THE JOURNAL OF PEDIATRICS • www.jpeds.

com ORIGINAL
ARTICLES
Early Mobilization in Critically Ill Children: A Systematic Review
Carlos A. Cuello-Garcia, MD, PhD1, Safiah Hwai Chuen Mai, PhD1, Racquel Simpson, MA1, Samah Al-Harbi, MD2, and
Karen Choong, MD, BCh, MSc1

Objective To characterize how early mobilization is defined in the published literature and describe the evi-
dence on safety and efficacy on early mobilization in critically ill children.
Study design Systematic search of randomized and nonrandomized studies assessing early mobilization-
based physical therapy in critically ill children under 18 years of age in MEDLINE, Embase, CINAHL, CENTRAL,
the National Institutes of Health, Evidence in Pediatric Intensive Care Collaborative, Physiotherapy Evidence Da-
tabase, and the Mobilization-Network. We extracted data to identify the types of mobility-based interventions and
definitions for early, as well as barriers, feasibility, adverse events, and efficacy outcomes (mortality, morbidities,
and length of stay).
Results Of 1199 titles found, we included 11 studies (2 pilot trials and 9 observational studies) and 1 clinical prac-
tice guideline in the analyses. Neurodevelopmentally appropriate increasing mobility levels have been described
for critically ill children, and “early” mobilization was defined as either a range (within 48-72 hours) from admission
to the pediatric intensive care unit or when clinical safety criteria are met. Current evidence suggests that early
mobilization is safe and feasible and institutional practice guidelines significantly increase the frequency of reha-
bilitation consults, improve the proportion of patients who receive early mobilization, and reduce the time to mo-
bilization. However, there were inconsistencies in populations and interventions across studies, and imprecision
and risk of bias in included studies that precluded us from pooling data to evaluate the efficacy outcomes of early
mobilization.
Conclusions The definition of early mobilization varies, but seems to be feasible and safe in critically ill chil-
dren. The efficacy for early mobilization in this population is yet undetermined because of the low certainty of the
evidence available. (J Pediatr 2018;203:25-33).

See editorial, p 10

hildren are at risk of physical, neurocognitive, and psychosocial sequelae as a result of critical illness.1-3 These

C complications significantly impact the functional recovery and quality of life of critically ill children and their
families after hospital discharge.4,5 As a result, there is great interest in acute rehabilitation interventions initiated in
the intensive care unit (ICU) setting for both children and adults. There is a growing body of evidence demonstrating safety,
efficacy, and cost effectiveness of early mobilization in critically ill adults.6-12 Multimodal, interdisciplinary approaches to
mobility-based physical therapy are associated with decreased muscle weakness, sedation requirements, delirium, length of
mechanical ventilation, and length of hospital stay in adults.8-12 However, the evidence in children is unclear, particularly with
respect to what constitutes mobilization, the timing, appropriateness, and approaches to mobilizing children in the pediatric
ICU (PICU).
The objective of this review was to systematically evaluate the literature on early mobilization in critically ill children. Our
specific aims are to characterize the spectrum of definitions of (1) mobility-based therapies or interventions, (2) “early” mo-
bilization, and (3) safety criteria for mobilization. Also, we aim to assess adverse events and efficacy outcomes (ie, mortality,
morbidities, days in PICU) related to mobilization in critically ill children.

Methods
We followed the PRISMA guidelines and the Cochrane Handbook for conduct-
ing systematic reviews and meta-analysis13,14 and the protocol was registered on
From the 1Department of Pediatrics and Critical Care,
PROSPERO.15 Master University, Hamilton, Ontario, Canada; and
2
Pediatric Department of Medical College at King
Abdulaziz University, Jeddah, Saudi Arabia
C. C.-G. is an Editorial Board member for The Journal of
Pediatrics. The authors declare no conflicts of interest.
ICU Intensive care unit
PICU Pediatric ICU 0022-3476/$ - see front matter. © 2018 Elsevier Inc. All rights
RCT Randomized controlled trial reserved.
https://doi.org10.1016/j.jpeds.2018.07.037

25
THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume 203 • December 2018

Search Strategy measures. The maximum score for each area is 4, 2, and 3
The electronic databases MEDLINE, Embase, CINAHL, and points, respectively. A total score of 3 or lower indicates low
Cochrane Central Register of Controlled Trials (CENTRAL) methodologic quality, and a score of 4-5 indicates moderate,
were searched for eligible studies from inception to April 2017 and 6 or greater indicates high quality for an observational
and updated in March 2018, using a detailed strategy study. We assessed quality of randomized trials with the Co-
(Appendix 1; available at www.jpeds.com) We manually chrane risk of bias tool.17 Quality assessments were done in-
searched the reference list of included studies, and the follow- dependently by researchers who were not coauthors on any of
ing databases for published or ongoing registered trials the included papers.
or studies: US National Institutes of Health (https://
clinicaltrials.gov/), Randomized Trials in Paediatric Intensive
Data Synthesis and Statistical Analyses
Care (http://picutrials.net), Physiotherapy Evidence Data-
Subgroups analyses, sensitivity analyses, or specific assess-
base (http://www.pedro.org.au/), and the Mobilization Network
ment of publication bias for the efficacy outcomes were not
(http://mobilization-network.org/).
set a priori because we deemed it improbable to find an
important number of published randomized or registered
Eligibility Criteria for Review
clinical trials in pediatrics. The data was summarized descrip-
Studies were included if they were (1) completed or regis-
tively in tables using counts, proportions, means and SD, or
tered protocols of randomized, controlled trials or
medians and IQR where appropriate. Summary statistics
nonrandomized studies, (2) specifically conducted in criti-
and combined data from eligible studies are presented as
cally ill children under 18 years of age admitted to a PICU, (3)
means and SD, or risk ratios with 95% CI. For efficacy
evaluated a mobilization intervention, and (4) were pub-
outcomes, we performed an overall assessment of the cer-
lished in full text or as abstracts describing ongoing regis-
tainty of the body of evidence (also called quality of the
tered clinical trials in any language. We included clinical practice
evidence or confidence in the effect estimates) for each
guidelines on mobilization published specifically in critically
outcome following the Grading of Recommendations Assess-
ill children to evaluate descriptions of timing and interventions.
ment Development and Evaluation (GRADE) approach.18
Children aged 31 days to 18 years admitted to a PICU (con-
We used the GRADEpro Guideline Development tool
stituting >50% of the study population) were included, and
(www.gradepro.org) to produce a summary of findings table
studies conducted in adults or neonates were excluded from
and evidence profiles.
our analyses. Studies including exercise or mobility-based phys-
iotherapy delivered in the PICU were considered for inclu-
sion. We excluded studies if they focused primarily on
Results
nonmobility or chest physiotherapy interventions or initi-
ated the intervention after PICU discharge.
We retrieved a total of 1199 citations (after removal of 185 du-
Our primary outcome was to present and characterize the
plicates), of which, after title and abstract screening, 92 full-
spectrum of how “early mobilization” is defined in published
texts articles were assessed, yielding 12 studies on mobilization
literature, types of mobility therapy, patient selection, and safety
in the PICU (Figure; available at www.jpeds.com) consisting
criteria for initiating or suspending mobilization. Secondary
of 1 clinical practice recommendation19 and 11 individual
endpoints were the feasibility, safety, and efficacy outcomes
studies. These 11 studies evaluated mobilization in a total of
related to early mobilization, such as mortality, length of stay,
1178 children with a range of medical-surgical and neurocritical
and PICU-acquired morbidities (ie, weakness, pressure ulcers,
care diagnoses, conducted across 3 different countries. Of these
delirium).
studies, there were 2 pilot randomized controlled trials
(RCTs),20,21 3 prospective single arm studies,22-24 4 pre-post in-
Data Extraction
tervention (before-after) studies,25-28 and 2 retrospective cohort
Citations were reviewed and managed using Covidence (https://
studies.29,30 The characteristics of these studies and main results
www.covidence.org/). Titles and abstracts were screened by 2
for definitions are summarized in Table I and Table II. Details
independent reviewers. Disagreements were resolved by con-
of excluded studies are provided in Appendix 2 (available at
sensus. Full texts of included and uncertain studies were re-
www.jpeds.com).
viewed in duplicate, with a third reviewer as necessary. Data
were extracted by 2 independent researchers. Disagreements
were resolved by consensus and by a third reviewer when nec- Risk of Bias Assessment
essary. Study authors were contacted for additional informa- In nonrandomized studies, the Newcastle-Ottawa Scale quality
tion or clarification when necessary. score ranged from 5 to 7, that is, moderate to high quality
(Table III). The 2 included RCTs were pilot feasibility trials with
Assessment of Methodological Quality a low risk of bias from the randomization process (selection
We used the Newcastle-Ottawa Scale 16 to assess the bias), incomplete outcome data (attrition bias), or selective re-
methodologic quality of nonrandomized studies. The porting. There is some potential for performance and detec-
Newcastle-Ottawa Scale contains 3 major domains: selection tion bias in both RCTs owing to the inability to blind
of subjects, comparability between groups, and the outcome participants and investigators to the intervention.
26 Cuello-Garcia et al
Early Mobilization in Critically Ill Children: A Systematic Review

December 2018
Table I. Characteristics of included studies
Author Year Design n Inclusion criteria Interventions Outcome(s) assessed
Choong30 2012 Single center 91 Children aged 0-17 years who required None. Description of acute rehabilitation Rehabilitation practices in PICU.
retrospective study a >24-h PICU stay practices. Clinical outcomes in patients who were
mobilized vs not mobilized.
Abdulsatar22 2013 Prospective single 12 Children aged 3-18 years with a ≥48-h Interactive video game using Nintendo Wii Feasibility and safety, limb accelerometry,
arm study PICU stay Boxing for minimum 20 min, twice a day, muscle strength, and caregiver/
for 2 d. participant satisfaction.
Choong29 2014 Multicenter 600 Children aged 0-17 years who required None. Description of acute rehabilitation Rehabilitation practices in 6 PICUs,
Retrospective study a >24-h PICU stay practices. predictors of mobilization.
Clinical outcomes in patients who were
mobilized vs not mobilized.
Choong23 2015 Prospective single arm 31 Hemodynamically stable children with an Passive (using in-bed cycling) and/or Feasibility and safety.
study anticipated >24-h PICU length of stay active (using interactive video games),
according to patient's level of
consciousness and cognition, for a
minimum of 10 and a maximum
of 20 minutes on day 1, and a minimum
of 20 minutes on day 2.
Tsuboi25 2016 Pre–post study 57 (23 in the period Age <16 years, after liver transplantation. Early mobilization implementation for Proportion of PT consults and comparisons
before early postoperative liver transplant recipients in of PT before and after; safety and clinical
mobilization, 34 in the PICU. outcomes (duration of mechanical
the period after early ventilation, length of stay, and mortality).
mobilization)
Wieczorek26 2016 Pre-post design 200 (100 in each; pre Children 1 day to 17 years old with a PICU Implementation of an interdisciplinary early Feasibility and safety.
(“PICU-Up!” study) and post stay of >72 h mobilization program. Proportion of PT and OT consultations and
intervention) mobilization activities by PICU day 3.
Choong20 2017 Pilot RCT (“wEECYCLE”) 30 Children 3-17 years, not being mobilized at Early mobilization with usual care Feasibility, time to mobilization and safety.
the time of screening and expected to PT (control arm) or addition of in-bed Clinical outcomes: PICU acquired
stay in the PICU for additional 48 hours cycling for 30 min/d, 5 d/ morbidities, length of stay, mortality, and
wk (intervention arm). functional outcomes.
Fink21 2017 (abstract Pilot RCT 58 Children 3-17 years old with a new Early, protocolized assessment and therapy PT, OT, and SLP consultation rate and
only) traumatic/nontraumatic brain insult and consisting of PT, OT, and adverse events.
PICU admission of >48 h SLP (intervention arm) versus usual care.
Alqaqaa28 2018 (abstract Observational, quality 183; 73 in the Not described Education and training on the benefits of Mobilization rate; incidence of safety events,
only) improvement project; preintervention early mobilization and techniques to PT, OT, SLP orders, ICU and hospital days,
pre-post design group, 110 in the safely mobilize critically ill children. discharge disposition.
postintervention Family advisors assisted in incorporating
group patient and family feedback into staff
education.
Arteaga27 2018 (abstract Observational pre-post 40 2 months to 18 years of age; expected PICU ABCDEF bundle quality improvement A comparison of preimplementation and
only) design 11 in the length of stay of ≥3 days, and collaborative: (A), readiness for postimplementation bundles of
preintervention requirement for invasive or noninvasive extubation (B), sedation choice (C), care (median) in mechanical ventilation

ORIGINAL ARTICLES
group, 29 in the ventilation; patients with severe disability, delirium management and prevention (D), days, and PICU and hospital days.
postintervention coma or vegetative state, and brain death early mobilization (E), and family Functional status and performance were
group were excluded engagement (F) in the PICU. also measured.
Sargent24 2017 (abstract Observational 6 Patients 10-18 years old, hemodynamically In-bed cycling. Heart rate, blood pressure, respiratory rate,
only) prospective single stable with calf length of >10 inches, oxygen saturations, and tidal volumes.
arm study intact skin integrity and no These were measured before, during and
contraindications to exercise after treatments.

OT, Occupational therapy; PT, physical therapy; SLP, speech and language therapy.
27
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Table II. Results: Definitions, time to mobilization, and criteria for terminating early mobilization, main results, and adverse events
Definition of early Time to Contraindication Criteria for terminating Adverse
Author Year mobilization mobilization, d* of mobilization early mobilization Main results events
Choong30 2012 Any mobility activity within 48 1.5 (0.3-2.7) Not described. Not described. 15.1% of patients received early None reported.
hours of PICU admission. mobilization. A significantly
All activities focused on greater duration of
enhancing physical function vasoactive infusions,
and strength. mechanical ventilation and
PICU stay in patients who
were not mobilized was
observed.
Abdulsatar22 2013 Not defined. 9.5 (range, 1-56). Cardiorespiratory instability, Accidental tube dislodgement, Upper limb activity was None reported.
inability to comply/ musculoskeletal injury, pain significantly greater during
comprehend instructions, or discomfort, intervention compared with
physical inability to mobilize cardiorespiratory instability. the rest of the day. Grip
limb. strength did not change from
baseline.
Choong29 2014 Any mobility activity within 48 2 (1-6) Not described. Not described. 9.5% received early No difference
hours of PICU admission. mobilization. Significantly between mobility
All activities focused on greater duration of and nonmobility
enhancing physical function vasoactive infusions, length groups.
and strength. of PICU stay and delirium in
patients who were mobilized.
Choong23 2015 Not defined. 5 (3-10) Cardiorespiratory instability, Persistent hypo/hypertension, Interventions are safe and None reported.
intracranial hypertension, brady/tachycardia, oxygen feasible. Cycling increases
unstable spine or desaturation, pain or lower limb activity;
musculoskeletal injury, discomfort, and safety interactive videogame is
surgery/fixed deformities or concerns (eg, tube feasible only in a minority of
extremities. dislodgement). patient.
Tsuboi25 2016 Not defined. 9 (range, 7-13) Hemodynamic instability, Threat of or actual device Significantly increased PT None reported.
intracranial hypertension, dislodgement, vital signs consults and proportion of
cervical spine instability, day exceeding a threshold, patients who received PT
of thoracic or abdominal patient's unacceptability. after early mobilization
surgery. compared with before early
mobilization implementation.
Wieczorek26 2016 Passive/active activity within 72 Not described. Report ECMO, open chest or abdomen, Unexpected extubation or line Significant increase in OT and None reported.
hours of PICU admission. Any number of children with unstable fractures, or specific removal, decline in PT consults post PICU-Up!
increasing activity levels from activities in the first 3 medical orders. physiologic status or strategy. No significant
1 (repositioning) to 3 (sitting- days. behavior. difference in clinical
up, out-of-bed or outcomes.
ambulation).
Cuello-Garcia et al

(continued)

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Early Mobilization in Critically Ill Children: A Systematic Review

December 2018
Table II. Continued
Definition of early Time to Contraindication Criteria for terminating Adverse
Author Year mobilization mobilization, d* of mobilization early mobilization Main results events
Choong20 2017 As soon as possible in the 1.5 (1-3) cycling group. Based on published practice Cardiorespiratory instability, Intervention reported as feasible None reported.
absence of contraindications. 2.5 (2-7) control group. guidelines. increase work of breathing; and acceptable.
Any graduated, pain or discomfort not
developmentally appropriate resolved with analgesia, and
active and or strengthening patient refusal.
exercises.
Fink21 2017 (abstract Any activity within 48 hours of Not reported. Not reported. Not reported. Intervention reported as feasible None reported.
only) PICU admission. Bed mobility, and acceptable.
transfers, activities of daily
living, passive range of
motion, OT.
Alqaqaa28 2018 (abstract Not defined. Not reported. Not reported. Not reported. Intervention was feasible and None reported.
only) safe. Increase in the
percentage of patients
mobilized. For non-MV
patients, PICU days
decreased a mean of 1.1
days, but no difference for
MV patients.
Arteaga27 2018 (abstract Not defined. Not reported. Not reported. Not reported. Fewer days on mechanical None reported.
only) ventilation, length of stay in
the ICU, and hospital length
of stay in the postintervention
group. No deaths reported.
Sargent24 2017 (abstract Not defined. Not reported. Not reported. Not reported. In-bed cycling was safe and None reported.
only) feasible and acceptable.

ECMO, extracorporeal membrane oxygenation; MV, mechanical ventilated.

*Reported as median (IQR) unless otherwise specified.

ORIGINAL ARTICLES
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Table III. Newcastle-Ottawa scoring of included observational studies (before-after studies, prospective, and retrospec-
tive cohorts)
Abdulsatar22 Choong23 Tsuboi25 Wieczorek26 Choong29 Choong30 Alqaqaa28 Arteaga27 Sargent24
2013 2015 2016 2016 2014 2012 2017 2017 2018
Selection
1. Representativeness of the * * * * * * — * *
exposed cohort
2. Selection of the NA NA * * * * — * NA
nonexposed cohort
3. Ascertainment of exposure * * * * * * * * *
4. Demonstration that * * * * — — * * *
outcome of interest was
not present at start of
study
Comparability
1. Comparability of cohorts NA NA — — * * * * NA
on the basis of the design
or analysis
Outcome
1. Assessment of outcome * * * * * * — — —
2. Was follow-up long enough * * * * * * * * *
for outcomes to occur
3. Adequacy of follow-up * * * * * * * — *
Total score 6 6 7 7 7 7 5 6 5

NA, not applicable.

A study can be awarded a maximum of 1 star for each numbered item within the Selection and Outcome categories. A maximum of 2 stars can be given for Comparability.

Mobility Interventions, Timing, and Definitions
of “Early”
Mobilization was specifically described by 4 of 11 individual
studies and the clinical practice guideline, as graduated, de-
velopmentally appropriate, active, and/or strengthening exer-
cises (Table I). These same studies categorized chest
physiotherapy, passive range of motion, stretching, and repo-
sitioning as “nonmobility” interventions. The studies by Choong
et al in 2015 and Wieczorek et al respectively defined levels of
increasing mobility activities to objectify physical therapy goals
and included neurodevelopmental play as a mobility
intervention.23,26 Four studies used interactive videogames and/
or in-bed cycling to facilitate mobilization.3,22-24
“Early” mobilization was defined as within 48 hours of PICU
admission in 3 studies21,29,30 and 72 hours of PICU admission
in another.26 The wEECYCLE pilot RCT evaluated early mo-
bilization practice guidelines as their standard of care, which
recommended screening for appropriateness within 24 hours
of PICU admission, and defined early as when contraindications
are absent and a set of systems-based safety criteria are met.19,20
Appropriateness, Safety Criteria, and Feasibility of
Mobilization
All of the interventional studies considered cardiorespiratory
instability, intracranial hypertension, and spinal instability as
contraindications to mobilization (Table II). The PICU Up!
study included extracorporeal life support and having an
open chest or abdomen as contraindications.26 However, none
of these studies explicitly defined thresholds for cardiorespi-
ratory instability. The wEECYCLE Pilot20 and PICU Up!26
studies both specified that vasoactive infusions and/or high
mechanical ventilatory support are not contraindications but
30
precautions to mobilization. All studies considered similar
adverse events for interrupting or terminating mobilization
based on acute hypotension or hypertension, arrhythmia,
hypoxemia, accidental device dislodgement, patient intoler-
ance, and falls.
All 11 included studies reported that mobilization was fea-
sible in the PICU and 3 of these studies identified barriers and
threats to implementing mobilization in this population.26,29,30
The most common barriers to mobilizing critically ill chil-
dren were resource limitations, excessive patient sedation, the
need for patient cooperation, and apprehension with early mo-
bilization expressed by healthcare personnel and family care-
givers. None of the included studies observed a significant
increase in adverse events attributable to mobilization (Table II).
We estimated from a total of 11 studies reporting on 1178 chil-
dren, only 13 patients (1.1%) experienced an adverse event at-
tributable to mobilization.
Efficacy of Mobilization
The 4 pre-post studies and the wEECYCLE Pilot RCT found
that the institution of interdisciplinary early mobilization pro-
grams significantly increased the frequency of rehabilitation
consults, improved the proportion of patients who receive early
mobilization, and reduced the time to mobilization.20,25-28 The
following efficacy outcomes have been evaluated as second-
ary endpoints: duration of mechanical ventilation, PICU du-
ration of stay, mortality, and PICU-acquired morbidities. Only
1 study measured functional outcomes.20 The effect of mobi-
lization on these outcomes and the certainty of the evidence
as assessed using GRADE are summarized in Table IV. The
overall certainty of evidence for these outcomes was low or very
low. We decided not to obtain pooled estimates owing to the
Cuello-Garcia et al
December 2018 ORIGINAL ARTICLES

Table IV. Summary of findings: Early mobilization compared with usual care in children admitted to PICUs.
No. of participants
Outcomes (studies)
Mortality (no. of deaths recorded) 88 (2 RCT)
Mortality (no. of deaths recorded) 1220 (9 observational studies)
Length of stay in PICU (days recorded) 30 (1 RCT)
Length of stay in PICU (days recorded) 1171 (7 observational studies)
PICU-acquired Morbidities¶ 30 (1 RCT)
PICU-acquired morbidities¶ 636 (2 observational studies)
Certainty of the
evidence (GRADE) Narrative results
⊕⊕○○ No deaths in any patient were reported in 2 pilot RCTs.20,21
Low*
⊕○○○ Across 9 studies, 4 deaths were reported among
Very low†,‡,§ 494 children receiving mobilization (0.8%) vs 27 of
720 (3.75%) in control group.22-30
⊕⊕○○ Authors reported an overall length of PICU stay of 8.0 days
Low* (IQR, 5.0-13.8) with no distinction among groups.20
⊕○○○ Two studies (n = 257 patients) did not detect a significant
Very low†,‡,§ difference between groups.25,26 Three studies27,28,30
with 314 patients favor the mobility group; while one
multicenter study29 with 600 patients observed a
difference favoring the group without mobilization. One
study did not present results by group of study.22
⊕⊕○○ 6 of 30 patients (20%) developed morbidities. No statistical
Low* comparisons were made between early mobilization vs
control groups in this pilot RCT.20
⊕○○○ Morbidities were present in 5 of 178 participants (2.8%) in
Very low†,§ the mobility group, and in 6 of 458 (1.31%) in the control
group.29,30

GRADE Working Group grades of evidence.

High certainty (⊕⊕⊕⊕): We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty (⊕⊕⊕○): We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially
different.
Low certainty (⊕⊕○○): Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low certainty (⊕○○○): We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
*Pilot single-center trial with 30 patients and no events in total mortality. These studies aimed to assess the feasibility of future clinical trials.
†Most cohort studies were uncontrolled with no assessment or adjustment of confounders.
‡Important differences in study design, clinical setting, patients' characteristics, and interventions.
§Small number of patients. We preferred not to perform a pooled estimate (meta-analysis). The small number of patients and events preclude gives a judgment of serious about imprecision.
¶Composite outcome of at least one morbidity –weakness, pressure ulcer, joint contracture, or delirium.

heterogeneity of interventions, study design, clinical settings,
and characteristics of study participants.
Discussion
The results of this systematic review of early mobilization in
critically ill children demonstrate the following key findings:
(1) “early” is defined as either a range (within 48-72 hours)
from PICU admission, or when contraindications are absent
and clinical safety criteria are met, (2) neurodevelopmentally
appropriate increasing mobility levels have been defined for
critically ill children, (3) mobility-based physical rehabilita-
tion is safe and feasible, and (4) the efficacy for early mobili-
zation in this population is as yet undetermined because of the
low certainty in the currently available evidence.
Although the evidence on early mobilization in critically ill
adults has been accumulating, this field of research in criti-
cally ill children is still in its infancy. There are several reasons
why this field of research is lagging behind in pediatrics com-
pared with adults and unique challenges to conducting early
mobilization research in this population exist. First, buy-in is
challenging. Clinicians and families caring for critically ill chil-
dren remain skeptical or uncomfortable about early mobili-
zation, not only because of the implications it may have on
other concurrent interventions, such as sedation, but also owing
to the resources and potential workload required to mobilize
a patient.31 Second, the PICU population is heterogeneous; these
children span across broad developmental and cognitive ages.
Early Mobilization in Critically Ill Children: A Systematic Review
More than 60% of children have chronic comorbidities and
one-half have baseline functional disabilities.3,32 Defining mo-
bility is, therefore, not straightforward in critically ill chil-
dren and needs to consider the cognitive, functional, and
developmental abilities for each child. Third, it is challenging
to evaluate the dose-response and efficacy of mobility inter-
ventions, because the appropriate dosing of this intervention
in terms of intensity and duration has yet to be established in
children with varying and evolving severity of critical illness.
Although there are several tools for assessing, describing, and
measuring mobility in critically ill adults,14,33,34 these mea-
sures are not validated in children. Levels of permissible mo-
bility activities have been empirically developed for children,
but are inconsistent.3,26 Therefore, the patient selection, safety,
and feasibility results from this systematic review may be used
to advance the development of similar tools in children.
The safe timing for initiating mobilization in children with
high severity illness who are receiving invasive support and the
best timing for a mobility intervention to impact on patient
outcomes cannot be answered with the current evidence. The
included studies in this review that defined early varied between
using a timeframe from PICU admission, that is, within 48-
72 hours, and empiric clinical measures reflective of current
clinician comfort with mobilization surrogates. Tradition-
ally, cardiorespiratory instability is a common reason to im-
mobilize patients.35 The results of this review suggest that levels
of comfort with mobilization may be evolving with increas-
ing safety and feasibility data in children and indirect evi-
dence from the adult population. Cardiorespiratory instability
31
THE JOURNAL OF PEDIATRICS • www.jpeds.com
is no longer a contraindication to mobilization, but rather a
precaution to mobilization.20,26
Other reviews agree with our results.6,7,36 Although we did
not include retrospective evidence from case series, case-
control studies, or indirect evidence from adult populations,
we were successful at including several prospective
interventional studies23-28 and 2 pilot RCTs20,21 in pediatric popu-
lations that emerged since the last published review.36 Our in-
clusion criteria aimed at also including observational studies
and guidelines that were helpful with the definition of early
mobilization and provide information on feasibility issues. What
is consistent from this current body of pediatric literature is
that early mobilization is safe and feasible. This study not only
highlights the need for more research in this area, but it is also
an important first step in prompting the development of stan-
dardized descriptions for patient selection, timing, and dosage
of mobilization in critically ill children and determining ap-
propriate patient-centered outcomes to evaluate its efficacy and
how these may be best measured in future trials on early
mobilization.
The main strength of our review is that it provides infor-
mation on 2 fronts: first, for describing how early mobiliza-
tion interventions are defined and used, as well as feasibility
and safety issues; and second, for evaluating the efficacy of clini-
cally important outcomes using GRADE. Our work aims at
highlighting the aspects of safety and feasibility, especially on
the contraindications for considering early mobilization and
the criteria for terminating, as described in Table II.
Although pediatric data are scarce, the variability in defi-
nitions and contraindications to early mobilization also varies
among the adult literature (eg, from <48 hours to <72 hours),
even when more evidence from this population is
available.7,10,11,37,38 However, both bodies of evidence are in agree-
ment in terms of safety and feasibility of early mobilization
interventions.
As in any review, our limitations include the possibility of
bias in the review process. We tried to avoid this by rigor-
ously following the PRISMA guidelines and reporting process,
with a published protocol, and transparently performing all
screening, data extraction, and risk of bias assessment in
duplicate and with a third assessor when discrepancies were
found.
The evidence from current interventional studies suggest that
the use of institutional early mobilization guidelines and the
support of interdisciplinary team education and resources in-
creases the proportion of patients who receive acute rehabili-
tation consults and assessments, as well as the frequency of and
the time to mobilization for these children. However, there are
patient-, caregiver-, and resource-related barriers to execut-
ing mobility therapy in this population. The impact of early
mobilization on the efficacy outcomes in critically ill chil-
dren remains to be seen owing to the paucity of prospective
trials and, therefore, the low certainty in the evidence to date.
Although this is a challenging field of study in pediatrics, the
evidence for early mobilization in critically ill children is
growing and it is clear that further research on its efficacy is
needed. ■
32
Volume 203
Submitted for publication Apr 23, 2018; last revision received Jun 18, 2018;
accepted Jul 11, 2018
Reprint requests: Carlos A. Cuello-Garcia, MD, PhD, Department of Pediatrics
and Critical Care, Master University, Hamilton, Ontario, Canada. E-mail:
cuelloca@mcmaster.ca
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Acute rehabilitation practices in critically ill children: a multicenter study.
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tion in critically ill children. J Pediatr Intensiv Care 2012;1:183-92.
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et al. Experiences of four parents with physical therapy and early mobil-
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Rehabil Med 2016;9:159-68.
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38. Castro-Avila AC, Seron P, Fan E, Gaete M, Mickan S. Effect of early re-
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33
THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume 203

15. intensive care unit/ or intensive care/ or critical illness/

Appendix 1 16. coronary care unit/ or burn unit/
17. (ICU or intensive care or critical care).ti,ab.
Search Strategies. All searches performed on the different da-
18. Critical* ill*.ti,ab.
tabases from inception to February 2016. An updated search
19. or/15-18
and rerun of the strategy was performed on April 5, 2018.
20. 14 and 19
21. pediatrics/
MEDLINE. Ovid MEDLINE(R) In-Process and Other Non-
22. juvenile/ or child/ or boy/ or brain damaged child/ or girl/
Indexed Citations, Ovid MEDLINE(R) Daily and Ovid
or handicapped child/ or hospitalized child/ or pre-
MEDLINE(R) 1946 to Present, Ovid OLDMEDLINE(R) 1946
school child/ or school child/ or toddler/
to 1965
23. adolescent/ or hospitalized adolescent/
1. Physical Therapy Modalities/ 24. or/21-23
2. physiotherap*.ti,ab. 25. 20 and 24
3. (mobiliz* or mobilis*).ti,ab.
4. Rehabilitation/ CINAHL. Searched on February 17, 2016. Updated April 5,
5. rehab*.ab,ti. 2018.
6. Exercise Movement Techniques/
7. Exercise Therapy/ Search
8. Exercis*.ti,ab. ID# Search Terms
9. Ambulat*.ti,ab. S27 S23 AND S26
10. or/1-9 S26 S24 OR S25
11. (Early or earlier or accelerat* or acute or immediate*).mp. S25 (MH “Pediatrics”)
S24 (MH “Child”) OR (MH “Adolescent, Hospitalized”) OR (MH
[mp = title, abstract, original title, name of substance word, “Adolescence”) OR (MH “Child, Disabled”) OR (MH “Child,
subject heading word, keyword heading word, protocol Hospitalized”) OR (MH “Child, Medically Fragile”) OR (MH “Child,
supplementary concept word, rare disease supplemen- Preschool”)
S23 S15 AND S22
tary concept word, unique identifier] S22 S16 OR S17 OR S18 OR S19 OR S20 OR S21
12. 10 and 11 S21 TX Critical* ill*
13. Early Ambulation/ S20 TX ICU or intensive care or critical care
S19 (MH “Burn Units”)
14. 12 or 13 S18 (MH “Critical Illness”) OR (MH “Critically Ill Patients”)
15. Intensive Care Units/ or Critical Care/ or Critical Illness/ S17 (MH “Critical Care”)
16. Burn Units/ or Coronary Care Units/ or Intensive Care S16 (MH “Intensive Care Units”) OR (MH “Coronary Care Units”) OR (MH
“Intensive Care Units, Pediatric”) OR (MH “Respiratory Care
Units, Pediatric/ or Respiratory Care Units/ Units”)
17. (ICU or intensive care or critical care).ti,ab. S15 S13 OR S14
18. Critical* ill*.ti,ab. S14 (MH “Early Ambulation”)
S13 S11 AND S12
19. or/15-18 S12 TX Early or earlier or accelerat* or acute or immediate*
20. 14 and 19 S11 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10
21. child/ or child, preschool/ or pediatrics/ or Adolescent/ S10 (MH “Ambulation Therapy (Saba CCC)”) OR (MH “Assistive Device
Therapy (Saba CCC)”) OR (MH “Mobility Therapy (Saba CCC)”)
22. 20 and 21 S9 TX Ambulat*
S8 TX Exercis*
Embase. 1974 to 2016 February 12. Updated April 5, 2018. S7 (MH “Exercise Therapy: Joint Mobility (Iowa NIC)”) OR (MH “Exercise
Therapy: Ambulation (Iowa NIC)”)
1. physiotherapy/ or chest wall oscillation/ or home S6 (MH “Therapeutic Exercise”)
S5 TX rehab*
physiotherapy/ or joint mobilization/ or pediatric S4 (MH “Rehabilitation”) OR (MH “Rehabilitation, Pediatric”)
physiotherapy/ S3 mobiliz* or mobilis*
2. physiotherap*.ti,ab. S2 TX physiotherap*
S1 (MH “Physical Therapy”) OR (MH “Pediatric Physical Therapy”) OR
3. (mobiliz* or mobilis*).ti,ab. (MH “Physical Therapy Assessment”) OR (MH “Physical Therapy
4. rehabilitation/ Practice, Research-Based”) OR (MH “Physical Therapy Practice,
5. pediatric rehabilitation/ Evidence-Based”) OR (MH “Research, Physical Therapy”)
6. rehab*.ab,ti.
7. kinesiotherapy/
8. Exercis*.ti,ab.
9. Ambulat*.ti,ab.
10. or/1-9
11. (Early or earlier or accelerat* or immediate*).mp.
12. 10 and 11
13. mobilization/
14. 12 or 13

33.e1 Cuello-Garcia et al
December 2018 ORIGINAL ARTICLES

CENTRAL. Search strategy (Searched on February 17, 2016).

Updated April 5, 2018.

ID Search
#1 MeSH descriptor: [Physical Therapy Modalities] this term only
#2 physiotherap*.ti,ab
#3 (mobiliz* or mobilis*) .ti,ab
#4 MeSH descriptor: [Rehabilitation] this term only
#5 rehab*.ti,ab
#6 MeSH descriptor: [Exercise Movement Techniques] this term only
#7 MeSH descriptor: [Exercise Therapy] this term only
#8 Exercis*.ti,ab
#9 Ambulat*.ti,ab
#10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9
#11 (Early or earlier or accelerat* or acute or immediate*) .ti,ab
#12 #10 and #11
#13 MeSH descriptor: [Early Ambulation] explode all trees
#14 #12 or #13
#15 MeSH descriptor: [Intensive Care Units] explode all trees
#16 MeSH descriptor: [Critical Care] this term only
#17 MeSH descriptor: [Critical Illness] this term only
#18 (ICU or intensive care or Critical Care or Critical* ill*) .ti,ab
#19 #15 or #16 or #17 or #18
#20 #14 and #19
#21 MeSH descriptor: [Child] explode all trees
#22 MeSH descriptor: [Pediatrics] this term only
#23 MeSH descriptor: [Adolescent] this term only
#24 #21 or #22 or #23
#25 #20 and #24

Early Mobilization in Critically Ill Children: A Systematic Review 33.e2

THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume 203

Appendix 2
Excluded Studies.

Author Year Title Reference Reason(s) for exclusion

Anderson et al 2012 Early attention impairment and recovery Journal of Head Trauma Rehabilitation Interventions of interest not
profiles after childhood traumatic brain 2012;27(3):199-209 compared/described
injury non-PICU population
non-PICU setting
Arceneaux and Meyer 2009 Treatments for common psychiatric International Review of Psychiatry Narrative review
conditions among children and 2009;21(6):549-58
adolescents during acute rehabilitation
and reintegration phases of burn injury
Batterham et al 2014 Effect of supervised aerobic exercise British Journal of Anaesthesia Adult population
rehabilitation on physical fitness and 2014;113(1):130-7 Interventions of interest not
quality-of-life in survivors of critical compared/described
illness: an exploratory minimized
controlled trial (PIX Study)
Berney et al 2002 Can Early Extubation and Intensive Physiotherapy Research International Retrospective study
Physiotherapy Decrease Length of Stay of 2002;7(1):14-22
acute quadriplegic patients in intensive
care? A retrospective case control study
Bower and McLellan 1992 Effect of increased exposure to Developmental Medicine and Child Non-PICU setting
physiotherapy on skill acquisition of Neurology 1992;34(1):25-39 Non-PICU population
children with cerebral palsy
Burnsworth et al 1992 Immediate ambulation of patients with Journal of Burn Care & Rehabilitation Retrospective review
lower-extremity grafts 1992;13(1):89-92
Cameron et al 2015 Early mobilization in the critical care unit: A Journal of Critical Care Narrative review
review of adult and pediatric literature 2015;30(4):664-72
Carlile et al 2010 Prophylaxis for venous thromboembolism Journal of Trauma 2010;68(4):916- Nonmobility intervention
during rehabilitation for traumatic brain 923 Non-PICU population
injury: a multicenter observational study Non-PICU setting
Castilho and Beccaria 2009 Acquired risk factors and of deep-vein Revista Nursing 2009;11(129):92-8 Nonmobility intervention
thrombosis prophylaxis in ICU
Caulfield 2013 The key role of physiotherapy on Pediatric Transplantation 2013;17:84 Case series
developmental and health outcomes in
paediatric ventricular assist devices
Choong et al; Canadian 2014 Acute rehabilitation practices in critically ill Pediatric Critical Care Medicine Retrospective study
Critical Care Trials Group children: a multicenter study 2014;15(6):e270-9
Choong et al 2014 Acute rehabilitation practices in critically ill Pediatric Critical Care Medicine Retrospective study
children: a multi-center study 2014;15(4 Suppl 1):12-13
Choong et al 2012 Acute rehabilitation in critically ill children Journal of Pediatric Intensive Care Retrospective study
2012;1(4):183-92
Cui et al 2012 Physical and occupational therapy utilization Critical Care Medicine 2012;40(12 Retrospective study
and patient outcomes in a pediatrics Suppl 1):202
intensive care unit
Denes 2009 [Consequence of secondary complications Orvosi Hetilap 2009;150(4):165-9 Retrospective study
during the rehabilitation of patients with
severe brain injury]
Dinh et al 2013 Predictors of transfer to rehabilitation for Injury 2013;44(11):1551-5 Retrospective study
trauma patients admitted to a level 1 Nonmobility intervention
trauma centre–a model derivation and
internal validation study
Garstka et al 1974 Postoperative care for scoliotic children after Chirurgia Narzadow Ruchu i Ortopedia Nonmobility intervention (changing in
a corrective surgical procedure (Polish) Polska 1974'39(4):463-5 ventilation setting)
Genc et al 2014 What are the hemodynamic and respiratory Critical Care Nursing Quarterly Adult population
effects of passive limb exercise for 2014;37(2):152-8 Retrospective study
mechanically ventilated patients receiving
low-dose vasopressor/inotropic support?
Gobiet 1977 [Progresses in the treatment of skull-brain Der Chirurg 1977;48(7):461-6 Nonmobility intervention
injuries in childhood] (monitoring of intracranial pressure)
Gobiet 1995 [Effect of multiple trauma on rehabilitation Zentralblatt fur Chirurgie Interventions of interest not
of patients with craniocerebral injuries] 1995;120(7):544-50 compared/described
Goldberg 2008 [Commentary on] Fontan fenestration ACC Cardiosource Review Journal Letters/commentary
closure has no acute effect on exercise 2008;17(12):18 Nonmobility intervention
capacity but improves ventilatory (prefenestration and
response to exercise postfenestration closure exercise
testing with expiratory gas
analysis)
(continued)

33.e3 Cuello-Garcia et al
December 2018 ORIGINAL ARTICLES

Author Year Title Reference Reason(s) for exclusion

Goldstein 2011 Acute kidney injury in children: prevention, Contributions to Nephrology Narrative review
treatment and rehabilitation. 2011;174:163-72 Nonmobility (kidney rehabilitation)
Hayes et al 2014 Pediatric ambulatory ECMO Lung 2014;192(6):1005 Letters/commentary (Letter to the
Editor)
Hu et al 2010 Early and intensive rehabilitation predicts Disability and Rehabilitation Adult population
good functional outcomes in patients 2010;32:1251-9
admitted to the stroke intensive care unit
Irdesel et al 2007 Rehabilitation outcome after traumatic brain Neurocirugia 2007;18(1):5-15 Adult population
injury
Jaffe 2008 Pediatric trauma rehabilitation: a value- Journal of Trauma 2008;64(3):819-23 Narrative review
added safety net
Jedrzejewska et al 2009 Rehabilitation of children after Wiadomosci lekarskie 2009;62(1):3- Non-PICU population
craniocerebral injuries with particular 10
attention paid to the reflex stimulation
Powiertowski's method: Preliminary study
Jones et al 2003 Rehabilitation after critical illness: a Critical Care Medicine Adult population
randomized, controlled trial 2003;31(10):2456-61
Kasotakis et al 2012 The surgical intensive care unit optimal Critical Care Medicine Adult population
mobility score predicts mortality and 2012;40(4):1122-8
length of stay
Kuwabara et al 2011 Reconsidering the value of rehabilitation for Value in Health 2011;14(1):166-76 Adult population
patients with cerebrovascular disease in
Japanese acute health care hospitals
Langhorn et al 2015 Testing a reality orientation program in Journal of Neuroscience Nursing Adult population
patients with traumatic brain injury in a 2015;47(1):E2-10
neurointensive care unit
Lanthemann et al 2009 Swiss Romande burn center: a model of Burns 2009;35 (Suppl 1):S10 Qualitative descriptive study
multidisciplinary team work and network
organization
Lazar et al 1989 Prediction of functional outcome by motor Archives of Physical Medicine and Adult population
capability after spinal cord injury Rehabilitation 1989;70(12):819-22
Lippert-Gruner 2010 Early rehabilitation of comatose patients Neurologia i Neurochirurgia Polska Adult population
after traumatic brain injury 2010;44(5):475-80
Lippert-Gruner et al 2006 Early neurorehabilitation after severe brain Ceska a Slovenska Neurologie a Adult population
trauma Neurochirurgie 2006;69(4):302-7
Lippert-Grüner et al 2003 Outcome of prolonged coma following Brain Injury 2003;17(1):49-54 Adult population
severe traumatic brain injury
Maczka et al 2011 Pulmonary rehabilitation within intensive Polish Annals of Medicine Adult population
care units exemplified by traffic collisions 2011;18(1):66-75
casualties
Mancin et al 2012 Vocal output communication aids for Brain Injury 2012;26(4-5):471-2 Nonmobility
temporarily impaired owners (VOCA.TIO): Qualitative descriptive study
digital aids for a very early rehabilitation
targeting cognition, behavior,
communication and motor function in a
pediatric intensive care unit: a feasibility
study
Melchers et al 1999 An early onset rehabilitation program for Restorative Neurology and Nonmobility intervention
children and adolescents after traumatic Neuroscience 1999;14(2-3):153-
brain injury (TBI): methods and first 60
results
Meuli and Lochbuhler 1992 Current concepts in pediatric burn care: European Journal of Pediatric Surgery Narrative review
general management of severe burns 1992;2(4):195-200
Moront and Eichelberger 1994 Advances in the treatment of pediatric Current Opinion in General Surgery Narrative review
trauma 1994;cb8:41-9
Moront et al 1994 The injured child. An approach to care Pediatric Clinics of North America Narrative review
1994;41(6):1201-26
Munkwitz et al 2010 A perspective on early mobilization for adult Journal of Pediatric Rehabilitation Adult population
patients with respiratory failure: lessons Medicine 2010;3(3):215-27
for the pediatric population
Pacetti et al 1996 A retrospective analysis of timing of Swiss Surgery 1996;2(6):235-7 Retrospective study
mobilisation and start of enteral feeding
in 19 patients treated nonsurgically for
splenic trauma
Patman et al 2012 Exploring the capacity to ambulate after a Journal of Critical Care Retrospective study
period of prolonged mechanical 2012;27(6):542-8
ventilation.
(continued)

Early Mobilization in Critically Ill Children: A Systematic Review 33.e4

THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume 203

Author Year Title Reference Reason(s) for exclusion

Rodriguez et al 2012 Effects of early exercise on the number of Journal of Burn Care and Research Non-PICU pediatric population
joint release interventions in children with 2012;33(2 Suppl 1):S73 (exercise implemented at 6 months
severe burns postburn)
Non-PICU setting
Roth et al 2013 Effect of early physiotherapy on intracranial Neurocritical Care 2013;18(1):33-8 Adult population
pressure and cerebral perfusion pressure
Salem and Ahmed 2014 Use of virtual reality gaming systems for Journal of Pediatric Rehabilitation Narrative review
children who are critically ill Medicine 2014;7(3):273-6
Salorio et al 2008 Intensive care unit variables and outcome Pediatric Critical Care Medicine Retrospective study
after pediatric traumatic brain injury: a 2008;9(1):47-53 Non-PICU setting
retrospective study of survivors
Schreiber and Mai 1990 Some considerations relative to specific Rehabilitation 1990;29(4):238-41 Adult population
early rehabilitation in patients with severe
craniocerebral trauma
Schultz 2010 “Critical illness polyneuropathy” is also an Kinderkrankenschwester Case report
illness in pediatric intensive care 2010;29(7):280-1
medicine
Seel et al 2013 Specialized early treatment for persons with Archives of Physical Medicine and Retrospective study
disorders of consciousness: program Rehabilitation 2013;94(10):1908-
components and outcomes 23
Semenova et al 2012 Our experience of severe traumatic brain Brain Injury 2012;26(4-5):685 Retrospective study
injury treatment in children Nonmobility intervention (the
monitoring of intracranial pressure)
Takaada et al 2012 Effectiveness of early phase rehabilitation Brain Injury 2012;26(4-5):428 Retrospective study
for pediatric and adolescent traumatic
brain injury patients in the critical care
and emergency unit
Tasseau et al 2005 [Intensive care handling: specific Annales Francaises d'anesthesie et Adult population
expectations of rehabilitation] de reanimation 2005;24(6):679-82
Tederko et al 2006 Problems of adaptation to wheelchair in Ortopedia Traumatologia Rehabilitacja Adult population
early stage rehabilitation after spinal cord 2006;8(6):672-9
trauma
Tepas et al 2009 The effect of delay in rehabilitation on Journal of Pediatric Surgery Retrospective study
outcome of severe traumatic brain injury 2009;44(2):368-72
Wright 2013 Physio findings Frontline 2013;19(3):18-19 Letters/commentary
Yager et al 2011 Advances in simulation for pediatric critical Current Opinion in Pediatrics Narrative review
care and emergency medicine 2011;23(3):293-7
Yeung et al 2013 Delayed mobilization after microsurgical Laryngoscope 2013;123(12):2996- Retrospective study
reconstruction: an independent risk factor 3000 Adult population
for pneumonia
Zieger 1992 Early rehabilitation of neurosurgical Zentralblatt fur Neurochirurgie Narrative review
intensive care patients emerging from 1992;53(2):92-113
coma. On the philosophy and practice of
an interdisciplinary approach
Arteaga et al 2018 Bundling the bundles: can we change Critical Care Medicine 2018;46(Suppl Different study design
culture with a holistic approach to patient 1):629.
care in the ICU?
Cui et al 2017 Physical and occupational therapy utilization Journal of Critical Care 2017;40:15- Wrong intervention and study design
in a pediatric intensive care unit 20
Hunter et al 2017 Overcoming nursing barriers to intensive Intensive & Critical Care Nursing Wrong intervention and study design
care unit early mobilisation: a quality 2017;40:44-50
improvement project
Kawai et al 2018 PICU liberation collaborative: bundle to Critical Care Medicine 2018;46(Suppl Wrong intervention
eliminate delirium improves ICU culture 1):638
and outcomes
McGibbon et al 2017 Mobilising within the paediatric intensive Intensive Care Medicine Experimental. Different study design
care unit: a service evaluation Conference: 30th Annual Congress
of the European Society of
Intensive Care Medicine, ESICM,
2017;5(2 Suppl 1).
Miura et al 2018 Normal baseline function is associated with Journal of Intensive Care Medicine Different study design
delayed rehabilitation in critically ill 2018.
children.
Norman et al. 2017 Delirium in the critically ill child Clinical Nurse Specialist Wrong study design
2017;31(5):276-84.
Simone et al 2017 Implementation of an ICU bundle: an Pediatric Critical Care Medicine Wrong intervention
interprofessional quality improvement 2017;18(6):531-40.
project to enhance delirium management
and monitor delirium prevalence in a
single PICU

33.e5 Cuello-Garcia et al
December 2018 ORIGINAL ARTICLES

Figure. Study flow diagram.

Early Mobilization in Critically Ill Children: A Systematic Review 33.e6