My name is Brenda Morrow. I am a clinician scientist with a physiotherapy background from South Africa, and I'm delighted to be speaking today on the E and F of the liberation bundle. So you've seen the bundle, and again, I can reiterate, you cannot see the E and F factors. That's early mobility and family engagement in isolation from the rest of the bundle. But I am going to be focusing on that as per my mandate. So we've heard a little bit about the whys, but I think certainly in terms of early mobility, it's really important to emphasize why it's so important, because if we really understand the why, it becomes much easier to actually do it and to implement it. This was a small systematic review we did a couple of years ago, which really just showed what we know, that PICU mortality has been declining steadily over the past years. Unfortunately, it's much more notable in high-income countries, which is the red line in this graph. Low and middle-income settings are lagging far behind. But I think it's safe to say that mortality in the pediatric ICU is becoming relatively rare, which is obviously fantastic. But we also know that simply being alive is not the same as being able to live life to the fullest. So we need to look at functional outcomes, not just surviving. How can children thrive after their ICU discharge as well? If we look at immobility alone, and we see these effects in the astronauts after space missions, immobility alone without the critical illness can affect adversely every single organ system, with respiratory stasis, secretion stasis, infection, embolisms, cardiovascular effects of postural hypertension, for example, neurological effects, delirium, depression, anxiety, musculoskeletal complications, including osteoporosis, severe muscle weakness and atrophy, and joint contractures. And those short-term complications of critical illness and immobility may persist in the post-intensive care syndrome. So this we have known about in adults for many, many years. More recently, Joseph Manning and colleagues have applied and conceptualized this concept in the PICS-P framework, the pediatric framework. So we know that these consequences of critical illness and immobility may affect your physical health, cognitive, emotional, and social health adversely in the short and in the long term. And this may have considerable impact on the child's ability to function in everyday life and on their neurodevelopmental outcomes. Importantly, it doesn't just affect the child. It also affects their siblings, their family, and their extended community. And the trajectory of recovery is highly variable and may last days, weeks, months, and possibly even decades. So if keeping still has so many problems, surely it makes sense to work against that. And that's really the premise behind early mobility and rehabilitation within the PICU. By incorporating movement, active exercise, into our critical care, we're really aiming to improve outcomes, improve duration of PICU stay, improve duration of mechanical ventilation duration, and importantly, allow children to be able to be children and function appropriately on discharge from the PICU. So we ask the question, what is early mobilization? And I get this a lot. And there have been variable definitions from applying physical activity within the first 48 to 72 hours or the more pragmatic definition from my colleague in the front, Karen Chung, that really it's mobilization that's initiated as soon as possible after admission when it's safe to do so in the absence of contraindications. We ask about safety and efficacy. Unfortunately, and this is the case in so many aspects in pediatrics, this bundle element is not supported by high-level evidence. Empirical studies in this area are really challenging to do in the first place, but we have relatively few pediatric-specific studies. Most of the studies we have are relatively small, and I'll come to the Park PICU, which are somewhat different. Observational studies, many are retrospective studies, limiting the strength of evidence that we have in support of efficacy. We do have a number of smaller studies that have been combined in systematic reviews which suggest benefit, and certainly our adult studies have shown benefit for a number of outcome measures. But these smaller studies together really do suggest that early mobilization within the PICU is both safe and feasible. And as I said, we don't have robust evidence in support of efficacy, but in the evidence table, scientific rationale, expert opinion, and experience is part of our evidence base. It makes physiological sense and clinical sense to mobilize patients. And in the absence of harm, we need to start practicing. The Park PICU studies, mobilization practices, again, and we've heard this from Sapna earlier, have really only reported minor adverse events, and these are transient changes in vital signs. And even in specialized populations, such as those on ventricular assist devices, post-liver transplant, and ECMO, have also not shown serious adverse events. So I think it's safe to say that it appears to be safe. When we look at who should be mobilized, what is interesting is that a number of studies have shown that early mobilization is more strongly supported and practiced in older children. And really, that younger infants seem to be relatively neglected in terms of implementing early mobility. So I think that not only should infants and young children receive early mobility, I actually think they need to be specifically targeted for early mobility practice, because we tend to forget about them. The other people that may benefit more from early mobility practice are the people who are more likely to receive early mobility practice. And I think this is a very important point. The other people that may benefit more from early mobility, and we don't know this empirically, are the long-stayers. The problem is, and we've shown this in our unit, that on admission, one cannot predict who is more or less likely to be a long-stayer. And if we wait, the problem of waiting, you actually miss the boat. By the time you realize that this is the child that's going to be spending weeks or months in your ICU, you may already have the adverse sequelae. So we do need to start as soon as possible for all our patients. So for me, the who is everyone. All patients who are admitted to the PICU should be assessed for early mobility intervention, and this should be implemented as soon as it's appropriate to do so, regardless of age, regardless of premorbid functional level, regardless of their condition. But the nature of the mobility needs to be appropriate to the child as they present to you. So my story is that I have always mobilized children. I think maybe it was naivety. When I started practicing in 1996, I walked into a pediatric ICU, having never stepped into one before, and was expected to run the physio program alone. I had children that were lying there not moving, so I moved them. And it was only almost 20 years later that protocols started to be developed, that people started to wake up to the fact that this was important, at which stage I was giggling in the back, saying, well, we've kind of always done this. But I certainly think that there's safety in protocols. There's safety in knowing that you're practicing in the same way as other people. And so I was delighted to be invited by my esteemed colleague to join this group to develop practice recommendations for early mobilization in critically ill children based on available evidence and expert consensus. And this really is very comprehensive. It provides all the contraindications and precautions that you need to understand and the indications for early mobility. It provides you with a recipe, really, on the type of activities that we might be doing with children in different contexts, as well as providing stopping rules. When do you need to step down and realize that this is not appropriate for this child? In summary, though, we do recommend that early mobilization should be commenced as early as possible following the PICU admission. And really, early mobility or rehabilitation is a progressive approach. It's a graded approach according to how your child is presenting. And remember that children will change from day to day. So although you might think it's a one-way progression, it's not always a one-way progression. If your child is acutely ill, if they are sedated and they need to be sedated, one could start with passive interventions, active holding in the parent's arms, passive range of movement exercises, positioning appropriately. And as the child's condition changes and improves, one can then start incorporating activities that require greater participation on behalf of the patient and greater active participation. Now, in adults, the goal of mobilization is usually independent ambulation out of the bed. But remember, we're dealing with a range of ages from birth and in some units up to 18 or even beyond that. And so that cannot be your goal. You have to set your goals of mobilization according to your individual patient and based on a full clinical assessment. And we need to remember that mobility activities include preambulation activities appropriate to the child's developmental level. A lot of people will say, well, we can't do it because we don't have the equipment. And I do note that many of the published studies use fairly expensive equipment like psychologometers, gaming consoles. We've never had those, and I don't believe that they are necessary in order to achieve your mobility goals. I think it's nice to have, but as I say, we've been mobilizing patients forever. When I started working, we didn't even have standing frames. Even now, you can see we use very simple equipment. I believe that all you need is your own body and a willing and capable team. Please excuse lack of PPE. This was before COVID, and our rules have changed somewhat. This little girl had a high spinal tumor, and at this stage, although it looks like she's actively participating, in actual fact, she had grade 0 at the most grade 1 muscle power below the neck. She was highly motivated, however, and said she at least wanted to be able to move her own wheelchair. And so she asked every single day to get onto the floor and work. I think yoga helps a little bit in getting your body positioned appropriately, but as I say, you don't need expensive equipment to do what's necessary. One slide seems to be missing here, but never mind. Oh, sorry. Play is so important. Play is a child's functional activity of daily living. Adults might have various work activities that they do, but children need to play. Play is essential for a number of important outcomes, including attaining neurodevelopmental milestones of motor function, cognitive function, social functioning, problem solving, communication, and the list goes on. Importantly, play is also fun. Incorporating play into mobility activities in the ICU can change the experience that the child has in the unit to a much more positive one, potentially reducing the impact of some of the adverse psychological consequences of PICU stay. So there are a number of different types of play activities that one can incorporate in our mobility activities. Construction, block play, active play, dancing, playing with a balloon or a ball, bringing in music play, creative play, doing drawings, for example. What about water activities, hydrotherapy? Again, this is something that I did. I've been doing it for many years. But one way of really bringing water play safely into a unit is bringing a small paddling pool into the unit, which we've done now for a number of patients. It's warm, soapy water. It's comfortable for the child. They have so much more freedom of movement in the water, and they can really play while getting all the benefits of mobilization in a safe, contained environment, even while fully ventilated. If you look at the literature, there's a wealth of barriers that people report. I do believe that these barriers are largely based in fear, fear of the unknown. And I think that most of them can be overcome, and largely they can be overcome through good interprofessional communication. In terms of equipment, we've looked at that. I don't think you need fancy equipment to achieve your mobility goals, and certainly we've never had that equipment. We do have guidelines or practice recommendations that one can follow, which also highlight which patients are appropriate. How do you tackle medical complexity? In terms of insufficient resources, I was interested in the slide that Debbie showed about the costs of delirium care. I think that it's much more cost-effective to prevent the complications of immobility rather instead of implementing mobility practice. So it's resource-effective to implement mobility in ICU. As far as safety concerns go, we've repeatedly shown that there really are no major safety concerns if you work appropriately. And in terms of aspects like over-sedation and pain, well, we have the liberation bundle in place. If you get everything right, I think we start losing these barriers, we start breaking them down. My suggestion is wherever you are in the world, if you are looking to start an early mobilization process within your unit, is be pragmatic. Start where you are, use what you have, and do what you can. In this regard, something is always better than nothing. And one of the resources that all of us should have is family presence and engagement in the PICU. We know from the Park PICU studies that family engagement and presence is positively associated with out-of-bed mobilization. So family engagement really requires a collaborative process that helps parents to really understand the rationale and the benefits and the process of early mobilization. And if they fully understand it, they can start becoming actively involved. And that active involvement also allows some activities to be sustained beyond the relatively brief mobilization session by whichever health professional is providing it. Parents really are best placed to determine their child's level of comfort and pain, and they are best able to communicate with their child and understand their child's verbal and nonverbal communication. So by having the parent there as an interpreter, if you will, it really will improve the child's level of cooperation and motivation. But moving away from family with the sole purpose of improving mobility outcomes, we need to remember that wherever you are in the world, a child that's admitted to the PICU remains a child with children's needs. Being admitted to a PICU is terrifying. You're in a foreign environment with strange noises, strange people, strange equipment, with things being done to you that you cannot understand unless there's a trusted adult there who is able to explain it to you and provide comfort. And we know that there are huge psychological consequences of PICU stay on the child, and I do believe that these impact on a number of physical outcomes as well. I also don't think that we don't always appreciate the pressure that having a child in the PICU has on the parent. Not being aware of how your child is, not understanding what is being done to your child, and not being able to take care of the child yourself must have huge impact on the parent. And I know as a parent myself, if you didn't let me help my child while they were in an ICU, I would be absolutely devastated and wouldn't be able to cope. So we know that for a child in the PICU, family is an important source of comfort, a source of familiarity at a time when the child really needs it the most. It helps the child to feel reassured, safe, and orientated. And in that regard, it may, although this is not proven, it may reduce problems, for example, of delirium. Just having the parent present, though, is also not enough. We need to engage in a family-centered care approach, which is really a partnership approach to health care decision-making. It allows us to provide care that's respectful of and responsive to individual preferences, beliefs, needs, and values. And it has been suggested that by engaging in family-centered care and improving communication and involvement of the family within this care, we can ultimately improve health outcomes. I'm sorry this slide got corrupted along the way, but family-centered care looks different in different socio-geographic regions. So it's been reported that in some developed countries, family-centered care really more involves care that's led by the parents in dialogue with the medical staff, whereas where I work, in Africa, family-centered care is more about the active participation in physical, psychological, and social care of the child. But regardless of where you are, I think that parental engagement and participation in the care of the critically ill child is always associated with reduced parental anxiety and child anxiety and higher satisfaction levels. It's also been shown to facilitate parent-child bonding. It empowers parents, and it provides hope. Again, I'm sorry, but there was a text box that disappeared along the way. If we're looking at the effect on outcomes of parental participation, we do not have pediatric empirical evidence. Adult studies have shown positive clinical outcomes related to family participation in terms of reduced delirium and reduced cardiovascular complications. Now, we don't have the evidence in children, and I really don't think we can assign children to a control group here. It would not be ethical in any way. But I think we can all intuitively appreciate the countless benefits that allowing and encouraging parental participation could have on the child outcomes and certainly on parental satisfaction levels. You saw the child that I showed earlier looking terrified in the ICU shortly after receiving a tracheostomy for Guillain-Barre syndrome. This is the same child having been mobilized into a standing position and allowing the parent to be involved in the care. We don't need empirical evidence necessarily to see the obvious. But early mobilization and family engagement have huge benefits for both the child and the parent. Thank you.

early mobility

family engagement

pediatric ICU

immobility

critical care

parent-child bonding