± 21.1 days. Among all AFP patients, 42 (61.8%) required respiratory support. All patients received intravenous immunoglobulin (IVIG) treatment. Twenty-five out of 43 Guillain-Barré syndrome (GBS) patients, seven out of 11 and transverse myelitis (TM) patients, and 11 out of 14 acute disseminated encephalomyelitis (ADEM) patients received therapeutic plasma exchange (TPE). Among the 14 intubated GBS patients, five received IVIG treatment for two days or less, and nine received IVIG treatment for four days or more. The invasive mechanical ventilation (MV) durations (in days) showed that patients who received IVIG treatment for four days or more had a significantly longer intubation period (p: 0.044). Out of GBS patients, received only IVIG (monotherapy), and received IVIG and TPE (combined) treatment. The combined treatment group had a longer PICU stay (p: 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eIn our study revealed that combination therapies (IVIG and TPE or steroid and TPE) led to prolonged MV and PICU stay durations compared to monotherapies (IVIG or steroids) in AFP patients. Moreover showed that in intubated GBS cases, administering 2 g/kg/day IVIG for two days significantly reduced the duration of invasive MV.\u003c/p\u003e","manuscriptTitle":"Evaluation of Patients Diagnosed with Acute Flaccid Paralysis Followed and Treated in Pediatric İntensive Care: A Multi-Center Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-16 05:34:11","doi":"10.21203/rs.3.rs-3948249/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93d22afa-1c32-4391-a726-0bdd231b0283","owner":[],"postedDate":"February 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-18T20:22:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-16 05:34:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3948249","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3948249","identity":"rs-3948249","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}