| ABSTRACTS/RÉSUMÉS | |
| Neonatal-Perinatal Medicine (Platform Presentations) / Présentations plateformes en médecine néonatale et périnatale | e31 |
| Abstract presentation A (Platform) / Présentation d’affiches A (plateforme) | e34 |
| Abstract presentation B (Platform) / Présentation d’affiches B (plateforme) | e39 |
| Poster Session 1 / Séance de résumés par affiches 1 | e43 |
| Poster Session 2 / Séance de résumés par affiches 2 | e75 |
| DEPARTMENTS/RUBRIQUES | |
| Author Index to Abstracts / Index des auteurs des résumés | e105 |
| Index to Abstracts / Index des résumés | e109 |
. 2015 Jun-Jul;20(5):e30.
Paediatr Child Health. 2015 Jun-Jul;20(5):e31.
Abstract
BACKGROUND:
Current resuscitation guidelines recommend 3:1 Compression:Ventilation (C:V) ratio, however the most effective C:V ratio in newborns remains controversial. We recently demonstrate that if chest compressions (CC) are superimposed by sustained inflations (SI) return of spontaneous circulation (ROSC) and mortality are improved in asphyxiated newborn piglets when compared to standard coordinated 3:1 resuscitation. However, this has not been studied in newborns.
OBJECTIVES:
To determine if CC superimposed with SI impacts ROSC in infants <33 weeks with bradycardia or asystole compared to coordinated 3:1 C:V resuscitation.
DESIGN/METHODS:
In a pilot study, infants born <33 weeks gestational age with an heart rate <60/min or asystole were randomized to receive either “3:1 C:V” or “SS+CC”. Infants randomized to 3:1 received coordinated CC and ventilation according to the current resuscitation guidelines. Infants randomized to “SI+CC” received uninterrupted CC at a rate of 90/min superimposed by a SI of 30 sec. The default settings for airway pressures were peak inflation pressure of 24 cm H2O and a positive end expiratory pressure of 6 cm H2O. The primary outcome was duration of CC to achieve ROSC. Deferral of consent was approved by the institutional ethics committee. The trial was registered at ClinicalTrials.gov: NCT02083705.
RESULTS:
Five infants were randomized to each group; the mean (range) gestational age was 25 (24–27) weeks vs. 26 (23–28) weeks in the in the SI+CC and 3:1 group (P=0.433), respectively. Mean (SD) birth weight in the SI+CC group was 797 (208) g vs. 808 (182) g in the 3:1 group, (P=0.465) respectively.
Mean (SD) ROSC was significantly decreased in the SI+CC group with 31 (8) sec vs. 138 (72) sec in the 3:1 group (P=0.011). One infant in each group died and only one infant in the 3:1 group received epinephrine. One infant in the SI+CC group and three in the 3:1 had intracranial hemorrhage grade 3 or greater. Three infants in the SI+CC group had necrotizing enterocolitis vs. one infant in the 3:1 group (P=0.197).
CONCLUSION:
Preterm infants <33 weeks had significant shorter ROSC when CC were superimposed by SI compared to using 3:1.
Paediatr Child Health. 2015 Jun-Jul;20(5):e31.
Abstract
BACKGROUND:
Birth asphyxia is associated with acute kidney injury (AKI); severity may correspond with degree of hypoxia. Previous work by our group demonstrated lower cardiac output in neonates undergoing therapeutic hypothermia (TH). The relevance of these changes to AKI remains unknown.
OBJECTIVES:
To describe longitudinal renal haemodynamic changes during TH and re-warming (RW) and evaluate their relationship with cardiac output in neonates with and without AKI.
DESIGN/METHODS:
Prospective observational study of 18 term and near-term infants with hypoxic-ischaemic encephalopathy (HIE) who received TH. Doppler ultrasound was used to assess left ventricular output (LVO) and renal artery (RA) blood flow parameters – systolic and end-diastolic velocity (Vs and Vd), and resistive index (RI) during cooling [TH I (24 h) and II (72 h)] and post re-warming [RW I (12 h) and II (>24 h)]. AKI was defined as anuria/oliguria (100 mmol/L; or anuria/oliguria for >36 h; or any serum creatinine >125 mmol/L; or rising serum creatinine postnatally.
RESULTS:
There was no difference in baseline demographics or severity of HIE between neonates with (n=8) vs without (n=10) AKI. All 18 infants survived till discharge. Neonates who developed AKI had higher RA RI 24 h after TH was initiated [Table 1]. There was a temporal increase in LVO in both groups (P<0.01, two-way ANOVA), without intergroup difference. Neonates in the non-AKI group only showed an increase in RI (P=0.01) and a trend towards increase in RA Vs over time (P=0.05). Early changes in end-diastolic flow (EDF) were seen in both groups, which normalized over time.
CONCLUSION:
Elevated RA RI at 24 h after introduction of TH is associated with and predicts AKI. The fall in cardiac output and renal systolic flow after TH is not associated with AKI.
| AKI | Non-AKI | p-value | ||
|---|---|---|---|---|
| *LVO | Hypothermia I | 106 [92, 119] | 107 [96, 126] | 0.887 |
| Hypothermia II | 97 [88, 151] | 114 [93, 119] | 0.696 | |
| Re-warming I | 145 [123, 173] | 154 [144, 177] | 0.328 | |
| Re-warming II | 145 [135, 182] | 162 [151, 174] | 0.470 | |
| *RA Vs | Hypothermia I | 0.40 [0.33, 0.46] | 0.33 [0.27, 0.40] | 0.173 |
| Hypothermia II | 0.37 [0.29, 0.43] | 0.39 [0.30, 0.52] | 0.633 | |
| Re-warming I | 0.33 [0.24, 0.54] | 0.47 [0.39, 0.68] | 0.336 | |
| Re-warming II | 0.45 [0.40, 0.50] | 0.41 [0.30, 0.52] | 0.689 | |
| *RA RI | Hypothermia I | 0.79 [0.70, 1.00] | 0.66 [0.61, 0.72] | 0.012 |
| Hypothermia II | 0.70 [0.68, 0.83] | 0.81 [0.75, 0.84] | 0.083 | |
| Re-warming I | 0.74 [0.64, 0.84] | 0.83 [0.69, 0.97] | 0.336 | |
| Re-warming II | 0.77 [0.71, 0.79] | 0.72 [0.67, 0.74] | 0.066 | |
| #Abnormal Renal Doppler (absent or reverse EDF) | Hypothermia I | 3/8 | 1/10 | 0.206 |
| Hypothermia II | 0/8 | 1/10 | 0.556 | |
| Re-warming I | 1/7 | 2/8 | 0.554 | |
| Re-warming II | 0/6 | 0/9 | ||
| #Bidirectional or right-to-left shunting at atrial or ductus level at any stage | 3/8 | 2/10 | 0.382 | |
*
Expressed as median [interquartile range]; Mann-Whitney U test
#
Fisher’s exact test
Paediatr Child Health. 2015 Jun-Jul;20(5):e31–e32.
Abstract
BACKGROUND:
Bronchopulmonary dysplasia (BPD), a chronic lung disease of prematurity, is currently considered a disease of abnormal vascular and alveolar growth. Mechanisms involved in impaired lung vascular development are poorly understood. Both endothelial progenitor cells (EPCs) and vascular endothelial growth factor (VEGF) are important factors in normal vascular development.
OBJECTIVES:
To test the hypothesis that in infants delivered at <32 weeks gestation, umbilical cord blood levels of EPCs and VEGF are lower in infants who develop BPD as compared to infants who do not develop the disease.
DESIGN/METHODS:
Umbilical venous cord blood samples were obtained within 30 minutes of birth. EPCs were measured using flow cytometry and were defined as cells expressing the surface markers CD-34, CD-133 and vascular endothelial (VE) cadherin with more mature endothelial cells defined as expressing CD-34 and VE cadherin. VEGF was measured using a quantitative sandwich enzyme linked immunoassay. BPD was defined as oxygen dependency at 36 weeks postmenstrual age. Exclusion criteria included chromosomal and congenital abnormalities. Mann-Whitney test was used for continuous variables and the χ2 or Fisher’s exact test for dichotomous data. Multivariate logistic regression was performed to estimate the odds ratio (OR) for development of BPD. A P<0.05 was considered statistically significant.
RESULTS:
There was no effect of mode of delivery, chorioamnionitis or preeclampsia on EPC numbers.
CONCLUSION:
Levels of EPCs or VEGF at birth did not affect the risk of development of BPD in our group of premature infants. Further studies are needed before these cells and VEGF can be considered as biomarkers for prediction of BPD.
RESULTS
| Variable | BPD, n=30 | No BPD, n=55 | P value |
|---|---|---|---|
| Gestation, weeks | 27.4 (IQR 4) | 30 (IQR 2) | 0.00 |
| Birth weight, g | 1012 (IQR 543) | 1372 (IQR 315) | 0.00 |
| Males, n (%) | 18 (60) | 28 (51) | NS |
| C-Sections, n (%) | 15 (43) | 28 (51%) | NS |
| Chorioamnionitis, n (%) | 12 (34) | 18 (33) | NS |
| Antenatal steroids, n (%) | 29 (97) | 50 (91) | NS |
| Preeclampsia, n (%) | 6 (20) | 10 (18) | NS |
| Respiratory distress syndrome, n (%) | 27 (90) | 40 (80) | NS |
| VEGF, pg/mL | 535 (IQR 608) | 338 (IQR 507) | NS |
| CD-34, CD-133, VE-cadherin +ive (n) | 130 (IQR 152) | 77 (IQR 120) | NS |
| CD-34, Ve-cadherin +ive | 15 (32) | 14 (29) | NS |
Data reported as median for continuous variables. IQR Interquartile range; NS Nonsignificant
Paediatr Child Health. 2015 Jun-Jul;20(5):e32.
Abstract
BACKGROUND:
We have previously shown reliability of transcutaneous bilirubin (TcB) devices for screening preterm infants for hyperbilirubinemia. Few studies have evaluated the validity of TcB in preterm infants following initiation of phototherapy using devices currently available in practice.
OBJECTIVES:
To compare the accuracy of JM-103 TcB device with total serum bilirubin (TSB) in preterm infants during phototherapy (PT) and post-phototherapy (post-PT) phases.
DESIGN/METHODS:
The neonates were included if they met the following criteria: 28-35 weeks of gestation, >24 h and <28 days old and needed total serum bilirubin (TSB) measurement for clinical reasons. TcB was measured at forehead and sternum using JM 103 device when the blood sampling for TSB estimation was conducted. We calculated correlation coefficient statistic and mean bias (TcB-TSB) along with limits of agreement using Bland-Altman plot analysis.
RESULTS:
A total of 90 preterm infants were enrolled in the study, with mean weight of 1847 g (SD 488) and mean GA 32.4 weeks (SD 1.89), providing comparisons during pre-PT, PT and post-PT phases. The main results are presented below in Table 1 and Table 2.
The results show that TcB underestimated TSB both during PT and post-PT phases; however, the bias and precision significantly improved during the post-PT phase. During phototherapy the correlation of TcB with TSB was poor, with exposed site (sternum) showing worse results than the covered site (forehead). However, in the post-PT phase, the correlation coefficients were similar for both TcB measurement sites, and equivalent to those in pre-PT phase.
CONCLUSION:
TcB is unreliable for estimation of serum bilirubin during phototherapy; however, it is possible to use JM103 device in post-PT phase to reduce blood samplings in preterm infants.
TABLE 1.
Comparison of TcB measured at forehead with TSB
| Readings | Correlation coefficient | Bias (μmol/L) | Precision (SD) | |
|---|---|---|---|---|
| Pre PT | 81 | 0.85 | 0.65 | 28 |
| During PT | 66 | 0.72 | −52.4 | 40.7 |
| Post PT | ||||
| • All readings | 61 | 0.88 | −28.8 | 30.5 |
| • <24 h | 22 | 0.84 | −27.3 | 28.9 |
| • ≥24 h | 39 | 0.89 | −29.7 | 31.7 |
TABLE 2.
Comparison of TcB measured at sternum with TSB
| Readings | Correlation coefficient | Bias (μmol/L) | Precision (SD) | |
|---|---|---|---|---|
| Pre PT | 80 | 0.87 | 5.8 | 27.9 |
| During PT | 65 | 0.51 | −69.2 | 42.5 |
| Post PT | ||||
| • All readings | 66 | 0.87 | −19.6 | 34.7 |
| • <24 h | 22 | 0.80 | −25 | 34.5 |
| • ≥24 h | 44 | 0.89 | −16.9 | 34.7 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e32–e33.
Abstract
BACKGROUND:
The use of non-invasive ventilation (NIV) modalities has increased in recent years in an effort to minimize lung injury among preterm infants. Non-invasive high frequency oscillatory ventilation (NIHFOV) is a relatively new modality that is gaining popularity despite limited clinical data.
OBJECTIVES:
To evaluate the effectiveness of NIHFOV versus bi-phasic continuous positive airway pressure (BP-CPAP) in preterm infants who fail therapy with CPAP.
DESIGN/METHODS:
Infants with birth-weight <1250 grams being managed on CPAP were randomly assigned to NIHFOV or BP-CPAP if they were to meet pre-determined criteria for CPAP failure. Infants were eligible only after 72 h of age, and as long as they were <2,000 grams at time of randomization, irrespective of previous respiratory support. Strict protocols for adjustment of settings as well as criteria for failure were implemented for both study arms. Primary outcome was failure of assigned NIV mode; secondary outcomes included need for endotracheal mechanical ventilation (EMV) at 72 h and 7 days post-randomization and bronchopulmonary dysplasia (BPD).
RESULTS:
Thirty infants were randomized to NIHFV (n=14) or BP-CPAP (n=16). There was no difference in postmenstrual age [28.9 (2.0) vs. 28.9 (2.1) weeks, P=0.68], weight at time of randomization [920 (220) vs. 1000 (300) grams, P=0.73] or other baseline demographics between NIHFV vs. BP-CPAP groups. Failure of assigned NIV mode was not statistically different, although the trend favoured NIHFV [42.9% vs. 62.5%, P=0.28]. There was no difference in the rates of EMV at 72 h and 7 days post-randomization or BPD rates, as shown in Table 1.
CONCLUSION:
Non-invasive high frequency ventilation was not superior to BP-CPAP in this pilot study, despite a trend towards lower failure rates. Larger, appropriately powered studies are warranted to confirm or refute the present findings.
TABLE 1.
| Outcomes | NIHFV n = 14 | BP-CPAP n = 16 | P value |
|---|---|---|---|
| NIV Failure, n (%) | 6 (42.9) | 10 (62.5) | 0.28* |
| EMV 72 h post randomization, n (%) | 5 (35.7) | 5 (31.2) | 1.00† |
| EMV 7 days post randomization, n (%) | 6 (42.9) | 6 (37.5) | 0.77* |
| BPD, n (%) | 10/12 (83.3) | 14 (87.5) | 1.00† |
*
Chi-square test;
†
Fisher’s Exact test
Paediatr Child Health. 2015 Jun-Jul;20(5):e33.
Abstract
BACKGROUND:
Pulse oximetry screening (POS) for critical congenital heart disease (CCHD) in newborns is gaining acceptance in clinical practice. The geographical setting of Ontario in relation to its vast yet sparsely populated regions presents unique challenges with regards to POS implementation.
OBJECTIVES:
Evaluate the incidence of missed CCHD cases and the trends over time in Ontario, Canada over 10 years as a first step towards consideration of POS.
DESIGN/METHODS:
Data from multiple, linked, administrative health and demographic datasets were used to determine the annual incidence of total and missed cases of CCHD in Ontario from 2002–11, along with baseline demographics including designated level of birth hospital. Patients discharged home prior to diagnosis of CCHD were considered to have “missed CCHD” and were further subcategorized into “definitely missed” [1 of 9 pre-determined severest CCHDs and re-admission within 30 days or death] and “possibly missed” [1 of 6 less severe CCHDs requiring readmission in first year of life resulting in either cardiac intervention or death]. Annual trends in incidence of missed CCHD were evaluated during study period.
RESULTS:
Of 1,343,850 total births in Ontario during the study period, 2787 (0.21%) had a diagnosis of CCHD and 438 (15.7%) cases of CCHD were missed. Of these 438 patients, 66 were definitely and 372 were possibly missed CCHD cases and the proportion delivered in hospitals without neonatal intensive care capability was 77.3% and 82.5%, respectively. There was no discernible change in the incidence of missed CCHD cases over the ten year period.
CONCLUSION:
Despite a low overall incidence of CCHD, a significant proportion of CCHD cases were not diagnosed prior to discharge home, and the vast majority were delivered in non-tertiary hospitals. Further research is required to evaluate the logistical and economic impact of POS implementation in Ontario in light of these data.
Paediatr Child Health. 2015 Jun-Jul;20(5):e33.
Abstract
BACKGROUND:
Between July 2011 and June 2013, 34 pediatric residents were randomized to perform 213 endotracheal intubations (ETI) using either the videolaryngoscope (VL) or the classic laryngoscope (CL) in the Neonatal Intensive Care Unit (NICU) at CHU Ste-Justine. Success rate of ETI was improved in residents learning with the VL (75.2 vs 63.4%). It is unknown if the ETI skill learned from the VL is maintained when residents switch to the CL.
OBJECTIVES:
Assess if the ETI skill acquired from the VL is transferable to the CL in the NICU.
DESIGN/METHODS:
Phase 2 of the randomized controlled trial was held between January 2012 and December 2013. Primary outcome: Success rate and learning curve (Generalized estimating equations). Secondary outcomes: a) Time to successful intubation (Mann-Whitney Test); b) Comparison of success rates between both phases of the study for each group (χ2 test).
RESULTS:
Twenty-three of the 34 randomized residents completed phase 2 of the study and performed 55 ETI using the CL. In both groups, prior training, experience in the NICU and with neonatal ETI were similar. Patient characteristics, success rate and time to successful intubation are presented in the table. In phase 2, learning curve of the CL group remained stable at 80% success rate with ongoing intubations while it decreased slightly but not significantly to 75% for the VL group. Success rates in phase 1 and phase 2 of VL group (75.2 vs 62.5%, P=0.16) and CL group (63.4 vs 77.4%, P=0.10) did not differ.
CONCLUSION:
Residents improved success rate of ETI with the VL slightly decreases, but not significantly, when switched to the CL. Time to successful intubation is also similar in both groups. This suggests that the acquired skill from the VL is maintained with the CL. The VL is a promising tool for teaching ETI as residents reach higher success rates more rapidly and the acquired skill is transferable to the CL.
| VL group n=24 | CL group n=31 | P | |
|---|---|---|---|
| Patient characteristics | |||
| Median gestational age, weeks | 29 2/7 | 27 2/7 | 0.94 |
| Median birth weight, g | 1135 | 1090 | 1.00 |
| Median age at ETI, weeks | 31 1/7 | 31 1/7 | 0.39 |
| Median weight at ETI, g | 1200 | 1200 | 0.27 |
| Male, n (%) | 11 (48) | 16 (52) | 0.50 |
| Success Rate, n (%) | 15 (62.5) | 24 (77.4) | 0.49 |
| Median time to successful intubation, s | 56,5 | 43 | 1.00 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e33–e34.
Abstract
BACKGROUND:
Delivery of inadvertent high tidal volume (VT) during positive pressure ventilation (PPV) in the delivery room is common and associated with hemodynamic brain injury in animal models.
OBJECTIVES:
To examine if high VT delivery during PPV at birth causes brain injury in preterm infants <29 weeks gestation.
DESIGN/METHODS:
A flow-sensor was placed between the mask and the ventilation device. VT values were compared with recently described reference ranges for VT in spontaneously breathing preterm infants at birth. Infants were divided into two groups: VT < or >5.8 mL/kg (normal and high VT, respectively). Brain injury (eg, intraventricular hemorrhage (IVH)) was assessed using routine ultrasound imaging within the first days after birth.
RESULTS:
A total of 65 preterm infants were included, 49 (75%) had high VT and 16 (25%) normal VT. The mean (SD) gestational age and birth weight in high and normal VT group was similar, 26 (2) and 26 (1) weeks, 858 (251) g and 915 (250) g, respectively. IVH in the high VT group was diagnosed in 25 (51%) infants compared to two (13%) infants in the normal VT group (P=0.008). IVH in the high VT group was 12/25 grade I, 3/25 grade II, 1/25 grade III, and 9/25 had grade IV compared to 1/2 grade I, and 1/2 grade IV in the normal VT group.
CONCLUSION:
High VT delivery during mask PPV at birth is associated with hemodynamic brain injury. Strategies to limit VT delivery during mask PPV should be used to prevent high VT delivery.
Paediatr Child Health. 2015 Jun-Jul;20(5):e34.
Abstract
BACKGROUND:
The incidence of Neonatal Abstinence Syndrome (NAS) has been steadily increasing. Canadian Institute for Health Information (CIHI) reported that the number of NAS cases increased from 171 diagnoses in 2003–2004 to 654 in 2010–2011, and the number of hospital beds used, rose from 5.6 per day to 23.4. Symptoms of NAS are varied and range from irritability and poor feeding to development of seizures. In March 2012, the Provincial Council for Maternal and Child Health (PCMCH) provided revised clinical practice guidelines for the management of NAS in order to standardize its management across all units, with the most notable change resulting in a decrease in time intervals for both Finnegan scoring and morphine therapy.
OBJECTIVES:
The current study aimed to evaluate the PCMCH guidelines on newborn outcomes such as treatment duration, length of stay, and total amount of morphine prescribed, when compared to the previous management guidelines.
DESIGN/METHODS:
A retrospective cohort study was conducted, comparing medical records of mother-infant pairs exposed to methadone or other opioids antenatally two years prior to the implementation of the PCMCH guidelines (March 2010–March 2012) and two years after implementation (April 2012–March 2014).
RESULTS:
Of the 167 charts screened for inclusion, 90 mother-infant pairs met the criteria. Gestational age at delivery and birth weight was similar for newborns managed under the previous guidelines or the PCMCH guidelines. Compared to newborns managed under the previous guidelines, newborns under the PCMCH guidelines required treatment for shorter duration (31.7±16.0 days vs. 24.1±11.5 days, P=0.016), had a reduced length of hospital stay (39.8±15.9 days vs. 31.2±11.1 days, P=0.006), and demonstrated a trend towards decreased total amount of morphine (9.39±5.15 mg/kg vs. 7.10±4.85 mg/kg, P=0.054).
CONCLUSION:
To our knowledge, this is the first study to evaluate the impact of the PCMCH guidelines on newborn outcomes since its implementation in March 2012. The current study demonstrates that under the PCMCH guidelines, there is reduced treatment duration, reduced length of hospital stay, and a trend towards decreased total amount of morphine prescribed. Future research should look to replicate these findings in a larger sample size.
Paediatr Child Health. 2015 Jun-Jul;20(5):e34.
Abstract
BACKGROUND:
Vitamin D is important for bone health and may be protective against fracture risk. Few studies have evaluated the association between vitamin D and fracture risk in children and none have evaluated this association in early childhood.
OBJECTIVES:
To evaluate if vitamin D exposures, including serum 25 hydroxyvitamin D (25[OH]D) concentration, vitamin D fortified cow’s milk intake and vitamin D supplementation, were associated with fracture risk in children <6 years of age.
DESIGN/METHODS:
A case-control study was conducted. Cases were recruited from a pediatric fracture clinic and matched controls were obtained from children enrolled in the TARGet Kids! primary-care research network. Controls were matched to cases on age, sex, height and season of blood draw. Serum 25(OH)D was measured using liquid chromatography tandem mass spectrometry. Typical daily cow’s milk intake and vitamin D supplementation were obtained through a parent completed questionnaire. The odds of fracture risk was estimated using adjusted odds ratios (aOR) and 95% confidence intervals (CI) obtained from conditional logistic regression, with adjustment for skin type, waist circumference, outdoor free play time, neighbourhood income, soda consumption and child birth weight.
RESULTS:
A total of 206 cases were recruited from 2009-2013 and were matched to 343 controls. Serum 25(OH)D concentration was not significantly associated with fracture risk (per 10 nnmol/L increase, aOR=0.95 [95% CI 0.88 to 1.03]). Cow’s milk was not associated with reduced odds of fracture (>2 cups vs. 2 cups per day aOR=1.39 [95% CI 0.86 to 2.23]). A statistically significant association was observed between child vitamin D supplementation and decreased odds of fracture (yes vs. no: aOR=0.42 [95% CI 0.27 to 0.63]).
CONCLUSION:
Serum 25(OH)D concentration was not associated with fracture risk among young children yet children’s use of supplements containing vitamin D was associated with a 58% reduction in odds of fracture risk. Future studies are needed to understand the relationship between vitamin D supplementation and fracture risk.
Paediatr Child Health. 2015 Jun-Jul;20(5):e34–e35.
Abstract
BACKGROUND:
A landmark in the prevention of severe respiratory syncytial virus (RSV) infection was established with the release of palivizumab, a recombinant, humanized, genetically-engineered monoclonal antibody. Palivizumab has been deemed safe in clinical trials without major, serious adverse events (SAEs).
OBJECTIVES:
The primary objective is to evaluate the safety and tolerability of palivizumab for RSV prophylaxis in high-risk Canadian children.
DESIGN/METHODS:
Subjects were recruited into a prospective registry (CARESS) with monthly follow-up during the 2008–2013 RSV seasons. AEs were monitored from enrollment until 30 days after the last palivizumab dose. AEs involving death, life-threatening events, hospitalization or prolongation of hospital stay, persistent or significant disability or incapacity, or medical/surgical intervention to prevent serious outcome, qualified as SAEs and were assessed for severity and relationship to palivizumab. SAEs possibly or probably related to palivizumab were reported to the coordinating centre within 24 hours of occurrence. Possibly or probably related SAEs were also assessed for severity: mild, transient, well-tolerated events; moderate, SAEs interrupting usual activities; severe, incapacitating or life-threatening events. Classification was independently performed by the registry clinicians. Data were analyzed by standard descriptive methods. χ2 or Fisher Exact Tests were used to examine group differences in proportions.
RESULTS:
13,025 infants were enrolled and received 57,392 injections: premature infants ≤35 weeks gestational age (n=8224; 63.1%), children aged <2 years with chronic lung disease (n=978; 7.5%), hemodynamically significant congenital heart disease (CHD, n=1442; 11.1%) and those with other pre-existing high-risk medical disorders (n=2381; 18.3%). 915 patients were hospitalized for a respiratory illness (RIH rate: 7.03%) of which 196 tested RSV-positive (RSVH rate: 1.76%). All RIHs were not or probably not related to palivizumab. 62 single or multiple SAEs were documented in 52 infants. Fourteen events in six patients out of the 62 SAEs were hypersensitivity reactions that were deemed possibly (n=10) or probably (n=4) related to palivizumab, resulting in a reporting rate of 0.00028 events per patient-month. The 14 hypersensitivity reactions included 11 as moderate and 3 as mild. The remaining 48 serious events in 46 patients were categorized as not related (n=39), probably not related (n=5), and unclassifiable (n=4).
CONCLUSION:
Using an active surveillance system, a very small proportion of infants in the CARESS registry experienced SAEs that had a clear relationship with palivizumab and these events appear to be idiosyncratic. In routine practice, palivizumab appears to be a safe and well-tolerated antibody for RSV prophylaxis in high-risk children.
Paediatr Child Health. 2015 Jun-Jul;20(5):e35.
Abstract
BACKGROUND:
Immunoprophylaxis with palivizumab is recommended for infants at high risk of RSV-related hospitalization. Palivizumab is an expensive sole-sourced biologic pharmaceutical available in single dose vials which expires 6 h upon reconstitution, resulting in potentially high rates of drug wastage. Palivizumab has a short shelf life and requires cold-chain storage making left-over inventory costly and undesirable. Principles of Lean production and Just-In-Time production can be applied to minimize wastage and costs.
OBJECTIVES:
To describe the outcome of Lean management and Just-In-Time inventory control in the operations of a provincial RSV immunoprophylaxis program.
DESIGN/METHODS:
The Manitoba RSV Immunoprophylaxis Program (MB RSVP) coordinates the use of palivizumab for eligible patients in the province of Manitoba, Canada, a region of 650,000 square km with population of 1.27 million. Yearly PDCA cycles using Lean management principles have resulted in a centralized provincial coordinating centre that manages RSV immunoprophylaxis including patient enrolment, coordination of injection through a network of health care providers (to allow for cohorting and vial sharing), just-in-time ordering and shipping of palivizumab to clinic sites, and continuious inventory tracking. Dosing reports from sites function as a Kanban system triggering future shipment of palivizumab. Regular discussion with all involved in the Program fosters involvement, problem solving, and continuous improvement. The overall objective is limitation of wastage while maximizing patient benefit.
RESULTS:
Over three seasons (2011–2014), the MB RSVP enrolled and organized RSV immunoprophylaxis for 868 patients with over 3500 doses provided. The Program was effective in limiting wastage of palivizumab (mg of drug ordered but not given to patient) to 10% (range 8.4% to 12.8% per year). Just-in-time ordering reduced left over inventory from 157 vials (in 2012) to 75 vials (in 2014) resulting in a decreased inventory carrying cost from $118,000 to $56,000 Canadian respectively ($752/50 mg).
CONCLUSION:
Using Lean business management principles and Just-In-Time inventory control resulted in minimum wastage of palivizumab and decreased yearly left-over inventory of palivizumab in a provincial RSV prophylaxis program.
| Year | N | Doses Given | Clinics Involved | Vials Used (50 mg) | Wastage | Vials Left at Year End | Inventory Cost |
|---|---|---|---|---|---|---|---|
| 2011–12 | 291 | 1029 | 42 | 1804 | 12.8% | 157 | $118,064 |
| 2012–13 | 315 | 1260 | 49 | 2241 | 8.4% | 145 | $109,040 |
| 2013–14 | 262 | 1213 | 49 | 1823 | 9.1% | 75 | $56,400 |
| 2011–14 | 868 | 3502 | 5868 | 10% |
Paediatr Child Health. 2015 Jun-Jul;20(5):e35.
Abstract
BACKGROUND:
Iron deficiency is a common childhood problem that can have lasting negative cognitive and psychomotor developmental effects. To prevent iron deficiency, the new 2014 Canadian nutrition recommendations for healthy term infants from six to 24 months recommend iron-rich complementary foods such as meat and meat alternatives two or more times a day.
OBJECTIVES:
The purpose of our study was to evaluate the association between meat and meat alternatives consumption and iron status in young children and to assess the association between red meat consumption and iron status among children meeting current Canadian recommendations for meat consumption.
DESIGN/METHODS:
Healthy children, ages 12–36 months, were recruited from a primary care practice-based research network. A cross-sectional study was conducted. Children’s meat and meat alternatives consumption was measured by a validated questionnaire, NutriSTEP®. Multivariable regression analyses were used to evaluate an association between meat consumption and serum ferritin, and iron deficiency (serum ferritin <14 μg/L) adjusting for potential confounding variables.
RESULTS:
A total of 875 children (median age 19 months) were included. 72% of children met the recommended intake of meat and meat alternatives two or more times per day and 66% of children ate red meat in the past three days. Adjusted regression analyses revealed that eating meat or meat alternatives was not associated with serum ferritin (0.38 μg/L [95% CI −0.98 to 1.82], P=0.59) or with iron deficiency (odds ratio [OR]=0.87 [95% CI 0.69 to 1.09], P=0.23). Among children who ate meat or meat alternatives according to recommendations, red meat consumption was not associated with serum ferritin (0.33 μg/L [95% CI −2.51 to 3.54], P =0.83) or with iron deficiency (OR=1.19 [95% CI 0.70 to 2.03], P=0.50).
CONCLUSION:
Meat consumption according to current Canadian recommendations may not be associated with iron status in young Canadian children. This study and other evidence suggests that other modifiable determinants (e.g., daily cow’s milk intake and breastfeeding duration) may be more promising targets for the prevention of iron deficiency in early childhood.
Paediatr Child Health. 2015 Jun-Jul;20(5):e35–e36.
Abstract
BACKGROUND:
Anemia is the most common haematological disease of infancy and childhood. It is a nutritional problem of global importance. The diagnosis and management of anemia largely depends on clinical assessment for pallor, especially in developing countries.
OBJECTIVES:
This study was done to find out the usefulness of sites of pallor in detecting anemia.
DESIGN/METHODS:
This case control study done in a medical college hospital included 300 children in the age group of 6 months to 5 years. The study was approved by Institutional ethical committee. Detailed history and examination was done. Pallor was assessed in four sites (conjunctiva, tongue, nailbed and palm). Children with pallor at any one site were taken as study group (n=150) and without pallor at all four sites as controls (n=150). Children in shock and already diagnosed cases of anemia were excluded from the study. Hemoglobin estimation and other relevant investigations were done. Anemia was diagnosed according to WHO criterion (Hb <11 g/dL in 6 months - 5 yrs). Anemia was divided into mild, moderate and severe (haemoglobin 10–10.99, 7–9.99 and <7 g/dL, respectively). Statistical analysis was done by mean, percentage, χ2 test.
RESULTS:
Both groups were comparable in characteristics of age and gender (P>0.05). Out of 150 patients with pallor, 119 had anemia, whereas non pallor control group had 45 anemics. Mean haemoglobin in pallor group was 9.34± 2.2 g/dL and in no pallor group was 11.43±1.04 g/dL. Sensitivity and specificity of pallor for anaemia detection are estimated at 72.6% and 77.2%respectively. Pallor was identified in 69.30%, 57.30%, 72% and 80% in conjunctiva, tongue, nailbed and palm respectively. Forty one per cent had pallor in all four sites. All the four sites had significant correlation with anemia (P<0.001). Sensitivity to detect anemia ranged between 54.3 and 66.5% and specificity ranged between 89 and 92.6% in four sites. Sensitivity of conjunctival pallor to detect mild, moderate and severe anaemia was 22.1, 78 and 100%, tongue pallor was 20.8, 63.2 and 89.5%, nailbed pallor was 36.4,70.6 and 94.7%, palmar pallor was 44.2, 83.8 and 94.7% respectively.
CONCLUSION:
Pallor is useful in detecting anemia. Has good sensitivity in moderate and severe anemia but not in mild anemia. The best predictor of anemia in this study was palmar pallor followed by nail bed pallor.
Paediatr Child Health. 2015 Jun-Jul;20(5):e36.
Abstract
BACKGROUND:
New advances in blood culture incubation systems – continuous monitoring blood culture systems (CMBCS) – now allow for more precise determination of blood cultures’ “time to positivity” (TTP).
OBJECTIVES:
We aimed to determine whether a period of 36 hours (instead of the traditional 48 hours) was sufficient to detect all blood cultures positive for pathogenic bacteria in infants between the ages of 0 and 90 days presenting to the emergency department (ED) of an urban tertiary care pediatric center and undergoing a septic workup.
DESIGN/METHODS:
We performed a retrospective study of all positive blood cultures collected in the ED from infants 0 to 90 days old, over a 5-year time period (from March 13th 2008 to July 29th 2013). In our institution, blood culture bottles are received and incubated 24 hours a day, seven days a week in a CMBCS (VersaTREK; Thermo Scientific). The TTP was calculated using the time interval from blood culture registration into the system to the time of gram stain, obtained from the microbiology Laboratory Information System (SoftMic, Medisolution). Medical charts were reviewed using a standardized data collection form to obtain relevant clinical information. With the help of a microbiologist-infectious disease specialist and a pediatrician, cultures were further divided into pathogenic or contaminant, based on organism and clinical presentation.
RESULTS:
Three thousand five hundred fifty-nine (3559) blood cultures were collected from infants 0 to 90 days old in the ED during the study period. Of these, 98 (2.8%) were positive, collected from 96 infants (64 boys; 34 girls) with a mean age of 40.4 days. Among these positive cultures, 52 (53.1%) were deemed pathogenic and 46 (46.9%) were deemed contaminant, for a true prevalence of bacteremia of 1.5%. At 24, 36, 48, and 50 hours of incubation, 87.8% (86/98), 96.9% (95/98), 99% (97/ 98), and 100% (98/98) of all cultures were positive, respectively. If we consider only those organisms deemed pathogenic, at 24 and 36 hours respectively, 96.1% (50/52) and 100% (52/52) were positive. Mean TTP for pathogens and contaminants was 14.40 hours and 23.18 hours, respectively (P<0.001).
CONCLUSION:
An incubation period of 36 hours was sufficient to detect 100% of blood cultures positive for a pathogenic organism. Further research is needed to determine the impact of a shorter period of observation on hospital stay and antibiotic use.
Paediatr Child Health. 2015 Jun-Jul;20(5):e36–e38.
Abstract
BACKGROUND:
Over the last two decades, prescriptions of second-generation antipsychotics (SGAs) to children have increased significantly. During this time period, there has also been a growing body of literature demonstrating an increased risk of metabolic complications in children treated with SGAs. Prospective studies clearly suggest that SGAs confer increased risk for development of weight gain and dyslipidemia over the short term (<3 months). Although long-term SGA use in children is a common practice, investigation of metabolic complications over the long-term is limited to retrospective reports. Thus, we conducted a prospective longitudinal study to assess the impact of SGAs on metabolic complications during the first 12 months of treatment.
OBJECTIVES:
To determine the risk of developing obesity and related metabolic complications in children following long-term treatment with risperidone or quetiapine.
DESIGN/METHODS:
This was a one-year naturalistic longitudinal study conducted between February 2009 and March 2012. A total of 115 children aged two to 18 years without prior exposure to SGAs were enrolled at initiation of treatment with either risperidone or quetiapine. Metabolic parameters were measured at baseline and months 6, and 12. Data of 37 participants (20 risperidone-treated and 17 quetiapine-treated) who completed 12 month monitoring were used in the analysis.
RESULTS:
After one year of SGA treatment, mean weight increased significantly by 10.8 kg (95% CI 6.6, 10.5 kg) for risperidone and 9.7 kg (95% CI 6.5, 12.8 kg) for quetiapine. BMI z-score also increased significantly in both groups (P<0.001). There was a high incidence of children becoming overweight or obese [6/15 (40.0%) for risperidone-treated and 7/14 (50.0%) for quetiapine-treated]. The mean levels of fasting glucose (for risperidone-treated) and ratio of total cholesterol to HDL cholesterol (for quetiapine-treated) increased significantly by 0.23 mmol/L (95% CI 0.03, 0.42 mmol/L) and 0.48 mmol/L (95% CI 0.15, 0.80 mmol/L), respectively.
CONCLUSION:
Children treated with risperidone or quetiapine are at a significant risk for developing obesity, elevated waist circumference and dyslipidemia over 12 months of treatment. These data emphasize the importance of regular monitoring for early identification and treatment of metabolic side-effects.
TABLE 1.
Baseline characteristics
| Variable | Total (n = 37) | Risperidone (n = 20) | Quetiapine (n = 17) | P¥ |
|---|---|---|---|---|
| Demographics, n (%) | ||||
| Age, years, mean (95% CI) | 13.5 (12.4, 14.6) | 13.5 (11.8, 15.2) | 13.5 (12.1, 14.9) | 0.692 |
| Male sex | 18 (48.7) | 10 (50.0) | 8 (47.1) | 0.858 |
| Ethnicity | 0.431 | |||
| Caucasian | 17 (46.0) | 8 (40.0) | 9 (52.9) | |
| Other | 20 (54.0) | 12 (60.0) | 8 (47.1) | |
|
| ||||
| Family history, n (%) | ||||
| Diabetes | 15 (40.5) | 7 (35.0) | 8 (47.1) | 0.692 |
| Hyperlipidemia | 14 (38.9) | 8 (42.1) | 6 (35.3) | 0.431 |
| Cardiovascular diseases | 12 (33.3) | 6 (31.6) | 6 (35.3) | 0.397 |
|
| ||||
| DSM-IV-TR diagnosis, n (%) | ||||
| Psychotic disorders | 9 (25.0) | 5 (26.3) | 4 (23.5) | 0.847 |
| Mood disorder | 4 (11.1) | 1 (5.3) | 3 (17.7) | 0.326 |
| Depressive disorder | 8 (22.2) | 3 (15.8) | 5 (29.4) | 0.434 |
| Bipolar disorder | 6 (16.7) | 3 (15.8) | 3 (17.7) | 1.000 |
| Attention deficit hyperactivity disorder | 8 (22.2) | 4 (21.1) | 4 (23.5) | 1.000 |
| Oppositional defiant disorder | 4 (11.1) | 4 (21.1) | 0 | 0.106 |
| Pervasive development disorder | 1 (2.78) | 0 | 1 (5.9) | 0.472 |
| Anxiety disorder | 13 (36.1) | 6 (31.6) | 7 (41.2) | 0.549 |
| Adjustment disorder | 1 (2.8) | 1 (5.3) | 0 | 1.000 |
| Reactive attachment disorder | 2 (5.6) | 0 | 2 (11.8) | 0.216 |
| Mental retardation or personality disorder | 7 (18.9) | 2 (10.0) | 5 (29.4) | 0.212 |
| GAF score, mean (95% CI) | 51 (47, 56) | 53 (48, 57) | 50 (43, 58) | 0.971 |
|
| ||||
| Anthropometric Measurements: mean (95% CI) | ||||
| BMI z-score | 0.05 (−0.31, 0.41) | −0.06 (−0.58, 0.47) | 0.18 (−0.36, 0.71) | 0.542 |
| BMI percentile | 51.6 (41.3, 61.8) | 49.0 (33.7, 64.3) | 54.6 (39.5, 69.6) | 0.542 |
| Weight status, n (%) | 0.130 | |||
| Normal (<85th percentile) | 29 (78.4) | 15 (75.0) | 14 (82.4) | |
| Overweight (≥85th – <95th percentile) | 6 (16.2) | 5 (25.0) | 1 (5.9) | |
| Obese (≥95th percentile) | 2 (5.4) | 0 | 2 (11.7) | |
| WC, cm | 71.6 (66.9, 76.3) | 69.8 (63.9, 75.6) | 73.6 (65.3, 81.9) | 0.616 |
| WC ≥90th percentile, n (%) | 2 (6.9) | 1 (6.7) | 1 (7.1) | 1.000 |
| SBP z-score | 0.24 (−0.10, 0.57) | 0.14 (−0.35, 0.63) | 0.35 (−0.16, 0.85) | 0.679 |
| DBP z-score | 0.46 (0.24, 0.68) | 0.40 (−0.09, 0.70) | 0.52 (0.16, 0.88) | 0.653 |
CI Confidence interval; GAF Global assessment of functioning; BMI Body max index; WC Waist circumference; SBP Systolic blood pressure; DBP Diastolic blood pressure.
¥
Difference between groups (by χ2 and Fisher exact tests)
TABLE 2.
Change to anthropometric parameters at 6 and 12 months
| Variable | 6 months | 12 months | ||
|---|---|---|---|---|
|
|
|
|||
| Mean (95% CI) | p | Mean (95% CI) | p | |
| Weight, kg | ||||
| All | 7.9 (6.5, 9.3) | <0.001 | 10.3 (8.1, 12.4) | <0.001 |
| Risperidone | 8.6 (6.6, 10.5) | <0.001 | 10.8 (6.6, 10.5) | <0.001 |
| Quetiapine | 7.2 (5.1, 9.2) | <0.001 | 9.7 (6.5, 12.8) | <0.001 |
|
| ||||
| BMI kg/m2 | ||||
| All | 2.81 (2.26, 3.37) | <0.001 | 3.34 (2.52, 4.16) | <0.001 |
| Risperidone | 2.90 (2.14, 3.67) | <0.001 | 3.51 (2.40, 4.62) | <0.001 |
| Quetiapine | 2.71 (1.90, 3.52) | <0.001 | 3.14 (1.94, 4.35) | <0.001 |
|
| ||||
| BMI z-score | ||||
| All | 0.68 (0.51, 0.86) | <0.001 | 0.69 (0.45, 0.93) | <0.001 |
| Risperidone | 0.75 (0.51, 0.99) | <0.001 | 0.78 (0.45, 1.11) | <0.001 |
| Quetiapine | 0.60 (0.35, 0.85) | <0.001 | 0.59 (0.23, 0.95) | <0.001 |
|
| ||||
| BMI percentile | ||||
| All | 19.82 (14.39, 25.26) | <0.001 | 19.70 (12.51, 26.88) | <0.001 |
| Risperidone | 21.73 (14.24, 29.22) | <0.001 | 22.85 (13.09, 32.62) | <0.001 |
| Quetiapine | 17.69 (9.79, 25.58) | <0.001 | 16.16 (5.55, 26.76) | <0.001 |
|
| ||||
| WC, cm | ||||
| All | 8.8 (6.8, 10.9) | <0.001 | 10.3 (8.0, 12.7) | <0.001 |
| Risperidone | 10.8 (7.9, 13.6) | <0.001 | 11.5 (8.1, 14.8) | <0.001 |
| Quetiapine | 6.9 (4.0, 9.8) | <0.001 | 9.1 (5.9, 12.4) | <0.001 |
|
| ||||
| SBP z-score | ||||
| All | −0.40 (−0.87, 0.07) | 0.097 | −0.31 (0.77, 0.15) | 0.189 |
| Risperidone | −0.49 (−1.11, 0.12) | 0.117 | −0.32 (−0.96, 0.32) | 0.329 |
| Quetiapine | −0.30 (−1.02, 0.42) | 0.379 | −0.30 (−0.96, 0.36) | 0.379 |
|
| ||||
| DBP z-score | ||||
| All | −0.25 (−0.58, 0.08) | 0.221 | −0.21 (−0.55, 0.13) | 0.221 |
| Risperidone | −0.35 (−0.77, 0.08) | 0.114 | −0.43 (−0.90, 0.04) | 0.073 |
| Quetiapine | −0.15 (−0.65, 0.35) | 0.553 | 0.03 (−0.45, 0.51) | 0.912 |
BMI Body mass index; DBP Diastolic blood pressure; SBP Systolic blood pressure; WC Waist circumference;
Paediatr Child Health. 2015 Jun-Jul;20(5):e38.
Abstract
BACKGROUND:
The Neonatal Resuscitation Program (NRP) guidelines recommend the presence of intubation-skilled personnel in high risk deliveries and provide a list of 40 antepartum and intrapartum risk factors. The evidence behind the relative importance of these risk factors is not well-investigated.
OBJECTIVES:
To evaluate the significance and predictive value of each of the NRP-listed ante/intra-partum risk factors for the need of intubation at birth.
DESIGN/METHODS:
In this population-based study, perinatal data of all infants born at ≥35 weeks’ gestation in Nova Scotia between 1994 and 2014, were identified and reviewed from the Nova Scotia Atlee Database. Infants with whom it was decided prior to birth no resuscitation were excluded. Correlation between the different NRP-listed risk factors and need for intubation at birth was examined. Variables that were significant (P<0.05) in univariate analyses were entered into the regression model.
RESULTS:
During the 20-year study period, 176,365 infants ≥35 weeks gestation were born. In presence of any risk factor, 0.3% of them required intubation at birth as compared to 0.08% in absence of any risk factor (P<0001). On logistic regression analysis, only 15 of the NRP- listed risk factors had significant correlation with the need for intubation at birth (Table 1). Delivery in tertiary care centre didn’t have an impact.
CONCLUSION:
The presence of intubation-skilled person at birth may not be indicated in all the NRP-listed ante/intra partum risk factors. This finding is of particular importance for the less-resourced primary health care units.
| Predictor | Predictor present % intubated | Predictor absent % intubated | Adjusted OR | 95% CI | P |
|---|---|---|---|---|---|
| Maternal Neurological disease | 0.82 | 0.31 | 2.3 | 1.2–4.4 | 0.02 |
| Drug therapy during pregnancy | 0.56 | 0.28 | 1.6 | 1.2–2.0 | 0.0003 |
| Polyhydramnios | 2.37 | 0.30 | 2.3 | 1.2–4.3 | 0.01 |
| Fetal major anomaly | 2.04 | 0.26 | 5.4 | 4.2–6.9 | <0.0001 |
| Fetal anemia or isoimmunization | 1.24 | 0.29 | 2.7 | 1.9–3.9 | <0.0001 |
| Fetal hydrops | 33.3 | 0.30 | 13.3 | 4.7–37.8 | <0.0001 |
| Fetal distress | 1.6 | 0.21 | 3.9 | 3.0–5.1 | <0.0001 |
| Gestational age <37 weeks | 1.07 | 0.27 | 4.0 | 2.6–6.3 | <0.0001 |
| Use of general anesthesia | 2.67 | 0.26 | 4.0 | 2.9–5.5 | <0.0001 |
| Small for gestational age | 1.04 | 0.29 | 2.2 | 1.5–3.1 | <0.0001 |
| Rupture for Membranes>24h | 0.53 | 0.30 | 1.6 | 1.1–2.4 | 0.03 |
| Chorioamnionitis | 2.16 | 0.26 | 4.0 | 2.5–6.3 | <0.0001 |
| Intrapartum hemorrhage | 1.75 | 0.30 | 2.3 | 1.1–4.8 | 0.02 |
| Placental abruption | 3.21 | 0.29 | 3.6 | 2.4–5.4 | <0.0001 |
| Cord prolapse | 5.14 | 0.30 | 6.0 | 3.3–10.9 | <0.0001 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e38–e39.
Abstract
BACKGROUND:
Well appearing febrile infants with viral illnesses cannot be easily distinguished from those with occult life-threatening infections by history and physical exam alone.
OBJECTIVES:
This national practice variation study sought to assess current approaches to febrile infants under 6-weeks of age, and determine how management is influenced by respiratory virus testing.
DESIGN/METHODS:
A scenario-based survey describing two hypothetical cases of febrile infants without a focus aged 3- and 5-weeks was sent to ED and inpatient physicians at all of the 15 tertiary pediatric centers across Canada. Participants were asked multiple-choice questions regarding management decisions with and without results of respiratory virus testing. χ2 testing was used to compare proportions.
RESULTS:
Response rate was 78% (n=329; 190 ED physicians, 139 inpatient physicians). Investigations most commonly performed for both 3- and 5-week old infants were urine culture, urine analysis, CBC and blood culture. Lumbar puncture was performed less frequently in 5-week old infants (49% vs. 93%, P<0.0001). Conversely, respiratory virus testing was performed more frequently among 3-week old infants (46% vs. 34%, P<0.05). Older infant age decreased rate of admission, however detection of a respiratory virus further reduced admissions among both 3-week (83% vs. 95%, P<0.001) and 5-week old infants (36% vs. 52%, P<0.001). Similarly, empiric antibiotic treatment was initiated less frequently in older infants, and was further reduced by detection of a respiratory virus among both 3-week (65% vs. 92%, P<0.001) and 5-week old infants (25% vs. 39%, P<0.001). Inpatient physicians were more likely than ED physicians to admit (68% vs. 41%, P<0.001) and start antibiotic therapy (52% vs. 30%, P<0.001) in 5-week old infants. Among inpatient physicians, 81% would discharge 5-week old infants in ≤24 h with a detectable respiratory virus and otherwise negative workup; whereas admission duration among 3-week old infants was highly variable.
CONCLUSION:
The management of febrile infants under 6-weeks differs between ED and inpatient physicians, and by infant age. Respiratory virus testing could potentially reduce admissions and empirical antimicrobial treatment, as well as permit earlier discharge. Establishment of clinical guidelines for this patient population is warranted.
Paediatr Child Health. 2015 Jun-Jul;20(5):e39.
Abstract
BACKGROUND:
Adolescent sleepiness due to insufficient sleep is prevalent and associated with significant negative consequences on heath and well-being. Negative sleep hygiene practices have been shown to impede adequate sleep duration. Sleep promotion programs are successful in improving sleep knowledge but not at promoting positive sleep hygiene practices as they only focus on providing sleep information. The novel Motivating Teens to Sleep More (MTSM) program incorporates a motivational interviewing style, stage-based techniques, and personalized activities.
OBJECTIVES:
The objective was to identify potentially effective ways to improve sleep hygiene practices and reduce sleepiness in adolescents, thus increasing health and well-being. The current study evaluated the effectiveness of the motivation-focused MTSM program with embedded sleep education compared to a sleep education control condition. Expected outcomes included reduced negative sleep hygiene behaviours, increased bodily awareness of sleepiness after nights of too little sleep, and decreased external signals of sleepiness following the program.
DESIGN/METHODS:
Twenty-one high school students were randomly assigned to the MTSM program or the control condition, which each consisted of four 1-hour, one-on-one, sessions. As part of the MTSM program, participants were guided through a body scan focusing on bodily signals of sleepiness and were invited to create an action-plan to improve a sleep hygiene behaviour. Negative sleep hygiene practices (e.g., use of technological devices at bedtime), internal signals of sleepiness after nights of too little sleep (e.g., eyes feeling heavy) and external signals of sleepiness (e.g., teacher telling you that you seem tired) were assessed via online questionnaires before and after the program and at three-months follow-up.
RESULTS:
Negative sleep hygiene practices significantly decreased in the experimental but not control group following the program (F[2, 18] = 3.66, P=0.046) and the improvements were sustained at three-months follow-up (F[2, 18] = 4.04, P=0.026). Self-reported external cues of sleepiness significantly decreased in both groups at three month follow-up compared to prior to the program (F[2, 18] = 4.12, P=0.034). Bodily awareness of sleepiness showed no differences.
CONCLUSION:
The data suggest that the MTSM program and sleep education sessions were effective in decreasing external signals of sleepiness but only the students receiving the MTSM program adopted healthier sleep hygiene behaviours. The motivational strategies of the MTSM program seem instrumental in driving sustained sleep hygiene improvements. The null internal cues of sleepiness finding may indicate that the body scan activity was insufficient in enhancing bodily awareness of sleepiness and that more intensive mindfulness strategies are needed in future sleep promotion programs.
Paediatr Child Health. 2015 Jun-Jul;20(5):e39–e40.
Abstract
BACKGROUND:
Conversion Disorder (CD) is categorized within the group of disorders known as Somatoform disorders in the Diagnostic and Statistical Manual (DSM-IV). In the past, CD has been classified within the term ‘hysteria’ or ‘hysterical conversion reactions’. Children and adolescents presenting with CD describe symptoms that are suggestive of a medical illness but on further history, examination and investigation cannot be explained in terms of known pathology and pathophysiology. Most commonly, the symptoms represent neurological disease. Frequently reported symptoms include pseudo seizures, paraesthesias, paresis, abnormal gait and other abnormal movements. The symptoms are not intentionally produced. According to the DSM-IV definition, there must be a recognized psychological stress that can be related to the onset of symptoms; however, this may not be immediately evident at presentation.
There are no epidemiological studies to provide an estimate of the prevalence of paediatric CDs in Canada. Further, there are no clear guidelines for the management of children and youth presenting with this difficult diagnosis. Many children require admission to hospital for costly investigations and consultations with a range of health professionals including general paediatricians, paediatric neurologists, psychiatrists, physiotherapists and occupational therapists. Failure of aggressive treatment can lead to serious long-term complications such as muscle wasting, osteoporosis, scoliosis or even contractures. Deteriorating academic function, social isolation and psychological distress are also commonly seen.
Several barriers currently exist to the prompt diagnosis of CD in children and youth: 1) Knowledge of the clinical symptoms of pediatric CD is limited; 2) a diagnosis of CD is often only considered as a diagnosis of exclusion after extensive and costly medical work-up; 3) systematic clinical surveillance of children at risk for CD (ie. Children who have either experienced a previous attack or have predisposing psycho-social factors); and 4) clinical, epidemiological, or biological risk markers predictive of CD have yet to be defined consistently.
Basic descriptive, epidemiological research is crucial to informing policy on appropriate investigation, management and resource allocation for care provision.
OBJECTIVES:
To estimate prevalence and describe the clinical features of children and adolescents presenting with a Conversion Disorder to specialists across Canada.
DESIGN/METHODS:
National surveillance methodology through the CPSP was used to study the incidence and clinical characteristics of paediatric conversion disorder in Canada. From September 1, 2011 to August 31, 2013, a total of 195 cases were reported to the CPSP with 130 of those confirmed. The detailed questionnaire completion rate at the time of analysis was 76%. Twenty-one cases were excluded either because of duplication or not meeting eligibility criteria. Of the 130 confirmed cases, 28% were male and 72% were female, with an average age of 14 years (range 8–18 years). Approximately 10% of cases were children 10 years of age or younger and only four of these 13 children were male. The minimal estimated incidence of conversion disorder is approximately 58 cases per year in the Canadian paediatric population.
RESULTS:
Demographically, 55% of cases originated in Ontario, 25% in Western Canada and 12% in Quebec. The remaining 8% of cases were in Atlantic Canada 75% of cases were Caucasian, 9% were Black, 7% were First Nations, with the remaining 9% being Asian, Middle Eastern or of unknown ethnicity.
87% of cases had multiple conversion symptoms, which varied widely across the spectrum but included, altered motor function, altered sensation, altered or loss of consciousness, visual changes, speech disturbances, psychosis and dizziness. The most common presentations were disturbance of voluntary motor function (56%), abnormal movements (45%), pseudo-seizures (42%), sensory symptoms (38%), visual deficits (27%), speech disturbance (11%) and hearing deficits (7%).
The majority of cases (63%) required hospital admission to determine diagnosis, with an average stay of 13 days (range 1–110; SD ± 20.3). On average, five specialists and subspecialists were involved in the diagnostic work-up of these youth (range 1–13; SD ± 2.5). The specialists consulted most frequently were paediatricians followed by child psychiatrists. The most common subspecialty consulted was paediatric neurology followed by adolescent medicine. There were also multiple consults within specialties. The average number of investigations done per case was 3.5 (range 0–9; SD ± 1.7), typically consisting of extensive blood work, brain imaging (>90% had MRI/CT scans), EEG and EMG studies. Antecedent stressors (family conflict, bullying, academic pressure, peer pressure, abuse, and a personal and/or family history of depression and/or anxiety) were reported in 95% of cases. A prior history of mental health concerns was reported in 37% of cases and 38% of cases had a family history of anxiety and/or depression. In terms of functional impairment, approximately 65% of affected adolescents had missed school for an average of 36 days (range 1–300; SD ± 58).
Psychotropic medications for anxiety or depression had been previously prescribed in approximately 28% of cases. The average duration of symptoms, from time of onset to diagnosis, was between one and six months, with most cases (72%) confirmed by the six-month time point.
CONCLUSION:
Conversion disorder is a significant burden for affected children and adolescents, their families, and the Canadian health system, with a minimum estimated incidence of 1.7 cases per 10,000 children. CPSP results indicate a female gender preponderance and an adolescent age distribution that are consistent with the literature. The identified association of CD with anxiety and depression highlights the potential impact of more common life stressors. Identifiable stressors were found in 95% of cases, which is higher than the 60% to 70% range reported in the literature. However, the types of stressors reported are consistent with Australian and British surveillance studies.
There was a considerable time delay of between one to six months from onset to diagnosis and many patients saw several health professionals with numerous investigations performed prior to being definitively diagnosed. The delay suggests a potential lack of awareness and also a reluctance to consider conversion disorder as a positive diagnosis as opposed to a diagnosis of exclusion.
Paediatr Child Health. 2015 Jun-Jul;20(5):e40.
Abstract
BACKGROUND:
Alcohol is the most commonly used drug by Canadian adolescents, and can lead to a host of negative short and long-term outcomes. Understanding more about youth drinking can help develop more effective strategies for treatment and prevention. This study, gathering data through the Canadian Pediatric Surveillance Program (CPSP), has been initiated to fill in knowledge gaps and provide epidemiologic data about severe alcohol intoxication among Canadian adolescents.
OBJECTIVES:
The objectives of the surveillance study included: 1) To obtain national epidemiological data outlining the incidence of severe alcohol intoxication among adolescents. 2) To describe the demographics, presentation to hospital, co-ingestions, co-morbidities, management and short-term outcomes. 3) To use the data to increase awareness and education. 4) To facilitate harm reduction strategies.
DESIGN/METHODS:
Through the established methodology of the CPSP, paediatric physicians have been actively surveyed on a monthly basis for identified cases of severe alcohol intoxication. A detailed questionnaire was then completed for each new case.
The case definition includes any adolescent meeting the following criteria:
Between 11–15 years of age
Blood alcohol level >0 g/L (if drawn)
Presenting with severe intoxication with impaired consciousness requiring prolonged ER observation (≥6 h) or hospital admission.
RESULTS:
Interim analysis from the initial 18 months of data collection yielded 42 reported cases, and 37 completed questionnaires. Of these, 31 cases met the case definition. There were 15 males and 16 females, with a mean age of 14.4 years. Cases were reported from across the country, except from Manitoba and the Territories. The age of first-ever alcohol use was unknown for the majority of cases (n=22, 73.3%), and only 13.3% of these adolescents were known to have a prior ER visit related to alcohol use. The mean blood alcohol level was 2.4 g/L. There was no difference in blood alcohol level between sexes. Twenty seven cases contained information on type of alcohol use, with the majority of cases (21, 77.8%) indicating the use of “spirits”. Alcohol was frequently consumed outside of the parents’ home, at friends, parties or outdoors (22/30 cases, 73%). Concurrent use of other substances was common (11/28, 39.3%), most frequently cannabis. Ten (32.3%) of these adolescents required mechanical respiratory assistance. No child died from severe alcohol intoxication. Follow-up was provided for 20 (66.7%) cases, the majority from adolescent medicine subspecialty clinics.
CONCLUSION:
To date, a number of Canadian adolescents with severe alcohol intoxication have presented to pediatric ERs, or were admitted at pediatric hospitals, with very high blood alcohol levels. Almost 1/3 of cases required some respiratory support. Concurrent use with other substances was high.
Paediatr Child Health. 2015 Jun-Jul;20(5):e40–e41.
Abstract
BACKGROUND:
Preeclampsia (PE) affects 2–7% of otherwise healthy women, and is diagnosed by newly elevated BP after 20 weeks gestation, with associated proteinuria. The etiology of PE is largely unknown. Many theories have been proposed, including mechanisms involving oxidative stress, angiogenic imbalance, and immunologic intolerance between feto-placental and maternal tissue. Delivery is the only definitive cure, with other treatments focused on symptom management. Gestational hypertension occurs in 6–17% of pregnancies, and is defined as newly elevated blood pressure (BP), with the absence of proteinuria, after 20 weeks gestation in a previously normotensive individual. These hypertensive disorders of pregnancy are associated with adverse health outcomes including perinatal deaths, preterm birth, intrauterine growth restriction (IUGR), neonatal morbidity, and infants that are small for gestational age. Previous studies have demonstrated a link between PE and neurodevelopmental delay; however there has been disagreement on whether this effect is protective or harmful. Additionally the independent effects of gestational age (GA), birth weight, and PE are unclear, and the vast majority of studies have been retrospective or cross-sectional in nature.
OBJECTIVES:
To prospectively examine whether infants of women with a PE pregnancy, compared to infants of women without a PE pregnancy, have differences in anthropometric measurements and/or neurodevelopmental performance.
DESIGN/METHODS:
Women were recruited into this longitudinal prospective cohort following a pregnancy with (n=129) or without PE (n=140). Anthropometric measurements were performed on offspring at birth, one, three, and five years of age. The Ages and Stages Questionnaire (ASQ) was completed yearly, until age five.
RESULTS:
Anthropometrics did not differ between severe PE and controls after birth. The proportion of ASQ categories failed was significantly different in years 1, 3, and 4. Comparison of the distribution of number of categories failed revealed that severe PE children failed significantly more categories at year 1. A subgroup analysis indicated that preterm birth significantly contributes to this relationship, which persists through year 5. Logistic regression indicated that severe PE and IUGR are associated with increased odds of failure, while increased GA is protective.
CONCLUSION:
Growth delays experienced by children born to mothers with PE are not found beyond one year of age; however neurodevelopmental changes persist with preterm birth.
Figure 1).
Comparison of ages and stages questionaire failures between the severe preeclampsia and control groups at years 1 through 5 of follow up
Figure 2).
Comparison of ages and stages questionaire failures between the Preeclampsia & preterm and preeclampsia & term groups at years 1 through 5 of follow-up
TABLE 1.
Anthropometric measurements at birth, 1, 3, and 5 years postpartum
| Control | Severe PE | P value | |
|---|---|---|---|
| Birth, median (IQR) | |||
| Total at birth, n | 140 | 95 | |
| Weight (kg) | 3583.0 (3278.0–3864.0) | 2315.0 (1380.0–3262.0) | <0.001 |
| Length (cm) | 51.0 (48.5–53.0) | 45.0 (40.5–50.0) | <0.001 |
| Abdominal girth (cm) | 33.0 (31.5–35.0) | 28.5 (23.4–32.6) | <0.001 |
| Head circumference (cm) | 35.0 (34.0–35.5) | 32.5 (29.0–34.3) | <0.001 |
| Year 1, median (IQR) | |||
| Total at follow up, n | 121 | 66 | |
| Age (months) | 12.0 (12.0–13.0) | 13.0 (12.0–15.0) | <0.05 |
| Weight (kg) | 10.4 (9.8–11.5) | 10.0 (9.2–10.9) | <0.05 |
| Height (cm) | 77.0 (75.0–79.0) | 75.0 (72.0–80.0) | NS |
| Abdominal girth (cm) | 48.0 (46.0–50.0) | 46.8 (44.0–49.0) | <0.05 |
| Head circumference (cm) | 47.5 (46.0–48.5) | 47.0 (45.8–48.2) | NS |
| Year 3, median (IQR) | |||
| Total at follow up, n | 62 | 43 | |
| Age, (months) | 36.0 (36.0–37.0) | 36.0 (36.0–37.0) | NS |
| Weight (kg) | 15.3 (13.7–16.8) | 14.2 (13.2–15.4) | <0.05 |
| Height (cm) | 98.0 (94.0–101.0) | 96.0 (93.0–98.8) | NS |
| Head circumference (cm) | 50.0 (49.0–51.5) | 50.2 (49.0–51.0) | NS |
| Waist circumference (cm) | 51.9 (49.0–53.6) | 50.0 (48.1–52.9) | NS |
| Hip circumference (cm) | 54.0 (51.9–56.6) | 54.3 (51.1–57.0) | NS |
| Year 5, median (IQR) | |||
| Total at follow up, n | 16 | 17 | |
| Age, (months) | 61.0 (60.0–61.0) | 60.0 (60.0–61.0) | NS |
| Weight (kg) | 19.30 (17.4–21.8) | 19.50 (17.91–22.2) | NS |
| Height (cm) | 113.0 (109.8–116.2) | 114.0 (107.0–117.0) | NS |
| Head circumference (cm) | 51.0 (50.5–51.6) | 52.0 (52.0–54.0) | <0.05 |
| Waist circumference (cm) | 52.5 (50.5–54.1) | 53.5 (51.0–56.0) | NS |
| Hip circumference (cm) | 59.5 (55.4–64.5) | 59.0 (55.5–61.5) | NS |
Paediatr Child Health. 2015 Jun-Jul;20(5):e41–e42.
Abstract
BACKGROUND:
Selecting appropriate measure(s) for clinical and/or research applications for children and youth with Cerebral Palsy (CP) poses many challenges. The newly developed International Classification of Functioning (ICF) Core Sets for children and youth with CP serve as universal guidelines for assessment, intervention and follow up. Importantly, the ICF Core Sets can guide professionals in selecting the most appropriate outcome measures to comprehensively capture information regarding children and youth with CP.
OBJECTIVES:
To identify valid and reliable measures used with children and youth with CP, and to characterize the content of each measure using the ICF Core Sets for children and youth with CP as a framework.
DESIGN/METHODS:
A systematic review of the literature was completed using multiple search engines likely to capture studies involving children with CP published between 1998 and 2013. Inclusion criteria consisted of: studies on children and/or youth with CP and interventional or observational studies published in English. All clearly defined outcome measures used in the studies were retrieved. Measures were classified as discriminative, predictive and evaluative. Psychometric properties were extracted when available. Construct of the measures identified in studies were linked to the ICF by two trained professionals. Subsequently, the content of each multiple-item measure (i.e. questionnaires) was analysed using the ICF Core Sets for children and youth with CP as a reference. Descriptive analysis was conducted in SPSS and content comparison was performed in Excel.
RESULTS:
Overall, 233 studies met inclusion criteria that described 80 multiple-item measures. Of these, 57 measures (72%) included reliability and validity testing. The majority of the measures were discriminative, generic and designed for school-aged children. Measures with proven psychometric properties contained considerable variability in the degree to which their content represented the ICF Core Sets for children and youth with CP. Primarily, measures covered the ICF components of body functions and activities and participation. Mental functions, mobility, and self-care were the most frequent areas represented by the measures. Overall, measures reflected few categories comprising the ICF Core Sets, ranging between 2% to 44% depending on the type of Core Set (comprehensive versus brief Core Set). A single measure covered the majority of the environmental factors included in the ICF Core Sets.
CONCLUSION:
Results from this content analysis provide novel information by applying the ICF Core Sets to characterize measures used with children and youth with CP. Few measures include items comprising the ICF Core Sets. As such, a combination of measures is needed to provide a comprehensive representation of the relevant areas of functioning included in the ICF Core Sets. Our results will guide professionals seeking appropriate measures to meet their research and clinical needs.
Paediatr Child Health. 2015 Jun-Jul;20(5):e42.
Abstract
BACKGROUND:
The importance of positive healthcare interactions, including labour and delivery experiences, has been well documented. Positively engaging with care providers is perhaps even more important for adolescents, who tend to avoid seeking health care for a number of reasons. Pregnant and parenting youth (PPY) are a subgroup of adolescents whose health care access has historically been suboptimal. As a group, teen mothers and their children are at increased risk for poor medical and mental health outcomes and therefore require health care engagement for both their children and themselves. Negative health care interactions may lead to disengagement of this already vulnerable group.
OBJECTIVES:
The purpose of this qualitative study was to explore influences that shaped PPY’s views about health and well-being, and whether their perceptions informed their social and health behaviours.
DESIGN/METHODS:
Five semi-structured focus groups were conducted at two urban community centres known to service PPY. A convenience sample of 26 participants was recruited across both sites. Focus groups were audio recorded and transcribed verbatim; transcripts were analyzed thematically.
RESULTS:
Participants were a mean age of 18.7 years. While many PPY described positive healthcare encounters, almost every participant could recount at least one healthcare event they perceived as negative and detrimental. Positive health care encounters tended to feature mutual respect, support, open dialogue, and non-judgmental attitudes. Descriptions of negative encounters featured a fear of judgment; the presence of remarks that questioned the capacity and ability to raise a child; the expression of assumptions about drug abuse and the teen parent lifestyle; and the use of language implying that early childbearing was necessarily a mistake. Many of the young parents expressed a sense of heightened surveillance by healthcare providers when attending appointments for their children; others felt their responses to routine questions were faced with skepticism. For some, perceptions of negative interactions contributed to a general sense of mistrust and hesitance to access health care, and several reported delaying care because of fear of judgment by their providers. Participants felt strongly that physicians should provide unbiased, supportive, and non-judgmental care.
CONCLUSION:
Engaging PPY as partners in their care and introducing discussions about their prior health care experiences could help identify potential issues with mistrust or fear that may have developed. Establishing this dialogue could also clarify their expectations and goals of the health care relationship. Learning from their experiences will help inform youth friendly and patient-centered health care practices.
Paediatr Child Health. 2015 Jun-Jul;20(5):e42.
Abstract
BACKGROUND:
Although oral corticosteroids (OCS) are the cornerstone of acute asthma management in the emergency department (ED), recent trials have questioned the efficacy of OCS in preschool-aged children presenting with viral-induced wheezing episodes.
OBJECTIVES:
The aim of the study was to determine the magnitude, and potential determinants, of OCS responsiveness in children presenting to the ED with moderate or severe asthma.
DESIGN/METHODS:
We conducted a prospective multicentre cohort study of children aged 1–17 years presenting to the ED with an acute moderate or severe asthma exacerbation, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 4–7 or 8–12, respectively. All children received standardized treatment with prednisone or equivalent (2 mg/kg in four sites and 1 mg/kg in one site, maximum: 50 mg) and severity-specific co-interventions (salbutamol with/without ipratropium bromide) as per national guidelines. Key determinants included age, sex, baseline PRAM, site, viral aetiology (polymerase chain reaction [PCR] on nasopharyngeal swabs), tobacco exposure (salivary cotinine) and OCS dose. The primary efficacy endpoint was ED management failure (i.e., hospital admission, prolonged (≥8 hours) ED stay, or a return visit within 72 hours with an admission or prolonged stay).
RESULTS:
Of the 973 participants, most were preschoolers (75.1%), males (66.3%) and presented with a moderate (72.5%) exacerbation. Children received 2 mg/kg (82.2%) or 1 (17.8%) mg/kg of prednisone or equivalent: 165 (17.1%) experienced ED management failure; 579 (62.1%) had a PCR-confirmed viral infection (45% rhinoviruses; 17.3% respiratory syncythial virus; 9.7% metapneumovirus); 53 (5.3%) had elevated salivary cotinine (≥4 ng/mL); and 260 (26.8%) had suspected (1≤ cotinine <4 ng/mL) or reported environmental tobacco smoke exposure. After adjusting for co-variables, ED management failure was significantly associated with baseline PRAM (OR 1.49 [95% CI 1.34 to1.65], for each additional PRAM point), concurrent pneumonia (OR 4.56 [2.73 to 7.61]) and sites. The two sites with protocolized asthma management initiated by nurses were associated with 50% lower admission rates. Of note, age, sex, PCR-confirmed viral infection, saliva cotinine, and dose/kg of OCS were not significantly associated with the magnitude of response.
CONCLUSION:
Preschool age and viral triggers do not increase the risk of ED management failure or poor response to OCS in children. However, increasing severity of the exacerbation, concurrent pneumonia, and sites were significantly associated with ED management failure. In sites with protocolized asthma management, rapid administration of OCS (irrespective of dose) decreased by half the risk of ED treatment failures.
Paediatr Child Health. 2015 Jun-Jul;20(5):e42–e43.
Abstract
BACKGROUND:
There is no clear consensus regarding the use of skull radiological evaluation for young children who sustained a head trauma without traumatic brain injury.
OBJECTIVES:
The primary objective of this study was to derive and validate a clinical decision rule to identify skull fracture among children younger than two years of age with head trauma and no need for head tomography.
DESIGN/METHODS:
This was a prospective cohort study performed in three tertiary care pediatric emergency departments. Participants were all children younger than 24 months of age who sustained a head trauma and for whom head tomography was not highly recommended according to the PECARN head CT scan rule. The primary outcome was the presence of a skull fracture according to radiological report. A-priori, 28 independent variables were identified through a literature review and experts consensus. All participants were initially evaluated by a physician using a standardized datasheet before radiological evaluation. Radiological evaluation was left to the treating physician discretion. A clinical decision rule was derived using recursive partitioning. It was estimated that a sample of 45 cases of fracture would be necessary to derive the rule. Then, a second sample including at least 40 patients with a skull fracture were prospectively recruited for the validation.
RESULTS:
A total of 811 patients were recruited during the derivation period. Among them, 49 had a skull fracture. Recursive partitioning was used to derive a simple clinical decision rule to identify skull fracture. Parietal or occipital swelling/hematoma and age younger than two months of age were the items of the rule. It showed a sensitivity of 94% (95% CI 83% to 99%) and specificity of 86% (95% CI 845 to 89%) in the derivation phase. Subsequently, 856 participants were recruited during the validation phase including 44 with a skull fracture. The clinical decision rule had a sensitivity of 89% (95% CI 76% to 95%) and a specificity of 87% (95% CI 84% to 89%). Using the rule would have decreased the number of radiological evaluation from 366 to 148. Four of the five missed fractures were in children younger than four months of age.
CONCLUSION:
This clinical decision rule identifies young children at higher risk of skull fractures following an acute head trauma with no definitive indication for head tomography.
Paediatr Child Health. 2015 Jun-Jul;20(5):e43.
Abstract
BACKGROUND:
Children with hemiplegic cerebral palsy (HCP) experience upper limb sensory processing and motor deficits. Current interventions focus on motor deficits while sensory impairments are overlooked. Movement and sensation are intimately related and theories on motor behavior support addressing both. While constraint-induced movement therapy (CIMT) has demonstrated effectiveness in improving upper limb motor function in HCP, its impact on sensory function remains unknown at both the clinical and neural level.
OBJECTIVES:
The primary objective of this study was to evaluate the effectiveness of CIMT in improving clinical and neural sensory function in children with HCP.
DESIGN/METHODS:
Ten children with HCP were recruited from the HCP registry (CP-NET). Participants attended a 3-week CIMT intervention and completed neuroimaging and clinical assessments one week before and one week after CIMT. Bilateral somatosensory evoked fields (SEFs) to tactile stimulation were recorded using magnetoencephalography (MEG) to assess neuroplastic changes in the somatosensory cortex (SI) corresponding to the affected hand (measured by mean peak amplitude of the SEF). Clinical sensory assessments included: two-point discrimination (2PD), tactile registration, stereognosis (to assess tactile function), proprioception and kinesthesia tests (body motion awareness). Paired parametric and non-parametric tests assessed changes in clinical sensory measures. Voxel-wise permutation analysis evaluated significant differences in brain activity in the region of interest of the S1 cortex, pre- and post- CIMT.
RESULTS:
Post CIMT, there was a reduction in mean target degree error of the proprioceptive task (4.6 degrees, P=0.03) indicating an increase in joint position sense accuracy. Other clinical sensory measures including tactile registration of the index finger, 2PD and kinesthesia showed trends towards improvement post CIMT. MEG data revealed a significant post-CIMT increase (P≤0.05, moment=5.57 nanoamperes) SEF amplitude at a latency of 50 milliseconds corresponding to neuronal changes within the affected S1 post central gyrus (BA3) contralateral to the affected hand.
CONCLUSION:
This study found improved proprioception in children with HCP after CIMT along with positive trends in other sensory modalities. Importantly, neuroplastic change in sensory processing of tactile information was also identified in the primary sensory area of the injured hemisphere. This study provides a basis for further research to be done on how CIMT addresses deficits in various sensory modalities. Sensory deficits should be considered a critical factor to remediate in “motor” rehabilitation programs aimed to improve functioning.
Paediatr Child Health. 2015 Jun-Jul;20(5):e43.
Abstract
BACKGROUND:
Poorly controlled inflammatory bowel disease (IBD) in children can lead to long- term complications in adulthood. There is a need for an imaging modality to effectively monitor IBD in the pediatric population. The current gold standard, ileocolonoscopy, requires anesthesia in children. Computed tomography (CT) is associated with a risk of radiation and is not recommended for repeated use. Magnetic resonance imaging (MRI) has proven to be effective, but may have limited availability. Transabdominal ultrasound is accessible, safe and well-tolerated in children; however, data to support its effectiveness in monitoring pediatric IBD is limited.
OBJECTIVES:
The purpose of our study was to evaluate the accuracy and reliability of ultrasound (US) in the detection and monitoring of inflammation in pediatric IBD.
DESIGN/METHODS:
57 children were retrospectively included from an established database of children with IBD, and cross-referenced with Picture Archiving and Communication (PACs) database. Patients that had endoscopy and sonography within 60 days were included for comparison. Ultrasound parameters included: bowel wall thickness, mesenteric fat, hyperemia and lymphadenopathy. The weighted kappa statistic was calculated to assess agreement between sonographic and endoscopic findings. Using ordinal logistic regression and proportional odds models, a grey-scale ultrasound (US) score was created to using parameters that best predict disease activity, compared to gold standard endoscopy.
RESULTS:
There was moderate agreement in disease severity between sonographic and endoscopic findings (weight kappa=0.55). Significant clinical predictors of pediatric IBD disease severity were bowel wall thickness and hyperemia (P<0.05). According to this novel scoring system, 66% of patients were classified correctly, disease severity was under-estimated in 14% of patients and over-estimated in 17% of patients. The AUC was 90% for normal versus active disease. Additional analysis will be conducted with 76 patients from the same database.
CONCLUSION:
The parameters bowel wall thickness and hyperemia best predict disease severity in children with IBD. These parameters can be combined into an accurate predictive score, effective in the detection of inflammatory activity in children with inflammatory bowel disease.
Paediatr Child Health. 2015 Jun-Jul;20(5):e43–e44.
Abstract
BACKGROUND:
Antimicrobial prophylaxis is used in surgical patients to prevent wound infection because this possible complication is associated with increased patient morbidity and increased costs for the health-care system. New guidelines have been recently published.
OBJECTIVES:
To describe how antimicrobial prophylaxis was used in paediatric patients at our centers, and to review if prescription was in accordance with the new guidelines.
DESIGN/METHODS:
A descriptive retrospective analysis for paediatric patients admitted to four university hospitals and who underwent selected surgeries (cardiac, appendectomies, closed fracture, scoliosis) between April 1st 2012 and March 31st 2013. Compliance criteria evaluated were choice of antibiotic, dosage, duration and timing of administration. The utilization of pre-printed orders for the prescription of antibiotics used in surgical antimicrobial prophylaxis was another aspect evaluated.
RESULTS:
A total of 222 children were included in the compliance analysis. For all surgeries, the choice and the duration of therapy showed the highest compliance scores (>85%), except for cardiac surgery (duration: 63%). Criteria for dosage and timing of dose administration showed varying scores, according to the types of surgery (scores for dosage from 18% to 100% and scores for timing from 65% to 100%). In particular, cefazolin doses were quite variable (from 13 mg/kg/dose to 50 mg/kg/dose), and the maximal dose prescribed (in grams/dose) was often found to be lower than recommended. As seen in the table, global compliance to all criteria (choice, dosage, timing of administration, duration) was also quite variable according to the type of surgery. Finally, utilization of pre-printed orders was infrequent (<20%).
CONCLUSION:
For several types of surgery, a relatively low percentage of paediatric patients received optimal prophylactic antibiotic treatment based on the four essential criteria. Many recommendations have been made to improve current practice.
TABLE 1.
Compliance to all four criteria according to the type of surgery1
| Type of surgery (N=222) | Elective (Nantibiotic = 84) 1 | Emergency (Nantibiotic = 136)1 |
|---|---|---|
| Cardiac surgery (n=65) | 2/60 (3%) | 2/6 (33%) |
| Appendectomy (2 criteria2) (n=78) | 4/4 (100%) | 66/100 (66%) |
| Closed (simple) fracture (n=61)3 | 2/2 (100%) | 9/30 (30%) |
| Scoliosis (n=18) | 6/18 (33%) | - |
1
Compliance evaluated for each antibiotic prescribed;
2
Choice and timing were excluded (difficulty to assess compliance explained by delay to obtain confirmation of diagnosis);
3
Some patients did not receive antimicrobial prophylaxis
Paediatr Child Health. 2015 Jun-Jul;20(5):e44.
Abstract
BACKGROUND:
Following case reports of deaths in children associated with codeine use came a shift in practice from codeine to other opioids for post-surgical pain management. This shift brings about concerns regarding morphine use and safety at home, which have not yet been addressed in this population.
OBJECTIVES:
The aim of this study was to describe the actual at home use of morphine as a pain reliever after surgery in children 0 to 12 years of age. The safety of this usage was examined as well.
DESIGN/METHODS:
This prospective observational study was conducted at a pediatric university health center. Patients younger than 12 years undergoing surgery and receiving a morphine prescription upon discharge were recruited. A telephone interview was conducted in order to describe the reality of morphine use at home. The primary outcome was compliance with the discharge prescription, although many other aspects of morphine use were analysed.
RESULTS:
A total of 243 subjects were included and 219 completed the study. The median age was 4.0 years and the most frequent surgery was an ear-nose-throat procedure (55.1% of cases). A prescription for morphine to be taken on a regular basis was handed to 47.5% of the subjects whereas 52.5% received a prescription for morphine to be taken as needed.
In the “as needed” group, although 76% (95% CI, 68%-84%) of parents filled the morphine prescription after surgery, most administered less than two doses to their child. The most frequent reasons for non-compliance in the group with a regular basis prescription were the absence of pain and the relief of pain with morphine given as needed only.
The medication was stored in a closed space, out of sight, in 56% of cases. The most reported specific storage locations were the closet (48%), the counter (24%) and the table (7%). For the disposal of morphine at the end of the treatment, 55% indicated that they were planning to return the remaining quantity to their pharmacy for safe destruction. Nine percent indicated that they would keep it at home.
CONCLUSION:
This study sheds light upon the necessity to question the change in practice from codeine to morphine. The results demonstrate a need to minimise the quantity of morphine prescribed and dispensed, while ensuring adequate yet safe use of this medication.
Filling and Compliance With Morphine Prescription
| Morphine prescribed on a regular basis (n = 104 | Morphine prescribed as needed (n = 115 | |||
|---|---|---|---|---|
| n | % | n | % | |
| Participants having filled prescription after discharge | 99 | 95 | 87 | 76 |
| Participants compliant to morphine prescription | 58 | 56 | 96 | 85 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e44.
Abstract
BACKGROUND:
Studies of physical activity (PA) in young children have generally included only participants with at least four days of accelerometer wear-time. It is unclear whether four days characterizes usual PA in children 5 years and under. Investigating this protocol may inform future studies of early childhood obesity.
OBJECTIVES:
To determine the minimal number of days, and what days, of accelerometer monitoring are needed to reliably estimate usual PA in young children.
DESIGN/METHODS:
Ninety children (mean age=32 [range 4 to 70] months) were instructed to wear an Actical accelerometer for seven consecutive days and had at least four valid days. Intraclass correlation coefficients (ICC) and 95% CI were calculated for mean daily total PA and moderate-to-vigorous PA (MVPA) minutes derived from four days of monitoring. The Spearman-Brown prophecy formula was used to determine the required days of monitoring needed to achieve reliability estimates of 0.70, 0.80, and 0.90.
RESULTS:
A single day produced a reliability of ICC=0.70 (95% CI 0.58–0.79) and ICC=0.69 (95% CI 0.57–0.79) for total PA and MVPA, respectively. Spearman-Brown analyses indicated that two days are needed to achieve a reliability of 0.80. There were no differences between week-days and weekend days in mean total PA (205 (95% CI 187–222) vs. 210 (95% CI 192–228); P=0.70) or in mean MVPA minutes 26 (95% CI 20–32) vs. 29 (95% CI 23–36); P=0.45).
CONCLUSION:
Any two weekdays or weekend days of accelerometer monitoring can be used to assess usual PA in children 5 years and under. The use of a simpler protocol may improve compliance and feasibility for studies of PA in early childhood.
Paediatr Child Health. 2015 Jun-Jul;20(5):e44–e45.
Abstract
BACKGROUND:
Cheerleading has gradually become more important in Canada and represents an accessible way for youth to be physically active.
OBJECTIVES:
To determine the differences in the injuries encountered by cheerleaders according to their age, in order to propose safety guidelines taking into account the developmental stages of children.
DESIGN/METHODS:
Retrospective database review of cheerleading injuries extracted from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) database between 1990 and 2010. The injuries were compared by age group (5–9; 10–14; 15–19; 20 and over) according to their gender, mechanism, body part injured, nature and gravity.
RESULTS:
Overall, in 20 years, there were 1496 cases of injuries documented secondary to cheerleading (Median age 15, 4 (IQR=2, 2) years; The number of injuries reported increased by roughly 200% between 1990 and 2010. 1410 females [94%]). 2% of cases were 5-9 years old (Age Group-AG- 1), 40% were 10-14 (AG 2), 52% were 15-19 (AG 3) and 6% were 20 and over (AG 4). In AG 1, 2, and 3, girls were predominant while the gender ratio was close to 1:1 in AG 4. In AG1, injuries mainly occurred through tumbling while in the other groups stunts and projection skills were the ones involved.
In all age groups, the upper limbs were the most injured, followed by the head and neck, and the lower limbs.
Fractures were predominant in AG 1 (37%) and 2 (22%). However, sprains/strains were the most common injuries in AG 2, 3 and 4 with 29, 28, and 25% respectively. In all age groups, the injuries were in majority minor (requiring no follow-up). However, individuals in AG1 had a higher proportion of moderate (43%-requiring follow-up and treatment) and severe (3%-requiring admission and specific treatment) injuries. No fatalities were reported.
CONCLUSION:
Children’s developmental stages affect their ability to participate in sports and the responses of their bodies to impact forces. Our findings concerning cheerleading injuries seem to indicate that younger children (5–9 years old) are more likely to suffer moderate to severe injuries. Thus, on a local basis the use of appropriate safety measures including safety mats, and spotters to catch falling athletes should be mandatory. On a national basis, Canadian Legislation should be emitted to standardize the approach to security in the practice of Cheerleading.
Paediatr Child Health. 2015 Jun-Jul;20(5):e45.
Abstract
BACKGROUND:
Fetal alcohol spectrum disorder (FASD) is a leading cause of preventable developmental delay in Canada, estimated to affect 3-10 per 1000 live births. Caused by prenatal exposure to alcohol, FASD encompasses a continuum of physical and/or central nervous system abnormalities. The annual cost of FASD in Canada is estimated at $5.3 billion. The majority of these costs are related to associated mental illness, academic difficulties, legal problems, and unemployment. Given the prevalence of FASD in Canada, and the substantial social and economic consequences, government attention should be high and cross-sectoral government strategies are warranted. Such strategies should be well-designed, well-funded, and appropriately evaluated. Yet, little information has been synthesized about the FASD policy profile in Canada.
OBJECTIVES:
To systematically review the FASD strategic policy profile in Canada in order to understand how different jurisdictions are responding to FASD by identifying priorities, goals, key components of government strategies, and the extent to which a cross-sectoral approach is utilized.
DESIGN/METHODS:
A national cross-jurisdictional scan of all government documents was conducted in June 2014 based on Arksey and O’Malley’s scoping review methodology. To meet our inclusion criteria, documents had to be publicly available, strategic or priority-setting, developed by a federal, provincial, or territorial government body, and address FASD specifically.
RESULTS:
Of the 209 records identified, 30 documents met our inclusion criteria; eight were FASD-specific strategic documents and 22 were other government strategies that supported FASD activities. Of the eight FASD-specific strategies, two were federal, two were produced by inter-governmental partnerships, and four were regional (British Columbia, Alberta, Manitoba and Yukon). Jurisdictions ranged from having no publicly released strategic documents to having comprehensive ten-year strategic plans. Some strategies focused on FASD as an individual issue whereas others used a social ecological model. Similarities among strategies included the commitment to a cross-sectoral approach and the focus on primary prevention.
CONCLUSION:
This national policy scan provides valuable cross-jurisdictional insights about the FASD landscape in Canada. Across Canadian jurisdictions, significant variability was found with respect to the policy profile of FASD and the framing of the FASD issue. These cross-jurisdictional findings are useful to policymakers by synthesizing FASD strategies and identifying jurisdictional gaps. Further, for clinicians and researchers, it is helpful to understand opportunities for knowledge translation and avenues for informing evidence-based FASD policies.
Paediatr Child Health. 2015 Jun-Jul;20(5):e45.
Abstract
BACKGROUND:
Patients and clinicians may have different priorities than health researchers. Providing patients, parents and clinicians a voice in selecting and prioritizing research topics is important in setting the research agenda for child health.
OBJECTIVES:
To identify the most important unanswered research questions in pediatric preventive care from the perspective of parents and clinicians, and to identify whether differences exist between questions submitted by parents and clinicians.
DESIGN/METHODS:
Based on the James Lind Alliance’s Priority Setting Partnerships protocol, an online questionnaire was circulated to parents of children aged 0 to 5 years enrolled in a primary care practice-based research network, and to pediatricians and family physicians in the Ontario Medical Association. The questionnaire used one open-ended question and eight questions about specific domains to ask respondents to submit the most important research questions in pediatric preventive care. Similar submissions were combined into indicative questions through a consensus-building process. Unanswered indicative questions were identified by reviewing existing guidelines and multiple databases to determine if a relevant systematic review or high-quality trial exists. Fisher’s exact test was used to identify statistically significant differences between the responses of parents and clinicians.
RESULTS:
Respondents included 42 clinicians and 102 parents, who submitted a total of 239 and 765 questions about pediatric preventive care, respectively. Most submissions pertained to nutrition and obesity (20.1% for clinicians, 18.3% for parents), illness prevention (19.2% and 17.2%) and parenting and behaviour (16.3% and 15.2%). Parents were more likely to ask questions about screen time (8.0% of parent submissions vs 4.6% of clinician submissions, P<0.05) and sleep (8.7% vs 6.3%, P<0.05) than clinicians. Of the original questions, 148 clinician questions (61.9%) and 397 parent questions (51.9%) were unanswered. These were combined into 79 indicative questions. The most frequently endorsed questions included discipline strategies, the impact of electronic devices on development, and interventions to promote healthy sleep.
CONCLUSION:
There was general agreement between parent and clinician research priorities. The 79 indicative questions will go through final priority setting steps with parents and clinicians, using the nominal group technique to attain consensus on the top 10 unanswered research questions in pediatric preventive care. Identifying the research priorities of parents and clinicians is important in advancing the care of children.
Paediatr Child Health. 2015 Jun-Jul;20(5):e45–e46.
Abstract
BACKGROUND:
Recommendations for preventive care in children, including screening maneuvers, anticipatory guidance and specific interventions, should be based on sound evidence. The health maintenance recommendations should be effective if applied, should not cause unintended consequences (harm), and should optimize the time spent in clinic between the primary care provider and family. The Rourke Baby Record (RBR) is a tool for primary care providers, which includes preventive care recommendations based on available evidence.
OBJECTIVES:
We sought to rank recommendations for preventive care in the most recent iteration of the RBR by order of priority based on level of evidence and strength of recommendation. We also highlighted advantages and drawbacks to assigning a priority value to preventive services in children based on the current classification system.
DESIGN/METHODS:
We assigned a level of evidence (low, moderate, or high) using the GRADE system and a strength of recommendation (weak or strong) for each of the recommendations in the 2014 RBR. We gave the highest values to strong recommendations supported by high quality evidence, and the lowest values to weak recommendations supported by low quality evidence. We re-examined the evidence base for strong recommendations and ranked them according to 1) importance of outcomes, 2) uncertainty and magnitude of estimates of benefits or harms, and 3) feasibility for implementation during well-baby and well-child visits.
RESULTS:
The number of preventive care recommendations in children supported by high quality studies is limited. A large majority of recommendations are based on expert consensus. Recommendations that ranked high in priority had a large potential for health improvement, including immunizations, growth monitoring, breastfeeding counseling, vehicle safety and counseling to prevent sudden infant death syndrome. We highlight some of the difficulties encountered in developing an evidence base for pediatric preventive care, including the lack of evidence for long-term health benefits and the poor methodological quality of studies. Evidence of benefits and harms from randomized controlled trials is often lacking for ethical or feasibility reasons.
CONCLUSION:
Except for maneuvers with a clear potential for health improvement such as immunizations, the evidence is limited for preventive care recommendations, leaving clinicians with little empirical guidance on how to implement them. While evidence of causality between preventive care and better health outcomes should be established, estimates of benefits from randomized trials should not always be sought. Observational study designs or quasi-experimental designs of high quality can make a large contribution to the evidence base in this field and should be considered in future research.
Paediatr Child Health. 2015 Jun-Jul;20(5):e46.
Abstract
BACKGROUND:
International travelers are susceptible to a wide spectrum of travel related morbidities. Paediatric travelers, along with travelers visiting friends and relatives (VFR) are both recognized high-risk groups. Despite the rising number of paediatric VFR travelers, their characteristics and risk profiles are not well described.
OBJECTIVES:
To describe the risk-determining demographic and travel characteristics of paediatric international travelers.
DESIGN/METHODS:
A descriptive analysis was conducted on pre-travel consultations completed between January 2013 and May 2014 at a Tertiary Care Family Travel Medicine Clinic. Data on demographics and travel characteristics were extracted from 312 consultations that met the inclusion criteria. 50% of consultations were for children <18 years of age (n=156), of which 31% were for young children (<5 years of age). We compared putative factors between VFRs and non-VFRs among children only.
RESULTS:
VFR children were on average significantly younger than non-VFR children (mean±SD: 5.4±4.1 vs 10.6±5.2 years of age, P<0.01). They were more likely to visit destinations in Asia (48% vs 29%, P<0.05), travel for longer duration (median (IQR): 31 (21–59) vs 12 (10–21) days, P<0.01), and stay with locals, friends and/or relatives (81% vs 13%, P<0.01). They were less likely to visit destinations in the Caribbean (0% vs 20%, P<0.05), participate in organized tour groups (4% vs 66%, P<0.01) and stay in hotel accommodations (41% vs 74%, P<0.01). See selected results in Table 1.
CONCLUSION:
VFR children traveling internationally are on average younger, more likely to travel for longer duration, and stay with locals, friends and/or relatives. They are potentially more susceptible to travel-related morbidities due to their young age and high-risk travel characteristics. These findings can help develop targeted pre-travel care for VFR children traveling internationally.
TABLE 1.
Demographic and Travel Characteristics of VFR vs non-VFR Children
| Characteristics | VFR (n=59) | Non-VFR (n=97) | P |
|---|---|---|---|
|
|
|
||
| n (%) | n (%) | ||
| <5 years | 32 (54) | 17 (18) | < .01 |
| Age, years, mean ± SD | |||
| <18 | 5.4±4.1 | 10.6±5.2 | < .01 |
| <5 | 2.2±1.3 | 1.5±1.2 | .07 |
| Destination | |||
| Asia | 28 (48) | 28 (29) | < .05 |
| Africa | 19 (32) | 17 (18) | .18 |
| South America | 13 (22) | 9 (9) | .75 |
| Caribbean | 0 (0) | 17 (20) | < .05 |
| Central America | 5 (8) | 19 (20) | .06 |
| Europe* | 0 (0) | 1 (0) | NA |
| Accommodations | |||
| Hotel | 24 (41) | 70 (74) | < .01 |
| Local | 49 (81) | 13 (13) | < .01 |
| Travel duration, days; median (IQR) ** | 31 (21–59) | 12 (10–21) | < .01 |
| Organized tour ** | 2 (4) | 62 (66) | < .01 |
*
Did not compare group due to insufficient sample size.
**
Missing data: Travel duration: VFR=8, non-VFR=4, Organized tour: VFR=5, non-VFR=2.
Abbreviations: SD=standard deviation. IQR=interquartile range.
Paediatr Child Health. 2015 Jun-Jul;20(5):e46.
Abstract
BACKGROUND:
Unintentional trauma is the principal cause of death in the population under 20 years of age. Between 2000 and 2002, for this age group, the province of Quebec had a death rate almost twice that of Canada, and almost 10 times that of France.
OBJECTIVES:
The objective of this study is to describe the epidemiology of injuries and deaths following cycling accidents in the province of Quebec for people aged 24 and under between 2007 to 2012.
DESIGN/METHODS:
The road trauma registry of the Société d’assurance automobile du Québec concerning cycling accidents in the province from 2007 to 2012 was used to determine the frequency (rate per 100 000 person-year) of injuries and deaths for three groups: 0 to 15 years old, 16 to 24 years old and 25 years old and older. The data were evaluated for the province, for the different administrative regions and for the eight largest cities. The incidences were compared with the provincial incidence for the total population. The circumstances surrounding the accidents were also evaluated.
RESULTS:
From 2007 to 2012, the incidence of injuries and deaths decreased from 31.9 (OR 1.26 [95% CI 1.21 to 1.35]) to 24.2 (OR 0.90 [95% CI 0.86 to 0.94]). The 16-24 years old group presented the highest frequency (55.4 [OR 2.45 (95% CI 2.35 to 2.55)]), while the 25 years old and older presented the lowest one (20.3 [OR 0.49 (95% CI 0.47 to 0.51)]). Only the drop in frequency for the 0-15 years old was significant (47.0 [OR 1.82 (95% CI 1.68 to 1.97)]) to 20.7 [OR 0.78 (95% CI 0.69 to 0.88)]). Important discrepancy between regions and city in the province were noted.
CONCLUSION:
The incidence of injuries and deaths following a cycling accident have decreased significantly from 2007 to 2012 in the province, most importantly for 0-15 years age group. Cyclist aged between 16 and 24, and those living in larger cities had significantly higher incidence. The results obtained will help target prevention campaigns for the different age groups, regions and cities of the province of Quebec.
Paediatr Child Health. 2015 Jun-Jul;20(5):e47.
Abstract
BACKGROUND:
Pediatric insomnia affects an estimated 30% to 35% of children, and is a common reason for parental concern. Despite minimal safety data and limited indications, recent evidence indicates that physicians frequently recommend medication for children with sleep problems. Canadian data on the frequency and type of medication used, and on parental attitudes toward sleep-promoting medication in children are lacking.
OBJECTIVES:
To characterize parental attitudes and the usage of sleep-promoting over-the-counter (OTC) and prescription (RX) medications for children.
DESIGN/METHODS:
In this prospective, pilot survey study, caregivers presenting with their children (birth to 18 years) to a pediatric emergency department at a tertiary care centre between March 2012 and April 2014 completed a 20-item modified version of the Pediatric Sleep Medication Survey. This instrument was originally developed by Judith Owens and colleagues to assess physician prescribing habits of sleep medications in children.
RESULTS:
Three hundred fifty surveys were distributed, of which 346 surveys were sufficiently complete to be analyzed. Children were on average eight years old (SD±5). 49.1% were female, and 73% Caucasian. The three most common sleep problems experienced repeatedly by children in our sample were bedtime resistance/delayed sleep onset (43.5%, with 8.6% having received medication to treat this), frequent night awakenings (32%), and difficulty falling asleep or returning to sleep after awakening.
21.4% of children had received an OTC sleep-promoting medication on at least one occasion, and 4.6% at least one RX sleep-promoting medication. In young children, pain reliever combinations (e.g. Tylenol PM) were the most commonly used OTC medications (7.2%) to facilitate sleep. In children 6 to 18 years of age, melatonin was the most frequently cited OTC medication (19.3%) of children in our sample, used at least once between the ages of 6 to 18 years. Benzodiazepines (2%) were the most frequently reported RX medications used for sleep in nearly all ages.
Many parents endorsed that medication for sleep problems should be used only if other treatments have failed (53.4%), or in combination with behavioural techniques (27.4%). Some parents (18.9%) also felt that giving sleep-promoting medication was appropriate in order to provide respite for the family. Concern regarding short- or long-term side effects (65.1%) and development of tolerance or habituation (53.7%) were the most frequently cited reasons against sleep medication usage.
CONCLUSION:
Over-the-counter and prescription medications were commonly used to treat sleep problems for children in our sample. Canadian-wide data on the use of pharmacotherapy to treat, and guidelines for managing pediatric sleep disorders are urgently needed, along with pediatric data on sleep medication safety and dosing. Counselling for families should focus on emphasizing behavioural strategies and discouraging pharmacotherapy for managing pediatric insomnia.
Paediatr Child Health. 2015 Jun-Jul;20(5):e47.
Abstract
BACKGROUND:
The management of ADHD remains filled with areas of uncertainties for specialists involved in patient care.
OBJECTIVES:
To identify the challenges in ADHD management in Canada.
DESIGN/METHODS:
Between December 2013 and June 2014, 40 specialists and 10 primary care physicians (PCPs) from across Canada participated in the online REFLECT survey (pilot project) that assessed their perceptions regarding their ADHD practice. Actual practice was evaluated via 414 chart audits – three visits/patient over five months. The cumulative loss to follow up (n=414) was 38 by Visit 1 and 119 by Visit 2.
RESULTS:
Paediatricians, child/adolescent psychiatrists and PCPs comprised 48%, 22% and 20% of the respondents, respectively; 76% and 48% had been in practice and treating ADHD for >20 years, respectively. The survey revealed that most respondents perceived themselves to closely follow best practices and guidelines; however, while 78% reported using rating scales to monitor response and all prioritized duration of efficacy as predominantly dictating the choice of pharmacotherapy, the review of the chart audits suggest otherwise. Figure 1 summarises the perceived vs actual use of rating scales in establishment of patient-defined treatment goals at each visit stratified by speciality. Pharmacotherapy was changed for 40% and 37% of patients at Visits 1 and 2, respectively. Suboptimal symptom control resulted in intensification (up-titration; Visit 1 73%; Visit 2 68% or addition of another agent; Visit 1 44%; Visit 2 30%) or discontinuations without replacement (Visit 1 43%, Visit 2 32%). Side effects triggered down-titration for 55% and 45% of patients at both Visits 1 and 2, respectively.
CONCLUSION:
The pilot phase of the REFLECT survey and chart audit suggest wide inconsistencies in the assessment and management of ADHD in Canadian specialist and primary care practices that are likely contributing to the persistent care gap. The national IRB approved REFLECT survey study should confirm these findings.
Figure 1).
Perceived vs. actual use of rating scales in establishment of patient-defined treatment goals at each visit stratified by speciality (in %)
Paediatr Child Health. 2015 Jun-Jul;20(5):e47–e48.
Abstract
BACKGROUND:
Drooling (sialorrhea) in children can lead to complications such as choking, aspiration and skin breakdown as well as psychosocial disability (e.g. isolation). In case of failure of conservative treatment, management usually consists of either duct ligation or surgical removal of one of the submandibular glands. It is unknown if the efficacy of this approach might be limited by a compensatory increase in the activity of the remaining salivary glands.
OBJECTIVES:
The objective of this study was to determine the functional compensation of salivary flow by the remaining glands after the duct ligation and/or removal of one submandibular gland. The salivary flow was measured using a diagnostic method based on isotope tracing.
DESIGN/METHODS:
We retrospectively reviewed the clinical charts of drooling patients managed with duct ligation and/or submandibular gland excision performed between 2011 and 2014. The clinical manifestation, salivary gland scintigraphy with technetium-99m (99mTc)-pertechnetate pre- and post-surgery are reported.
RESULTS:
Eight cases were included with follow-up times range from 12 to 36 months. There were three females and five males, aged from five to 19 years old. The post-surgical salivary gland scintigraphy reported a dynamic increase in the parotid glands and the remaining submandibular gland in all cases of surgical excision. In two-thirds of the patients, sialorrhea was controlled post-excision of the one submandibular gland. However, 66% of duct ligation patients had transient sialorrhea control.
CONCLUSION:
We report a case series of eight patients showing the first time physiological compensation after ligation or removal of a submandibular gland for drooling. Identifying the mechanism responsible for this phenomenon may contribute to improve the management of drooling patients. Importantly, duct ligation did not appear to be as effective as surgical removal.
Paediatr Child Health. 2015 Jun-Jul;20(5):e48.
Abstract
BACKGROUND:
Infants delivered by elective caesarean section have similar need for resuscitation as infants delivered by spontaneous vaginal deliveries. Approximately 10% of deliveries are estimated to require neonatal resuscitation with 1% requiring extensive measures. A health care provider certified by the Neonatal Resuscitation Program but without advanced airway skills is therefore considered sufficient at low risk deliveries.
OBJECTIVES:
We undertook this study to determine the use of resuscitation and the health care providers in attendance at caesarean section deliveries in our centre.
DESIGN/METHODS:
A retrospective chart review of 200 emergent and elective caesarean section deliveries was conducted in a small urban centre between January 2012 and 2013. Indications for caesarean section delivery were recorded. Health care providers present, whether the infant received suctioning, bag/mask ventilation, oxygen, intubation, or compressions, and APGARS at 1 and 5 minutes were recorded. χ2 tests used to determine potential differences between health care provider type and the use of resuscitation or not. Odds ratios are presented as a measure of effect size. The non-parametric Mann-Whitney test was used to examine differences in Apgar scores by group (resuscitation or not) to account for the significant skew in the distribution of APGAR scores at both 1 and 5 minutes.
RESULTS:
220 infants were delivered through 200 caesarean section deliveries. Indications for caesarean section were maternal request (2%), failure to progress (18%), fetal distress (24%), previous caesarian section (35%), fetal indicators (18%), and maternal illness indicators (3%). 108/220 (49%) infants received suctioning, 26/220 (12%) received bag/mask ventilation, 23/220 (10%) received oxygen, and 15/220 (7%) were intubated. No infants required chest compressions. APGARs were lower in the group that received any form of resuscitation (1 minute z=−3.78, P<0.001; 5 minute z=−3.35, P<0.001). Gestational age (P=0.94), multiple fetuses (P=0.86), fetal heart rate (P=0.33), and prolonged rupture of membranes (P=0. 80) were not significantly associated with infants receiving resuscitation. Meconium in liquor (P<0.05) and fetal decelerations (P<0.005) were significantly associated with receiving resuscitation. Infants were less likely to receive resuscitation if a pediatrician was in attendance (P<0.001, OR=0.32, CI=0.16–0.65) however respiratory therapist attendance at the caesarean section significantly increased rate of resuscitation (P<0.01, OR=2.22, CI=1.23–4.02).
CONCLUSION:
The resuscitation rate in our centre was found to be significantly higher than expected. It was found that pediatrician presence at delivery decreased resuscitation requirements and respiratory therapist increased risk for resuscitation. Reasons for these observations need to be explored.
Paediatr Child Health. 2015 Jun-Jul;20(5):e48.
Abstract
BACKGROUND:
The association between vitamin D and wheezing in early childhood is unclear.
OBJECTIVES:
The primary objective was to evaluate the association between vitamin D exposure, during both pregnancy and childhood, and early childhood wheezing. Secondary objectives were to evaluate the associations between vitamin D exposures and early childhood asthma and wheezing severity.
DESIGN/METHODS:
We conducted a cohort study of children (0 to 5 years) recruited from 2008-2013 through the TARGet Kids! primary care research network. Vitamin D exposures included: maternal vitamin D supplement use during pregnancy, child vitamin D supplementation, and children’s 25-hydroxyvitamin D (25(OH)D) concentrations. Outcomes measured were parent reported childhood wheezing, diagnosed asthma and wheezing severity. Vitamin D supplement and wheezing data were available on 2478 children and blood samples were available on 1275 children. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using logistic regression adjusted for age, sex, ethnicity, body mass index, birthweight, outdoor play, breastfeeding duration, daycare status, parental smoking and asthma family history.
RESULTS:
Vitamin D supplementation during pregnancy was associated with lower odds of childhood wheezing (aOR=0.65; 95% CI 0.46–0.93). In early childhood, neither 25(OH)D (aOR per 10 nmol/L =1.01, 95% CI 0.96–1.06) nor vitamin D supplementation (aOR=1.00; 95% CI 0.81–1.23) were associated with wheezing. No significant associations were observed with diagnosed asthma or wheezing severity.
CONCLUSION:
Vitamin D supplementation during pregnancy was associated with reduced odds of wheezing but child vitamin D supplementation during childhood and childhood 25(OH)D were not associated with wheezing. The timing of exposure may be important in understanding the association between vitamin D and childhood wheezing.
Paediatr Child Health. 2015 Jun-Jul;20(5):e48–e49.
Abstract
BACKGROUND:
Children’s eating behaviours and food preferences developed in early life impact on optimal growth and development. Children who consume inadequate nutrients are at risk of malnutrition, obesity, and other negative health consequences. Furthermore, dietary patterns established in early childhood carry forward into later childhood and adulthood, emphasizing the importance of developing healthy eating practices at an early age. Breastfeeding is associated with early infant food preferences and healthy eating behaviours, however, less is known about how breastfeeding is related with early childhood diet. Existing results are mixed, indicating longer breastfeeding duration is associated with healthier dietary behaviours in preschoolers, but conversely with dental caries and deficiencies of iron and vitamin D.
OBJECTIVES:
To determine whether total breastfeeding duration is associated with eating behaviours among children 3–5 years, as assessed by the Nutritional Screening for Every Preschooler (NutriSTEP) questionnaire. Secondary objectives include examining the relationship between total breastfeeding duration and outcomes: dietary intake, total nutritional risk summary score, sweetened drink consumption, and sweet-savoury snack consumption.
DESIGN/METHODS:
Cross-sectional data analysis of children 3–5 years, recruited from seven primary care practices in an urban setting (n=3070). A baseline health questionnaire that included the NutriSTEP assessment was completed by a parent upon their child’s study enrolment. Multivariable linear regression was used to evaluate the association between total breastfeeding duration (continuous measure) and eating behaviours (5 item sub-score). Similar models were created to examine the secondary outcomes. Pre-specified, clinically relevant covariates were included in adjusted models.
RESULTS:
The average total breastfeeding duration was 11.36 months. In unadjusted analyses, total breastfeeding duration was significantly associated with all primary and secondary outcomes. In adjusted analyses, significant associations remained for all outcomes (except snacking); for each one month increase in total breastfeeding duration a decrease in the following outcomes were observed: eating behaviours sub-score −0.02 (95% CI −0.03 to −0.01); dietary intake sub-score −0.02 (95% CI −0.04 to −0.01); total nutritional risk summary score −0.05 (95% CI −0.08 to −0.02); and sweetened drinks consumption −0.02 (95% CI −0.02 to −0.01). Child’s age and sex, bottle use in bed, number of siblings, maternal age, education, ethnicity and income, were significant covariates in adjusted models.
CONCLUSION:
Longer total breastfeeding duration is associated with decreased nutritional risk, particularly in eating behaviours and dietary intake, as well as decreased sweetened drink consumption. Our findings support heightened awareness of breastfeeding as a primary preventative health measure to enhance healthy eating in childhood.
Paediatr Child Health. 2015 Jun-Jul;20(5):e49.
Abstract
BACKGROUND:
Parenteral nutrition (PN) support plays an important role in the management of many hospitalized pediatric patients, yet nutrition education has historically been underrepresented in many residency programs. Online learning is a potential means to augment teaching with regard to parenteral nutrition. Web-based education is advantageous in that it provides enhanced capability for asynchronous access to information.
OBJECTIVES:
The aim of this project was to assess the impact of an interactive web-based teaching module, designed to improve residents’ PN ordering skills, on pediatric trainees’ knowledge acquisition and perceived proficiency in ordering PN.
DESIGN/METHODS:
Pediatric residents were asked to complete a 30-minute web-based educational module designed to improve their PN ordering skills. Knowledge acquisition was assessed with questions embedded at the beginning and the end of the module. Additionally, first-year pediatric residents (PGY1s) completed self-appraisal and self-confidence questionnaires immediately prior to the module, and one week later, to assess change in perceived proficiency in ordering PN.
RESULTS:
Residents’ test scores (% correct answers) improved significantly following module completion (mean score pre-module: 49% versus post: 77%, P<0.001). Of the PGY1s (n=20), none had ordered PN prior to this assessment but 25% had been exposed to PN previously. Prior to the module, on a scale from 1-7 (1= min; 7=max), 95% of PGY1s found ordering PN stressful (score 5-7) and felt minimally equipped to order PN (score 1-2); however, the vast majority (85%) felt that knowing how to order PN was important (score 6-7). Following module completion (n=13), 75% still felt that ordering PN was stressful but 46% felt more equipped to order PN (mean score post module: 4 versus pre-module: 1; P<0.001). Trainees did not feel confident in correctly ordering various macro- and micronutrients prior to completing the module (0-5% confidence). Their confidence improved by 10-50% following module completion (all comparisons P<0.001, except for sodium and potassium requirements were comparisons were not statistically significant). Similarly, confidence with monitoring of macro- and micronutrients increased by 10-40% after module completion (all comparisons P<0.05, except for glucose monitoring were comparisons were not statistically significant).
CONCLUSION:
An interactive online learning module improved pediatric residents’ parenteral nutrition-related knowledge and self-reported proficiency in ordering PN, thus providing support for the use of web-based education as a means to support nutrition education and training in the health professions.
Paediatr Child Health. 2015 Jun-Jul;20(5):e49.
Abstract
BACKGROUND:
Determining vitamin D deficiency or insufficiency as defined by the Canadian Paediatric Society (CPS) is accomplished through measuring serum levels of 25-hydroxyvitamin D. Variation in 25-hydroxyvitamin D measurement may lead to misdiagnosis. Several different 25-hydroxyvitamin D assays are used in clinical practice but the comparability of these assays is unclear.
OBJECTIVES:
The primary objective was to examine the agreement in 25-hydroxyvitamin D concentration measured by three different assays on the same serum sample: Diasorian Liason® (DL), Tandem Mass Spectrometry (MS) and Roche electrochemiluminescence (ECL).
DESIGN/METHODS:
Serum samples from a cohort of children under 5 years of age were included in this study. 25-hydroxyvitmain D concentration was measured using DL, MS and ECL at two laboratories. Agreement between assays was explored using Spearman correlations and Bland-Altman plots. CPS endorsed 25-hydroxyvitamin D cut-points, 50 nmol/L and 75 nmol/L, were used to compare differences in classification of vitamin D status. In addition, clinical predictors of 25-hydroxyvitamin D, such as cow’s milk intake and vitamin D supplementation, were modeled using three separate multivariate linear regression models with 25-hydroxyvitamin D for each assay as the outcome. The r-squared was compared between models to determine the variation in vitamin D predictors accounted for by each 25-hydroxyvitamin D assay.
RESULTS:
264 participants were included in this study. Mean age was 43 months, 56% were male, 64% were European, and mean zBMI was 0.26. The percentages of children falling below each cut-point (50 and 75 nmol/L) were respectively: 7% and 44% for DL; 4% and 35% for MS; and 9% and 36% for ECL. The spearman correlation coefficient was 0.46 for DL and MS, 0.65 for MS and ECL and 0.55 for DL and ECL. The three assays appeared to have poor agreement on Bland Altman plots: DL and MS mean difference was 6.5 (STD 28); MS and ECL mean difference was 1.7 (STD 25); and DL and ECL mean difference was −4.7 (STD 26). The variability in vitamin D clinical predictors explained by each assay was 8.6% using DL, 7.5% using ECL and 1.4% using MS.
CONCLUSION:
It appears that there is relatively poor agreement between all three assays commonly used for 25-hydroxyvitamin D measurement. DL and ECL explain more of the variability in vitamin D predictors. More consideration needs to be given to the accuracy of 25-hydroxyvitamin D measurement in children.
Paediatr Child Health. 2015 Jun-Jul;20(5):e49–e50.
Abstract
BACKGROUND:
Nutrition plays an essential role in the growth and development, school-readiness and well-being of children. Temperament is defined as constitutionally based individual differences in reactivity and self-regulation. While temperament tends to be relatively stable over time, there is evidence that links between early temperament and child health outcomes are malleable. Temperament is increasingly recognized as an early childhood behavioral risk factor, and may impact screen time use, outdoor play and childhood obesity. The relationship between temperament and child nutrition is however less clear.
OBJECTIVES:
The primary objective is to investigate if early temperament factors in preschool aged children are associated with later nutritional risk. The secondary objective is to examine the relationship between early temperament and later dietary intake and eating behaviour.
DESIGN/METHODS:
Longitudinal data was collected through a primary care practice based research network (TARGet Kids!). At each visit nutritional risk was assessed with the total score of the Nutrition Screening Tool for Every Preschooler (NutriSTEP®) and its dietary intake and eating behavior subscales. In addition temperament was measured at each visit with the very short form of the Child Behavior Questionnaire including three domains: Negative Affectivity (e.g. discomfort, frustration), Effortful Control (e.g. inhibitory- and attentional control) and Surgency (e.g. impulsivity, activity).
Multivariate linear regression modeling was used to examine the effect of the three temperament domains with changes in total score of nutritional risk, and dietary intake and eating behavior subscores over time adjusted for the covariates age, gender, neighborhood income, maternal education, parent BMI, and baseline NutriSTEP score.
RESULTS:
693 children were included (mean age at baseline 3.1 years, 49.7% male, mean follow-up 14 months) with a mean total NutriSTEP® score of 13.9 (SD 5.9) at follow-up. For each one point increase in effortful control at baseline (mean score 5.4 [SD 0.7]) there was a significant decrease in total nutritional risk score (adjusted β −0.68 [95% CI −1.06 to −0.29]) and a healthier dietary intake (adjusted β −0.51 [95% CI −0.78 to −0.25]) over time, independent of covariates. For each one point increase in negative affectivity (mean score 3.7 [SD 0.8]), there was a small increase in poor dietary behaviours (adjusted β 0.01 [95% CI 0.00 to 0.02]) but no effect on total nutritional risk score or dietary intake subscore was found. No relationship with surgency was identified.
CONCLUSION:
Early childhood temperament impacts future nutritional risk in preschool children. Interventions to promote early effortful control in young children may lead to reduced nutritional risk.
Paediatr Child Health. 2015 Jun-Jul;20(5):e50.
Abstract
BACKGROUND:
Cilia are microtubule-based structures marking the surfaces of most eukaryotic cell types, with crucial roles in cell division, axis determination, migration and differentiation. Ciliary mutations give rise to a spectrum of human disorders, collectively termed ‘ciliopathies’, with which midline neuroanatomical defects are strongly associated. However, an association between isolated neuroanatomical defects and ciliary dysfunction has never been proven. One test for ciliary function is measurement of nasal nitric oxide, which correlates with mean ciliary beat frequency. It is a sensitive, noninvasive test, currently used in screening for Primary Ciliary Dyskinesia.
OBJECTIVES:
To determine whether children with congenital isolated midline neuroanatomical defects suffer from ciliary dysfunction, using measurement of nasal nitric oxide.
DESIGN/METHODS:
We measured the nasal nitric oxide levels of 26 children ages 6–17, with congenital midline central nervous system defects, who are otherwise healthy. We evaluated the effect of a number of variables including: age, gender, and anomaly (brain, spinal cord, or combined) on our measurements. We compared our results to the previously established normal range (153.6-509.9 nL/min), and to the cutoff for children with Primary Ciliary Dyskinesia (77 nL/min).
RESULTS:
The overall range for nasal nitric oxide in our cohort was 56.5 to 334.7 nL/min, with age, gender, and anomaly not having a significant effect on the result. The overall mean, 217.7 nL/min, was significantly lower than the pre-established mean in normal children of the same age, 314.51 nL/min (P<0.05). Four subjects (15.4%) had mean nitric oxide levels below the lower end of normal, with two (7.7%) having values below the cutoff for Primary Ciliary Dyskinesia.
CONCLUSION:
This is the first study reporting an association between ciliary dysfunction and isolated congenital midline neuroanatomical defects, not in the context of any known syndrome or ciliopathy. A possible candidate underlying both includes tubulin, a gene family encoding the microtubule alpha and beta subunits, necessary for proper ciliary formation. The tubulin gene products play a pivotal role in neuronal migration, cortical laminar organization, and guidance of radial glia, and their mutations were shown to result in a number of neuroanatomical malformations. Further studies are warranted to investigate this possible genetic link. From a clinical perspective, longitudinal studies will be required to determine whether nasal ciliary dysfunction in children with congenital midline brain anomalies has any clinical bearing on their respiratory function later in life.
| Group | Subjects | Age (years) | nNO (nl/min) | |||
|---|---|---|---|---|---|---|
|
|
|
|
||||
| Total (Females) | Mean (SD) | (Min, Max) | Mean (SD) | (Min, Max) | ||
| Brain midline defects | 4 (3) | 8.2 (1.9) | (6.1, 11.7) | 191.5 (62.5) | (114.2, 275.7) | |
| Congenital hydrocephalus | 4 (3) | |||||
|
| ||||||
| Spinal cord midline defects | 9 (4) | 10.1 (3) | (6, 15.5) | 205 (87.9) | (56.5, 334.7) | |
| Myelomeningocele | 6 (3) | |||||
| Tethered cord | 3 (1) | |||||
|
| ||||||
| Combined brain and spinal cord defects | 13 (6) | 10.7 (4) | (6, 17.7) | 234.5 (47.9) | (172, 334.4) | |
| Myelomeningocele with congenital hydrocephalus | 6 (3) | |||||
| Myelomeningocele with Chairi II malformation | 5 (1) | |||||
| Holocord syrinx with Chiari II malformation | 2 (2) | |||||
|
| ||||||
| Total | 26 (13) | 9.3 | (6, 17) | 217.7 (68.8) | (56.5, 334.7) | |
Paediatr Child Health. 2015 Jun-Jul;20(5):e50.
Abstract
BACKGROUND:
Non-invasive positive pressure ventilation (NiPPV) refers to the administration of inspiratory and expiratory pressure support via a properly fitting facial mask. NiPPV is helpful in treating obstructive sleep apnea and impaired gas exchange due to hypoventilation in children with progressive neurologic diseases such as Duchenne muscular dystrophy, spinal muscular atrophy or myotonic dystrophy. However, in these children, recurrent pneumonias due to hypoventilation and impaired cough clearance can also lead to significant morbidity and mortality. To our knowledge, there have been few studies of the potential reduction in incidence of pneumonias following the use of home nocturnal NiPPV in children with an underlying neurological or neuromuscular disease.
OBJECTIVES:
Our objective was to identify a change in the rate of pneumonias before and after the initiation of NiPPV in children with neurologic or neuromuscular conditions. We aimed to determine if the number of hospitalizations for respiratory illnesses two years prior to the initiation of NiPPV decreased compared to the number of hospitalizations two years after the initiation of NiPPV.
DESIGN/METHODS:
This was a retrospective single-institution chart review study. Patients aged one to 18 years with an underlying neurological or neuromuscular disease and who had been prescribed nocturnal NiPPV were included. Patients were identified through the clinical records of their treating pediatric respirology and neurology physicians. We excluded subjects with a tracheostomy, or those using NIPPV solely for the treatment of obstructive sleep apnea. Pre and post pneumonia rates were compared via paired t-tests.
RESULTS:
Twenty-nine patients were eligible for this study, but fifteen were removed because they met the exclusion criteria. For the remaining fourteen patients, the mean number of pneumonias two years before the initiation of NiPPV was 1.71 (SD = 3.29), and the mean number of pneumonias two years after initiation was 2.07 (SD = 2.79). The difference between the pre and post NiPPV rates of pneumonias was not significant (P=0.59). The sample size was too small to examine disease subgroups.
CONCLUSION:
There was no statistically significant difference between the number of episodes of pneumonia before and after the initiation of non-invasive positive pressure ventilation in children with neurologic or neuromuscular conditions at our tertiary care pediatric institution. The small sample size, and/or the potential confounding factor of advancing disease severity over the observation period, potentially impacted our ability to identify differences in rates of pneumonia admissions.
Paediatr Child Health. 2015 Jun-Jul;20(5):e51.
Paediatr Child Health. 2015 Jun-Jul;20(5):e51.
Abstract
BACKGROUND:
Natural and man-made disasters can have traumatic impacts on the health care system, especially if the system is not prepared to act in a crisis situation. In an intensive care setting, having an emergency plan is especially prudent due to the complexity and severity of the patient population. Neonatal Intensive Care Units (NICU) deliver care to very sick babies, and ideally should have an emergency plan in place should a disaster occur that requires evacuation. This prompts the question: what can the NICU do to improve their preparedness to respond to disasters?
OBJECTIVES:
The objective of this study was to evaluate the level of preparedness and response plans of three provincial NICUs in the event of an emergency.
DESIGN/METHODS:
A survey was distributed to 104 healthcare professionals over three NICUs and consisted of nine questions in a yes/no format designed to evaluate various aspects of an emergency response plan, including known emergency plans, transportation, evacuation, and triage. Responses were anonymous, and responders were only asked to state their role in the NICU and their work site.
RESULTS:
Response rate was 63.4% (n=66 respondents) including nurses, physicians, respiratory therapists and neonatal administrators. 91% of respondents were not aware of any plan or policy detailing emergency evacuation protocols at their site. 78.8% of respondents did not know how to properly transport sick babies requiring additional equipment or ventilators. Over 50% were not aware of specific transport mechanisms, and 66.7% were not aware of any additional supports in place for infants who are unable to be transported. Finally, 95% of respondents were unaware of any plans for the use of staging stations elsewhere in the hospital during emergent situations, and 98.5% were unaware of any provincial protocol to coordinate and use the other NICUs in case of an emergency.
CONCLUSION:
Taken together, these results strongly suggest the need for developing regional and provincial emergency protocols for use in the NICU. A strong proportion of respondents were unaware of any such protocol or emergency response plan, which prompts the need for developing disaster modules and implementing provincial wide standardized disaster training to ensure that these NICUs can be adequately prepared to respond in light of a potential disaster.
Paediatr Child Health. 2015 Jun-Jul;20(5):e51.
Paediatr Child Health. 2015 Jun-Jul;20(5):e51.
Abstract
BACKGROUND:
Traditionally, preterm infants with respiratory distress syndrome (RDS) were intubated to receive surfactant, and many of them were left on mechanical ventilation for some time. With the advent and benefits of non-invasive respiratory support has come the need of using less invasive methods for administering surfactant. InSurE (Intubation, Surfactant administration, and Extubation) technique is widely used for surfactant delivery in preterm infants with RDS, however it still implies intubation and positive pressure ventilation. Less invasive surfactant administration (LISA) into trachea using a thin catheter in spontaneous breathing infants while on CPAP has been described as an alternative method to provide surfactant without the need of intubation.
OBJECTIVES:
To conduct a systematic review of randomized trials (RCTs) comparing LISA with InSurE in preterm infants with RDS for clinical outcomes.
DESIGN/METHODS:
We searched MEDLINE, CENTRAL and EMBASE (until September 17, 2014). Additional citations were identified from trial registries, conference proceedings and bibliography of selected articles. Included studies were RCTs, comparing LISA with InSurE, in preterm infants with RDS, and reporting any of the prespecified clinical outcomes during primary hospitalization. No language restrictions were applied. Data was extracted independently by two reviewers.
RESULTS:
Four RCTs, enrolling 767 infants, were included. LISA resulted in a significant reduction in the composite outcome of death or BPD at 36 weeks (RR 0.74 [95% CI 0.58–095], P=0.02) (Figure 1), mechanical ventilation within first 72 h after birth (RR 0.71 [95% CI 0.51–0.98], P=0.04) Results of the other outcomes are presented in Table 1.
CONCLUSION:
LISA, compared with InSurE, resulted in a reduction in the composite outcome of death or BPD at 36 weeks and less mechanical ventilation in first 72 h after birth.
TABLE 1.
Results of other outcomes
| Outcome or Subgroup | Studies | Participants | RR (95% CIs) |
|---|---|---|---|
| BPD36 | 3 | 504 | 0.63 (0.38, 1.04) |
| Mortality | 3 | 556 | 0.81 (0.29, 2.29) |
| Death or BPD36 | 4 | 767 | 0.74 (0.58, 0.95)* |
| Mechanical ventilation (in first 72 h) | 2 | 336 | 0.71 (0.51, 0.98)* |
| Mechanical ventilation (any) | 2 | 420 | 0.61 (0.34, 1.08) |
| Pneumothorax | 3 | 556 | 0.65 (0.34, 1.25) |
| PDA needing Medical/Surgery Rx | 3 | 556 | 1.09 (0.57, 2.08) |
| Severe IVH | 3 | 556 | 0.89 (0.57, 1.39) |
| NEC>= Stage 2 | 3 | 556 | 0.64 (0.28, 1.47) |
Paediatr Child Health. 2015 Jun-Jul;20(5):e52.
Abstract
BACKGROUND:
Neonatal bone health is a problem of growing interest and concern because of the increasing recognition of its impact upon childhood, adolescence and even adulthood. Osteoporosis in adulthood often has its roots in childhood. Some forms may be prevented by proper attention to neonatal and childhood bone health. A premature infant likely suffers lifelong decreased bone mineral density as a result of its early birth and the lack of adequate mineral stores that are typically present in full-term infants. Caffeine is now one of the most commonly prescribed drugs in the NICU to treat apnea of prematurity. Later studies in preterm infants confirmed the diuretic effect of caffeine, and revealed a significant increase in creatinine clearance and urinary calcium excretion. The effect of caffeine treatment on bone health of premature infants was not studied before.
OBJECTIVES:
1) The primary outcome is to study the effect of caffeine, as the most frequently used medication in NICU, on bone of premature infants. The effect on bone density is mainly based on X-ray data, which were taken every two weeks during the hospital stay.
DESIGN/METHODS:
This is a quantitative descriptive Cohort. This cohort study started from birth till 12 weeks of age. As a pilot study this research study included 109 infants. Cases were defined as premature infants less than 31 weeks gestational age and birth weight less than 1500 grams. Variables considered in this study include:
Demographic Data. gestational age in weeks, gender, birth weight in grams and maternal parity level, which was recorded as categorical data; high if more five, moderate if three or four and low parity if one or two. Vitamin D was included as longitudinal data
Laboratory data. serum phosphate levels were collected on biweekly basis plus or minus one week as found in Attachment Reflection Laboratory Data Retrieval System. The phosphate level was recorded as categorical data; high if more than 2.5 mmol/L, normal if ranged between 1.8 to 2.5 mmol/L, low if between 1.3 to 1.8 mmol/L and very low if less than 1.3 mmol/L. This was considered at any time point during the cohort study.
RADIOLOGICAL DATA:
The chest radiographs were undertaken to investigate any clinical problems. The radiological data (x rays) were reviewed by pediatric radiologist, who did not know about the patients’ data, on a biweekly basis in the first 12 weeks of life at least, using Koo et al., criteria. The ethics approval was obtained from the Health Research Ethics Board at University of Manitoba number# H2013: 231 and The Health Sciences Centre Research Impact Approval was obtained from the Health Science Center. Number# RI2013: 088.
RESULTS:
The mean gestational age of this cohort was 27 weeks (27±1.6); the cohort includes 54 males and 55 females. The average birth weight of this cohort was 665±229 grams. Of the 109 infants, 85 were born to mothers of low maternal parity (77.9%), 16 (14.6%) of moderate maternal parity and eight of high maternal parity (7.5%). The median duration of TPN were 21 days with 1st and 3rd quantiles of 11 and 32 days respectively. we dichotomize the radiological findings by collapse of categories of grade levels. Grade 1, 2 and 3 were collapsed together as Osteopenia of prematurity because we lack enough events in each of the three grades. In the same time we considered grade 0 as normal. So the mixed model is generalized mixed model for binary outcome. The average dose of caffeine was 425.33±235.2 mg as a cumulative dose and the average duration of caffeine therapy was 60±45.8 days. There were 79 infants who received diuretics (73%). The median diuretic dose was 5.9 mg with 1st and 3rd quantiles of 1, 25.8. There were 79 infants who received diuretics (73%). The median diuretic dose was 5.9 mg with 1st and 3rd quantiles of 1, 25.8. There were 79 infants who received diuretics (73%). The median diuretic dose was 5.9 mg with 1st and 3rd quantiles of 1, 25.8.
CONCLUSION:
The results of this study revealed a strong correlation between exposure to caffeine (either cumulative dose or duration) and the presence of OP. About 8% of infants with MBD further developed spontaneous rib fractures secondary to OP.
Table 1 indicates that higher cumulative dose of caffeine is associated with an increase in the probability of Osteopenia of Prematurity (OP). The effect of caffeine was true even when we controlled the effect of other variables (average weight, the gestational age steroid and vitamin D). The odds of OP is 1.10 times (95% CI 1.05–1.15) higher for every 5 mg/kg increase in caffeine dose when the effect of steroids, Vitamin, gestational age and average biweekly weight are controlled.
The graph demonstrates the difference between the gestational ages, 25 and 30 weeks in regard of OP probability when both are exposed to the same dose of caffeine. The probability of OP is higher in lower gestational age (25 weeks) than the 30 weeks gestational age.
Figure 1).
Probability of OP with increasing caffeine dosage in 25 weeks and in 30 weeks gestational age
TABLE 1.
Results from Multivariable Generalized Mixed Model
| Effect | Estimate | Standard Error | P value |
|---|---|---|---|
| Intercept | 5.63 | 5.59 | 0.321 |
| Caffeine Cumulative Dose, mg | 0.39 | 0.05 | 0.007 |
| Steroid Cumulative Dose, mg | 0.17 | 0.05 | 0.035 |
| Vitamin D, units | −1.64 | 0.47 | 0.006 |
| Average Biweekly Weight, grams | −0.01 | 0.0001 | <0.0001 |
| Gestational age, weeks | −0.41 | 0.19 | 0.0408 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e52–e53.
Abstract
BACKGROUND:
NEC remains a major cause of morbidity and mortality in very low birth weight infants. Surgery is required in a third of cases, however randomized trials have shown no clear advantage of laparotomy versus peritoneal drain for initial management, although data on neurodevelopment is lacking.
OBJECTIVES:
To examine outcome and neurodevelopment at 18 months of infants with NEC treated by laparotomy or peritoneal drain.
DESIGN/METHODS:
Data was examined on all infants <29 weeks gestation (GA) born between January 2010 and December 2011 with NEC Stage II or greater, admitted to Canadian Neonatal Network (CNN) NICUs and followed to 18 months. Infants were stratified by medical and surgical treatments. Significant difference between group outcomes was assessed by Fisher’s exact test and ANOVA test for categorical and continuous variables, respectively. Odds ratios with 95% confidence intervals (CIs) were calculated using standard methods.
RESULTS:
3,233 infants <29 weeks GA were admitted to CNN sites during study period and 260 developed NEC. 174 infants survived to discharge and detailed neurodevelopmental data was obtained on 152 (87%). Infants treated with drain or drain and laparotomy had significanly lower birth weights, longer length of stay and higher mortality than the laparotomy group. At 18 months, head, weight and linear growth remained significanly lower in the drain group, however there were no significant differences in the rates of cerebral palsy, vision or hearing impairments or neurodevelopmental in the treatment groups.
CONCLUSION:
Mortality in the drain group is higher, however long term neurodevelopmental outcomes are similar for both surgical groups.
TABLE.
| Variable | NEC Medical management | NEC Laparotomy | NEC Drain or Drain + Laparotomy | P value |
|---|---|---|---|---|
| Patient number | 154 | 67 | 39 | |
| Birth weight g, (mean, SD) | 914 (263) | 955 (200) | 758 (208) | 0.05 |
| Gestational age at birth wk (mean, SD) | 25.9 (1.5) | 26.0 (1.4) | 25.3 (1.3) | 0.25 |
| Duration of stay, days | 101 (40) | 126 (48) | 134 (69) | <0.01 |
| Survival to discharge (%) | 115 (74.7%) | 46 (68.7%) | 13 (33.3%) | <0.001 |
| 18 month weight, kg | 10.89 (1.69) | 10.54 (1.5) | 9.32 (2.4) | 0.03 |
| Mean, SD | ||||
| 18 month height, cm Mean SD | 80.0 (3.6) | 79.6 (3.9) | 74.6 (5.2) | <0.01 |
| 18 month head circumference, cm mean SD | 46.7 (1.8) | 46.4 (2.0) | 44.8 (1.7) | 0.02 |
| Bayley-III scores, Mean SD | ||||
| Cognitive delay, | 92.2 (18.9) | 84.8 (17.3) | 92.0 (17.8) | 0.15 |
| Language | 84.4 (15.0) | 81.9 (17.4) | 88.9 (13.9) | 0.54 |
| Motor, fine/gross | 88.3 (15.7) | 79.7 (20.0) | 82.0 (20.7) | 0.07 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e53.
Abstract
BACKGROUND:
Severe and fatal cases of invasive candidiasis (IC) have been reported in extremely low birth weight (ELBW) infants who develop this disease perinatally. Prospective observational studies of the early onset disease (EOD) variant of IC in ELBW infants are lacking.
OBJECTIVES:
To describe the clinical pattern of EOD in ELBW infants
To determine perinatal factors associated with EOD
To determine mortality rate and long term neurodevelopmental outcome in EOD compared to LOD ELBW infants and factors associated with these outcomes.
DESIGN/METHODS:
A secondary analysis of the multicentre Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC) prospective case control study of neonatal candidiasis was conducted. ELBW infants with EOD, (onset within first seven days of life) and LOD (onset after seven days of life) and ELBW controls without IC were identified. Factors associated with occurrence and outcome of EOD in ELBW infants were identified using logistic regression.
RESULTS:
Of 69 cases of neonatal IC in the PICNIC cohort, EOD occurred in 14/45 (31%) of ELBW infants compared to 2/24 (8%) infants ≥1000 g (P=0.039). Among the ELBW cohort, there were 14 cases of EOD, 31 LOD cases and 84 controls. Birth weight <750 g, gestational age <25 weeks, histological presence of chorioamnionitis, and vaginal delivery were all strongly associated with EOD (P<0.01). C. albicans was more likely to cause infection in EOD than in LOD infants, [11 (79%) versus 12 (39%), resp.; (P=0.023)]. Disseminated disease was more common in EOD (93%) than in LOD (42%); P=0.003) as was pulmonary involvement (86% versus 24%; P=0.0002) and cardiovascular disease (75% versus 30%; P=0.044). EOD was associated with a higher mortality rate than LOD or controls (71% versus 32% versus 15%, resp.; P=0.007). Twelve of 14 infants received antifungal therapy, in eight (67%) of whom it was begun within 48 hours of the day of disease onset. Neurodevelopmental impairment (NDI) and mortality combined occurred at a similar rate in EOD and LOD infants (86% versus 72%) but at higher rates than in controls (32%; P=0.007).
CONCLUSION:
The early onset variant of IC in ELBW infants has a very poor prognosis; even worse than IC presenting after one week of life. The role of perinatal transmission in the pathogenesis of EOD is supported by its association with histological chorioamnionitis, vaginal delivery and pulmonary infection. Dissemination and cardiovascular involvement is common in early onset perinatally-acquired IC, and affected infants often die. Early empiric treatment should be considered for ELBW infants at high risk, i.e. those with pneumonia, delivered vaginally, whose mothers had an intrauterine foreign body or who have histological evidence of chorioamnionitis.
Paediatr Child Health. 2015 Jun-Jul;20(5):e53.
Abstract
BACKGROUND:
Neonatal Candidiasis (NC) is a leading cause of infectious disease-related death in very low birth weight (VLBW) infants. It is associated with high mortality and morbidity. Research over the last decade has focused on the long-term outcome of survivors of this disease. There is a need to review data from these studies to quantify the long-term impact of this disease.
OBJECTIVES:
To conduct a systematic review with the aim of doing a meta-analysis of the available data from cohort studies.
DESIGN/METHODS:
We conducted a search of MEDLINE (1946 to November 2014) and EMBASE (1974 to November 2014) using the OVID search engine. Combinations of MeSH and text phrases/words used included: candida, Candida albicans, Candida glabrata, Candida tropicalis, candidiasis, cutaneous candidiasis, invasive candidiasis, infant, newborn, LBW, VLBW, extremely premature, premature, cerebral palsy, blindness, deafness, child development and developmental disabilities. Observational studies in English conducted on VLBW infants were selected. Articles were reviewed by two independent reviewers. Data on study design and year of publication, sample size and estimate of effect were collected. Studies were assessed for study quality. Mantel Haenszel method (fixed effects) was used to calculate summary estimate of odds ratio.
RESULTS:
Nine observational studies were selected of which two were case controls and the other seven were cohort studies. Seven studies involving 4194 infants were included in the metaanalysis. Overall NDI occurred in 47% of infants with NC as compared to 31% of uninfected infants. Neonatal candidiasis was associated with an increased risk of NDI (OR= 2.66 (95% CI 1.40–3.93).
CONCLUSION:
Neonatal candidiasis is associated with a significant risk of neurodevelopmental impairment in extremely low birth weight infants. Preventive strategies should target this group.
Paediatr Child Health. 2015 Jun-Jul;20(5):e53–e54.
Abstract
BACKGROUND:
Small for gestational age premature (SGA) neonates are an important subset among the preterm population. SGA preterm infants may suffer from complications of both prematurity and intrauterine growth retardation. There is considerable controversy in the literature, with some studies reporting an increase in neonatal mortality and morbidity in SGA premature neonates; while other studies reporting no risk difference. The varying results could be due to use of different growth standards, or inclusion based on liberal birth weight criteria. Given the uncertainty we designed a study, in a well defined sample, with sex specific, valid, population based growth standards, in order to evaluate neonatal morbidities affecting SGA neonates born at less than 31 weeks of gestation.
OBJECTIVES:
To compare the rate of neonatal morbidities in SGA and AGA neonates born at less than 31 weeks of gestation.
DESIGN/METHODS:
This was a hospital based cohort study of infants admitted or transferred into the neonatal intensive care unit at a tertiary referral center in South western Ontario, Canada. All neonates less than 31 weeks of gestation, born between January 1, 2000 to Dec 31, 2012, and who survived till discharge, were identified retrospectively. The neonates were classified as AGA (10th to 90th percentile) or SGA (<10th percentile) as per their birth percentile based on Kramer et al. Infants with major congenital anomalies were excluded. Maternal and neonatal demographic data and data regarding neonatal morbidities such as RDS, BPD, Mechanical Ventilation, PDA, PDA treatment, NEC, IVH, PVL, Sepsis, ROP, treatment for ROP were extracted from the Neonatal Perinatal Database.
RESULTS:
A total of 923 neonates met the inclusion criteria of which 9.5% were SGA and 87.6% were AGA. As expected maternal PIH rate was higher in the SGA group (51.1%) compared to the AGA group (51.1% vs. 14.0%; P<0.001). A higher proportion of SGA babies were delivered via Cesarean section (89.8% vs. 60.2%; P<0.001). Neonatal morbidities like RDS, BPD, sepsis, NEC, Sepsis, ROP, IVH and PVL were found to be statistically no different in the two groups. Hemodynamically significant PDA was significantly lower in SGA infants (39.8% vs. 53,8%; P=0.01). The need for mechanical ventilation was also found to be lower in SGA infants (68.2% vs. 78.6%; P=0.03). Days on oxygen and number of days to full feed were comparable in the two groups.
CONCLUSION:
SGA preterm infants born at less than 31 weeks of gestation were found to have similar rates of neonatal morbidities such as RDS, BPD, NEC, ROP as their AGA peers. SGA infants had lower rates of mechanical ventilation and hemodynamically significant PDA.
Paediatr Child Health. 2015 Jun-Jul;20(5):e54.
Abstract
BACKGROUND:
Vancomycin is often prescribed in the NICU for suspected or proven gram-positive infections. Achieving therapeutic serum concentrations can be challenging in neonates, particularly if aiming for high trough concentrations (15–20 mg/L) when MRSA is a concern.
OBJECTIVES:
To evaluate our vancomycin dosing protocol to determine the proportion of infants with adequate dosing at first check and assess safety.
DESIGN/METHODS:
Retrospective chart review of neonates admitted to two university-affiliated NICUs who received IV vancomycin between January 1st and December 31, 2012 (Period 1, 15–20 mg/kg/dose) and January 1, 2013 and February 28th, 2014 (Period 2, 20–22 mg/kg/dose). The outcomes were the proportion of neonates with target trough levels (5–15 mg/L), the proportion with higher trough levels (15–20 mg/L) and the proportion with toxic trough levels (>20 mg/L).
RESULTS:
116 neonates received vancomycin, including 74 (mean gestational age 29.8+/− 4.8 weeks, mean birth weight 1.5 +/− 0.9 kg) with trough levels pre-3rd dose. There was no difference between the dose/kg of vancomycin between the two periods (Period 1 mean 20.4 mg/kg; Period 2 mean 20.9 mg/kg). 56 of 74 neonates (75.7%) achieved the target trough (Table 1). Only seven (9.5%) achieved a higher trough. Four (5.4%) infants had a trough level >20 mg/L. Less than 2/3 of infants ≤28 weeks and ≤14 days achieved an adequate trough.
CONCLUSION:
Our vancomycin dosing protocol is effective when targeting trough levels of 5–15 mg/L, except in the most immature infants. It is suboptimal if targeting higher trough levels. Further research is needed to develop a protocol that effectively achieves therapeutic trough levels in extremely preterm infants in their first weeks of life.
| Age Category | First Pre-Vancomycin Level | Total acceptable levels (5–20 mg/L) (%) | |||
|---|---|---|---|---|---|
| 0–4.99 (mg/L) | 5–14.99 (mg/L) target | 15–20 (mg/L) | >20 (mg/L) | ||
| 0–14 days, ≤28 weeks GA (dosed Q24H) | 6 | 10 | 1 | 0 | 11/17 (64.7%) |
| 0–14 days, 29–34 weeks GA (dosed Q18H) | 1 | 8 | 1 | 0 | 9/10 (90%) |
| 0–14 days, ≥35 weeks GA (dosed Q12H) | 0 | 10 | 0 | 1 | 10/11 (90.9%) |
| >14 days, ≤ 28 weeks corrected GA (dosed Q18H) | 0 | 7 | 0 | 1 | 7/8 (87.5%) |
| >14 days, 29–34 weeks corrected GA (dosed Q12H) | 0 | 13 | 2 | 0 | 15/15 (100%) |
| >14 days, ≥35 weeks corrected GA (dose Q8-12H) | 0 | 7 | 3 | 2 | 10/12 (83.3%) |
| Infant, corrected GA ≥42 weeks and PNA > 4 week (dosed Q6H) | 0 | 1 | 0 | 0 | 1/1 (100%) |
| Total | 7 | 56 | 7 | 4 | |
| Total % | 9.5% | 75.7% | 9.5% | 5.4% | |
Paediatr Child Health. 2015 Jun-Jul;20(5):e54–e55.
Abstract
BACKGROUND:
As neonatal care advances, an increasing number of infants survive the immediate complications of preterm birth. In addition to ongoing physical health problems associated with preterm birth, these babies are more prone to delays in multiple domains of child development including cognitive, behavioral, and language development. Delay in these domains may impact future success in both academic and social endeavors. Compounding the issue is that preterm birth is more common, and increasing most rapidly, in low socioeconomic populations- a group already disadvantaged in the same domains of child development.
OBJECTIVES:
In our study, we look to establish if very preterm birth and living in an urban area of low socioeconomic status (SES) at time of birth negatively influences language development in infants at 18 months adjusted age and 36 months.
DESIGN/METHODS:
Using combined data from our local Neonatal Database and Neonatal Follow Up Database, we assessed the relationship between socioeconomic status and language outcomes in very preterm babies by comparing scores on validated language tools, administered during neonatal follow up care between SES groups. Univariate analysis and multivariable logistic regression was performed to evaluate the association between low SES and language development.
RESULTS:
Maternal and infant characteristics were compared between low SES, and combined average and high SES babies. Of the characteristics assessed, significant differences existed in maternal age, diabetes, and gestational age. Mortality and major neonatal morbidities associated with prematurity were compared between groups, and no association was found with SES. No significant difference in language outcomes were observed in our population at 18 months adjusted age, however by 36 months low SES babies had significantly more delayed composite language scores compared to average/high SES babies (odds ratio = 4.9, p-value= 0.01). There was a trend demonstrated towards poorer performance in both expressive and receptive language assessment compared to average and high SES babies.
CONCLUSION:
In our setting, low SES is associated with greater language delay in very preterm babies by 36 months. Further study is needed to assess if this delay is associated with school readiness, or other outcomes later in life. These results support prospective studies to evaluate the success of multidisciplinary interventional programs to modify the social risk and outcomes in low SES populations.
Paediatr Child Health. 2015 Jun-Jul;20(5):e55.
Abstract
BACKGROUND:
Gram-negative sepsis (GNS) is associated with increased neonatal mortality and morbidity compared with Gram-positive and fungal sepsis. Limited research has examined the differences in short-term and long-term outcomes of early-onset and late-onset GNS.
OBJECTIVES:
To compare short-term and long-term outcomes of neonates with early-onset and late-onset GNS with those who did not develop sepsis in Canadian NICUs.
DESIGN/METHODS:
A retrospective cohort study of neonates GA ≤29 weeks admitted between April 1, 2009 and September 30, 2011 was conducted using data from the Canadian Neonatal Network (CNN) and Canadian Neonatal Follow-Up Network (CNFUN) databases. Demographics and rates of mortality, BPD, ROP, NEC, and IVH were compared between three groups: a) early-onset GNS (EOS), b) late-onset GNS (LOS) and c) those with no sepsis. Follow-up metrics and composite neurodevelopmental impairment (NDI) indices at 18–21 months CGA were compared between the three groups.
RESULTS:
2182 infants met inclusion criteria; 29 (1.5%) developed EOS and 171 (7.8%) LOS. Baseline comparison revealed lower GA (P<0.01), birth weight (P<0.01), Apgar scores at 1 and 5 minutes (P<0.01) and higher SNAP II scores (P<0.01), higher rate of chorioamnionitis (P<0.01), and longer duration of stay (P<0.01) among those who developed GNS. E. coli and Citrobacter were more common among EOS, while LOS was associated with Enterobacter, Enterococcus, Klebsiella, and other gram-negative organisms (P<0.01). NEC was more common in neonates with LOS (AOR [95% CI]: 3.81 [2.14, 6.79]).
CONCLUSION:
GNS in Canadian NICUs is associated with an increased rate of NEC and increased length of hospital stay. There was no difference in neurodevelopmental impairment rates between groups when adjusted for confounders.
TABLE 1.
Long-term neurodevelopmental outcomes of infants with GNS relative to those without sepsis
| Outcome | EOS AOR (95% CI) N=29 | LOS AOR (95% CI) N=171 |
| NDI* | 1.73 (0.63, 4.30) | 1.02 (0.70, 1.49) |
| Severe NDI† | 1.64 (0.72, 3.75) | 1.05 (0.72, 1.53) |
*
NDI is one of: CP with GMFCS >2, Bayley-III (motor, cognitive, or language) <85, hearing loss, or visual impairment
†
Severe NDI is one of: CP with GMFCS >3, Bayley-III (motor, cognitive, or language) <70, hearing aid or cochlear implant, or bilateral visual impairment
Paediatr Child Health. 2015 Jun-Jul;20(5):e55.
Abstract
BACKGROUND:
A guideline regarding perinatal management of extremely premature infants (EPI – 22–25 wks GA) is being developed in Ottawa. To date, no research has examined the immediate effect of healthcare providers (HCP) education on knowledge and attitudes regarding EPI, despite the fact that assessment of barriers and facilitators is critical to guideline implementation.
OBJECTIVES:
1) To determine if HCP knowledge of and attitudes towards EPI changed after attending a presentation about survival and neurodevelopmental impairment of EPI and associated ethical issues; 2) to explore the correlation between knowledge and attitudes of HCP.
DESIGN/METHODS:
Local HCP (neonatal and obstetrical nurses, trainees and consultants; pediatricians) working with EPI or their parent(s) attended a presentation. Participants completed a pre/post survey. Changes in knowledge and attitudes were analyzed using the McNemar test and marginal homogeneity test. Association between knowledge and attitudes was assessed using Spearman correlation.
RESULTS:
One hundred and sixty of 508 potential participants attended a presentation (attendance rate = 31%); 130 completed both surveys (response rate = 81%). HCP knowledge for each GA significantly improved following the presentation (P≤0.001). Of the 16 items assessing HCP attitudes, all but one demonstrated a significant ‘positive’ shift in the modal category (i.e. more likely to consider resuscitation) (P=0.04 to P<0.001) after the presentation. Based on post-presentation responses, Spearman correlation between knowledge and attitudes ranged from 0.04 to 0.40 with a median of 0.22 (eg. Table). Some attitudes did not significantly correlate with HCP knowledge (eg. use of epi during resuscitation of 24 wk infant based on survival knowledge (P=0.16)).
CONCLUSION:
The survey results revealed a statistically significant improvement in knowledge and alteration in attitudes of HCP after attending a presentation about EPI. The correlation between knowledge and attitudes varied but was generally low.
Table 1.
| Response for: “If the parents request INTENSIVE care for their baby, I would resuscitate” (n) | |||||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Never | Occasionally | Quite often | Almost always | Always | Total | ||
| Response for: “The survival rate for 23 wk GA infants is:” | Nil | 1 | 2 | 0 | 0 | 0 | 3 |
| 1–24% | 1 | 28 | 10 | 2 | 7 | 48 | |
| 25–49% | 5 | 30 | 22 | 18 | 9 | 84 | |
| 50–74% | 0 | 3 | 4 | 6 | 2 | 15 | |
| 75–100% | 0 | 0 | 0 | 0 | 0 | 0 | |
| Total | 7 | 63 | 36 | 26 | 18 | 150 | |
Spearman Coefficient 0.24, p = 0.003
Paediatr Child Health. 2015 Jun-Jul;20(5):e56.
Abstract
BACKGROUND:
Human milk may carry many live bacteria including skin microflora and pathogens and these may be implicated as a source in neonatal sepsis. There is no consensus amongst human milk banks on acceptable bacteria thresholds prior to milk pasteurization. The threshold in the Toronto, Canada bank is 100 ×105 CFU/L.
OBJECTIVES:
To determine whether infant NICU admission is a risk factor for greater bacterial growth in milk donated to a human milk bank.
DESIGN/METHODS:
This is retrospective cohort study of all human milk donated to the Rogers Hixon Ontario Human Milk Bank in Toronto, Canada from Jan 2013 to Jun 2014 inclusive. Data was abstracted from a prospectively maintained database. All donated milk is cultured on blood and MacConkey’s agar every two weeks during the donation period. Bacteria were defined a priori as either skin microflora or pathogen. Each culture was reported in CFU ×105/L.
RESULTS:
There were 199 donor mothers during the study period of which 63 had babies in the NICU. Mothers of inpatients had similar maternal age and rate of operative delivery compared to mothers of outpatients but their infants had significantly lower birth weight and gestational age. The mean number of cultures for each group was six over a three month donation period. There was a wide range of microflora and pathogens grown with the mothers of inpatients having significantly greater abundance of microflora but not pathogens at every time period. The tables indicate culture results from the first sample.
CONCLUSION:
Our human milk cultures prior to pasteurization indicate a high level of live bacteria. This has important implications for determining discard rates in the bank. It may be of additional importance in recommending guidelines for milk expression techniques while in the NICU to minimize such bacterial growth. The donor mothers in this study come from NICUs which foster skin-to-skin care and the presence of skin microflora in milk may be of benefit to the fragile preterm infant.
| NICU Admission | Microflora CFU | *p<0.0001 | ||
|---|---|---|---|---|
| 0 ×105/L | 1–9 ×105/L | 10–100 ×105/L | >100 ×105/L | |
| no (n=136) | 47% | 27% | 19% | 7% |
| yes(n = 63) | 19%* | 11%* | 30%* | 40%* |
| NICU Admission | Pathogen CFU | *no significant difference | ||
|---|---|---|---|---|
| 0 ×105/L | 1–9 ×105/L | 10–100 ×105/L | >100 ×105/L | |
| no (n=136) | 69% | 7% | 12% | 13% |
| yes (n = 63) | 76%* | 5%* | 8%* | 11%* |
Paediatr Child Health. 2015 Jun-Jul;20(5):e56.
Paediatr Child Health. 2015 Jun-Jul;20(5):e56.
Abstract
BACKGROUND:
Necrotizing enterocolitis (NEC) is a common causes of morbidity and mortality in NICUs. Prolonged duration of empiric antibiotic therapy alters the normal gut flora and may increase the risk of NEC; however, such an association needs to be investigated in larger cohorts.
OBJECTIVES:
To examine the association between the duration of antibiotic exposure and the development of stage 2 or 3 NEC in very preterm neonates.
DESIGN/METHODS:
A retrospective case-control study of neonates born at <29 weeks and admitted between 2010 and 2013 was conducted using data from the Canadian Neonatal Network. Infants were excluded if they had culture-proven sepsis. Baseline demographics were compared between those who developed NEC and those who did not. The number of NPO and empiric antibiotic days until the development of NEC were calculated for cases and compared with those for the two controls (GA, birth weight and sex-matched) in each cluster for the same postnatal age at which each case developed NEC.
RESULTS:
A total of 224 cases of NEC and 447 controls were studied. There were no differences in chorioamnionitis, SNAP-II scores, PDA or inotrope use between those who developed NEC and those who did not. A multiple regression analysis controlling for NPO days and antenatal steroid use revealed that the duration of antibiotic exposure was higher in the NEC cases as compared with controls (P<0.01). Antibiotic treatment of more than four days was associated with significantly higher adjusted odds ratios of NEC.
CONCLUSION:
Empiric antibiotic exposure of more than four days in very preterm neonates of <29 weeks was associated with an increased risk of NEC after controlling for confounders. Further prospective studies on reasons for empiric usage of antibiotics and its association with neonatal morbidities is warranted.
Paediatr Child Health. 2015 Jun-Jul;20(5):e57.
Abstract
BACKGROUND:
Central venous and arterial lines are commonly used in NICUs to provide nutrition and medications and for monitoring of blood pressure; however they have the potential to contribute to serious complications. Knowledge of current practice is limited and larger cohort studies are warranted.
OBJECTIVES:
To determine the trend and pattern of central catheter use for the period between 2005 and 2013 and identify variation amongst Canadian NICUs.
DESIGN/METHODS:
A retrospective cohort study of neonates <30 weeks gestational age (GA) admitted between 2005 and 2013 was conducted using data from the Canadian Neonatal Network. Data on the use of central venous lines (CVLs) over three time periods (2005–2007, 2008–2010 and 2011–2013) while data on central arterial catheters (UACs) from 2010 to 2013 were examined. Baseline demographics and morbidities were compared between infants who had a central line and those who did not.
RESULTS:
20792 infants <30 weeks were admitted during the study period. The use of central venous lines (CVL) increased since 2005–2007 for all GAs (Figure 1). This was due to an increase in UVC and PICC lines while the use of surgical CVLs decreased over time. CVL use varied significantly between units [AOR (95% CI) range: 0.10(0.05, 0.19) to 4.87 (2.35, 10.11)] (Figure 2). Infants who received CVLs had a significantly lower BW, GA and higher SNAP II scores than those who did not. SGA and surfactant use were more common in the CVL group. Multivariable analyses adjusting for GA, SNAP II and surfactant use showed that IVH ≥ grade 3, NEC, late onset sepsis and mortality were higher in the infants with CVLs (P<0.0001). There was a decrease in UAC use from 2010 to 2013 (P=0.002).
CONCLUSION:
CVL use in infants<30 weeks increased over the time period of this study in Canadian NICUs while UAC use decreased. The risk of mortality and major morbidities were increased among those who received CVLs. Further studies are warranted to develop standardized guidelines for central line insertion.
Paediatr Child Health. 2015 Jun-Jul;20(5):e57.
Abstract
BACKGROUND:
In our tertiary center all infants with evidence of perinatal hypoxia-ischemia are outborn and transported for assessment of level of encephalopathy and need for cooling. Temperature monitoring during transport is a central and challenging component of their management. Given the lack of consensus on whether therapeutic hypothermia should be initiated outside the NICU, the choice of the target temperature is usually made by the neonatologist responsible for the transport.
OBJECTIVES:
To evaluate the effectiveness of temperature control during transport in infants referred to our tertiary center.
DESIGN/METHODS:
From June 2012 to June 2014 medical records of infants with GA ≥36 weeks, birth weight ≥1800 g and <6 h of life at time of referral for possible cooling were reviewed. Data on demographics, severity of fetal acidemia, presence of perinatal events, ages at referral call and NICU admission, assessment on the level of encephalopathy, and temperature at arrival of transport team and admission to our NICU were collected.
RESULTS:
A total of 131 eligible infants were transported. Temperature monitoring and recording was variable. There was no recorded temperature in 7% of patients at the referring centers and 1.5% at NICU admission. Several different sites were used: axillary, rectal, or esophageal. Normothermia (36–37°C) was recommended in 84% of the cases with recorded temperatures of 36.4±0.9°C at referring center and 36.1±0.9°C at NICU admission. Infants submitted to passive cooling had temperatures of 34.6±1.5°C and 34.2±1.1°C at referring centers and NICU admission, respectively. There were a large proportion of neonates with temperatures outside the desired range (Figure 1). The level of encephalopathy was mostly assessed by the transport nurse (96%), using neurological exam in all cases. At admission 73 infants (56.1%) had either a normal / Sarnat I neurological exam. Five of the 21 infants submitted to passive cooling (24%) had a normal / Sarnat I exam at admission. Two cases of overcooling were observed in the passive cooling (5%) and six cases of overheating (4.5%) in the normal temperature groups.
CONCLUSION:
Current temperature monitoring and control of infants with evidence of hypoxia-ischemia transported to our center is sub-optimal and requires the development and implementation of a well defined protocol.
Paediatr Child Health. 2015 Jun-Jul;20(5):e58.
Abstract
BACKGROUND:
Effective communication between neonatologists and families is essential to family-centered care. Neonatal-Perinatal Medicine (NPM) training, however, focuses on knowledge acquisition, rather than communication skill development. Presently, there is no standardised approach to communication skills training in Canada.
OBJECTIVES:
The purpose of this project was to develop, implement and evaluate a simulation based communication skills workshop for Neonatal-Perinatal Medicine trainees.
DESIGN/METHODS:
A questionnaire to assess current communication teaching methodology and trainee confidence was sent to NPM program directors and trainees across Canada. A workshop that included both didactic teaching and simulated parent encounters was then developed based on deficits identified in the needs assessment. Trainee communication skills were assessed in pre and post workshop scenarios using qualitative (Calgary-Cambridge – CC) and quantitative (Global Rating Scale – GRS) assessment tools. One month later, trainees participated in another simulated encounter to evaluate retention. Trainees completed questionnaires pre and post workshop, as well as one month post workshop to assess perceived confidence, communication skills and workshop satisfaction.
RESULTS:
Two thirds of training programs do not offer formal communication skills training. Eight trainees completed the workshop; four of these completed the retention assessment. Five trainees improved on both the GRS and CC with mean scores (sd) increasing from 29.6 (±1.8) to 33 (±2.4) out of 45 and 83.1 (±2.6) to 89.9 (±3.0) out of 100, respectively. At the one month post assessment, three trainees were equivalent to, or improved from, their post workshop assessment with scores of 35.3 (± 1) and 95.2 (±1.7). In pre vs. post workshop surveys, there were trends towards increasing confidence in discussing palliative care (33.3% vs. 77.8%), conflicts of opinion (44.4% vs. 66.7%) and religious or spiritual beliefs (33.3% vs. 66.7%). Seven of eight trainees “agreed” or “strongly agreed’ that the workshop met their expectations and all “agreed” or “strongly agreed” that the workshop improved their communication skills.
CONCLUSION:
The implementation of a simulation based communication skills workshop resulted in improved confidence amongst trainees and improved qualitative and quantitative assessments in almost two-thirds of cases. Similar workshops should be implemented to enhance communication skills teaching across Canadian NPM programs.
Paediatr Child Health. 2015 Jun-Jul;20(5):e58.
Abstract
BACKGROUND:
Resuscitation rooms, which are separate areas from delivery and operative rooms, are environments that are specially designed to provide adequate space for resuscitating and stabilizing newborn infants.
OBJECTIVES:
The primary objective of our study was to assess the impact of having a dedicated resuscitation room (infant stabilization room, ISR), on time to full stabilization and quality of care.
DESIGN/METHODS:
We conducted a prospective cohort quality improvement study at a level three perinatal centre. All infants less than 33 weeks gestational age were included. The study was conducted over a period of three years (February 2011 to June 2014), and was divided into four phases – pre-implementation phase (February 2011 to Jan 2012), implementation phase (Feb 2012 to July 2012), post-implementation phase (August 2012 to July 2013) and sustainability phase (August 2013 – June 2014). ISR was successfully commissioned in February 2012. Workflow, design, equipment, staffing, stocking and roles of caregivers were modified and tested using simulation, in-servicing and education over multiple PDSA cycles. Patient health records were reviewed for frequency of interventions and time to complete interventions; intubation, umbilical or peripheral vascular catheters, initial imaging, surfactant and time to full stabilization. Impact on quality and teamwork were assessed by participant observation and focus groups at multiple time points.
RESULTS:
Total number of preterm infants included in the study was 769; 233, 102, 244 and 190 infants in phases 1 to 4 respectively. The mean gestational age (29 weeks), mean birth weight (1300 g) and gender distribution were similar across all the four phases of the study. The time to full stabilization reduced from 88 minutes in the pre-implementation phase to 73 minutes in the post-implementation phase. Similar reductions were noted in the time to intubation, insertion of vascular catheters, surfactant and x-rays. The number of resuscitations occurring in the infant stabilization room increased over the course of the study. The ISR provided more space and avoided overcrowding. Resuscitation and stabilization were able to occur as a continuum. One baby, one bed and one ventilator strategy for the first 48 hours promoted minimal handling of the infants. Parents experienced less chaos and anxiety, were able to attend resuscitation in the ISR and the mother was able to see the infant before being transferred to NICU.
CONCLUSION:
Having a dedicated resuscitation room tends to decrease time to interventions, stabilization time and improves teamwork and quality of care.
Paediatr Child Health. 2015 Jun-Jul;20(5):e58.
Abstract
BACKGROUND:
Unplanned extubations (UEs) are a common adverse event experienced by ventilated neonates in the Neonatal Intensive Care unit (NICU) and can lead to significant morbidity in an already vulnerable population. Despite the fact that UEs are increasingly recognized as an important quality of care metric, this adverse event was not being routinely reported at our institution. We sought to determine the rate of UEs in this NICU and identify risk factors to target future quality improvement interventions.
OBJECTIVES:
1. To determine the rate of UEs (# of UEs/100 ventilator days) in a level II/III NICU; 2. To identify risk factors associated with UEs.
DESIGN/METHODS:
Institutional ethics approval was obtained prior to start of the study. A retrospective chart review was conducted for all intubated neonates admitted to a 34 bed level II/III NICU from January 1st, 2013 until December 31st, 2013. An UE was defined as any removal of an endotracheal tube not directly ordered or intended by a physician. For each UE event, the following data were collected: gestational age, birth weight, gender, weight at time of extubation, time at which event occurred, reason for extubation, and total number of ventilation days.
UE rate was calculated by #UEs/100 ventilator days. Reasons for UEs were expressed by Pareto charting. Multivariate regression analysis was performed for gestational age, birth weight, and total ventilation time. Timing of event was categorized as either day or night shift and analyzed for significance using ANOVA.
RESULTS:
The UE rate was 3.28 UEs/100 ventilator days. Patient movement and adhesive failure accounted for over 50% of UEs. In 22.7% of cases, patients did not require re-intubation. Total ventilation time was the only statistically significant risk factor for UEs with a 7.3% increased risk per ventilation day past the mean. UEs were no more likely to occur on day versus night shift, nor were there any significant differences in the reasons for UE based on shift.
CONCLUSION:
The UE rate at this institution was higher than the suggested benchmark. More than 20% of patients did not require reintubation, reinforcing the need for more aggressive weaning protocols. Interestingly, night versus day shift was not found to be a significant risk factor. Total ventilation days independently predicted UE risk; pre-emptively identifying such patients is a potential avenue for future quality improvement interventions.
Paediatr Child Health. 2015 Jun-Jul;20(5):e59.
Abstract
BACKGROUND:
Alterations in the anticipated and expected parental role is documented as the single most stressful consequence of having an infant admitted to the NICU. Single family rooms (SFR) are thought to promote maternal bonding, breastfeeding and an increased sense of parental competency; with decreased rates of depression and anxiety.
OBJECTIVES:
To compare parent stress, self-competency, and perceived quality of care in a shared (DB) NICU versus a SFR NICU.
DESIGN/METHODS:
Parent perspectives were explored as a sub-study within a larger prospective observational cohort investigation of a NICU move from December 2013 to September 2014. Self-report questionnaires were administered over a one-month period in a DB NICU, and during a three-month interval in a new SFR NICU. The questionnaire contained items on spousal support and demographics and a compilation of scales including the Edinburg Postnatal Depression Scale (EDPS) and the Parental Stress Scale (PSS:NICU). Responses were compared using Pearson χ2 and Student’s t-test.
RESULTS:
Eight families from the DB NICU and nine families from the SFR NICU participated. The majority of participants reported Caucasian ethnicity (75%), Canada as their country of origin (65%) and English as a primary language (70.6%). Mean age was 30.9 (6.5) years and over one-half (56.2%) of the subjects reported a family income >$100,000/year. Parents reported their time in the NICU as very or extremely stressful (76.5%). Overall scores on the PSS:NICU were higher in the SFR NICU than in the DB NICU (65.7 versus 49.1, P=0.03). On the EDPS, 76% of participants had scores consistent with possible depression however, there was no difference between scores in the DB and SFR NICUs (13.2 vs 10.3, P=0.18). There was no difference in parenting sense of competency between groups (83.3 vs 80.3, P=0.47).
CONCLUSION:
Although families reported higher levels of stress in the SFR NICU than in the DB NICU, it is important to recognize that this was a study of only 17 participants. Notwithstanding, research has shown that parents do feel more isolated from other families in the SFR units, which could conceivably lead to higher stress levels. Future studies should also include evaluation of peer support systems within the unit. Similarly, larger samples are required to control for severity of infant illness.
Paediatr Child Health. 2015 Jun-Jul;20(5):e59.
Abstract
BACKGROUND:
In 2011, a new neonatal intensive care unit (NICU) with double-bedded (DB) rooms was opened in a tertiary children’s hospital in Canada. The unit moved to a single family room (SFR) NICU 31 months later. Other authors have identified increased nursing concerns regarding safety and communication in SFR NICUs while a family-friendly environment has been cited by parents as important.
OBJECTIVES:
To compare staff perceptions of work environment, accommodation of health care practice and extent of parental involvement in the DB and SFR NICUs.
DESIGN/METHODS:
A sub-study of staff perceptions was conducted as part of a larger prospective observational cohort study of the NICU move from December 2013 to September 2014. Self-report questionnaires were administered over a one month period in the DB NICU, and during a three month interval in the new SFR NICU. The questionnaire covered demographics, perceptions of work environment, health care practice and extent of parental involvement. Questionnaire responses were compared using bivariate analyses including χ2 test.
RESULTS:
There were 44 completed questionnaires: 26 from the DB NICU, 18 from the SFR NICU. All respondents were female; a majority were nurses (83%). Staff reported better access to equipment and supplies (50% vs 94.4%, P<0.05), better privacy for family interactions (36.0% vs 100%, P<0.001), increased opportunity for bonding and breastfeeding (19.2% vs 100%, P<0.001) and better ability to control ambient lighting (34.6% vs 100%, P<0.001) in the SFR NICU. Foot traffic was identified as a problem around neonates in the BD NICU, 26.9% vs 0, P<0.05 as was the ambient noise level 26.9% vs 0%, P<0.005. Parents seemed comfortable discussing their child’s condition (91.9% vs 88.8%, P=0.57), felt free to visit (94.6% vs 100%, P=1.0) and were actively involved in their child’s care (94.4% vs 94.4%, P=0.63) in both units.
CONCLUSION:
Staff adjustment was relatively smooth. There was no difference in staff perceptions of patient safety or staff isolation, in contrast to other reports. Staff perceptions of functionality and family support in the SFR NICU were significantly improved.
Paediatr Child Health. 2015 Jun-Jul;20(5):e59.
Abstract
BACKGROUND:
Bronchopulmonary dysplasia (BPD) is a major neonatal morbidity associated with adverse neurodevelopmental outcome at 18–24 months of age. Use of postnatal systemic corticosteroids has been shown to facilitate extubation and reduce the severity of BPD; however its use is associated with an increased risk of neurodevelopmental impairment mainly cerebral palsy (CP). Inhaled steroids are used alternatively, but their effect on neurodevelopmental outcome is not well documented.
OBJECTIVES:
To evaluate the neurodevelopmental outcomes at 18–24 months of neonates <29 weeks GA with BPD who are treated with inhaled steroids vs. systemic steroids vs. no steroid treatment.
DESIGN/METHODS:
This is a retrospective cohort study using data from the Canadian Neonatal Network (CNN) and the Canadian Neonatal Follow-Up Network (CNFUN) from April 2009 to September 2011. Neurodevelopmental impairment was defined as any one of Bayley III score <85 (cognition, motor or language), CP, or visual or hearing impairment. Severe impairment is defined as any one of: Bayley III score <70 for any of the three components, CP with gross motor function classification system (GMFCS) ≥3, severe visual impairment <20/200, or hearing impairment requiring aids/cochlear implant. Data for the three groups were compared using χ2 test and Student’s t test as appropriate.
RESULTS:
Of the 4119 neonates born during the study period, 1339 (32.5%) developed BPD. Of the 1339 infants, 817 did not receive steroids and follow-up data was missing for 56 infants. Of the remaining 466 neonates with follow-up data, 63 received inhaled steroids, 403 systemic steroids. Adjusted OR (95% CI) for neurodevelopmental outcomes after adjustment for GA, SGA, outborn, mode of delivery, and SNAP-II scores are presented below. Table 1
CONCLUSION:
In neonates <29 weeks GA who develop BPD, treatment with steroids is associated with worse outcome than those not treated with steroids. In comparing steroid treatment groups, inhaled steroids neither confers any benefit nor causes any harm compared to systemic steroids.
| Outcomes among neonates with BPD | Inhaled steroids (n=63) | Systemic steroids (n=403) | No steroids (n=817) |
|---|---|---|---|
| Neurodevelopmental impairment | 2.07 (1.03, 4.14) | 1.51 (1.10, 2.08) | 1 |
| Severe neurodevelopmental disability | 1.29 (0.69, 2.41) | 1.51 (1.10, 2.08) | 1 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e59–e60.
Abstract
BACKGROUND:
The sepsis risk calculator designed by Puopolo et al (Pediatrics 2011) estimates early onset neonatal sepsis (EOS) risk based on intrapartum factors, and has resulted in the safe evaluation of significantly fewer infants. This group has also provided further management strategies based on the clinical condition of the newborn.
OBJECTIVES:
To compare the risk estimate for EOS calculated using the newly published sepsis risk calculator of Puopolo et al to the standard clinical algorithm recommended by the Canadian Pediatric Society (CPS) and to find its utility within a local population.
DESIGN/METHODS:
All newborns (>36 weeks of gestation) born at a Canadian tertiary center between February 2014 and July 2014 were included. Infants born to mothers with inadequate GBS prophylaxis, chorioamnionitis or unknown GBS status with risk factors were screened and sepsis risk was estimated using a computerized calculator based on maternal predictors. These infants were followed to determine their management strategies based on clinical conditions.
RESULTS:
971 infants were born during the study period. Based on the CPS algorithm, 66 (6.7%) infants were evaluated. Demographic data are available in Table 1.
There was no culture positive sepsis in the study group. The sepsis risk calculator identified only two infants (3.03%) with a risk of >0.5/1000. When clinical variables were entered, antibiotic treatment was suggested for 7/66 (10.6%).
CONCLUSION:
Current strategies to reduce EOS based on preventive measures have resulted in a decrease in the risk of sepsis. Application of the sepsis risk calculator to our population truly depicts its strength but larger studies are needed to find the true incidence of EOS in the targeted population and to further evaluate the practical impact of this calculator on EOS identification.
| Descriptor | Absolute Mean Value (n=66) | % (n=66) |
|---|---|---|
| Maternal age (+/− SD) | 30.1±4.8 | |
| Multiple gestation | 3 | 4.5 |
| Gestational Age | ||
| 36–37 weeks | 9 | 13.6 |
| 38–39 weeks | 27 | 40.9 |
| 40–42 weeks | 30 | 44.5 |
| Maternal GBS status | ||
| positive | 59 | 92.4 |
| unknown with risk factors | 4 | 6.1 |
| negative | 1 | 1.5 |
| Neonate sex | ||
| Female | 27 | 40.9 |
| Male | 39 | 59.1 |
| Birth weight, g | 3477 (± 620) | |
| Number of infants requiring additional management as | ||
| Per sepsis risk calculator | 7 | 10.6 |
| Number of infants with culture-confirmed sepsis | 0 | 0 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e60.
Abstract
BACKGROUND:
Inhalation of nitric oxide (iNO) has been shown to improve oxygenation and reduce the need for ECMO in term and near term infants with persistent pulmonary hypertension. However, its efficacy in preterm population is debated with available trials heterogeneous in terms of the subjects enrolled. As per the NIH consensus development panel statement (2010) on the use of iNO, it is inadequately studied in preterm infants of <34 week gestation suspected with pulmonary hypertension or lung hypoplasia.
OBJECTIVES:
To study the use of iNO as rescue treatment in subset of preterm infants presenting with refractory hypoxemia on the day of birth.
DESIGN/METHODS:
Retrospective cohort study at a tertiary care neonatal unit. Subjects were infants born between 25 to 33+6 weeks gestation with refractory hypoxemia (defined as inability to maintain blood oxygen saturation (SaO2) within normal range despite being ventilated with >90% FiO2 for 30 minutes and having received at least one dose of surfactant) within 24 hours of birth and received a trial of iNO as rescue therapy. Response to iNO was defined as one or more of the following: 1) improvement in PaO2 by >20 mm Hg or 2) decrease in OI by >5 or 3) decrease in FiO2 requirements by >20%. Response was assessed at 1 h from initiation of iNO (early response) and at 24 h (sustained response).
RESULTS:
Sixty preterm infants were identified. Baseline parameters prior to initiation of iNO were as follows: Gestation age (mean + SD) = 28.2 +1.98 weeks; Birth weight (mean + SD) = 1246 +479 g; FiO2 (mean + SD) = 99.2+ 2.3%; and Oxygenation index: Median [IQR]= 24.9[18.7 – 34.8]. As per pre-determined criteria, 52 (88%) infants were considered early and 57 (95%) as sustained responders. Majority of early responders (51/52) had sustained response with iNO. There were 10 deaths during primary hospitalization; with six cases of NEC (stage ≥2); 10 cases of severe IVH and five cases of PVL.
CONCLUSION:
In this cohort of preterm infants diagnosed with refractory hypoxemia on the day of birth and received a trial of iNO as last resort, the majority showed an early and sustained response in terms of respiratory parameters. Placebo control trials are urgently needed to assess benefits in terms of BPD, death or long-term outcomes in this subset of population.
Paediatr Child Health. 2015 Jun-Jul;20(5):e60.
Abstract
BACKGROUND:
Therapeutic hypothermia (TH) for infants with perinatal asphyxia is effective at reducing death or disability. Current evidence suggests that the sooner cooling is commenced, the more likely it is to be beneficial.
OBJECTIVES:
To identify factors associated with early achievement of TH (core temperature 33–34 degrees) in two Ontario outborn level 3 NICUs.
DESIGN/METHODS:
Retrospective cohort study of asphyxiated newborns who received TH according to NICHD criteria in two academic level 3 Neonatal Intensive Care Units (NICU): SickKids (Toronto; January 2009 to December 2010) and CHEO (Ottawa; October 2009 to December 2013). All infants were transported by a neonatal transport team (NNTT). Multivariate linear regression including who initiated cooling and degree of resuscitation in the model was performed.
RESULTS:
The combined cohort is described in Table 1. Need for extensive resuscitation (CPR or epinephrine) was strongly associated with earlier initiation of TH (1.4 h, P=0.001). Waiting for advice from our tertiary care centers was associated with a 1.2 h delay (95% CI 0.5 – 2) in initiation of TH. Waiting for the NNTT to initiate cooling was associated with a delay of 2.5 h (95% CI 1.7 – 3.3) while waiting for admission to the NICU delayed onset by 5.7 h. Age at initiation of cooling was the only factor associated with age when TH was achieved, with each 1 h of delay being associated with a 0.8 h delay in reaching target core temperature. Gestational age, birth weight and site in the multivariate models did not change the findings significantly.
CONCLUSION:
Initiating passive cooling at the referring center, before transfer, is critical to earlier initiation and faster achievement of target core temperature in asphyxiated infants. Greater outreach education and development of clinical care pathways are needed to improve optimal delivery of TH to enhance outcome.
| Demographics | n=136 |
|---|---|
| Gestational age, mean (+/−SD) | 38 (±1.7) weeks |
| Birth weight, mean | 3.3 kg |
| 10 min Apgar score, mean | 4 |
| Arterial cord pH, mean | 6.93 |
| Resuscitation with PPV via bag+mask or less, n (%) | 31 (22.7) |
| Resuscitation with PPV via ETT, n (%) | 47 (34.6) |
| Resuscitation with CPR or epinephrine, n (%) | 58 (42.7) |
| TH initiated on site, before advice, n (%) | 43 (31.6) |
| TH initiated after call to NICU, n (%) | 48 (35.3) |
| TH initiated by NNTT, n (%) | 35 (25.7) |
| TH initiated by tertiary care center, n (%) | 10 (7.3) |
Paediatr Child Health. 2015 Jun-Jul;20(5):e61.
Abstract
BACKGROUND:
Premature infants often receive glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The evidence to support this practice remains unclear.
OBJECTIVES:
To establish the level of evidence regarding the use of glycerin enemas and suppositories in premature infants.
DESIGN/METHODS:
We conducted a systematic search of Medline, Embase, the Cochrane Library, and trial registries for randomized controlled trials that assessed the effects of using glycerin enemas and suppositories in premature infants. All records were reviewed independently and in duplicate. Abstracted data were meta-analyzed in Review Manager using a random effects model.
RESULTS:
We identified 185 premature infants treated prophylactically with glycerin enemas (n=81, one trial) or suppositories (n=104, two trials). Infants were less than 32 weeks gestation and had no congenital malformations. In all three trials, administration of glycerin enemas or suppositories started within the first two days of life and was stopped on or before day 15. This treatment strategy was associated with earlier initiation of stooling in one trial (2 vs 4 days, P=0.02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P=0.11). One other trial did not report stooling outcomes. Meta-analysis indicated that the use of glycerin enemas or suppositories had no statistically significant effect on time to full enteral feeds (0.7 days faster with treatment, P=0.49). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio=2.72, P=0.13). All three trials were limited by small sample sizes and the possibility of selective reporting. One study used a sham procedure to maintain blinding while the other two were open studies with no blinding. At least three other trials are underway.
CONCLUSION:
Daily administration of glycerin enemas or suppositories does not appear to expedite transition to full enteral feeding in premature infants less than 32 weeks gestation. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. These conclusions may change as more results become available. Careful monitoring of ongoing trials is required.
Paediatr Child Health. 2015 Jun-Jul;20(5):e61.
Abstract
BACKGROUND:
A poor prognosis based on mortality or disability rates can push physicians to discuss withdrawal of life-sustaining therapy (WLST) for newborns in the NICU. However, WLST may not be discussed with families of an older child despite a similar poor prognosis. Three patient populations with overlapping prognoses include: ventilated extremely premature infants (22–25 weeks) (EPI), ventilated term neonates with hypoxic ischemic encephalopathy (HIE) and ventilated children with traumatic brain injury (TBI).
OBJECTIVES:
1) To document the frequency with which physicians discuss WLST with families in each respective population; 2) to compare the frequency of discussions between populations; and, 3) to document the frequency of five possible ‘outcomes’ of WLST discussions in each population: WLST ‘late’ in clinical course, WLST ‘early’ in clinical course, WLST with ‘unexpected survival’, refusal of WLST with survival and refusal of WLST with death.
DESIGN/METHODS:
Retrospective chart review of cases from January 2003 to December 2013. Included cases met pre-specified inclusion criteria (eg. in-hospital survival of >24 hrs). Prevalence of WLST discussions and the outcome after WLST discussions will be determined using the Wilson score method. Comparisons will use Fisher’s exact test.
RESULTS:
Of the 300 charts reviewed to date, 155 were included: 95 EPI, 48 HIE and 12 TBI. WLST was discussed in 35 of EPI, 24 of HIE and one of TBI. For EPI, in 16 cases, WLST was ‘late’; in 12 cases, WLST was ‘early’; there was one ‘unexpected survival’. For HIE, in one case, WLST was ‘late’; in 16 cases, WLST was ‘early’; there was no ‘unexpected survival’. For TBI, there was no occurrence of WLST. For EPI, WLST was refused in six cases: three died and three survived. For HIE, WLST was refused in two cases: one died and one survived. For TBI, WLST was never recommended and thus never refused. Statistical comparison between populations will occur after chart review completion. In 55 EPI, 24 HIE and 11 TBI (90/155 cases), no discussion of WLST was documented.
CONCLUSION:
Preliminary data does not demonstrate a greater frequency of WLST discussions in EPI compared with HIE; this does not support literature suggesting a bias against EPI. There was a very low frequency of WLST discussions and actual WLST in TBI, as per the current literature. Despite guarded prognoses for these populations, discussion of WLST is relatively infrequent.
Paediatr Child Health. 2015 Jun-Jul;20(5):e62.
Abstract
BACKGROUND:
Preterm infants often respond differently to Indomethacin for PDA closure with some requiring multiple courses of the drug and subsequently surgical ligation.
OBJECTIVES:
To identify perinatal and postnatal risk factors associated with failure of primary course of indomethacin for treatment of PDA.
DESIGN/METHODS:
We studied infants who received indomethacin for PDA between 2010–2013. We identified those who failed primary pharmacotherapy and required subsequent courses or surgical ligation. Failure of primary course of indomethacin was defined as infants requiring more than one full course of indomethacin or received one full course of indomethacin followed by surgical ligation. Perinatal/neonatal variables in infants with and without indomethacin failure were compared by univariate analysis. Subsequently, variables which had significant difference two groups were selected to carry out logistic regression analysis.
RESULTS:
Out of 77 infants analyzed, 36 (46.7%) had primary indomethacin failure and nine infants (11.7%) underwent surgical ligation. Univariate analysis revealed that infants with primary indomethacin failure were significantly more immature, of male sex, did not receive a complete course of antenatal corticosteroids, indomethacin dose interruption was documented during clinical care and their mothers had clinical chorioamnionitis. (Table 1). The multivariable logistic regression analysis showed that dose interruption and clinical chorioamnionitis were independent risk factors for indomethacin failure (Table 2).
CONCLUSION:
Indomethacin dose interruption and clinical chorioamnionitis appear to be independent risk factors for primary indomethacin failure in preterm infants. This study generates an important and previously unexplored hypothesis regarding the role of dosage interruption in treatment failure. This could pave the way for future prospective cohort studies to better analyze this interaction and also prospective RCTs to potentially find a solution to this problem.
TABLE 1.
Baseline variables and univariate analysis of risk factors for indomethacin failure
| Variables | Indomethacin failure (n=36) *[mean± SD] | No indomethacin failure (n=41) *[mean± SD] | P value |
|---|---|---|---|
| Gestational age (week) | 24.7±1.3* | 26.2±2.2* | 0.001 |
| Birth weight (grams) | 748±145* | 922±287* | 0.001 |
| Sex (Male/Female) | 23/13 | 15/26 | 0.01 |
| Antenatal Corticosteroids | 18 | 22 | 0.75 |
| Clinical Chorioamnionitis | 22 | 7 | 0.0002 |
| RDS requiring surfactant | 34 | 10 | 0.05 |
| Postnatal age at indomethacin treatment (days) | 7.6±4.4* | 6.8±3.2* | 0.36 |
| TF at indomethacin treatment (mL/kg/d) | 143±9* | 147±10* | 0.10 |
| Platelet count at indomethacin start (×109/L) | 177±75* | 188±73* | 0.53 |
| Dose interruption during indomethacin treatment | 30 | 6 | <0.0001 |
| On Caffeine during indomethacin treatment | 35 | 39 | 0.45 |
| On phototherapy during indomethacin treatment | 21 | 20 | 0.54 |
| PDA ligation | 11 | 0 | – |
TABLE 2.
Multivariate logistic regression analysis
| Variable | p value | Odds ratio (adjusted) | 95% Confidence Intervals |
|---|---|---|---|
| Gestational age (Δ 1 week) | 0.302 | 0.82 | 0.56, 1.20 |
| Male sex | 0.966 | 0.97 | 0.23, 4.01 |
| Clinical Chorioamnionitis | 0.007 | 7.80 | 1.73, 35.00 |
| Dose interruption | <0.0001 | 27.14 | 5.94, 124.07 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e62.
Abstract
BACKGROUND:
Evidence of holding feeds during blood transfusion is not conclusive.
OBJECTIVES:
To determine the incidence of TANEC before and after implementation of holding feeds peri-PRBC transfusion.
DESIGN/METHODS:
A retrospective review was conducted on VLBW infants admitted to the NICU at Mount Sinai Hospital, Toronto, Canada during the period from June, 2006 to June, 2014. We defined NEC according to modified Bell’s criteria and TANEC as NEC occurring within 48 hours from receiving PRBCs transfusions. Epoch 1 was defined as the period before implementing the policy of Withholding feeds during PRBC transfusion (June 2006 to December 2011). Epoch 2 was defined as period after policy implementation (January 2012 to June 2014).
RESULTS:
1550 VLBW infants were admitted to NICU in Epoch 1, Of them 59 (3.8%) had NEC. 34% (20/59) of NEC cases had fulfilled the criteria for TANEC. 872 VLBW infants were admitted to NICU in Epoch 2, Of them 35 (4.0%) had NEC. 20% (7/35) of NEC cases fulfilled the criteria for TANEC. Comparison of demographic and baseline characteristics are in [Table 1]. There was clinical but not statistical difference in TANEC cases in Epoch 1 vs Epoch 2 [34% vs 20% respectively (p 0.16)]. Results comparing TANEC cases in Epochs 1 vs 2 are in [Table 2].
CONCLUSION:
There was trend for reduction in TANEC cases after implementing the policy of withholding feeding peri-transfusion of PRBCs. Larger, multicenter study is needed to answer other related clinical questions like holding feeds for longer periods to offer greater protection against TANEC.
TABLE 1.
Demographic and clinical characteristics
| Variable | Epoch 1(n=59) | Epoch 2 (n=35) | P value |
|---|---|---|---|
| GA (wks) | 26.64±2.3 | 26.46±2.5 | 0.72 |
| BW (g) | 918±301 | 870±304 | 0.45 |
| SGA % | 8.5 (5/59) | 11.4 (4/35) | 0.72 |
| Gender (male %) | 52 (31/59) | 57 (20/35) | 0.66 |
| Ant-steroid % | 94 (47/50) | 86 (30/35) | 0.26 |
| UAC % | 64 (36/56) | 68 (24/35) | 0.67 |
| PDA% | 48 (28/58) | 54 (19/35) | 0.57 |
| Indomethacin use % | 42 (25/59) | 37 (13/35) | 0.61 |
| Duration of Invasive Vent (days) | 13±12 | 12±13 | 0.78 |
| Duration of NIV (days) | 19±18 | 15±19 | 0.34 |
| Oxygen days (days) | 14±21 | 10±15 | 0.29 |
| Pre NEC Hematocrit | 0.31+0.08 | 0.30+0.07 | 0.46 |
| Postnatal Age at NEC (days) | 25±15 | 23±18 | 0.52 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e63.
Abstract
BACKGROUND:
Risk of death or neurodevelopmental impairment (NDI) is relatively high for extremely premature infants (EPI – 22–25 weeks GA). Given the notable prognostic uncertainty about the outcome, early intensive care and palliative care are both potentially acceptable options. Use of decision aids (DA) and decision coaching have been shown to improve decision quality and patient engagement in the decision making process. Although DAs have been evaluated in simulated antenatal counseling sessions for EPI, none have been tested during real life consultations.
OBJECTIVES:
1) To create a DA specific to our population; and 2) field test the DA and decision coaching in an at risk population.
DESIGN/METHODS:
The only published EPI DA was assessed using the International Patient Decision Aids Standards (IPDAS) tool. An existing working group for EPI was surveyed to identify key elements to include in a DA and feedback was sought from the local family decision services team, neonatologists and parents. Four neonatologists were trained in decision coaching and alpha-tested the DA. The revised DA along with decision coaching was then field tested on women (and partners) at risk of delivering between 23+0 and 24+6 weeks GA. Usefulness for decision making and degree of pre/post decisional conflict were assessed.
RESULTS:
Deficits were identified in the published DA (IPDAS score 13/35): need for more information overall, incorporation of local data and creation of a detailed palliative care description. The EPI working group identified seven key elements essential for the DA: survival; moderate/severe NDI rates; quality of life of survivors and their parents; and maternal risk of death and long term morbidity. Revisions were made to the DA and to the number and content of the decision cards (3-options, 6-key elements and 16-GA specific data). Post-modification IPDAS score was 31/35. Ongoing field testing (8 parents to date) suggests: neonatologists like using the DA; average consult is 50 mins; DA presents balanced and clear information; DA reduces parental decisional conflict (22/40 down to 4/40).
CONCLUSION:
We were able to improve the quality of an existing yet untested DA using multi-source feedback. Field testing to date demonstrates our DA’s promise for helping parents engage in the decision making process at the limit of viability.
Paediatr Child Health. 2015 Jun-Jul;20(5):e63.
Abstract
BACKGROUND:
Intravitreal injection of bevacizumab, a vascular endothelial growth factor inhibitor (VEGF), is used to treat retinopathy of prematurity (ROP). As bevacizumab can diffuse into the systemic circulation, potential long-term effect on brain development needs to be documented.
OBJECTIVES:
To compare neurodevelopmental outcomes at 18–22 months of preterm infants treated with bevacizumab versus laser.
DESIGN/METHODS:
Data from the Canadian Neonatal Network and the Canadian Neonatal Follow-Up Network databases were retrospectively reviewed. A total of 114 infants born at <29 weeks gestational age (GA) in 2010–2011 with severe ROP (≥ stage 3 or plus disease) requiring treatment and followed at 18–22 months corrected age (CA) were studied. Neurodevelopmental outcome was assessed using the Bayley Scales 3rd edition. Regression analyses were performed.
RESULTS:
Of the 114 infants, 32 had bevacizumab (GA 24.8±1.5 weeks, birth weight 740±160 g) and 82 had laser (GA 24.8±1.3 weeks, birth weight 711±132 g). Neonatal characteristics differed between the bevacizumab vs. laser therapy groups for male sex (62% vs. 42%), SNAP-II score (24 vs. 18), and late-onset sepsis (62% vs. 44%). Bevacizumab treated infants had lower motor scores after adjustment for potential confounders (table).
CONCLUSION:
Preterm infants treated with bevacizumab had lower motor scores compared to those treated with laser therapy. There was no difference in cognition and language scores. Further investigation on the long-term safety of anti-VEGF treatment for ROP is needed.
| Bayley-3 | Bevacizumab | Laser | Adjusted mean difference or odds ratios (95% CI) |
|---|---|---|---|
| Composite scores, mean (sd) | |||
| Cognition | 88.1 (13.7) | 90.6 (18.1) | 0.9 (−18.0, 8.9) |
| Language | 78.7 (21.0) | 87.4 (18.0) | −5.9 (−14.9, 3.0) |
| Motor | 76.1 (23.9) | 87.8 (12.5) | −12.0 (−20.0, −3.9) |
| Composite score <85, n (%) | |||
| Cognition | 11 (42) | 14 (22) | 1.99 (0.63, 6.29) |
| Language | 15 (60) | 24 (39) | 1.66 (0.55, 5.02) |
| Motor | 13 (52) | 16 (26) | 3.31 (1.10, 9.96) |
Adjusted for GA, sex, antenatal steroids, multiple birth, bronchopulmonary dysplasia, sepsis, severe brain lesions, maternal education.
Paediatr Child Health. 2015 Jun-Jul;20(5):e64.
Abstract
BACKGROUND:
Increased non-invasive ventilation (NIV) use has led to the introduction of numerous modalities. Bedside health care-providers’ (HCPs) understanding of NIV types, rationale, and possible misconceptions (previously not studied) were identified as some reasons for non-optimal NIV use at our centre.
OBJECTIVES:
To evaluate the impact of NIV-focused inter-professional education (IPE) on HCPs’ comfort and misconceptions with NIV use.
DESIGN/METHODS:
In this ongoing quality improvement study, a focused IPE curriculum on NIV was designed in form of workshops consisting of didactic and hands-on learning. Participants completed pre and post workshop questionnaires assessing the importance of understanding NIV for their role, possible misconceptions (evaluated using 19 objective knowledge-based questions), and level of comfort following participation. Responses were measured on a modified likert scale of 1 (strong disagreement) to 5 (strong agreement).
RESULTS:
Among 106 HCPs who have completed the workshop, the majority agreed or strongly agreed that NIV education was important for their role (91.5%) as well as favouring a combination of didactic and hands-on learning for NIV education (87.7%). Participants scored their perceived comfort with NIV following the workshop highly (4.4±0.8) and 93.4% would recommend it to a colleague. Knowledge scores on NIV increased from 73.8 (±30)% to 85.2 (±8.5)%, P<0.001. Table delineates all results from surveys by HCP groups.
CONCLUSION:
Focused, context specific IPE workshop helps improve HCPs’ understanding and comfort, while reducing misconceptions on NIV. Further research to assess optimal delivery of NIV education and impact on patient outcomes is required.
TABLE.
Detailed results by HCP category
| HCP Category (n) | NIV education importance* | Increased comfort post-workshop* | Recommend to others* | Pre-knowledge (%) | Post-knowledge (%) | P† |
|---|---|---|---|---|---|---|
| Nurse (74) | 4.8±0.6 | 4.5±0.7 | 4.7±0.5 | 73.5±34 | 84.4±8.0 | 0.008 |
| Medical Trainee (14) | 4.2±1.3 | 4.2±1.2 | 4.3±1.2 | 74.4±16.3 | 88.7±6.4 | 0.007 |
| Acute Care Nurse Practitioner (4) | 5.0±0.0 | 4.0±0.8 | 4.3±1.0 | 84.2±11.3 | 90.1±6.6 | 0.356 |
| Respiratory Therapist (8) | 4.9±0.4 | 4.9±0.4 | 5.0±0.0 | 75.7±0.21 | 88.8±9.0 | 0.127 |
| Other (3) | 5.0±0.0 | 3.5±1.7 | 3.5±1.7 | 68.4±19.1 | 76.8±15.1 | 0.447 |
| Overall (106) | 4.8±0.7 | 4.4±0.8 | 4.6±0.7 | 73.8±30 | 85.2(±8.5) | <0.001 |
*
Modified Likert scale: 1 to 5;
†
Comparison of knowledge; All results: mean ± SD
Paediatr Child Health. 2015 Jun-Jul;20(5):e64.
Abstract
BACKGROUND:
The rate of neonatal abstinence syndrome (NAS) has risen dramatically in North America, resulting in increased health care resource utilization. Marked variation in management of NAS has been reported in the United States and Europe, but data from Canada are limited.
OBJECTIVES:
Describe current NAS management practices in NICUs in Canada, including location for infant monitoring (admission to NICU vs. room-in with mother); location for pharmacological treatment; use of cardiorespiratory monitors when pharmacological treatment is initiated; breastfeeding recommendations; and discharge of infants on medication.
DESIGN/METHODS:
Qualified personnel in all Level II and Level III NICUs in Canada were emailed to request their participation, with follow-up if no response was received. A medical resident administered a structured, pre-tested telephone survey and data were analyzed using SPSS.
RESULTS:
Surveys were completed by 65 of 103 units (63.1%). Common practices included having a written NAS practice guideline (92.3%); using the original or modified Finnegan’s scoring system to monitor NAS signs (89.5%); using non-pharmacological treatment methods (e.g. dim lights, swaddling) (100%); using morphine as the first-line medication (96.9%); using monitors routinely during pharmacological treatment (93.8%); and admitting infants to the NICU for pharmacological treatment (89.2%). Practices that showed greater variability included where high-risk infants are observed (44.6% in the NICU, 52.3% rooming-in with the mother, 3.1% in either location or on a pediatric ward); use of adjunct medications (65.1% use overall with phenobarbital used most commonly [82.9%] followed by clonidine [41.5%]); breastfeeding practices (53.8% always encourage breastfeeding, 44.6% discourage breastfeeding if the mother is using illicit drugs, and 1.5% make recommendations on a case-by-case basis); and discharge of infants on first-line (36.9%) and adjunct medications (38.9%), where used.
CONCLUSION:
While most NICUs surveyed follow similar practices in scoring NAS signs and use of non-pharmacological and first-line pharmacological treatment, there is notable variation in practices related to parent involvement in care, such as maintaining the mother-infant dyad during monitoring and treatment, encouraging breastfeeding, and discharging the infant on medication. This underscores the need for further research that can be translated into best practices.
Paediatr Child Health. 2015 Jun-Jul;20(5):e64–e65.
Abstract
BACKGROUND:
Extended interval gentamicin dosing in neonates <35 weeks corrected gestational age (CGA) has been shown to achieve optimal serum peak concentrations compared to traditional once daily doses. However recommendations on exact dose and frequency vary. After a literature review, a dose of 5 mg/kg/dose every 48 hours was implemented at our institutions.
OBJECTIVES:
To characterize concentration-time profiles achieved with a gentamicin dose of 5 mg/kg every 48 hours in neonates <35 weeks CGA. To identify gentamicin pharmacokinetic parameters in neonates <35 weeks CGA: half-life (t1/2), clearance, and volume of distribution (V1).
DESIGN/METHODS:
Pharmacokinetics were prospectively analyzed after implementation of 5 mg/kg gentamicin as a single empiric dose for sepsis in neonates <35 weeks CGA (n=54). Serum samples were drawn at approximately 1 h, 24 h, and 48 h post dose. Target serum concentrations were 6–12 mg/L and 0.5–2 mg/L at 1 h and 48 h, respectively. Pharmacokinetic analysis was performed on available samples to determine if birth weight, gender, gestational age at birth, CGA, or postnatal age (PNA) affect gentamicin clearance, t1/2, V1, or serum levels.
RESULTS:
A one-compartment model best represented the pharmacokinetics of gentamicin for our population. Average pharmacokinetic parameters were: clearance 42±10 mL/kg/h, V1 0.578±0.087 L/kg, and t1/2 9.98±1.84 h. In all treatment courses when at least two serum levels were drawn (n=44), mean levels extrapolated to 1 h, 24 h, and 48 h were 8.24±1 mg/L, 1.6±0.48 mg/L, and 0.31±0.16 mg/L respectively. Neonates <14 days PNA had significantly higher gentamicin levels at 24 h (1.7±0.3 mg/L vs. 1.1±0.7 mg/L, P=0.002) and at 48 h post dose (0.34±0.14 mg/L vs. 0.2±0.2 mg/L, P=0.03). Clearance was significantly lower in neonates <14 days PNA (mean 38±5 mL/kg/h vs. 55±18 mL/kg/h, P=0.01) but was not affected by other covariates. V1 was not influenced by any covariates.
CONCLUSION:
A gentamicin dose of 5 mg/kg in neonates <35 weeks CGA and <14 days PNA results in post serum levels of 6–12 mg/L. Gentamicin clearance in neonates <35 weeks CGA was not affected by gestational age at birth, CGA, gender, or birth weight but increased as PNA increased suggesting the need to dose gentamicin more frequently than every 48 hours in neonates 14 days PNA. The risk of medication error may be reduced from this simplified approach.
Paediatr Child Health. 2015 Jun-Jul;20(5):e65.
Abstract
BACKGROUND:
Neonatal resuscitation guidelines recommend epinephrine during cardiopulmonary resuscitation (CPR) to elevate the coronary perfusion pressure (CPP) to allow more oxygenated blood enter the coronary arteries to improve myocardial blood flow. However, no study has assessed the effects of epinephrine on cardiac function.
OBJECTIVES:
To determine cardiovascular effects of epinephrine administration during resuscitation of newborn piglets with asphyxia.
DESIGN/METHODS:
Newborn piglets (n=8) were exposed to hypoxia and once bradycardia was achieved chest compression (CC) using 3:1 compression: ventilation ratio was started. Epinephrine was administered if heart rate remained <60/min with a max of four doses until either return of spontaneous circulation (heart rate >150/min for 15 s) or death. A Millar™ catheter (AD Instruments, Dunedin, New Zealand) was placed in the left ventricle to measure cardiac output (CO), stroke volume (SV) and ejection fraction (EF). Measurements were taken at baseline (BL), during positive pressure ventilation, during CC, and after each epinephrine (Epi1-4) administration.
RESULTS:
Mean (SD) age of piglets was 2 (1) days and weight was 2037 (250)g. EF, mean arterial blood pressure (MAP) and dP/dt, but not CO or SV, significantly increased during CC and Epi1-4 (vs. BL). There were significant increases in MAP after Epi2 and dv/dt after Epi4, compared to BL values, while all other parameters were similar.
CONCLUSION:
Epinephrine during neonatal CPR is in part is related to a vasoconstrictive action leading to increased MAP and thus CPP, which is important for the myocardial recovery following asphyxia in the newborn heart.
Results
| BL | CC | Epi 1–4 | |
|---|---|---|---|
| EF, % | 11 | 24 (P=0.048) | 26–42 (P<0.02) |
| MAP, mmHg | 19 | 49 (P<0.001) | 56–67 (P<0.001) |
| dP/dt, mmHg/s | 1144 | 3444 (P=0.002) | 4066–9540 (P<0.002) |
Paediatr Child Health. 2015 Jun-Jul;20(5):e65.
Abstract
BACKGROUND:
Mechanical ventilation in preterm neonates is associated with adverse health outcomes. Early extubation may mitigate these risks. Success rate and associated factors of early extubation are not clearly described.
OBJECTIVES:
Assess success rate of early extubation in infants <29 weeks gestation and identify factors associated with extubation outcome.
DESIGN/METHODS:
Retrospective study in a level 3 NICU (Ste Justine, Montreal, Canada). Neonates born in 2012 and 2013 at <29 weeks gestation intubated in the first seven days of life and extubated in the following 72 hours were included. Infants with congenital anomaly or that died before extubation were excluded. Primary outcome was success of early extubation (not requiring reintubation for >72 h). Secondary outcome was to identify factors associated with extubation success.χ2 was used for categorical variables, independent t test was used for continuous variables and multiple logistic regression (MLR) was performed to identify factors contributing to extubation success.
RESULTS:
Of the 209 patients born at <29 weeks gestation during the study period, 75 were included. Characteristics of infants who remained extubated (success) vs. were reintubated (failure) are presented. There were no differences in pre-extubation ventilatory parameters. MLR identified PDA as a significant contributor to extubation failure: OR 0.05 (95% CI 0.01 – 0.42). Patients failing early extubation had increased risk of severe ROP or death: OR 0.14 (95% CI 0.03 – 0.66).
CONCLUSION:
In our cohort of infants <29 weeks gestation, early extubation succeeded in 2/3 of patients. PDA might be a significant contributor to extubation outcome. Patients failing extubation had increased risk of severe ROP or death.
TABLE.
| Failure n = 26 (34,7%) | Success n = 49 (65,3%) | P | |
|---|---|---|---|
| Gestational age (weeks) | 26 5/7 + 1 3/7 | 27 3/7 + 1 | 0.05 |
| Birth weight (grams) | 877 + 233 | 1021 + 213 | 0.71 |
| Male | 18 (69) | 27 (55) | 0.17 |
| SGA | 2 (8) | 4 (8) | 0.66 |
| Chorioamnionitis | 3 (12) | 2 (4) | 0.22 |
| Oligohydramnios | 4 (15) | 3 (6) | 0.18 |
| PPROM | 5 (19) | 13 (27) | 0.34 |
| Gestational diabetes | 3 (12) | 9 (18) | 0.09 |
| Antenatal steroids | 17 (65) | 33 (67) | 0.80 |
| MgSO4 | 5 (19) | 10 (20) | 0.58 |
| C-section | 20 (77) | 31 (63) | 0.17 |
| Days prior to intubation | 1 + 0 | 1 + 1 | 0.14 |
| Age (days) at extubation | 3 + 1 | 3 + 2 | 0.14 |
| Surfactant treatment | 25 (96) | 39 (80) | 0.03 |
| Post extubation | 0.27 | ||
| CPAP | 0 (0) | 3 (6) | |
| NIPPV | 26 (100) | 46 (94) | |
| PDA | 25 (96) | 28 (57) | <0.01 |
| EOS | 0 (0) | 4 (8) | 0.17 |
*
Mean + SD or n (%)
Paediatr Child Health. 2015 Jun-Jul;20(5):e65–e66.
Abstract
BACKGROUND:
Poor growth in postsurgical infants is due to suboptimal caloric provision with variable Resting Energy Expenditure (REE). Indirect Calorimetry is the most accurate method to determine REE in the clinical setting. Knowledge of growth, energy expenditure and needs in postsurgical infants is limited.
OBJECTIVES:
Determine REE in postsurgical infants and delineate the relationship between REE, caloric intake and weight gain.
DESIGN/METHODS:
Serial determinations of REE, VO2 (O2 consumption), VCO2 (CO2 production), protein indices (albumin, prealbumin) and weight gain were done on infants who underwent major abdominal surgery between postop days 5–24 while on TPN with minimal enteral nutrition. Energy Balance (EB= Total calories - REE) was calculated.
RESULTS:
41 REE measurements, 40±10 minutes each were done on 16 infants. All values are Mean (SEM). Gestational age, birth weight and postop days to feed initiation were 35.5 (0.7) wks, 2.5 (1.5) kg and 20.7 (4.2) days respectively. REE was 48.2 (0.6) and EB 50.3 (0.75) kcal/kg/day, VO2 6.6 (0.11) and VCO2 6.3 (0.12) mL/kg/min. During study period, albumin was 26.3 (0.81) g/L and prealbumin 111.8 (10.95) mg/L. Serial REE showed an increasing trend (ΔREE=REE Final– REE First), associated with average weight gain during the REE study week and the succeeding week in 12 (75%) infants (Figure 1).
CONCLUSION:
Serial REE showed an increasing trend with average weight gain during and after the week of REE measurements possibly related to increased energy needs for tissue deposition in early growth and recovery phase. Suboptimal albumin and rising REE would thus signal the need to consider targeted aggressive nutritional supplementation in postoperative infants.
Figure 1.
Paediatr Child Health. 2015 Jun-Jul;20(5):e66.
Abstract
BACKGROUND:
The Canadian Paediatric Society (CPS) recommends Therapeutic Hypothermia (TH) be provided at level 3 NICUs. Initiation of TH within 6 h of life has been associated with benefit and is the current CPS standard of care. Given our large catchment area, the initiation of TH by conventional passive means often has to be considered at the referral hospital prior to or immediately upon arrival of the neonatal transport team (NNTT).
OBJECTIVES:
To determine the effectiveness of our approach to initiating TH within our region.
DESIGN/METHODS:
Retrospective cohort study of all cases accepted for TH, between October 2009 and December 2013 at CHEO, a university-affiliated level 3 NICU and transported by our NNTT. All infants had moderate to severe encephalopathy and met NICHD criteria for TH.
RESULTS:
Sixty infants (mean gestational age 39.1 weeks, birth weight 3.3 kg, arterial cord pH 6.9, Apgar scores 3 and 4 at 5 and 10 min) were included. The median time to initiation of TH was 123.5 mins and to target temperature 328 mins. No infant had temperatures <30°C when cooled, 3 (5.4%) were /= 1 h). Comparing In town v Out of town; the median age of referral was 101 v. 53.5 mins, median time to initiation of TH 98 v. 238 mins, median age at NNTT arrival 169 v. 218.5 mins and the median birth to target temperature 321 v. 367 mins.
CONCLUSION:
Meeting current CPS target for TH using passive cooling in a large catchment area is challenging. Preliminary studies using a servo-controlled device on transport indicate significant reductions in TH times in urban settings. The efficacy of novel technology in remote geographical areas remains to be determined.
Paediatr Child Health. 2015 Jun-Jul;20(5):e66.
Abstract
BACKGROUND:
Preterm birth is more common and on the rise in populations with low socioeconomic status (SES). The combined risk from preterm birth and SES has been coined as ‘double jeopardy’ referring to the cumulative effects that biological and social factors have on early infant development.
OBJECTIVES:
To determine if low SES in very preterm infants in a defined urban population is associated with death or neurodevelopmental impairment (NDI) at 18 months adjusted age and 36 months.
DESIGN/METHODS:
We used the deprivation index from the Canadian Population Health Initiative (CPHI) to classify our population based on postal code at the time of birth. Infants born less than 29 weeks gestation, born from 2008–2011 and residing in a major Canadian urban centre were included in this study. Infants with major congenital anomalies were excluded.
Birth postal code information and maternal/neonatal characteristics were obtained from a Neonatal Database. Follow-up information was obtained from a Neonatal Follow-up Database.
NDI assessed at 18 months adjusted and 36 months were defined as either a severe or moderate disability.
Severe Disability included one or more of the following: non-ambulatory cerebral palsy (CP), Gross Motor Functional Classification System (GMFCS) level 3–5, cognitive composite score less than 55, 3 SD below the mean, legal blindness <20/200, bilateral sensorineural hearing loss (SNHL) or two or more moderate disabilities.
Moderate Disability included one of more of the following: ambulatory CP, GMFCS level 1–2, cognitive composite score 55–69, less than 2 SD but greater than 3 SD below the mean, visual impairment <20/60, unilateral SNHL.
RESULTS:
There were 258 infants who met criteria for the study. At 18 months adjusted the association between low SES and death or NDI at 18 months was OR=2.52 (95% CI 1.32–4.85). This means that in comparison with infants born to average/high SES were at 2 1/2 times the odds of having either died or being disabled by the age of 18 months. In our evaluation of survivors we found no statistically significant association between SES and moderate/severe NDI, although there was a trend towards an association. There was no significant difference in survival or major neonatal morbidities between low and average/high SES groups.
CONCLUSION:
In our urban centre, SES is associated with death or moderate/severe NDI at 18 months adjusted age in infants born less than 29 weeks. More long-term follow up is required to determine if this association persists. Our study is limited by its small sample size and the low incidence of neurodevelopmental impairment.
Paediatr Child Health. 2015 Jun-Jul;20(5):e67.
Abstract
BACKGROUND:
Endotracheal intubation remains a common procedure in the neonatal intensive care unit (NICU). Rapid confirmation of endotracheal tube (ETT) placement at the point of care is important because tube malposition is associated with serious adverse outcomes, including hypoxemia, pneumothorax, right upper lobar collapse and death. An observational study recently reported that the PediCap® incorrectly identified tube position in up to one third of the analyzed intubations.
OBJECTIVES:
To determine if the use of a flow sensor (VN500, Draeger Luebeck, Germany) compared to a CO2 detector (Philips, Markham, ON) will improve confirmation of ETT placement in newborn infants within the first 10 inflations.
DESIGN/METHODS:
All term and preterm infants admitted to Royal Alexandra Hospital NICU who require endotracheal intubation were eligible. Infants were randomized to have ETT assessed by flow sensor or by CO2 detector. The primary outcome was number of inflations delivered before confirmation of ETT. The trial was registered at ClinicalTrials.gov: NCT01870622.
RESULTS:
100 infants were randomized (n=50 for each group); the mean (range) gestational age was 28 (23–41) weeks and birth weight was 1213 (490–4000) g. Number of intubation attempts ranged from 1 to 4 for all infants. In 25% the intubation was performed for surfactant administration with extubation shortly afterwards, while in 75% the infants were intubated for mechanical ventilation.
Mean (range) number of inflations needed to identify correct ETT was significantly lower in the flow sensor group with 2 (1–10) inflations vs. 8 (2–30) inflations in the CO2 detector group (P<0.001). ETT were correctly identified in 100% by the flow sensor within 10 inflations compared to 72% with the CO2-detector (P<0.05). The lowest heart rate and oxygen saturation at end of intubation in the CO2 detector and flow sensor group were 148 (28)/min vs. 159 (18) (P=0.03) and 71 (23) vs. 80 (17) (P=0.043), respectively.
CONCLUSION:
Using a flow sensor significantly decreases the time to correctly identify ETT in newborn infants compared to using CO2 detector.
Paediatr Child Health. 2015 Jun-Jul;20(5):e67.
Abstract
BACKGROUND:
At birth preterm infants have to facilitate the early development of an effective functional residual capacity (FRC), remove CO2, and improve oxygenation in order to achieve fetal-to-neonatal transition.
OBJECTIVES:
The aim of the study was to examine how preterm infants <35 weeks achieve lung aeration at birth.
DESIGN/METHODS:
Deliveries of preterm infants ≤35 weeks gestation at the Royal Alexandra Hospital were attend by the research team. Infants who received CPAP only were eligible for inclusion. A combined CO2 and flow-sensor was placed between the mask and the ventilation device. During spontaneous breathing tidal volume (VT) and exhaled CO2 (ECO2) were recorded for the first 200 breaths to analyze lung aeration patterns.
RESULTS:
Thirty preterm infants were included with a total of 3200 breaths were analyzed. The mean (SD) gestational age was 30.3 (2) weeks and birth weight 1517 (442)g. The mean initial VT for the first 30 breath was 5–6 mL/kg and ECO2 between 15–22 mm Hg. VT and ECO2 increased over the next 20 breaths to 7–8 mL/kg and 25–32 mm Hg. For the remaining observation period VT plateaued at 4–6 mL/kg and ECO2 continued to increase to 35–37 mm Hg (Figure 1A and B).
CONCLUSION:
Preterm infants start taking deeper breaths approximately 30 breaths after initiating spontaneous breathing to inflate their lung. Concurrently CO2 removal rises as alveoli are recruited. FRC is established in two phases – phase one involves large volume breaths with poor alveolar aeration (so poor CO2 elimination), and phase two involves smaller breaths but elimination of CO2 as a consequence of adequate aeration.
Paediatr Child Health. 2015 Jun-Jul;20(5):e67–e68.
Abstract
BACKGROUND:
Variability in neonatal outcomes between countries may be partly explained by differences in infant characteristics such as being small for gestational age (SGA). There is controversy whether to use country-specific birth weight (BW) references or a common reference for all countries when deriving BW z-scores (BWZ) and SGA for adjustment in comparative analyses.
OBJECTIVES:
To assess the effect of adjusting for BWZ or SGA status derived from country-specific or common references on the adjusted odds ratios (AOR) comparing neonatal outcomes between countries.
DESIGN/METHODS:
For singleton infants born 24–29 weeks’ GA and <1500 g (n=29,828) in the International Network for Evaluating Outcomes in Neonates (iNeo) database, we calculated BWZ and classified infants as SGA (<10th centile) using country-specific and common references (Fenton, internal iNeo, and Salomon’s fetal weight). The AOR comparing neonatal outcomes (mortality and morbidity combined, mortality alone, or NEC) between pairs of countries were estimated using logistic regression, adjusting for BWZ/SGA derived from different references. Percent differences in AOR for using different references were calculated
RESULTS:
The proportion of SGA infants varied between countries and references (see Figure). The median % difference (absolute value) in OR adjusted for BWZ/ SGA derived from country-specific versus common references was 3.0 (range 0 to 11.8) for mortality and morbidity combined; 2.1 (0 to 13.6) for mortality; and 0.9 (0 to 4.8) for NEC. Comparisons exceeding the predefined cut-off of a 10% difference in AOR were: NRNJ versus SNQ for mortality and UKNC versus NRNJ for mortality and combined mortality and morbidity.
CONCLUSION:
The impact of adjusting for BW for GA derived from country-specific or common references on between-country comparisons of neonatal outcomes in very preterm, very low BW babies is likely small and not clinically relevant.
Paediatr Child Health. 2015 Jun-Jul;20(5):e68.
Abstract
BACKGROUND:
Differences in mortality of very preterm neonates have been reported by national neonatal networks. These may reflect variations in case-mix, practices and population coverage of database. Valid comparisons aimed at identifying reasons for variation between countries require adjustment for potential confounders.
OBJECTIVES:
To compare mortality rates prior to discharge of very preterm neonates using eight national neonatal databases from nine member countries of the International Network for Evaluating Outcomes in Neonates (iNeo).
DESIGN/METHODS:
Data on neonates of 24 to 31 weeks GA, BW <1500 g, without major congenital anomaly and registered in national databases were retrieved from the iNeo database (2007–10). Mortality (all causes) was compared between each country and all others using standardized mortality ratios (SMR) and pair-wise comparisons were performed using AOR (95% CI). Subgroup analyses were conducted for neonates 24 to 28 weeks GA.
RESULTS:
58004 neonates were included in the analyses. Mortality ranged from 5% to 17% between countries. SMRs are presented in the Figure. Adjusted OR (95% CI) are presented in the Table.
Subgroup analyses of infants 24 to 28 weeks GA provided similar results.
CONCLUSION:
Variations in mortality between countries remained after adjustment for available confounders. Explanations for this variation may lie in differences in population coverage, recording of delivery room deaths, death after discharge from Level 3 NICUs, services organization, unmeasured characteristics, or care practices.
| ANZNN | CNN | INN | NRNJ | SNQ | SwissNeoNet | SEN1500 | UKNC | |
|---|---|---|---|---|---|---|---|---|
| N | 9281 | 7834 | 4398 | 12485 | 2182 | 2010 | 7667 | 10035 |
| ANZNN | 1 | 0.94 (0.85, 1.06) | 0.51 (0.45,0.58) | 2.92 (2.58,3.31) | 1.30 (1.08,1.57) | 0.71 (0.60, 0.85) | 0.37 (0.34,0.41) | 0.90 (0.80, 1.00) |
| CNN | 1.06 (0.95,1.18) | 1 | 0.54 (0.47, 0.61) | 3.09 (2.73,3.50) | 1.38 (1.14,1.67) | 0.76 (0.63,0.91) | 0.39 (0.35,0.44) | 0.95 (0.85,1.06) |
| INN | 1.97 (1.74,2.24) | 1.86 (1.64,2.12) | 1 | 5.77 (5.05,6.59) | 2.57 (2.11,3.13) | 1.41 (1.17, 1.70) | 0.73 (0.65, 0.83) | 1.77 (1.56,2.00) |
| NRNJ | 0.34 (0.30, 0.39) | 0.32 (0.29, 0.37) | 0.17 (0.15,0.20) | 1 | 0.45 (0.37, 0.54) | 0.24 (0.20, 0.29) | 0.13 (0.11,0.14) | 0.31 (0.27, 0.35) |
| SNQ | 0.77 (0.64, 0.93) | 0.73 (0.60, 0.88) | 0.39 (0.32, 0.47) | 2.24 (1.85, 2.72) | 1 | 0.55 (0.43, 0.69) | 0.29 (0.24, 0.34) | 0.69 (0.57, 0.83) |
| SwissNeoNet | 1.40 (1.17, 1.68) | 1.32 (1.11, 1.58) | 0.71 (0.59, 0.86) | 4.09 (3.40, 4.93) | 1.83 (1.44, 2.31) | 1 | 0.52 (0.44, 0.62) | 1.25 (1.05, 1.50) |
| SEN1500 | 2.69 (2.43, 2.99) | 2.54 (2.29, 2.82) | 1.36 (1.21, 1.54) | 7.86 (6.99,8.84) | 3.51 (2.92, 4.22) | 1.92 (1.61, 2.29) | 1 | 2.41 (2.18,2.66) |
| UKNC | 1.12 (1.00, 1.24) | 1.06 (0.95,1.18) | 0.57 (0.50, 0.64) | 3.26 (2.89,3.68) | 1.46 (1.21, 1.75) | 0.80 (0.67, 0.95) | 0.42 (0.38, 0.46) | 1 |
Adjusted for: GA, BWZscore, multiple birth, sex, antenatal steroids, cesarean section, GA*BWZscore, BWZscore*multiplebirth, BWZscore*BWZscore. Green: OR significantly lower than 1; Red: OR significantly higher than 1.
OR compare outcome between row vs. column: e.g. ANZNN vs. CNN OR 0.94
Paediatr Child Health. 2015 Jun-Jul;20(5):e68.
Abstract
BACKGROUND:
Care practices during neonatal transition can significantly impact both short- and long-term neonatal outcomes. The Evidence-based Practice for Improving Quality (EPIQ) II study was initiated in 2009 with the goal of improving neonatal outcomes (results in CMAJ 2014, 186:E485–94). As part of the study, the EPIQ Golden Hour Committee focused on transitional care (TC) practices in the first hour after birth, including use of the 2010 NRP recommendations for immediate management of preterm infants.
OBJECTIVES:
Determine the current management practices during the Golden Hour for infants of <32 weeks GA in Canadian NICUs.
DESIGN/METHODS:
A survey was emailed to all EPIQ II site investigators and/or co-ordinators in August 2014 with two monthly reminders. The survey included questions on unit characteristics, antenatal management, composition of the TC team, and management in the first hour after birth. The responses to the questions were categorized into four GA groups: 230/7–236/7 wks, 240/7–256/7 wks, 260/7–276/7 wks, and 280/7–316/7 wks.
RESULTS:
Of the 23 EPIQ II NICUs that were perinatal centers, 13 (56%) completed the survey. Eight sites had >15 level III NICU beds. Antenatal counseling was provided >75% of the time by 92% and 77% of units for GA <28 and 28 to 316/7 wks, respectively. A neonatal fellow or neonatologist/paediatrican was mostly responsible for counseling. 92% did not have a structured template for counseling although one-half used decision aids. The TC team consisted of three or more individuals for stabilization of infants of <28 wks GA and neonatologists were present in 92% of the units, this varied according to the time of the day. 77% of units practiced DCC, 100% used thermal wrap to maintain temperature, the initial FiO2 ranged from 21–40%, and 100% followed the NRP recommended oxygen saturation guide. In spontaneously breathing infants, CPAP was the initial mode of ventilatory support. Prophylactic surfactant was administered by 31% of units for <26 wk GA infants. Infants of <24 wks GA were most likely to be intubated and ventilated. Umbilical venous and arterial catheters were used by 92% for infants of 24 wks GA. Most units did not measure sound levels or offer skin-to-skin contact in the delivery room.
CONCLUSION:
Most Canadian NICUs practice NRP recommendations for preterm infants. DCC, thermal wrap, non-invasive ventilation, and FiO2 of <40% are used during the first hour after birth.
Paediatr Child Health. 2015 Jun-Jul;20(5):e69.
Abstract
BACKGROUND:
There is variability between countries in the health outcomes of very preterm neonates. Valid outcome comparisons aimed at identifying areas of improvement require adjustment for case-mix.
OBJECTIVES:
To compare mortality and major morbidity of very pre-term neonates between eight national neonatal databases from nine member countries of the International Network for Evaluating Outcomes in Neonates (iNeo).
DESIGN/METHODS:
Data on neonates born at 24 to 31 weeks GA, BW <1500 g, without major congenital anomaly and registered in national databases were retrieved from the iNeo database (2007–10). A composite outcome of mortality or any major morbidity (grade 3/4 IVH, PVL, treated ROP, or CLD) was compared between countries using standardized ratios (SR) and AOR (95% CI).
RESULTS:
58004 neonates were included in the analyses. The composite outcome rate varied from 26–42%. SR comparing the composite outcome between each country and all others are presented in the Figure.
CONCLUSION:
Marked variation in the composite outcome was identified between countries. Explanations for this variation may lie in different data definitions, data recording, health services organization, unmeasured population characteristics, or care provision practices. These results provide an opportunity for future detailed exploration of areas amendable to improvement.
Paediatr Child Health. 2015 Jun-Jul;20(5):e69.
Abstract
BACKGROUND:
Consensus regarding management for patent ductus arteriosus (PDA) in preterm infants is lacking and practices vary internationally.
OBJECTIVES:
To compare PDA treatments in very preterm infants from seven national neonatal networks worldwide.
DESIGN/METHODS:
Infants born at 24–28 weeks GA during 2007–10 with birth weight (BW) <1500 g and no major congenital anomalies were retrieved from the International Network for Evaluating Outcomes in Neonates (iNeo) database. PDA treatments of pharmacologic-only, ligation-only, or both pharmacologic and ligation were compared between each country and all others, using standardized ratios (SRs) and 95% confidence intervals (CI) with adjustment for case-mix factors. SR compared the observed and expected number of infants with each PDA treatment. For each country, the expected number was determined as the sum of the predicted probabilities from a multivariable logistic model derived using data from all other countries, and adjusted for linear and quadratic GA and BW Z-score, multiple birth, sex, antenatal steroid, cesarean section, and interactions GA*BW Z-score, BW Z-score*multiple birth.
RESULTS:
Marked variations in PDA treatment rates (either pharmacologic or ligation) were detected between countries ranging from 14% in the United Kingdom Neonatal Collaborative (UKNC) to 50% of neonates in Japan who received active treatments.[figure 1]. The rates of any ligation (with or without pharmacological treatment) varied from 3.2% in UKNC to 12% in Canada.
CONCLUSION:
PDA treatment rates varied significantly between countries. This may relate to differences in case ascertainment, diagnostic criteria, timing of evaluation, care provision practices, availability of surgical services, or unmeasured population characteristics. Future study is required to characterize differences in selection/indication of PDA treatment approaches and their effects on infants’ outcomes.
Paediatr Child Health. 2015 Jun-Jul;20(5):e69–e70.
Abstract
BACKGROUND:
The incidence of neonatal outcomes for VLBW/VPT neonates varies between high-income countries. These may be due to differences in health service organization and data collection.
OBJECTIVES:
To describe the organization of health services and data collection systems among the nine countries participating in the International Network for Evaluating Outcomes in Neonates (iNeo).
DESIGN/METHODS:
A survey was conducted to collect information on the organization of health services and data collection from directors of national neonatal data collection systems of each of the nine countries participating in iNeo. Data on prenatal, intrapartum, postnatal and post-discharge services organization were investigated.
RESULTS:
In all countries, maternal and neonatal health care is nationally funded and greater than 90% of women receive prenatal care. The proportion of women receiving early ultrasound ranged from 50–75% (1/9) to greater than 95% (2/9). Most countries have designated teams for neonatal transfers (7/9) with mandatory presence of a physician (6/7). The capacity of “step-down” units to offer respiratory and other neonatal support varied between and within countries. Selected characteristics that differ between countries are shown in the Table.
CONCLUSION:
Despite many similarities in the delivery of neonatal health services in high-income countries, differences related to organization and data collection processes need to be considered when comparing health outcomes between countries. These have important bearings for any benchmarking initiatives.
| Health services | ANZNN | CNN | INN | NRNJ | SEN 1500 | SNQ | SwissNeoNet | UKNC | |
| Australia | NZ | ||||||||
| Total Level III NICUs in network/Total in country | 29/29 | 30/30 | 23/23 | 73/93 | 36/NA | 7/7 | 9/9 | 44/55 | |
| Total NICUs in network /Total in country | NA | NA | 28/28 | 73/265 | NA | 37/37 | 14/14 | NA | |
| Definition of live birth | >20 w and 400g | No lower limit | ≥22w | ≥23w | ≥22w | No lower limit | |||
| National guidelines for antenatal maternal transfers | < 33w | <34w | <32w | No | Clinical need | <32w | Regional, no national | <32w | <28w and as indicated |
| Designated neonatal transport teams | Yes | Yes | Yes | No | No | Yes | Yes | Yes | Yes |
| % infants managed exclusively at “step down” neonatal units | <10 | 10–50 | <10 | 10–50 | none | 10–50 | <10 | 10–50 | |
| % infants retro-transferred to “step down” neonatal units | 10–50 | <10 | 10–50 | > 75 | 10–50 | ||||
| Long-term ventilation in “step down” units (% units) | <10 | >75 | <10 | 25–75 | <10 | > 75 | |||
| Network data collection | |||||||||
| Delivery loom deaths recorded | No | Partial | Yes | Partial | |||||
| Data collected from infants managed exclusively at “step down” neonatal units | Partially | Yes | No | Yes | No | Not appl. | Yes | Yes | |
| Data collected from infants retro-transferred to “step down” neonatal units | Yes | No | Yes | ||||||
ANZNN=Australia and New Zealand Neonatal Network, CNN=Canadian Neonatal Network, INN=Israel Neonatal Network, NRNJ= Neonatal Research Network of Japan, SNQ: Swedish Neonatal Quality Register, SwissNeoNet=Neonatal Network of Switzerland, SEN 1500=Spanish Neonatal Network, UKNC=UK Neonatal Collaborative; NA = not available; Not appl. = not applicable
Paediatr Child Health. 2015 Jun-Jul;20(5):e70.
Abstract
BACKGROUND:
In the Family Integrated Care (FICare) model of level III NICU care, parents are the primary caregivers for their infants. Components of this model include parent education, nursing staff education, and provision of physical and psychosocial support, which enable parents to be active partners in the care team. What is unknown is how best to translate this model to level II NICUs.
OBJECTIVES:
Capture the perspectives of administrators, healthcare personnel, and parents in four level II NICUs in Ontario regarding FICare implementation.
DESIGN/METHODS:
Focus groups were conducted separately for administrators and allied healthcare personnel, nurses, and parents (veteran and current) at each site using a semi-structured interview guide. Each focus group had 6–8 members; lasted for 1–1.5 hours; and was audio-recorded, transcribed, and analyzed using thematic content analysis.
RESULTS:
Perceptions of facilitators and barriers varied among the three participant groups. The overall perception of administrators and healthcare personnel was that elements of family-centered care were already being practiced including engaging parents in the care of their infant, providing written educational materials with some verbal reinforcement, and promoting discharge planning early in the clinical course. The administrators were interested in expanding on what was currently in place. Lack of physical space and amenities for families, different medical and nursing staffing models, and the wide variation in socio-cultural context of families were perceived as challenges to the FICare model. Nurses expressed concern around loss of control, safety, and legal consequences if parents were to take a more active role in infant care. In contrast, although parents were appreciative of the care provided, responses regarding education, communication, and support ranged from very satisfied to dissatisfied.
CONCLUSION:
Even though all three groups recognize the importance of engaging families in the care of their infant, there are unique challenges to the implementation of FICare in the level II NICU environment. To ensure the parent experience is incorporated, veteran parents should be actively involved with the healthcare team during translation (design and implementation) of the model.
Paediatr Child Health. 2015 Jun-Jul;20(5):e70.
Abstract
BACKGROUND:
Surfactant therapy has been a major breakthrough in the care of preterm infants. Early evidence on timing of administration favored a prophylactic approach, necessitating endotracheal mechanical ventilation (EMV). More recently there has been a concerted effort to avoid EMV in order to reduce bronchopulmonary dysplasia (BPD). The impact of this paradigm shift as it relates to timing of surfactant administration and outcomes are as yet unknown.
OBJECTIVES:
To compare a) the rate of prophylactic (within 15 minutes of birth) and rescue (after 15 minutes of birth) surfactant administration and b) short-term outcomes of all infants <29 weeks GA during two study epochs [2005–2008 vs. 2010–2013].
DESIGN/METHODS:
Data from the Canadian Neonatal Network were retrospectively reviewed for all infants <29 weeks GA during the two epochs. Data were analyzed using χ2 test for categorical data and Student’s t test or Wilcoxon Rank Sum test for continuous data.
RESULTS:
3980 and 5137 infants respectively were included in the two epochs, after excluding palliative cases, outborn infants and those with major congenital anomalies. Maternal and neonatal characteristics were statistically significantly different between the two epochs for: use of antenatal corticosteroids (90.9% vs. 92.9%), diabetes (6.5% vs. 8.5%), chorioamnionitis (21.3% vs. 28.2%), GA (26.3 + 1.5 vs. 26.2 + 1.5 weeks) and male sex (51.7% vs. 54.6%). Results for surfactant utilization, timing of administration and short-term outcomes are presented below.
CONCLUSION:
Surfactant administration rate was similar in the two epochs. In the more recent epoch later surfactant administration time and reduced use of multiple doses was associated with decreased duration of EMV and BPD and NI rates.
| Variable | 2005–2008 (n=3980) | 2012–2013 (n=5137) | P |
| Neonates administered surfactant, n (%) | 3071 (77.2) | 3909 (76.1) | 0.23 |
| Neonates who received ≥ 2 doses of surfactant | 1217 (39.6) | 1390 (35.6) | < 0.01 |
| Timing of surfactant administration, n (%) | < 0.01 | ||
| <15 min | 826 (27.7) | 814 (21.2) | |
| 15–30 min | 753 (25.2) | 835 (21.8) | |
| 30–120 min | 870 (29.2) | 1217 (31.8) | |
| >120 min | 533 (17.9) | 64 (25.2) | |
| EMV (days), median (IQR) | 9 (2, 30) | 6 (1, 25) | < 0.01 |
| BPD (36 weeks CGA) | 1424 (42.0) | 1714 (38.7) | < 0.01 |
| Nosocomial infection, n (%) | 1137 (28.6) | 475 (13.5) | 0.02 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e70–e71.
Abstract
BACKGROUND:
Delayed cord clamping (DCC) for up to 3 minutes has been found to improve in-patient outcomes in very preterm infants (Rabe 2008). The impact on neurodevelopmental impairment (NDI) is uncertain.
OBJECTIVES:
This retrospective study aimed to determine if there is an association between DCC and the incidence of severe NDI or death.
DESIGN/METHODS:
Data were abstracted from Neonatal Unit and Follow-Up databases for babies born 3 std. dev. below mean and Bayley III scores 2–3 std. dev. below mean.
Severe neurological impairment defined as:
non-ambulatory cerebral palsy (GMFCS 3–5)
composite Bayley III developmental scores >3 std. dev. below mean
legal blindness
hearing loss requiring hearing aids or cochlear implant
2+ moderate disabilities
RESULTS:
Of 227 babies eligible for DCC, 166 (73%) received DCC for ≥45 seconds and 61 (27%) did not receive DCC for ≥45 seconds. No differences in gestational age, birth weight, gender, mode of delivery, admission temperature and highest serum bilirubin were found between DCC and immediate clamping (ICC) groups. Scores of illness severity did not differ between the DCC and ICC groups either.
No significant difference in the incidence of severe NDI or death was found when babies who received DCC were compared to those who received ICC. Rates of survival without severe NDI were 142 infants out of 166 and 54 out of 61 for DCC and ICC, respectively (P=0.56). Secondary outcomes were also unaffected by DCC.
CONCLUSION:
This is the first study to look at 18 month outcomes following DCC. We found that DCC is not associated with improved or worse outcomes compared to ICC. Rates of survival without severe NDI are low in babies eligible for DCC and are not associated with DCC vs. ICC. The causes of NDI are multifactorial and may not be influenced by a single perinatal factor. Our analysis is limited by a small sample size due to the low rate of severe NDI in the cohort.
Paediatr Child Health. 2015 Jun-Jul;20(5):e71.
Abstract
BACKGROUND:
Infants delivered by elective caesarean section have similar need for resuscitation as infants delivered by spontaneous vaginal deliveries. Approximately 10% of deliveries are estimated to require neonatal resuscitation with 1% requiring extensive measures. A health care provider certified by the Neonatal Resuscitation Program but without advanced airway skills is therefore considered sufficient at low risk deliveries. Despite this, a retrospective chart review at our institution had suggested that over 40% of all caesarian section deliveries received suctioning or bag/mask ventilation.
OBJECTIVES:
We undertook this study to confirm the extent to which suctioning and bag mask ventilation were undertaken following elective caesarean section deliveries and to explore whether these resuscitation efforts were indicated.
DESIGN/METHODS:
This was an observational study of 50 elective caesarean deliveries in a small urban centre (approximately 4000 deliveries each year) between May 2014 and September 2014. Mothers were recruited for the study from the antenatal clinic and provided informed consent. All elective indications were included. Emergency caesarean sections were excluded. Presence of meconium, age at first cry (seconds), APGAR score, and timing of resuscitation interventions if used (suctioning, bag/mask ventilation) were recorded. Frequency distributions were used to describe data that was categorical in nature. Continuous data is presented as means and standard deviations or as medians and interquartile ranges (IQR indicates the 25th and 75th percentile) where the data was not normally distributed.
RESULTS:
Fifty-four infants were delivered through 50 elective caesarean sections. Caesarean section occurred due to maternal request (2%), maternal illness indicators (7%), fetal indicators (11%), and previous caesarean sections (80%). One infant was born through meconium liquor and one infant had a heart rate less than 120 bpm prior to delivery. 22/54 (41%) infants received suctioning during the first 10 minutes following delivery (mean = 99.1 seconds, range = 34–604 seconds). Eight of 54 (14%) infants received bag/mask ventilation using air and five (9%) infants received oxygen via bag/mask. All but one infant had a robust cry prior to suctioning or bag/mask. Median 1-minute APGAR’s were 9 (IQR 8–9) and median 5 minute Apgar’s were 9 (IQR 9–9).
CONCLUSION:
In observed deliveries, suctioning and bag/mask ventilation occurred after a robust cry by the infant in all but one case. This finding suggests that suctioning and bag/mask ventilation is occurring more frequently than indicated by Neonatal Resuscitation Program guidelines at our centre. Reasons for this observation need to be explored.
Paediatr Child Health. 2015 Jun-Jul;20(5):e71.
Abstract
BACKGROUND:
Skilled, guideline and timeline adhered neonatal resuscitation remains the cornerstone of advanced neonatal care ensuring a favorable outcome. There is a paucity of literature on how well individual centers are able to meet the standards set out in the Neonatal Resuscitation Program (NRP).
OBJECTIVES:
To compare the frequency of incomplete documentation and timelines for resuscitation intervention among a defined population of neonates i.e infants born at a gestational age ≥34 weeks who required positive pressure ventilation via an endotracheal tube at birth.
DESIGN/METHODS:
A multicenter retrospective chart review for the duration January 2011 to December 2014 was conducted. Level II and Level III centers were compared with each other and the gold standard NRP 2011. Data on demography, timelines to resuscitation intervention, documentation and outcomes were collected and analyzed.
RESULTS:
Two-year preliminary data identified 68 cases that met the inclusion criteria. Incomplete documentation was noted across all domains with a frequency ranging between 14 to 66%. The timelines to intervention were (mean, SD) 3.9 (4.3) minutes for intubation, 4.1 (4.76) minutes for initiation of chest compressions and 47.4 (47.3) minutes for establishment of vascular access. 13 (76.4%)of the infants received chest compression prior to intubation.
CONCLUSION:
In comparison to previous data from real life and simulated environments on timelines for resuscitation intervention in neonates, there exists a gap between guideline adherence and clinical practice. Using this information we hope to identify areas in which centers can target intervention to improve the delivery of NRP.
Paediatr Child Health. 2015 Jun-Jul;20(5):e71–e72.
Abstract
BACKGROUND:
TR 21 is by far the most common and well known chromosomal disorder in humans and a common cause of intellectual disability. However, the lack of outcome and resource utilization details among infants with TR 21 admitted to Level 3 NICU’s precludes effective antenatal counseling, anticipation of hospital course and resource planning.
OBJECTIVES:
To determine (i) the mortality, morbidity and resource utilization among infants with TR 21 admitted to L3 NICU (ii) Factors associated with mortality during hospital stay.
DESIGN/METHODS:
A retrospective cohort study on infants admitted to the NICU’s participating in the Canadian Neonatal Network for the epochs 2004–2009 and 2010–2013 was conducted. Data on demography, resource utilization and outcomes during hospital stay were collected. Association between outcomes (death, length of stay and oxygen at discharge) and predictors (gestational age, gender, outborn, severity of illness (SNAP score), mechanical ventilation (MV) and inotrope use were analyzed.
RESULTS:
482 and 438 infants with TR 21 during the two epochs (1% each of all L3 NICU admissions) were identified. The mean (SD) gestational age was 36.5 (3) and 36.4 (3) weeks respectively in the two epochs. In the second epoch, 21 (5%) infants died, 21(5%) of the infants required inhaled nitric oxide and 14 (3%)infants had late onset sepsis. The odds of higher deaths of TR 21 infants were associated with the use of inotropes. On logistic regression analysis, SNAP score, MV and inotrope use had fair association with death, [odds ratio (95% confidence interval) 0.98 (0.94,1.03), 11.1 (0.95,129.7) and 75.1 (10.7,530) respectively.
CONCLUSION:
Infants with Trisomy 21 admitted to L3 NICU have a significant mortality rate and receive a fair degree of intensive care support. Results could be used for improving effectiveness of antenatal counseling, planned serial cardiac function monitoring as well as facilitating resource planning at various levels of health care administration.
TABLE.
Resource utilization during NICU stay (2010–2013, second epoch)
| Characteristic | No of infants (%) |
| Mechanical ventilation | 115 (26) |
| Central line | 157 (36) |
| Inotrope use | 43 (10) |
| Antibiotics | 244 (56) |
| Inhaled Nitric oxide | 21 (5) |
| Laparotomy | 49 (11) |
| G Tube at discharge | 9 (2) |
| Oxygen at discharge | 53 (12) |
| Duration | Median (IQR) |
| Length of stay | 14 (7,30) |
| Mechanical ventilation days | 0 (0,1) |
| Oxygen days | 2 (0,7) |
| TPN days | 0 (0,7) |
For the epoch 2004–2009, 158 (33%) of the infants needed mechanical ventilation and the median length of stay was 14 (7,26) days. 33 (7%) and 28 (6%) infants had death and sepsis.
Paediatr Child Health. 2015 Jun-Jul;20(5):e72.
Abstract
BACKGROUND:
Conventional interval dosing (CID) regimens employ a lower gentamicin dose with shorter dosing interval while extended interval dosing (EID) regimens employ a higher dose with longer dosing interval. EID results in better therapeutic levels in term and preterm infants in the first week of life. However. clearance, serum half-life, and volume of distribution of gentamicin change during neonatal period. Limited data exists on the efficacy of EID in preterm infants 7 days of age.
OBJECTIVES:
To determine if EID of gentamicin achieves therapeutic serum trough (<2 μg/mL) and peak (5–12 μg/mL) levels compared to CID in preterm infants 7 days of age.
DESIGN/METHODS:
METHODS: Infants 7 days of age who received gentamicin for suspected/confirmed sepsis were included. Exclusion criteria included major congenital anomalies and renal dysfunction. Gentamicin was administered initially at 5 mg/kg/dose with the dosing interval based on a 22 h level after the first dose (EID). Trough and peak levels were measured before and after the third dose if the dosing interval was q 24 h and after the second dose if the interval was q 36 h or 48 h. These levels were compared with infants who had received gentamicin 2.5 mg/kg/dose every 8–24 h (CID). Statistical analysis was performed using a two way non-paired Student t test and χ2 or Fisher’s exact test.
RESULTS:
22 infants (56%) in the CID group had peak levels 5 μg/mL (P 2 μg/mL while all infants in EID group had trough levels <2 μg/mL (P <0.01). There was no effect on urine output or serum creatinine levels in both regimens. One infant in each group had sensorineural hearing loss.
CONCLUSION:
In premature infants 7 days of age, EID of gentamicin is safe and achieves more optimum therapeutic serum peak and trough levels as compared to CID of gentamicin.
RESULTS
| Characteristic | EID (n=39) | CID (n=39) | P value |
|---|---|---|---|
| Gestational age (wks) | 26±1.9 | 26±1.9 | 0.20 |
| Postmenstrual age(wks) | 31±4.0 | 30±3.0 | 0.35 |
| Postnatal age(days) | 34±28 | 32±21 | 0.77 |
| Birthweight(gms) | 902±243 | 819±259 | 0.14 |
| Wt. at start of gentamicin(gms) | 1338±688 | 1139±357 | 0.12 |
| Trough level(μg/mL) | 0.7±0.3 | 1.4±0.9 | <0.01 |
| Peak level(μg/mL) | 9.2±1.9 | 5.0±1.4 | <0.01 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e72.
Abstract
BACKGROUND:
Adrenal insufficiency is an important contributor to hemodynamic instability in the first few days of life in preterm infants. Preterm infants hypotensive on day 1 may have an innate inability to mount an adrenal response to stress, which could be studied by measuring umbilical cord cortisol levels.
OBJECTIVES:
To compare cord blood cortisol levels between infants <32 weeks gestation who need fluid bolus or inotropic support (F/I group) in the first 24 hours of life and infants who do not need such support (No F/I group).
DESIGN/METHODS:
This was a prospective observational study on infants <32 weeks gestation. Blood was drawn from the umbilical vein within 30 minutes of birth and cortisol was assayed using ELISA. Use of fluid bolus or inotrope in the first 24 hours of life was used as a marker for hemodynamic instability. The criteria for use of fluid boluses and inotropes are consistent in our unit. Cortisol levels were compared between the F/I and No F/I groups. Statistical analysis was performed using a two way non-paired Student t test or Mann-Whitney test and χ2 or Fisher’s exact test as appropriate.
RESULTS:
Infants in F/I group were more preterm, smaller, and received less antenatal corticosteroids (ANCS) and had significantly higher SNAPPE-II scores and rates of IVH, RDS, and mortality. Umbilical cortisol levels did not correlate with mean blood pressures at 1, 6, 12 and 24 hours of life. There was no effect of chorioamnionitis or mode of delivery (MOD) on cortisol levels.
CONCLUSION:
Umbilical cortisol levels in hemodynamically unstable preterm infants are not different from those in well preterm infants. We speculate that, unlike what is reported with term infants, preterm infants do not respond adequately to stressors like intrauterine infection and labor.
RESULTS
| F/I (n=25) | No F/I (n=68) | P | |
|---|---|---|---|
| Cortisol ng/mL, median (IQR) | 82 (77) | 118 (64) | 0.33 |
| ANCS, n (%) | 22 (88) | 67 (99) | 0.02 |
| Preeclampsia, n (%) | 2 (8) | 5 (7) | 0.49 |
| C-section, n (%) | 15 (60) | 37 (54) | 0.63 |
| Gestational age, weeks, mean ± SD | 26.9±2.2 | 28.4±2.2 | 0.007 |
| Birth weight, g, mean ± SD | 1032±290 | 1185±360 | 0.03 |
| Chorioamnionitis, n (%) | 16 (64) | 37 (54) | 0.41 |
| <10th percentile for BW, n (%) | 1 (4) | 7 (10) | 0.34 |
| Male, n (%) | 16 (64) | 35 (51) | 0.28 |
| Respiratory distress syndrome, n (%) | 24 (96) | 47 (69) | 0.007 |
| Grade 3/4 IVH, n (%) | 7 (28) | 6 (9) | 0.01 |
| SNAPPE-II, mean ± SD | 36±24 | 13±16 | 0.000 |
| Mortality, n (%) | 4 (16) | 2 (3) | 0.02 |
SD = standard deviation, IQR = interquartile range
Paediatr Child Health. 2015 Jun-Jul;20(5):e72–e73.
Abstract
BACKGROUND:
Youth substance abuse has been described as an international public health problem (Tortolero, 2012). In Canada, recent statistics demonstrate concerning trends in youth substance abuse toward increasing usage and a lower age at first use (Health Canada, 2012). Given these trends, recent decades have seen a proliferation in primary substance abuse prevention programs for children and youth focused on preventing the initial onset of alcohol and drug use. However, evidence for the effectiveness of these programs is fragmented, with heterogeneous measures and a variety of mediating factors reported in the literature (Riggs, Black, & Ritt-Olson, 2014).
OBJECTIVES:
The aim of the current project was to conduct a systematic review that synthesizes evidence in this area by: (i) identifying substance abuse prevention programs available for school-aged children and youth; and (ii) reporting the type and quality of evidence to support the effectiveness of identified programs.
DESIGN/METHODS:
We undertook a systematic search process using Cochrane Collaboration (2009) methods. To begin, a research librarian created a search strategy designed to identify studies relevant to the stated objectives. Eight academic databases were searched. All studies that met the following criteria were eligible for the first stage of inclusion: i) published in English; ii) evaluated the effectiveness of a substance abuse prevention program; iii) the program was delivered to school-age children and youth; and iv) the study included a control group. After screening articles using these initial criteria, two researchers independently engaged in a second stage screening process using the following criteria: i) the program was delivered to a general population of children/youth; ii) the program was designed as a primary prevention program; iii) the article described a final evaluation, as opposed to a pilot evaluation; and iv) the program only targeted children.
RESULTS:
The combined results of these two search strategies yielded over 100 articles that met inclusion criteria. Results indicate a number of primary prevention programs that demonstrate varying levels of evidence to support their effectiveness.
This presentation will discuss the key characteristics shared by programs at each evidence level, with the aim of providing practical information for decision-makers, practitioners, and other service providers seeking to select the most appropriate prevention initiatives for their communities.
CONCLUSION:
This review has a number of implications for the implementation of primary substance abuse prevention programs. This review also highlights a number of areas in which the quality of research in this field can be strengthened.
Paediatr Child Health. 2015 Jun-Jul;20(5):e73.
Abstract
BACKGROUND:
Exposure to Pediatrics is a unique and important part of many residency programs. However, increased numbers of residents due to the expansion of positions, short clinical rotations, and seasonal variability of pediatric cases can result in reduced clinical exposure, uneven clinical experiences, and unmet learning needs.
OBJECTIVES:
iLEARN-Peds was therefore developed as a creative solution to ensure achievement of Pediatric competencies. iLEARN-Peds is a series of eLearning modules designed to complement clinical experiences taking an experiential, case-based approach.
DESIGN/METHODS:
Module cases were selected by analyzing the pediatric learning objectives from all postgraduate programs whose residents rotate through Pediatrics. The most prevalent topics across programs were identified and cross-referenced with hospital visit data to determine the likelihood of residents’ exposure to the cases. Seasonal patterns of cases were then noted. Using these data, an expert panel selected the cases to be addressed by the modules.
Five modules were developed, piloted with residents for one year during their pediatric emergency rotations, and evaluated using a mixed-methods approach. Residents completed a pre-post knowledge test (10 items/module) and a satisfaction survey for each module, and participated in an expert-led one-hour face-to-face group tutorial that included a reflective exercise.
RESULTS:
Of the 237 residents who completed the pediatric emergency rotation, 199 completed the learning modules and 120 also completed the pre and post tests and satisfaction surveys. Results revealed high module satisfaction rates and a significant (P<0.001) improvement in knowledge following module completion. Findings from the tutorials suggest learners have been applying their new knowledge in the clinical setting.
CONCLUSION:
A series of case-based experiential eLearning modules can complement clinical experiences in Pediatrics. Using the five pilot cases to refine our process allowed for the creation of an additional 11 modules. iLEARN-Peds is now a mandatory component of the family medicine residency program and the pediatric emergency rotation. The platforms and processes developed through this project now serve as the Faculty of Medicine’s foundation for eLearning. Plans are underway to expand access to the modules and allow more comprehensive user tracking in keeping with the strategic direction of competency-based medical education.
Paediatr Child Health. 2015 Jun-Jul;20(5):e73.
Abstract
BACKGROUND:
Complete reporting of clinical trial protocols is essential to allow stakeholders to critically assess trial methodology, ethics, and validity. The SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) initiative aims to standardize protocol reporting guidelines and tackle inadequate reporting. However, SPIRIT does not offer guidance on the scientific, ethical and safety considerations unique to trials with children.
OBJECTIVES:
To address this gap in guidance and advance child health research, we present SPIRIT-Children (SPIRIT-C): An evidence-based SPIRIT extension for pediatric clinical trial protocols.
DESIGN/METHODS:
Potential reporting items to be included in the SPIRIT-C extension were identified through environmental scans of existing reporting recommendations and a three-stage Delphi process. A systematic literature review was conducted to gather empirical evidence regarding the importance of potential reporting items in pediatric clinical trial protocols, as well as to identify additional reporting recommendations. The results of the Delphi process and systematic review, along with feedback from youth advisors, were presented to an international group of pediatric clinical trial experts and stakeholders, who subsequently reached consensus on potential reporting items using nominal group techniques.
RESULTS:
The SPIRIT-C pediatric protocol reporting guideline includes nine additional reporting items that are recommended be addressed in all pediatric clinical trial protocols (Table 1).
CONCLUSION:
SPIRIT-C is the first evidence-based reporting guideline for pediatric clinical trial protocols, filling a gap in existing research guidance, thus helping researchers to improve their trials’ impact and child health outcomes.
TABLE 1.
Extension items to be included in pediatric clinical trial protocols
| Protocol section | SPIRIT-C extension item for pediatric protocols |
|---|---|
| Title | Title identifying a pediatric clinical trial with age group(s) stated |
| Roles and responsibilities | Description of the involvement of parents or children in designing the study, if any |
| Background and rationale | Description of potential for extrapolation from adult data, or why extrapolation is not considered possible; and why a trial is considered necessary in the pre-specified age group(s) |
| Eligibility criteria | Justification of the selected age group(s) and subgroups, addressing potential age-related differences in treatment effects |
| Outcomes | Explanation of the clinical relevance of the selected outcomes (benefits and harms) for the pre-specified age group(s) |
| Data collection methods | Explanation of the validity, feasibility, and responsiveness of the outcome measures for the pre-specified age group(s) |
| Harms | Plans for assessing outcomes and harms beyond the formal study completion date |
| Description of efforts to reduce risk of participation | |
| Ancillary and post-trial care | Plans, if any, for post-trial care beyond the pediatric age range |
Paediatr Child Health. 2015 Jun-Jul;20(5):e74.
Abstract
BACKGROUND:
Ethics and professionalism education is a required component of paediatric residency training. However, a dearth of established curricula persists and there is no consensus as to the topics that should be included. Significant barriers exist in the form of curricular crowding, making it imperative that educators prioritize residents’ ethics learning needs. Previous studies have been limited by the use of trainees’ self-reported needs alone. This is the first study to investigate the ethics learning needs of paediatric residents using a 360° assessment. Our hypothesis was that paediatricians and/or allied health care professionals (HCPs) would identify ethics learning needs not appreciated by trainees.
OBJECTIVES:
To identify and prioritize paediatric residents’ ethics learning needs using a 360° survey-based assessment.
To determine if differences exist between paediatric residents’ ethics learning needs as perceived by residents, paediatricians and allied HCPs.
DESIGN/METHODS:
Paediatric residents, respiratory therapists (RTs), registered nurses (RNs) and paediatricians working at a university children’s hospital rated the importance of twelve ethics themes as learning needs for trainees using a Likert scale. Kruskal-Wallis tests were used to compare the ratings of importance for each theme between the four groups of respondents. Pairwise comparisons were conducted using Dunn’s procedure with a Bonferroni correction.
RESULTS:
Response rates were 65%, 70%, 57% and 47% for residents (n=15), paediatricians (n=30), RTs (n=8) and RNs (n=71), respectively. The rated importance of seven of twelve ethics themes differed significantly between the four groups. Paediatricians rated five ethics themes as significantly more important than did RTs/RNs. Residents rated genetic screening/testing as significantly more important than RTs/RNs. A rank order list of ethics themes was generated for each group of respondents based on the percentage of respondents in each group rating the ethics theme as very important. Four ethics themes were in the top six for all groups of respondents.
CONCLUSION:
These results provide an interprofessional assessment of paediatric residents’ perceived ethics learning needs. High priority ethics topics were identified, allowing for a targeted curriculum in the context of limited instructional time. Contrary to our hypothesis, there were no instances where trainees rated an ethics learning need as less important than did paediatricians or allied HCPs.
Paediatr Child Health. 2015 Jun-Jul;20(5):e74.
Abstract
BACKGROUND:
Prescription errors are a preventable cause of mortality and morbidity. Pediatric patients are particularly at risk in part because of weight-based dosing. Moreover, errors seem to correlate with the prescriber’s level of training. In July 2013, we implemented a one-month immersion program for first-year residents (PGY1), which included a two-hour lecture by a pharmacist.
We hypothesized that this intervention would lead to an improvement of the prescription errors rate and quality of prescription.
OBJECTIVES:
To evaluate the effect of a two-hour lecture on the rate of prescription errors and the quality of prescriptions within first-year pediatrics residents.
DESIGN/METHODS:
We conducted a retrospective study at an academic pediatric tertiary care center with approval from Institutional Review Boards. All residents included in the study provided written informed consent. The pharmacy course was given to 11 PGY1 pediatric residents (cohort 2013). We compared them to 15 PGY-1 pediatric residents not exposed to the intervention from cohort 2012 and 2013. We analyzed the 50 first prescriptions of each resident at the beginning of residence.
RESULTS:
We collected data of 1300 prescriptions (451 patients) from 26 PGY-1; 550 in the exposed group and 750 in the non-exposed group. Prescriptions proceed from patients hospitalized in general (n=804) or specialty (n=262) pediatrics wards, neonatal intensive care unit (NICU) (n=215) and emergency department (n=16). Drugs more frequently prescribed were Antibiotics and Acetaminophen/Ibuprofen.
The rate of prescription errors in the intervention group was 9.6% compared to 11.3% in the control group (P=0.32). Four prescriptions were not written in the exposed group vs. none in unexposed group (P=0.01) and error of >10% of dosage was found in 0.9% of exposed prescription’s group compared to 2.1% in unexposed (P=0.04). Six percent were errors on children younger than three months and 5% were in antibiotic’s prescriptions, without significant difference between groups. There was a trend toward fewer errors in dosage, frequency and route of administration in the intervention group.
Despite that no statistical difference was found between both groups in the quality of prescriptions, many mistakes were highlighted: lack of written information on charts about allergy (67.8%), dosage/weight (45.5%), generic name (28.8%), weight (26.2%), date/hour (3.6%).
CONCLUSION:
Educational Intervention by pharmacist seems to influence positively the rate of prescription errors among junior pediatrics residents. This study also highlighted the most frequently types of prescription errors and quality mistakes that should be targeted by future interventions.
Paediatr Child Health. 2015 Jun-Jul;20(5):e74.
Abstract
BACKGROUND:
Multi-source feedback (360-degree feedback) involves the collection of feedback from multiple groups of assessors, including those who do not traditionally have a hierarchal responsibility to evaluate physicians. Allied health care professionals, administrative staff, colleagues, patients and their families contribute to the formative assessment of physicians through the completion of standardized forms that are compiled and then reviewed by the individual being assessed. Theoretically, the feedback collectively provides a thorough view of physician performance in daily practice in the humanistic and relational competencies, which traditionally are particularly difficult to assess.
OBJECTIVES:
To explore perceptions of multi-source feedback and prerequisites to an effective multi-source feedback program in postgraduate medical education from the perspectives of both paediatric residents and allied health care professionals.
DESIGN/METHODS:
This exploratory case study utilized a paediatric inpatient unit where multi-source feedback has not yet been implemented as part of a needs assessment. Three focus groups were conducted with purposefully recruited participants from three distinct groups: junior paediatric residents, senior paediatric residents, and allied health care professionals. Discussions were audio recorded, subsequently transcribed and analyzed with thematic analysis.
RESULTS:
Both residents and allied health care professionals expressed a strong interest in the concept of multi-source feedback. However, more in depth discussions identified barriers to residents’ acceptance of, and allied health care professionals’ provision of feedback. Interpersonal dynamics, concerns about (mis)understanding of roles and responsibilities and power hierarchies were identified as barriers to both accepting and providing feedback. Interest in opportunities to engage in bidirectional feedback amongst allied health care providers and residents were expressed by all three focus groups.
CONCLUSION:
The barriers and prerequisites to providing and accepting multisource feedback identified suggest limits to the efficacy of the multi-source feedback process. Our findings suggest that these factors should be considered in the design and implementation of multi-source feedback programs.
Paediatr Child Health. 2015 Jun-Jul;20(5):e75.
Abstract
BACKGROUND:
Orofacial clefts are the most common craniofacial malformation of the newborn. Worldwide rates vary based on ethnicity and geography.
OBJECTIVES:
We aimed to assess trends in the rate of cleft lip and palate (CLP) in a large number of countries across several world regions.
DESIGN/METHODS:
Preferred sources for data collection included national registries, regional registries, health ministries, and academic centers. When available, we captured the number of infants born with (1) cleft lip with or without palate (CL±P), and (2) isolated cleft palate (CP) from 1990 to 2013. Geographical data including national latitude, longitude and mean elevation was captured from validated sources. Annual rates per 10,000 live births were calculated and countries were grouped according to World Health Organization (WHO) regions (Americas, Europe, South East Asia, Western Pacific, Africa and Eastern Mediterranean).
RESULTS:
Data was captured from 55 countries. According to most recent data, the highest total rates of CLP were reported in Venezuela (38 cases/10,000 births), Iran (36 cases/10,000 births) and Japan (30 cases/10,000 births). In total, 64% of infants had CL±P and only eight countries reported a higher proportion of CP compared to CL±P. Preliminary analysis of temporal trends were assessed within WHO regions from 1990 to 2013. The Americas reported significant increases in the rate of CL±P from 10.3 cases/10,000 births to 12.37 cases/10,000 births (P=0.01) and total CLP from 13.5 cases/10,000 births to 15.3 cases/10,000 births (P=0.02). No other WHO region demonstrated a significant change in CLP rate. Countries at higher elevation (>1000 m) reported significantly higher rates of cleft lip ± palate than countries at lower elevation (mean rate of 12.4 versus 8.4 cases/10,000 births; P=0.02). In contrast, countries at higher elevation had significantly lower rates of cleft palate than countries at lower elevation (mean rate of 3.5 versus 5.2 cases/10,000 births; P=0.03).
CONCLUSION:
We conclude that the rate of CLP has remained stable throughout much of the world, with an increase noted in the Americas. Geographical variables may influence incidence rates, and should be investigated further. Analyses are limited by a paucity of data from certain regions (Africa, Eastern Mediterranean and Asia). Future efforts to develop comprehensive registries will allow for a more accurate assessment of the global burden of CLP.
Paediatr Child Health. 2015 Jun-Jul;20(5):e75.
Abstract
BACKGROUND:
Global health teaching at our institution is overseen by the Global Child Health Program (GCHP) of the Department of Pediatrics. The GCHP is lead by a multidisciplinary steering committee formed by physicians, nurses, allied health professionals, and pediatric residents. In order to fulfill adequately its teaching mandate, the Program developed a new competency-based, multi-disciplinary educational program that would reflect the complexity of Global Child Health in 2014.
OBJECTIVES:
Specific CanMEDS-based learning outcomes were created for each tier of the teaching program:
The General Pediatric Global Health Curriculum which consists of mandatory sessions for all pediatric residents.
The Advanced Curriculum in Pediatric Global Health, a two-year course with monthly teaching sessions offered to health professionals with a specific interest in this area of practice.
Global Health Elective.
DESIGN/METHODS:
A review of the literature was done using the terms “pediatric”, “global health” and “education’’. 382 articles were identified and 24 were selected after abstract review by the principal investigator. No Canadian competency-based pediatric curricula were identified. Based on the current literature, curriculum topics were chosen and CanMEDs outcomes were created. These were reviewed by the education subcommittee of the Global Child Health Program and by a pediatrician specialized in medical education.
RESULTS:
Three sets of outcomes were created, one for each aspect of the teaching program. They were further divided to follow the seven categories of the CanMeds framework (Example Table 1.)
CONCLUSION:
The learning outcomes of the Global Child Health Program are, to our knowledge, the first multidisciplinary Canadian competency based outcomes to be created. It is an essential guide used in our institution to teach all pediatric residents the basics of Pediatric Global Health and to allow our multidisciplinary group of health professionals to develop advanced skills and expertise in this constantly expanding field.
Health advocacy
ALL GENERAL PEDIATRIC RESIDENTS will be able to
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ALL participants in the ADVANCED CURRICULUM will
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ALL participants in a GLOBAL HEALTH ELECTIVE will be able to
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Paediatr Child Health. 2015 Jun-Jul;20(5):e75–e76.
Abstract
BACKGROUND:
In 2003, the Don & Elizabeth Hillman International Child Health Grant was created by the Canadian Pediatric Society (CPS) Global Child & Youth Health Section to promote international health opportunities for residents and fellows. Forty awards were administered ($750 – $1000) from 2003 to 2013, for use towards costs of paediatrics elective in low-middle income countries (LMIC). It is one of the few funding opportunities of its kind available to Canadian paediatric trainees. It is timely to evaluate the impact of providing supportive funds for such experiences and their effects on recipient career paths.
OBJECTIVES:
This evaluation aimed to describe interest, enablers, and perceived barriers of career activities in global health amongst those who completed a funded international elective during residency, and to examine how these experiences may influence the time dedicated to global health activities including local patient populations.
DESIGN/METHODS:
Past Hillman Grant recipients were contacted by email to complete an online survey, which was designed from review of relevant literature, to assess interest, perceived enablers and barriers in global health experiences and career paths. Data were collected and managed using REDCap electronic data capture tools hosted at University of British Columbia.
RESULTS:
Nineteen out of 40 grant awardees completed the online survey; five are still in residency or fellowship. While for 8/19, receiving the grant influenced their decision to go, the remainder would have done an international residency elective (IRE) regardless but qualitative review indicates that it assisted in lifting ‘burden of cost’ and was appreciated, but not sole influential factor in participating. Nearly half (47%) have pursued further training related to global health (GH), while another 36% are planning to do so in the future.
The majority (79%) endorsed that participation in an IRE encouraged future global health involvement, while all respondents felt the experience influenced their attitudes towards health care. Ten (of 14 total) pediatrician respondents indicated that they currently spend time in GH activities (both locally and abroad); respondents are involved with caring for families receiving social assistance (14/19), newcomer health (11/19), First Nations/Inuit/Metis health (10/19), GH education within Canada (14/19), and health education outside Canada (10/19).
Enablers to participation in GH activities include: family support (11/19), departmental support (10/19), international electives (9/19) and mentorship (8/19). Most significant barriers to participation in GH activities were: scheduling (16/19) with 68% of these indicating need to use vacation time, financial (15/19), and family obligations (10/19).
CONCLUSION:
Recipients of the Hillman grants generally are involved with the care of vulnerable children within and outside Canada, and for many, their international elective experience influenced those career directions.
Paediatr Child Health. 2015 Jun-Jul;20(5):e76.
Abstract
BACKGROUND:
Recent years have seen an uncontrolled rise in antimicrobial-resistant organisms, leading to increased morbidity, mortality, and healthcare costs. The impact of antimicrobial resistance is greatest on low-income countries, which face the double burden of fewer antibiotic choices and higher rates of infectious disease. Currently, Guyana has no national policy on rational prescribing. The WHO has developed prescribing indicators to detect barriers to good antimicrobial stewardship. There has been no previous research on antibiotic use in children in an outpatient setting in Guyana.
OBJECTIVES:
To characterize antibiotic prescribing patterns in children discharged from the emergency department at Georgetown Public Hospital Corporation (GPHC), as per WHO prescribing indicators.
DESIGN/METHODS:
A retrospective chart review of pediatric patients (aged one month – 13 years) seen in the GPHC emergency department between January and December 2012 was conducted. Patients who absconded from hospital prior to receiving therapy were excluded. Outpatient prescriptions for eligible patients were reviewed. Patient demographics, diagnosis, and drugs prescribed were recorded. If antibiotics were prescribed, the antibiotic class, dose, route, frequency and duration of therapy was recorded. The following WHO Prescribing Indicators were calculated: i) average number of drugs prescribed per patient encounter, ii) percentage of encounters with an antibiotic prescribed, iii) percentage of antibiotics prescribed by generic name, and iv) percentage of antibiotics prescribed from essential drugs list or formulary.
RESULTS:
811 patient encounters were included in the study. The mean patient age was 5.55 years. 59.6% (n= 483) patients were male. An average of 2.5 drugs were prescribed per encounter (WHO standard is 2.0). One or more antibiotic was prescribed during 36.9% (n = 299) of all encounters (WHO standard is 30%). 90.83% of antibiotics were prescribed from the essential drugs formulary list and 30% of the prescriptions included the drug’s generic name. The average duration of antibiotic therapy was 5.73 days. Of the 360 antibiotics prescribed, 74.7% (n= 269) were broad-spectrum. B-lactam penicillins were prescribed most frequently (51.4%), with amoxicillin being the most popular choice (33.9%). The most common diagnoses were injuries (25.8%), respiratory infections (19.5%), asthma (16.9%) and gastrointestinal infections (12.1%).
CONCLUSION:
Per WHO prescribing indicators, the pediatric emergency department at GPHC has higher than standard rates of antibiotic use and polypharmacy. Strengths of the department include adherence to the essential drug formulary and preference for generic agents whenever possible. While it was beyond the scope of this study, these results suggest that antibiotics are often inappropriately prescribed for non-infectious pediatric diagnoses.
Paediatr Child Health. 2015 Jun-Jul;20(5):e76.
Abstract
BACKGROUND:
Trampoline injuries remain an important pediatric injury necessitating either an emergency department (ED) visit or hospitalization. Parents are in the best position to advocate for the safety of their children during recreational use of trampolines. However, there is no evidence examining parental awareness and application of trampoline-related safety recommendations.
OBJECTIVES:
In parents of children who presented to the ED with extremity injuries, we determined the proportion of parents who were aware of the five key recommendations for safer recreational trampoline use in children. We also examined parental willingness to allow their children to use a recreational trampoline once informed that national pediatric and orthopedic societies have recommended a ban on home use of trampolines.
DESIGN/METHODS:
This was a prospective cross-sectional survey of parents presenting to a tertiary care pediatric emergency department with children 2–17 years of age with an extremity injury. The 24 question survey tool was pre and pilot tested on the target audience for question content and clarity. Assuming a sample proportion of parents who are aware of all five key recommendations to be 0.10, error of +1.5%, α=0.05, a β=0.2 resulted in a sample size of 1400.
RESULTS:
Of the 1423 enrolled parents, 542 (38.1%) had regular access to a trampoline and 125 (8.8%) of their respective children had a history trampoline injury. Importantly, only 116 (8.2%; 95% CI 6.8 to 9.6) of parents were aware of five key safety recommendations for home trampoline use. Parental knowledge of trampoline safety recommendations was less likely in those whose children had regular recreational trampoline use versus those without (OR =0.6 95% CI 0.4, 1.0), while those parents with children who had a prior trampoline related injury versus those without such injury were more likely to be aware of trampoline safety (OR = 2.3 95% 1.1, 5.1). 96.5% of parents reported that their primary care physician had never discussed trampoline safety with them. Prior to informing parents of the ban recommended by pediatric and orthopedic societies, the proportion of parents willing to own a home trampoline was 30.5%, while after this disclosure willingness decreased to 20.5% (P<0.0001).
CONCLUSION:
Trampoline safety knowledge of the five key recommendations among parents is low, but increases with exposure to a trampoline related injury. Parents were less willing to own a home trampoline once made aware of national recommendations. In this population, trampoline safety knowledge was not being discussed preventively in well child visits.
Paediatr Child Health. 2015 Jun-Jul;20(5):e76–e77.
Abstract
BACKGROUND:
Injury is the leading cause of death in Canadians ages 1–44 years. As providers of both well and acute care for children, general paediatricians and paediatric emergency medicine (PEM) physicians are strategically positioned to implement injury prevention and control practices. Currently, there is no literature describing the injury prevention and control curriculum within Canadian postgraduate training programs in either Paediatric Medicine or PEM.
OBJECTIVES:
We determined the proportion of Canadian Paediatric and PEM training programs that incorporated a formalized injury prevention and control component within their curriculum. We secondarily determined the proportion of programs where injury control currently has a high priority within the curriculum, as well as the proportion of program directors (PDs) who felt that injury control should be a high priority topic.
DESIGN/METHODS:
A novel cross-sectional survey was developed, based on expert opinion and existing literature. An electronic survey was distributed to all potential participants using modified Dillman methodology (via Survey Gizmo). It was sent to all Royal College Paediatric (n=17) and PEM (n=10) PDs from May to June 2014. The 20 question tool was pre and pilot tested prior to implementation.
RESULTS:
An overall response rate of 89% (24/27) was obtained (16/17 for Paediatric programs and 8/10 for PEM programs). The median number of trainees enrolled in the programs was 6.5 [IQR 5.5–7] for PEM and 37 [IQR 25–52] for Paediatric Medicine. Fifty seven percent [95% CI 25% to 84%] of PEM programs and 44% [95% CI 23% to 67%] of Paediatric programs formally incorporated injury prevention and control within their curriculum. Among these programs, 70% had between 1 h and 5 h total instruction time for injury epidemiology and prevention. All PEM PDs and 86% of Paediatric PDs felt that injury prevention and control should be mandatory in residency training (either ‘agree’ or ‘strongly agree’). No PEM or Paediatric PDs reported injury control as high priority (defined as 8–10 on a Likert scale) currently within the curriculum. However, 33% [95% CI 10% to 70%] of PEM PDs and 7% [95% CI 1% to 31%] of Paediatric PDs felt injury control should have high priority within their curriculum.
CONCLUSION:
Only half of surveyed PDs incorporate injury control training within their Pediatric Medicine or PEM curriculum. Despite its importance in securing a healthy future for Canada’s children, PDs currently do not feel it merits high priority within the curriculum. Further research is needed to understand this decision, before any effective changes can be implemented to curriculum content.
Paediatr Child Health. 2015 Jun-Jul;20(5):e77.
Abstract
BACKGROUND:
Drowning is the second leading cause of injury related death for Canadian children. For every child who dies from drowning, another five receive emergency department care for nonfatal drowning injuries. Approximately 50% of private pool drownings involve 1–4 year olds, with the majority lacking true four-sided fencing and self-closing, self-latching gates. Private pools are key locations for interventions, as safety features can be added to prevent children from accessing pools without caregivers’ awareness. Many cities in Canada have attempted to improve pool safety; however, by-laws do not fully identify with pool enclosure recommendations issued by the Office of the Chief Coroner of Ontario.
OBJECTIVES:
To identify drowning incidences involving the paediatric population in order to focus prevention efforts and develop potential intervention strategies.
DESIGN/METHODS:
A retrospective chart review was conducted from January 2004 to December 2013 for drowning and nonfatal submersion diagnoses in children under 18 across three urban hospitals. Cases where the manner of drowning was suicide or homicide were excluded. Medical records were examined using the electronic databases Sovera and Meditech.
RESULTS:
There were 61 drowning incidences during the ten years, and almost half (44%) of these occurred in private pools (Figure 1). Of those in private pools, 19 of 27 were in the 1 to 4 age group category. Moreover, 74% of incidences that occurred in private pools were classified as unsupervised/supervision distracted. Information regarding true 4-sided fencing showed no 4-sided fence in 10 of 27 cases and in 15 of 27 it was unknown. Of the eight deaths that occurred during the study period, seven of eight were within the 1 to 4 age group. Five of the deaths occurred in a private pool where there was no 4-sided pool fencing.
CONCLUSION:
The results identified the age group 1 to 4 as a vulnerable population to focus on with regard to drowning. In addition, a large portion of drowning incidences and deaths in this age group occurred in private pools, which offers a focal point for prevention. The results suggest that reducing the access of this age group to private pools may prevent and reduce drowning incidences and deaths. Thus, an initiative for by-law changes regarding the implementation of safer pool fencing in private pools across the country is needed to prevent drowning incidences, and has the potential to reduce the number of deaths and injuries from childhood drownings.
Figure 1).
Location of pediatric drownings.
Paediatr Child Health. 2015 Jun-Jul;20(5):e77.
Abstract
BACKGROUND:
Since the introduction of convenient new laundry packets to North American in 2012 there have been more frequent reports of child injuries related to liquid detergent packets. A recent study reported 17,000 cases gathered by poison control centres across the United States including several hundred serious injuries and at least one death.
In Canada there have been more than 100 cases seen in paediatric emergency departments. To obtain more information on Canadian children injured in such incidents the Canadian Paediatric Surveillance Program (CPSP) conducted a one-time survey of paediatricians across Canada.
OBJECTIVES:
To obtain more information on Canadian children injured in such incidents the Canadian Paediatric Surveillance Program (CPSP) conducted a one-time survey of paediatricians across Canada. The survey gathered information on number of cases seen, age groups most affected, types of exposures and injuries sustained point of access, treatment and disposition of the children.
DESIGN/METHODS:
In August 2014, the CPSP sent a one-time survey to approximately 2,500 active practicing paediatricians and subspecialists enrolled in the Program.
RESULTS:
CPSP gathered information on 54 children with injuries following exposure to single-load liquid detergent packets treated by paediatricians within the past year (2014). Half (56%) were less than 2 years of age and 43% were aged 2–4 years. All except 2 of the children were treated by reporting physicians in emergency departments (69%) and in-patient settings (28%). Three quarters of the incidents involved exposure to liquid detergent packets for laundry and the remainder were for dishwashers. Among cases where the point of access was known, two thirds of the children accessed detergent packets directly from the manufacturer’s original package or container and another 20% found a packet on the floor or lying around. Almost all the children (47 or 88%) were treated following ingestion or had exposure to the gastrointestinal tract, six sustained ocular injuries, four had dermal exposure and three suffered pulmonary exposure. The injuries and symptoms reported in order of frequency include: nausea and vomiting, chemical burns (mouth, esophagus or skin), pulmonary toxicity, conjunctivitis, respiratory distress, corneal ulcer or keratitis, and central nervous system depression. Twenty-five patients (46%) were admitted to hospital and of these, at least six were treated in intensive care units. Another six patients (11%) were treated and released with referral for medical follow up. Twenty-one patients (39%) were not seriously injured and released without need for medical follow up.
CONCLUSION:
Liquid detergent packets pose a hazard for young children and exposures resulted in serious injuries. Prevention may be enhanced by greater parent and caregiver awareness of the hazard combined with vigilance in safe storage of household chemicals, including detergent packets.
Paediatr Child Health. 2015 Jun-Jul;20(5):e78.
Abstract
BACKGROUND:
Passive immunization against RSV requires monthly doses to maintain adequate serologic levels to prevent RSV-related hospitalization. Up to five IM doses may be provided during the RSV season. Although patients enrolled into a RSV prophylaxis program are already pre-selected because of underlying risk factors, and self-selected by parental agreement to immunoprophylaxis, ensuring adherence to the monthly dosing schedule and the total number of doses remains a challenge.
OBJECTIVES:
To review the adherence to dosing schedule and number of doses for patients enrolled in a provincial RSV Prophylaxis Program.
DESIGN/METHODS:
The Manitoba RSV Prophylaxis Program (MB RSVP) coordinates RSV immunoprophylaxis for all patients in the province of Manitoba. This centralized program manages all aspects of RSV immunoprophylaxis including patient enrolment and medication ordering. One benefit of this centralized program is tracking of doses received and subsequent dose schedule for all enrolled patients. The MB RSVP provides phone calls reminding patients and health care providers (HCP) of upcoming palivizumab doses.
Anonymized data for three seasons (2011–14) were analyzed. Adherence was evaluated by number of doses received during the season and by adherence to the dosing schedule. The optimum number of doses a patient should receive was calculated from the date of first dose given to the end of the RSV prophylaxis season. Compliance with dosing schedule is calculated based on the provincial standardized dosing interval of 28 days with exception of 35 days between the fourth and fifth doses.
RESULTS:
Over the three seasons, 857 paediatric patients received at least one dose of palivizumab. 74.8% of patients received the expected number of doses during the season and 24% received less than expected. Overall, 58.4% of all doses were provided exactly according to schedule. (either exactly at 28 days interval, or exactly at 35 days interval between 4th and 5th doses). 81.1% of doses were given within a ± 3 day window around the scheduled date, 93% within ± 7 day window. Only 13.5% of all doses were given ≥4 days after schedule. Factors impacting adherence included parent or HCP non-compliance, patient death, loss-to-follow-up, relocation outside of province, vacation/travel, repair of cardiac lesion, and withdrawal of consent.
CONCLUSION:
A centralized provincial RSV prophylaxis program with central tracking of dosing schedule and regular phone reminder to parents and heath care providers is highly successful in ensuring adherence to both dosing schedule and total number of doses.
Paediatr Child Health. 2015 Jun-Jul;20(5):e78.
Abstract
BACKGROUND:
Recommendations for palivizumab immunoprophylaxis in premature infants have changed in response to general improvements in outcomes of premature infants and changes in demographic and frequency of RSV-related hospitalization. In August 2014, AAP revised its policy statement limiting palivizumab prophylaxis in premature infants to those <29 weeks gestation. The effect of this change is uncertain but can be estimated on previous cohorts.
OBJECTIVES:
To assess the impact of the revised eligibility criteria for palivizumab prophylaxis on the number of eligible premature infants and the cost of palivizumab used.
DESIGN/METHODS:
The Manitoba RSV Immunoprophylaxis Program coordinates RSV immunoprophylaxis for the province of Manitoba. The Program receives notification of all births <35 weeks gestation. Premature infants ≤32 weeks gestation, and 33–35 weeks gestation at high risk for RSV-related hospitalization (based on risk scoring or residing in remote communities) are eligible for immunoprophylaxis. Anonymized data from the three seasons (2011–14) on the number of premature infants enrolled, amount of palivizumab received, and proportional cost of palivizumab was abstracted and reanalyzed applying <29 weeks gestation as cut-off for eligibility.
RESULTS:
For the three seasons, 672 premature infants (Table 1) were enrolled and received palivizumab. Total cost of palivizumab for this cohort was $2,877,096 (Canadian). Limiting eligibility to <29 weeks gestation reduced enrollment to 113 premature infants with cost of palivizumab of $467,684. Revision to eligibility criteria would have resulted in 559 fewer infants receiving palivizumab and a cost reduction of $2,409,412 over the past three seasons.
CONCLUSION:
The AAP revised policy statement limiting palivizumab eligibility to premature infants <29 weeks gestation will have a large impact reducing number of premature infants eligible and the cost of palivizumab utilized. In a provincial-based cohort, retrospective application of the new eligibility criteria would have resulted in 559 fewer eligible infants and a cost reduction of $2.4 million over the past three seasons.
| Current Program Enrolment | Using Revised AAP Statement | |||||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| ≤32 | 33–35 | Total Premature Infants | Cost palivizumab | <29 | Cost palivizumab | Not Enrolled | Palivizumab expenditure decrease | |
| 2011–12 | 161 | 83 | 244 | 945,740 | 31 | 135,979 | 213 | 809,761 |
| 2012–13 | 155 | 82 | 237 | 1,071,825 | 35 | 138,458 | 202 | 933,367 |
| 2013–14 | 154 | 37 | 191 | 859,531 | 47 | 193,247 | 144 | 666,284 |
| 2011–14 | 470 | 202 | 672 | 2,877,096 | 113 | 467,684 | 559 | 2,409,412 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e78–e79.
Abstract
BACKGROUND:
Lyme disease, a tick-borne zoonoses caused by the bacterium Borrelia burgdorferi, is emerging in Canada, mostly due to the spread of tick vectors into central and eastern Canada. Surveillance in the US suggests that children, especially those 5 to 9 years of age, are at increased risk of infection.
OBJECTIVES:
Surveillance for childhood Lyme disease was initiated in July 2014 to i) explore incidence in children in Canada; ii) identify emerging locations of, and environmental risk factors for, Lyme disease; iii) define the spectrum of clinical presentation in Canadian children; iv) describe diagnostic methods used by paediatricians; and vi) describe treatment regimens used and the frequency of post-treatment clinical manifestations of Lyme disease.
DESIGN/METHODS:
Using the established methodology of the CPSP, approximately 2500 pediatricians receive a monthly electronic survey to report cases of suspected Lyme disease. Case reporters subsequently receive a paper-based, structured questionnaire by mail. The national case definition is used to determine cases as probable or confirmed Lyme disease cases.
RESULTS:
As of November 2014 20 cases (age range 2–12) have been reported from three provinces: Ontario, Quebec and Nova Scotia. Validation of these reports is in progress. We will describe in this presentation the process and questionnaire used to obtain information on childhood cases of Lyme, as well as details and analysis of data from cases reported in 2014.
CONCLUSION:
A pediatrician based reporting program to determine the frequency and characteristics of childhood Lyme disease cases in Canada appears feasible. The program will continue until 2017, and will define the specific epidemiology of this important infection in Canadian children.
Paediatr Child Health. 2015 Jun-Jul;20(5):e79.
Abstract
BACKGROUND:
Influenza is a viral infection which causes outbreaks and epidemics around the world each year.
During the influenza season of 2012–2013, community-wide influenza activity was declared in the region serviced by RPAC.
The recommendation for influenza vaccination indicates that all children >6 months of age be immunized, specifically children with asthma are highlighted in the recommendations.
OBJECTIVES:
Audit of the compliance of paediatric asthma patients with Influenza Vaccination during the 2014–2015 influenza season and assessment of relevant asthma related outcomes.
DESIGN/METHODS:
In the 2014–2015 audit year RPAC offered intra-nasal influenza vaccination as an alternative for children aged 2–6 years. An audit of consecutive patients during the influenza season was undertaken. Specifically a preset information data sheet was used to collect information.
RESULTS:
The initial audit (2012–2013) during the community wide influenza alert indicated a low rate of immunization (24%), with significant disease burden marked by increased unscheduled emergency room and hospital visits, increased need of prednisone use for asthma exacerbations, and increased antibiotic use for those children not vaccinated. After a review of the possible variables which led to decreased immunization rates, we enhanced our influenza practice by offering immunizations with the RRT at the time of the clinic during the 2013–2014 year.
Audit of the 2013–2014 year indicated that 383 children were offered immunization and 268 agreed for a rate of 59%.
In the 2014–2015 audit year RPAC offered intranasal influenza vaccination for children aged 2–6 years, and as an alternative to older children who refused injections.
An audit of consecutive patients during the 2014–2015 influenza season was undertaken.
The numbers for the 2014–2015 influenza year will be available in March 2015.
CONCLUSION:
After analysing the potential barriers to influenza immunization in a regional paediatric asthma clinic a decision was made to offer the immunization at the the clinic visit. The immunization was carried out by one of the registered respiratory technologists who are present at every asthma clinic visit. This simple enhancement resulted in a rate change of 24% to 59% of the children who were offerred the vaccine agreeing to the immunization. In the 2014–2015 year, in addition to the offer of immunization by traditional methods, RPAC also offerred the option of intrasnasal influenza immunization to children 2–6 years of age as the preferred vaccine and to any child at any age who refused the injectable vaccine.
Paediatr Child Health. 2015 Jun-Jul;20(5):e79.
Abstract
BACKGROUND:
Introduction: The distribution of Epstein Barr Virus (EBV)-associated pathologies varies worldwide. The EBNA-1 gene encodes a fundamental protein as it helps maintain the EBV episome and is expressed in all EBV-associated malignancies. It is unclear whether variation within EBNA-1 accounts for these different pathologies, or whether variation in the EBNA-1 sequence is simply due to varying geographical distribution.
OBJECTIVES:
To compare DNA sequences between patients with different EBV associated pathologies, to see if these can be explained by different mutations.
DESIGN/METHODS:
We sequenced the EBNA-1 gene from samples taken from transplant patients, which included asymptomatic transplant patients and patients with post-transplant lymphoproliferative disorder (PTLD), as well as patients with infectious mononucleosis (IM). Sequencing was done by Sanger methodology and the sequences were aligned with reference strains and compared with publically available databases.
RESULTS:
There were 20 samples; transplant = 11, IM = 9. Male to female ratio 1:1.2, age range 1–17 years. Of the transplant patients, four had PTLD. Phylogenetic trees showed there was great genetic diversity between strains when compared to publicly available sequences and no particular disease-related clustering. Within the carboxy terminal of EBNA-1 we found eighteen sites associated with amino acid substitutions; (residues 410, 429, 439, 471, 476, 487, 492, 499, 500, 502, 524, 525, 563, 574, 585, 588, 594, 595). Looking at the amino acid at position 487, transplant strains were more likely the P-Thr subtype, and less likely the P-Ala subtype, compared to IM strains; (71% of non-PTLD transplant strains were of the P-Thr subtype, compared to 75% of PTLD strains and 67% of IM strains, while 14% of non-PTLD strains were P-Ala, compared to 25% of PTLD strains and 33% of IM strains). Interestingly, 14% of non-PTLD transplant strains were of the V-Leu subtype. The percentage of amino acid substitutions was higher in the transplant patients, (52% in non-PTLD samples, 45% in PTLD samples, compared with 40% in IM samples).
CONCLUSION:
Conclusion: In conclusion, we generated 20 new EBNA-1 sequences from strains isolated in Toronto and showed that there is genetic diversity in EBNA-1 sequences within one city. Our initial findings suggest that the type and frequency of amino acid substitutions may vary between transplant patients compared with patients with infectious mononucleosis. Further research will define the significance of these observations, including the extent to which these findings relate to the severity of infectious mononucleosis or the genesis of EBV-related PTLD.
Paediatr Child Health. 2015 Jun-Jul;20(5):e79–e80.
Abstract
BACKGROUND:
Necrotizing fasciitis (NF) is a severe soft tissue infection that results in necrosis of the subcutaneous tissue and fascia. This infection, while devastating and requiring prompt recognition and management, is rare in the paediatric population. In Canada, only 2.93 cases per million youth occur annually. There has not been a dedicated Canadian paediatric study of necrotizing fasciitis management to date.
OBJECTIVES:
The rarity of NF in children means that emergency physicians are less likely to be familiar with its presentation and initial management. Given that rapid identification and treatment are predictive of positive outcomes, we sought to assess the promptness and appropriateness of management in paediatric cases of NF.
DESIGN/METHODS:
A retrospective chart review examined cases of paediatric NF treated at two tertiary care centres between 2003 and 2013. Times to antibiotic administration, arrival of consulting services, and debridement surgery were collected. The variability in the CTAS score at presentation, choice of antibiotics, total number of debridement surgeries, length of stay and resulting complications were assessed.
RESULTS:
Among the 13 patients identified over the 10-year period, Group A Streptococcus was most commonly isolated (8 cases). Appropriate antibiotics were administered on average 4.6 hours (range 1.0 – 25.5 hours) after presentation to the emergency department. The mean times to infectious disease and surgical consults were 13.2 hours (range 1.1 – 42.5 hours) and 9.8 hours (range 0.4 – 28.7 hours), respectively. Debridement surgeries were performed, on average, 21 hours (range 2.8 – 40.8 hours) after presentation. The mean length of hospital stay was 24 days (range 6 – 49 days).
CONCLUSION:
This is the largest Canadian study to assess the timeliness of hospital management of NF in the paediatric population. The large variability in the care of these patients reflects the lack of a standardized approach to their presentation. Given that prompt surgical management is the most important intervention to reduce NF-associated mortality, we have developed an evidence-based streamlining protocol for use in paediatric emergency departments.
Paediatr Child Health. 2015 Jun-Jul;20(5):e80.
Abstract
BACKGROUND:
Enteric fever, caused by Salmonella typhi and paratyphi, is estimated to cause 16 million cases and 600,000 deaths per year. After influenza, it is the 2nd most common cause of vaccine-preventable fever related admission following international travel. Although public health measures have effectively eliminated domestic acquisition, enteric fever continues to occur in Canada mainly as a result of travel.
OBJECTIVES:
To describe the epidemiology, microbiology, clinical presentation, management, and outcomes of patients with enteric fever diagnosed or treated at a large tertiary care paediatric centre over a 28-year period.
DESIGN/METHODS:
We performed a retrospective chart review of all patients seen under age 18 years with blood or stool cultures that were positive for S. typhi or S. paratyphi over the study period.
RESULTS:
We identified 126 children with positive cultures for S. typhi or S. paratyphi between January 1985 and December 2013. Of these, relapse was microbiologically confirmed in four cases and all recovered.
Most cases occurred in children who visited friends and relatives abroad, with 80% reporting a travel history to India, Pakistan, or Bangladesh. Of the patients for whom vaccination history was available, only 4.7% received a typhoid vaccine. There was significant resistance to ampicillin and ciprofloxacin but all isolates were sensitive to 3rd generation cephalosporins.
Over the last 13 years, there has been a 154% increase in the number of cases overall compared to the previous 15 year period and the proportion of cases originating from South Asia has increased from 66% to 85%. In many cases there was also evidence of a delay in diagnosis and treatment. The median number of physician visits prior to diagnosis was 3 (IQR 2–4, maximum 8) and the median duration between first physician contact and initiation of appropriate antibiotics was four days (IQR 2–7, maximum 27 days).
CONCLUSION:
Enteric fever remains a major, preventable global infectious disease, and this review highlights the unique aspects of prevention, recognition, and management in a resource-rich, multicultural setting. Children who travel to endemic areas to visit friends and relatives abroad should be targeted for prevention through counselling and vaccination. Upon return, clinicians must keep enteric fever on their differential for any child returning with fever from the Indian subcontinent, particularly since symptoms are nonspecific. Based on changing resistance patterns, we recommend that third generation cephalosporins be used as empiric therapy until culture and antibiotic susceptibility testing results are available.
Paediatr Child Health. 2015 Jun-Jul;20(5):e80–e81.
Abstract
BACKGROUND:
Guidelines give recommendations based on synthesis of evidence with the designed purpose to influence a physician’s care of the patient.
OBJECTIVES:
What is the degree of agreement between similar bronchiolitis treatment recommendations within different national guidelines?
DESIGN/METHODS:
Guidelines were searched with MEDLINE, EMBASE, and the grey literature. Recommendations within each guideline were categorized as 1) recommend for 2) optionally recommend 3) abstain from recommending and 4) recommend against a treatment. The degree of agreement between recommendations was evaluated using a weighted Kappa score. Pairwise comparisons of the guidelines were evaluated similarly.
RESULTS:
There were five guidelines: American Academy of Pediatrics (AAP), Scottish Intercollegiate Guidelines Network (SIGN), Clinical Practice Guidelines in the Spanish National Healthcare System (Spain), Pediatric Society of New Zealand (NZ), and Australian Health for Kids Guideline Development Group (AUS). There were 95 recommendations with 25 recommendations given in >2 guidelines. The overall weighted Kappa score for the treatment recommendations was 0.91 (CI 0.82, 0.98). This demonstrates excellent agreement. Overall agreement between the pairs ranged from the lowest of 0.82 (CI 0.60, 1.00) between the AAP and NZ guidelines to the highest degree of agreement of 0.96 (CI 0.88, 1.00) between the SIGN and Spain guidelines.
CONCLUSION:
Overall, there was excellent agreement of the bronchiolitis treatment recommendations internationally. Evidence synthesis and guideline generation is labor intensive and expensive. Globalization of guidelines would conserve resources and allow for greater resource utilization for implementation of guidelines at the bedside.
TABLE 1.
Pairwise Weighted Kappa Values
| AAP Guideline Weighted Kappa (CI) | SIGN Guideline Weighted Kappa (CI) | Spain Guideline Weighted Kappa (CI) | NZ Guideline Weighted Kappa (CI) | AUS Guideline Weighted Kappa (CI) | |
|---|---|---|---|---|---|
| n = # of recommendations | n | n | n | n | |
| AAP Guideline Weighted Kappa (CI) | – | 0.93 [0.79, 1.00] | 0.91 [0.79, 1.00] | 0.82 [0.60, 1.00] | 0.83 [0.64, 1.00] |
| n | N = 8 | N = 12 | N = 7 | N = 8 | |
|
| |||||
| SIGN Guideline Weighted Kappa (CI) | – | 0.96 [0.88, 1.00] | 0.93 [0.84, 1.00] | 0.93 [0.80, 1.00] | |
| n | N = 13 | N = 8 | N = 9 | ||
|
| |||||
| Spain Guideline Weighted Kappa (CI) | – | 0.94 [0.82, 1.00] | 0.91 [0.79, 1.00] | ||
| n | N = 9 | N = 14 | |||
|
| |||||
| NZ Guideline Weighted Kappa (CI) | – | 0.92 [0.77, 1.00] | |||
| n | N = 7 | ||||
|
| |||||
| AUS Guideline Weighted Kappa (CI) | – | ||||
| n | |||||
Paediatr Child Health. 2015 Jun-Jul;20(5):e81.
Abstract
BACKGROUND:
Aspiration pneumonia (AP) is the most common cause of hospitalization and death in children with neurologic impairment (CNI). Yet, very little is known about the conditions that contribute to AP in CNI or how it should be treated. Furthermore, it is unclear if current routine interventions in CNI, including G-tubes and acid suppression medication (ASM), have altered previously held assumptions about the microbiological causes of AP in these children.
OBJECTIVES:
(1) To describe the type, concentration and susceptibility profile of bacteria found in gastric aspirates of CNI with G-tubes; (2) to compare gastric flora of CNI in ambulatory settings to those admitted to hospital with AP; and (3) to explore predictors of bacterial colonization of the stomach.
DESIGN/METHODS:
We recruited CNI who were G-tube fed and on regular ASM. Outpatients were recruited from routine clinic visits at a children’s hospital in Canada; inpatients were admitted with a clinical diagnosis of AP. Excluded were immunocompromised patients and those on 24/7 home ventilation. Gastric aspirates were collected from the G-tube and sent for pH and microbial testing. All pathogenic bacteria were tested for antibiotic sensitivity.
RESULTS:
42 patients (21 inpatients, 21 outpatients) have been recruited to date. Omeprazole was the most common ASM (N=38). Among inpatients, 50% had an underlying genetic syndrome, mean pH of gastric sample was 5.6±2.2 and mean bacterial growth was 2.17×108 CFU/mL. Among outpatients, 65% had an underlying diagnosis of cerebral palsy, mean gastric pH was 5.4±1.8 and mean bacterial growth was 2.85×108 CFU/mL. All inpatient and outpatient samples collected with pH2 (n=38) showed growth, with Streptococcus viridans (22.7%), Klebsiella pneumoniae (10.8%) and Pseudomonas aeruginosa (8.9%) being the most common organisms grown. There was no significant difference in the types of organisms found in gastric samples of inpatients vs. outpatients. Antibiotic sensitivity rates assessed in pathogenic bacteria were 96.6%, 96.6%, 93.5% for ciprofloxacin, gentamycin and tobramycin, respectively.
CONCLUSION:
Traditionally considered a sterile environment, a variety of microorganisms, many of which are common flora of the oropharyngeal tract, are being found in gastric aspirates of study participants. This may be related to increases in gastric pH secondary to ASM. Further studies will be needed to correlate organisms grown in gastric aspirates of CNIs on ASM to those causing APs as this may have implications for the optimal treatment of APs in this patient population.
Paediatr Child Health. 2015 Jun-Jul;20(5):e81.
Abstract
BACKGROUND:
In an increasingly challenging fiscal climate, there is pressure to reduce inpatient length-of-stay. Current research suggests that unnecessarily-prolonged paediatric admissions are common, and that for many diseases, day-hospital management provides efficient care that is well-liked by patients and families. Many current paediatric inpatients may not require overnight nursing, and remain as inpatients to facilitate rapid services.
OBJECTIVES:
To develop and evaluate an Alternate Care Environment (“ACE Space”) that transitions inpatients to a day-hospital setting where they receive rapidly-arranged follow-up, investigations, interventions, and specialty consultations, while reducing inpatient length-of-stay.
DESIGN/METHODS:
At our single tertiary-care facility in Spring 2014, all paediatric medicine inpatients were audited for potential to be managed in a day-hospital setting. Families identified by ward staff were interviewed to determine their interest in day-hospital care. Physicians and nurses were interviewed to determine patient inclusion criteria. A Rapid Improvement Event finalized the ACE’s design. An ongoing pilot was launched in August 2014. In the ACE, patients receive inpatient-level access to hospital services. Outcome measures (ACE visit number, satisfaction, estimated savings of inpatient days, average inpatient length-of-stay), process measures (referral source, diagnosis, hours per visit, investigations, interventions, and specialty consultations), and balancing measures (ACE patients requiring inpatient admission, nursing resource utilization) are being tracked.
RESULTS:
Pre-pilot audits identified on average four patients per day (7.8% of total patients) as potentially manageable in a day-hospital setting. Sixteen of 26 “ACE-eligible” families (61.5%) said they would prefer going home at night. In its first 3.5 months, the ACE had 146 patient visits (39.6/ month), saving an estimated 139 inpatient bed days (38.2/month). There was a heterogeneous mix of diagnoses. Fifty-three of 55 families (96.4%) rated their overall experience as “very good” or “excellent”. Thirty-two patients received laboratory investigations, and 35 received diagnostic imaging (e.g. MRI). There were 18 IV or subcutaneous medication administrations, six central line procedures, 16 other procedures (e.g. urinary catheterization), 63 subspecialty consultations, and 21 allied health consultations. Four (2.7%) patients required inpatient admission from the ACE.
CONCLUSION:
These data demonstrate that some paediatric inpatients do not require overnight nursing, and can be safely managed in a day-hospital setting. The ACE provides a safe inpatient alternative for a heterogeneous mix of diagnoses and patient needs, and services that are not available or expedient in a clinic setting. Future work will analyze the ACE’s effect on inpatient length-of-stay and cost.
Paediatr Child Health. 2015 Jun-Jul;20(5):e81–e82.
Abstract
BACKGROUND:
Historically, most paediatric deaths have occurred in a hospital setting with up to 85% of these in the Paediatric Intensive Care Unit (PICU). The increase of children with chronic complex conditions (CCC) cared for at paediatric tertiary institutions, who often have shortened-life spans, has also come with an increase in the proportion of deaths at home. Few studies, however, have examined whether the growth of this population has had any effect on deaths within the hospital setting.
OBJECTIVES:
To describe the changes in in-hospital deaths amongst ‘general paediatric’ patients at a tertiary care children’s hospital in Canada over three different decades.
DESIGN/METHODS:
Data was collected for all children who died on the general paediatric wards or in the PICU at a children’s hospital in Canada in the years 1998, 2005 and 2012. Children who died in the PICU were considered to have a ‘general paediatric’ diagnosis if their underlying condition or diagnosis would have typically resulted in admission to a general paediatric ward. Data collected was related to: demographics, health services data, cardiopulmonary resuscitation (CPR) status and involvement of palliative care services. Comparisons between different groups were made using χ2 tests or ANOVA with Bonferri correction where appropriate. Institutional ethics review board approval was obtained.
RESULTS:
85 children met inclusion criteria; 35 in 1998, 27 in 2005, and 23 in 2012. Differences in location of death were noted across the three time periods. 94% of general paediatric patients died in the PICU in 1998; 59% in 2005, and 70% in 2012 (P=<0.001). The proportion of their lifespan spent as an inpatient increased from 16% to 24% (P=0.61) in this 14-year period. The proportion of patients with ‘no CPR’ orders at the time of death increased from 31% in 1998 to 87% in 2012 (P=<0.001). Patients with palliative care involvement increased from 8.6% in 1998 to 73.9% in 2012 (P=<0.001).
CONCLUSION:
The past 14 years has witnessed a reduction in the number of general paediatric inpatient deaths at a children’s hospital in Canada. Significant shifts in the characteristics of those children who died in hospital were also seen over this period: a greater proportion of their lives spent as inpatients; increased involvement of palliative care and decisions to not attempt CPR; and ultimately a greater number of deaths on the Paediatric Medicine Ward. These findings may have implications for the provision of quality inpatient end-of-life care for the growing number of children with CCC.
Paediatr Child Health. 2015 Jun-Jul;20(5):e82.
Abstract
BACKGROUND:
Peripheral Intravenous (IV) insertion in children is a traumatic procedure. Minimizing the number of IV lines a child needs throughout an admission improves the child’s care experience.
OBJECTIVES:
To identify modifiable factors affecting longevity of peripheral IV lines in children.
DESIGN/METHODS:
A retrospective chart review of IV lines on the pediatric ward in a small urban center (approximately 1700 admissions per year) was conducted between December 1st, 2013 and February 28th, 2014. IV lines which were removed because they were no longer required within 48 hours of insertion were excluded. The length of time an IV line spent in situ, its uses, location, and catheter size, and the reason for removal were recorded. Time spent saline locked or running at a rate of up to 10 mL/hour ‘to keep vein open’ (TKVO) was also recorded for each line. χ2, Fisher Exact, and Mann-Whitney U tests were used to identify factors associated with IV line longevity. The primary outcome in this analysis was survival of IV line at 48 hours after insertion, as this is a common duration of antibiotics for children awaiting negative culture results. This study received local ethics board approval.
RESULTS:
A total of 284 IV lines were reviewed; 139 IV lines met the inclusion criteria. Lines remained in situ for a median of 62.3 hours (range 0.3–368.5, interquartile range 36.0, 77.0). 59% (n=55) of lines which lasted more than 48 hours spent greater than 20% of the IV duration TKVO compared to 28% (n=13) of lines which failed prior to 48 hours (P=0.001). Catheter size (P=1.0), insertion site (P=0.23), spending greater than 20% of line duration saline locked (P=0.67), and running fluids and/or medications at a rate above 10 mL/hour for greater than 20% of line duration (P=0.81) were not associated with IV line longevity.
CONCLUSION:
In this retrospective analysis, the majority of IV lines which spent greater than 20% of their duration running fluids at TKVO rates remained in situ for at least 48 hours, whereas lines which spent greater than 20% of their duration saline locked were no more likely to survive than to fail at 48 hours.
Paediatr Child Health. 2015 Jun-Jul;20(5):e82.
Abstract
BACKGROUND:
With advancements in therapies, most children diagnosed with cancer will survive their initial malignancy. However, they are at risk of developing various treatment-related late effects that can manifest years after completion of therapy. Long-term follow-up (LTFU) care is crucial to the identification and management of late effects in childhood cancer survivors. Yet, research shows that many survivors fail to transfer to LTFU after discharge from a pediatric setting or subsequently drop out as adults. For some patients, the differences encountered in the delivery and organization of care between pediatric and adult centres may act as barriers to attendance in LTFU care.
OBJECTIVES:
Recognizing that many differences exist between pediatric and adult care services, we aim to describe adolescent childhood cancer survivors’ beliefs/expectations about the nature of adult healthcare.
DESIGN/METHODS:
Survivors of cancer in childhood or adolescence, between 15 to 19 years of age, who had not yet transitioned to adult LFTU cancer care, were recruited either in person or through mail. Participants completed a questionnaire which included a demographic survey and a newly developed ‘Expectations scale’. The scale contains 12 items designed to measure survivors’ expectations about the nature of adult LTFU care and has been found to be psychometrically valid and reliable.
RESULTS:
A total of 156 AYA survivors from three Canadian pediatric hospitals completed the scale. Regarding adult LTFU care, 68% of participants expected that the doctor will become like a friend, and 61% expected to spend a lot of time with the doctor during the appointment. Regarding the organization of their care, 87% expected to receive a reminder call before the appointment, while 88% expected to be called if they miss an appointment. Furthermore, 64% of survivors expected the doctor to look after all of their healthcare needs, not just those related to their prior cancer therapy.
CONCLUSION:
AYA childhood cancer survivors have specific beliefs/expectations about LTFU care, some of which may contrast with the reality of adult care services. Significant levels of unrealistic expectations may contribute to poor compliance with LTFU care. Prior to transfer, AYA survivors may benefit from preparation and education about the different culture of care that they will likely encounter in order to resolve dissonance and improve transition.
Paediatr Child Health. 2015 Jun-Jul;20(5):e82–e83.
Abstract
BACKGROUND:
Electronic-cigarettes (e-cigarettes) have been marketed as a smoking cessation tool. Use amongst adolescents has not been well-described.
OBJECTIVES:
To evaluate the prevalence, motivations, and risk factors for use of e-cigarettes in adolescents.
DESIGN/METHODS:
A population-based, cross-sectional universal screening study was performed in the geographically and administratively defined Niagara Region, Ontario, Canada. Data were collected from all grade-9 students through the Heart Niagara Inc. Healthy Heart Schools’ Program (2013–2014 school year). Questionnaires assessed cigarette, e-cigarette, and other tobacco use. Household income was assessed through the 2011 Canadian census.
RESULTS:
N = 2367 students (54% male, 14.6±0.5 years old) answered the questionnaire. Within the last month, 66 (3%) students reported smoking. Most students (1599, 70%) had heard of e-cigarettes, with 380 (24%) learning from a store sign/display. E-cigarette use was reported by 238 (11%) students, with 134 (56%) having used it once and 18 (8%) reporting frequent/daily use. The majority (171, 72%) tried it because it was “cool/fun/new” while 14 (6%) used it to help smoke less or quit. Use was greater amongst males, those whose family or friends smoked, and in those with cigarette or other tobacco use (Table 1). Self-identified fair/poor health rating (OR 1.9 (95% CI 1.2–3.0, P<0.001)) and high stress level (OR 1.7 (95% CI 1.1–2.7, P<0.001)) were associated with increased odds of e-cigarette use. E-cigarette use was associated with lower average household incomes (33.4±8.4 vs. 36.1±10.7 × $1000, P=0.001).
CONCLUSION:
E-cigarette use is common amongst Canadian adolescents. Smoking reduction and cessation do not appear to be motivating factors regarding its use. E-cigarette use is associated with individual, family, and friend tobacco use, among other associations. These findings support the implementation of strict regulations to help reduce use amongst Canadian adolescents.
TABLE 1.
Associations between e-cigarette use and various risk factors; all associations P<0.001
| Has tried e-cigarettes | Has not tried e-cigarettes | |
|---|---|---|
| Sex (n = 2278) | ||
| Male | 156 (13%) | 1071 (87%) |
| Female | 82 (8%) | 969 (92%) |
| Family member that smokes (n = 2241) | ||
| Yes | 178 (15%) | 979 (85%) |
| No | 58 (5%) | 1026 (95%) |
| Friends that smoke (n = 2235) | ||
| Yes | 168 (21%) | 616 (79%) |
| No | 68 (5%) | 1383 (95%) |
| Any smoking in the last 30 days (n = 2255) | ||
| Yes | 41 (67%) | 20 (33%) |
| No | 193 (9%) | 2001 (91%) |
| Ever tried cigarillo (n = 2270) | ||
| Yes | 60 (71%) | 24 (29%) |
| No | 176 (8%) | 2010 (92%) |
| Ever used water-pipe (n = 2259) | ||
| Yes | 38 (68%) | 18 (32%) |
| No | 196 (9%) | 2007 (91%) |
Paediatr Child Health. 2015 Jun-Jul;20(5):e83.
Abstract
BACKGROUND:
Physical literacy is a child’s capacity to achieve a healthy, active lifestyle. Leaders in healthcare and allied-health (health) are important partners for identifying children with physical literacy deficits. Current physical literacy assessments are time consuming and require resources not typically available in health settings.
OBJECTIVES:
We sought to develop and evaluate physical literacy screening tasks that would be suitable for health professionals in a variety of settings. The goal was to enable health professionals to quickly and accurately identify children in the lowest 10th percentile of physical literacy scores.
DESIGN/METHODS:
Children, eight to 12 years, were recruited from recreation, education and health settings. They performed the Canadian Assessment of Physical Literacy (CAPL), a detailed assessment of a child’s capacity for a physically active lifestyle. Children also answered simple questions about their own physical activity and performed eight potential physical literacy screening tasks, including one test of strength, two balance tests, one endurance test, and four motor skills assessments. Children were grouped as above/below the 10th percentile for CAPL score. Sensitivity and specificity scores for each screening task, and for combined pairs of screening tasks were calculated based on the 10th percentile groups.
RESULTS:
Study protocols were completed by 105 children (52.4% female). Sensitivity of individual test items to identify children below the 10th percentile for CAPL score ranged from 60% to 100%. Specificity for individual scores ranged from 9.6% to 87.8%. Two combination protocols were identified as having high specificity and sensitivity. Each combination contained two screening tasks: a) holding a one-leg balance test on the left leg for less than 34 seconds and a wall sit for less than 33 seconds (80.0% sensitivity, 93.3% specificity), and b) holding a one-leg balance test on the left leg for less than 40 seconds and self-reporting an activity level, as compared to their peers, below 6 out of 10 (60.0% sensitivity, 93.0% specificity). The positive predictive value of these protocols was high (98.8% and 97.9%, respectively).
CONCLUSION:
Two sensitive and specific physical literacy screening protocols for children eight to 12 years of age were identified for health settings. Reliability of the screening protocols and effectiveness of the screening task educational materials are on-going. Future research should evaluate the suitability of the screening tasks for children with identified disabilities/chronic illnesses, and the ability of healthcare and allied-health professionals to implement the screening tasks and utilize the results obtained for patient care.
Paediatr Child Health. 2015 Jun-Jul;20(5):e83–e84.
Abstract
BACKGROUND:
Fragile X syndrome (FXS) is the most common form of inherited intellectual and developmental disability. FXS is characterized by a behavioural phenotype which may include symptoms of autism and attention deficit-hyperactivity, in addition to mild physical features. The prevalence of FXS has been estimated at 1 in 4000 males and 1 in 5–8000 females. There is limited information in the medical literature on the demographics of fragile X syndrome in Canada. It is currently unclear whether the prevalence is similar to published rates in other populations, whether there is a delay in obtaining a diagnosis, and whether there are significant numbers of individuals with FXS, but without access to specialty care.
OBJECTIVES:
To ascertain the incidence of new diagnoses of FXS as well as obtain information about the demographics, clinical features, geographic distribution and management of FXS in Canada.
DESIGN/METHODS:
Paediatricians and paediatric subspecialists who participate in the Canadian Paediatric Surveillance Program (CPSP) were asked to identify newly diagnosed cases of fragile X syndrome seen between April 2012 and April 2014. When new cases were identified, the reporting physician was asked to complete a detailed questionnaire to obtain clinical data on the case. Quantitative and qualitative analyses will be performed to assess incidence, demographics including age at diagnosis, sex, ethnicity, geographic location, clinical features, and access to care for reported cases; with comparisons to previously published data.
RESULTS:
41 cases were reported during the study period and a total of 28 cases with completed questionnaires were included for data analysis. There were two females and 26 males. Cases were reported from many provinces across the country with the highest number of cases (n=12, 43%) reported in Ontario. The vast majority of cases were of Caucasian ethnicity. The majority of reporting physicians were responsible for ordering the diagnostic testing. The majority of cases were diagnosed after the age of three years. Additional patient demographic data, clinical features and services used will be analyzed and presented.
CONCLUSION:
New diagnoses of Fragile X syndrome are being made in Canada at a rate in keeping with expected prevalence. The geographic distribution and patient demographics were generally representative of the Canadian population. However there was evidence of delayed diagnoses based on generally early ages of parents reported first concern and late ages at diagnosis. Paradoxically the diagnostic laboratories across the country continue to perform enormous numbers of normal fragile X tests every year, raising the concern that the wrong children are being tested. Delayed diagnoses have been a consistent problem in the United States and the concern has led to a call for population-based screening. The CPSP study has shown that the experience of Canadian families affected by fragile X-related disorders is in many ways similar to American families, and that an improved approach to recognizing and diagnosing FXS would be of benefit.
Paediatr Child Health. 2015 Jun-Jul;20(5):e84.
Abstract
BACKGROUND:
Type 2 diabetes (T2D) is a global epidemic that currently affects 347 million people worldwide. Many of the abnormalities that characterize this disorder, particularly perturbations in glucose levels, appear to begin as early as 12 years of age. One proposition to explain its pathogenesis, the ‘fetal insulin hypothesis’, suggests that genetically determined impaired insulin secretion or action leads to poor insulin-mediated fetal growth and impaired insulin function in post-fetal life. Elevated glucose levels and an increased risk for T2D is a consequence of these impairments. While the hypothesis is compelling, to date little empirical evidence has been presented in its support.
OBJECTIVES:
We used a family-based design to explore genes responsible for elevated blood glucose at birth and in early infancy.
DESIGN/METHODS:
610 newborns, 643 mothers and 366 fathers enrolled in the Family Atherosclerosis Monitoring In EarLY Life (FAMILY) study were included. Plasma glucose and anthropometric characteristics were collected at birth, 3, and 5 years. Quantitative trait disequilibrium tests and mixed-effects regressions were conducted to uncover genes associated with glucose. A genotype score was also tested.
RESULTS:
Risk alleles for six loci increased glucose levels from birth to 5 years of age (ADCY5, ADRA2A, CDKAL1, CDKN2A/B, GRB10, and TCF7L2, 4.85×10−3 ≤ P ≤ 4.60×10−2). The six genes are also associated with impaired pancreatic function, low birth weight (a marker of poor fetal growth), and T2D, supporting a pattern consistent with the fetal insulin hypothesis. Effect sizes for these genes were similar to those in adults, suggesting age-independent effects.
CONCLUSION:
Ours is the first study to systematically explore genetics of glucose in early childhood and among a few to provide support for the fetal insulin hypothesis. Our results suggest that a unique subset of genes, involved in beta cell dysfunction, low birth weight, and increased T2D risk, modulate plasma glucose at birth and in early infancy.
Figure 1).
Biological model to explain how gene variants in/near ADYC5, ADRA2A, CDKAL1, CDKN2A/B, GRB10, and TCF7L2 are involved in reduced beta-cell mass/beta-cell dysfunction in early stages of life (fetus) and lead to low birth weight, perturbation of glucose metabolism in the early life that translates into high glucose levels and increased type 2 diabetes risk in adulthood
Paediatr Child Health. 2015 Jun-Jul;20(5):e84.
Abstract
BACKGROUND:
Despite clear guidelines, many school-aged children with persistent asthma are not prescribed long-term asthma controller by their physician.
OBJECTIVES:
To identify of key facilitators and solutions proposed by physicians to facilitate long-term prescription of asthma controller in children with persistent asthma (for ≥3 months or until follow-up with the treating physician).
DESIGN/METHODS:
We designed a two-phase mixed methods study. Following a qualitative study in which physicians proposed numerous facilitators and solutions to increase the prescription of long-term asthma controller, we developed a quantitative 175 item-questionnaire seeking physicians’ endorsement of proposed solutions and likely behaviour in one of four case vignettes of an individual (school-aged child or adult) with poor asthma control seen in the acute care or clinic setting. Using the Tailored design method, the questionnaire was sent to randomly-selected paediatricians (n=209), general practitioners (GP, n=525) and emergency physicians (EP, n=103), representing respectively 29%, 6% and 73% of the physician census tract of the College des médecins du Québec. Results are presented as weighted proportions. We focus this report on responses to the pediatric cases.
RESULTS:
After excluding 89 non-eligible physicians, we obtained a 56% participation rate (n=421) with 212 (115 paediatricians, 79 GP, and 18 EP) selecting a paediatric vignette (58% acute care; 42% clinic setting). Participants were predominantly women (79%), paediatricians (54.2%), practicing for a median of 11.5 years in an academic (53%) environment. Most physicians correctly identified the child as having uncontrolled (72%), persistent (81%) asthma and would have prescribed a long-term asthma controller (83%).
The following resources greatly increased physicians’ comfort in prescribing a long-term asthma controller: patient asthma education, use of lung function testing, concurring opinion from and access to specialists, frequent medical follow-ups, and the implication of allied healthcare professionals in patient self-management. Physicians highly endorsed proposals for: inter-professional team approach to patient self-management, professional education on asthma management, memory aids, computerized decision support tools, and computerized systems of waiting time for various health referrals.
CONCLUSION:
A large majority of surveyed physicians reported prescribing long-term asthma controller to the uncontrolled patient in the selected vignette, attesting to their general intention. An inter-professional team approach to guide patient self-management with allied health professionals, physician educational sessions, patient asthma education, decision support tool, and computerized waiting time for referrals were highly favoured by physicians treating children with asthma.
Paediatr Child Health. 2015 Jun-Jul;20(5):e84–e85.
Abstract
BACKGROUND:
Adherence to a formulary is essential for rational use of pharmaceuticals. Children represent a unique and challenging population: while efforts toward adult drug monograph formation have been successful, currently many countries lack a standardized formulary for drug therapy in children. Off-label drug use has been associated with an increased risk for adverse drug reactions. Furthermore, paediatric dosing is subject to a high rate of medication errors. Drug monographs (DMs) convey dosing recommendations and evidence supporting therapeutic use in specific populations. The lack of standardized paediatric DMs creates a problem for health care providers, researchers and parents as missing information often results in clinicians choosing the drug, dose and duration of therapy based on personal experience and Institutional recommendations rather than evidence. Current developmental pharmacology indicates that many paediatric subgroups require special dosing considerations, such as premature infants, neonates and obese children. Data on dosing in these populations is very rarely displayed in DMs tailored to the adult population.
OBJECTIVES:
To develop international standards for developing a paediatric DMs.
DESIGN/METHODS:
Following an international environmental scan of existing national formularies a committee of experts in paediatric therapeutics was established. It established a survey of essential items to be included in a paediatric DM to be completed via an International Delphi process. The survey covered areas including search criteria, age groups, adverse drug reactions and overdose, drug-drug interactions, dosing, precautions, formulation, drug properties, and lactation/breastfeeding. Participants from 36 countries spanning six continents were invited to participate in the first round of the Delphi in December 2014.
RESULTS:
Preliminary results include only the first 11 complete responses received. The majority of participants first consult a paediatric formulary (60%) when searching for information to select, prescribe, dispense, administer, monitor and advise on medicines for children. The remaining participant’s first source of information was the hospital formulary or a generic search engine (such as google). The most frequently consulted resource for consult was the British National Formulary for Children followed by Paediatric and Neonatal Lexi-drugs, Kinderformularium, NeoFax and the New Zealand formulary for Children. Further DM content specific results will be available at a later date.
CONCLUSION:
Preliminary results support the importance of developing standards for paediatric DMs as they are most frequently a first point of contact for information regarding paediatric dosing.
Paediatr Child Health. 2015 Jun-Jul;20(5):e85.
Abstract
BACKGROUND:
Inpatient subspecialty consultations are a crucial part of patient care on the general paediatrics wards and constitute a significant workload. Process, timeliness, communication, and overall quality of the consultation are longstanding issues. Recent published studies suggest that degree of completeness, timeliness, educational value, interaction between referring and consulting physicians, and overall consultation quality are important factors that impact patient care.
OBJECTIVES:
The objectives of this study are to: a) describe the current nature of subspecialty consultations on the general paediatrics ward of a tertiary care teaching hospital in Canada, b) audit compliance with a new hospital policy from 2013 governing consultations, and c) identify some of the major limitations in the current process.
DESIGN/METHODS:
The study involved a chart review, questionnaires completed by trainees from the general paediatrics ‘referring’ teams, and focus groups attended by the consulting and referring teams. Ethics approval was granted by the hospital Quality Management group. Descriptive statistical analysis was performed on the chart review and questionnaire data. Audio recorded data from the focus groups will be analyzed according to grounded theory methodology of open, axial and selective coding, constant comparison analysis, and cross comparison of themes among focus groups.
RESULTS:
Charts from two 2-week blocks were reviewed (n=123). Consults were requested for 70% of patients. The three most commonly consulted services were Neurology, Critical Care, and General Surgery, representing 10%, 9% and 7% of consults respectively. Compliance with essential documentation for initiating consultations according to hospital policy was variable; for example a staff consultant note was only found on 30% of consults. Teams requested advice on diagnosis (23%), treatment (15%) and both diagnosis and treatment (53%). Preliminary questionnaire responses (n=14) revealed that 86% of consultants provided initial recommendations within 12 hours of consult request. Referring teams found follow-up frequency to be ‘appropriate’ in 86% of cases. All consults were thought to have affected patient management. Only 25% of consultants who discussed initial recommendations directly with the patient/family communicated first with the referring team. Overall, 71% of referring individuals were satisfied with the consultation process. Focus group analysis is ongoing and will be completed in time for the poster.
CONCLUSION:
Subspecialty consultations are requested frequently on the general paediatrics ward and are viewed by referring teams as integral to patient care. Despite varying adherence to new consultation policy guidelines with some clear areas for potential improvements, overall satisfaction is currently running at 71% amongst trainees.
Paediatr Child Health. 2015 Jun-Jul;20(5):e85.
Abstract
BACKGROUND:
Poor feeding is a common nonspecific symptom of bronchiolitis in infants. Poor feeding predicts hospital admission in infants, while adequate feeding predicts safe discharge home from the emergency department in infants with bronchiolitis. A simple, reliable and valid measure of feeding adequacy may improve clinical decision-making about disposition in infants hospitalized with bronchiolitis. However, no such measurement tool exists.
OBJECTIVES:
To evaluate the measurement properties—validity, reliability, discriminatory power and responsiveness to change—of a visual analogue scale of feeding adequacy, for use in infants hospitalized with bronchiolitis.
DESIGN/METHODS:
Otherwise healthy infants six weeks to 24 months admitted to hospital with bronchiolitis were enrolled. On each day of the infant’s hospital stay, the primary caregiver and nurse were asked to independently rate the infant’s feeding on a feeding adequacy scale (FAS), a visual analogue scale (range 0–10). Other measures of the infant’s health status and hospital stay were recorded from the hospital chart. Spearman’s rank correlation, intra-class correlation, Ferguson’s delta and Wilcoxon signed rank were used to assess validity, reliability, discriminatory power and responsiveness to change, respectively.
RESULTS:
Twenty-six infants participated in this study. Median age was 2.9 months (range 1.5 to 18 months), and 17 (65%) were male. The FAS was valid, with a negative correlation between FAS on admission and length of stay (Spearman’s rank correlation=−0.52, P=0.008). Inter-rater reliability was good (intra-class correlation coefficient=0.72, 95% CI 0.46, 0.87) and the FAS was discriminatory (Ferguson’s delta=0.99). There was a significant difference between admission and discharge FAS scores (Wilcoxon signed rank test, P=0.002), reflecting responsiveness to change.
CONCLUSION:
This study suggests that the FAS is valid, reliable, discriminatory and highly responsive to change in infants hospitalized with bronchiolitis. This scale may be incorporated into future clinical practice guidelines to standardize efficient and safe discharge practices.
Paediatr Child Health. 2015 Jun-Jul;20(5):e85–e86.
Abstract
BACKGROUND:
Iron deficiency (ID) is the most common micronutrient deficiency in the world. Pre-school age children are a well-known high risk group for ID. Children from immigrant families may be at risk for ID due to a greater burden of acute and chronic infections, difficulty accessing health services, and cultural dietary practices. Conversely, such children may have family and community supports or exposure to selection and settlement policies when immigrating to Canada that improve their health status.
OBJECTIVES:
To assess serum ferritin levels (a measure of iron stores) in young children from immigrant versus non-immigrant families; and to evaluate the relationship between immigrant status and ID and iron deficiency anemia (IDA) and whether known dietary, environmental, or biologic determinants of low iron status influence this relationship.
DESIGN/METHODS:
This was a cross-sectional study of healthy urban children (12 to 72 months of age), recruited as part of TARGet Kids!, a primary care practice-based research network in Toronto, Canada. Laboratory assessment of serum ferritin and hemoglobin (Hgb) and standardized parent-completed surveys were completed between December 2008 and February 2013 during routine health maintenance visits. Multiple regression analyses were used to evaluate the association between immigrant status (Canadian born, immigrant from non-industrialized regions, immigrant from industrialized regions) and serum ferritin, ID (serum ferritin <14 μg/L), and IDA (serum ferritin <14 ug/L and Hgb ≤110 g/L).
RESULTS:
Of 2614 children included in the analysis (median age of 37 months) 48.5% were non-immigrants. Median serum ferritin was 30 ug/L and 10.4% of children had ID and 1.9% had IDA. After adjusting for ethnicity, age, sex, education, income quintile, cow’s milk intake, breastfeeding duration and bottle use, there were no significant associations between immigrant status and ferritin, ID or IDA. Significant predictors of low iron status included age, sex, cow’s milk intake, and breastfeeding duration.
CONCLUSION:
We found no association between family immigrant status and iron status including serum ferritin, ID, and IDA. The relationships did not change when clinically and biologically important covariates were included in the models. These data suggest that children of immigrant families may not need enhanced screening for iron status or targeted interventions for iron supplementation.
Paediatr Child Health. 2015 Jun-Jul;20(5):e86.
Abstract
BACKGROUND:
Breastfed infants are at increased risk for developing vitamin D deficiency and rickets due to minimal vitamin D in breast milk. While previous research supports the association between exclusive breast-feeding and vitamin D deficiency, little is known about the effect of total duration of breastfeeding, which includes both the periods of exclusive breastfeeding and after the introduction of complementary foods, on vitamin D status.
OBJECTIVES:
To determine whether total duration of breastfeeding is associated with serum 25-hydroxyvitamin D (25-OHD) level in early childhood and to explore the effect of vitamin D supplementation on the relationship between total duration of breastfeeding and vitamin D status.
DESIGN/METHODS:
A cross-sectional study of healthy children seen for primary health care between September 2011 and August 2013 was conducted through the TARGet Kids! practice-based research network. Adjusted linear regression was used to determine the association between total duration of breastfeeding and serum 25-OHD and to explore the effect of vitamin D supplementation. Adjusted logistic regression was used to assess the probability of 25-OHD <20 ng/mL in supplemented vs. non-supplemented children.
RESULTS:
An association that was modified by vitamin D supplementation was identified between total duration of breastfeeding and serum 25-OHD (P=0.0251). Every one month increase in total duration of breastfeeding was associated with a 0.11 ng/mL lower median serum 25-OHD level (95% CI −0.20, −0.02 ng/mL) among children who were not supplemented. The odds of serum 25-OHD <20 ng/mL increased by 6% with every one month increase in total duration of breastfeeding among children who were not supplemented (OR=1.06, 95% CI 1.03, 1.10). There was no statistically significant association between total duration of breastfeeding and 25-OHD among children who did receive vitamin D supplementation (P=0.43).
CONCLUSION:
Breastfed children who do not receive vitamin D supplementation beyond the first year of life may be at an increased risk of inadequate vitamin D status. Vitamin D supplementation appears to mitigate this risk. These findings support the use of vitamin D supplementation during breastfeeding of any type and duration.
Paediatr Child Health. 2015 Jun-Jul;20(5):e86.
Abstract
BACKGROUND:
Neonatal hypoglycemia is common and prematurity is a well-recognized risk factor. However, the incidence of hypoglycemia in the premature infant <33 weeks gestation immediately after birth is unknown.
OBJECTIVES:
To determine the incidence of hypoglycemia and associated risk factors in premature infants <33 weeks gestation.
DESIGN/METHODS:
Patient information including maternal and infant risk factors was collected prospectively (June 2013 to September 2014) for the Sustained Inflation Randomized Controlled Trial. Neonates born with gestational age <33 weeks were included. Neonates were excluded if they had congenital anomalies or conditions that may adversely affect breathing or ventilation. Hypoglycemia was defined as blood glucose of ≤2.6 mmol/L on cord blood gas sampling collected in the delivery room within the first hour of delivery.
RESULTS:
There were 175 premature infants with mean (SD) gestational age of 28.1 (2.5) weeks, birth weight of 1169 (406) g, and 51% were male. A total of 6.6% of infants had intrauterine growth restriction (IUGR) defined as a birth weight <10th percentile. Overall 69 (39%) of the patients had hypoglycemia within the first hour of birth. Initial correlation studies suggested a relationship between glucose values and birth weight Z-score. Risk factors for hypoglycemia included IUGR and hypertension in pregnancy (Table 1). Labor before delivery was protective of hypoglycemia and antenatal administration of magnesium sulphate trended towards being protective but did not reach statistical significance. The administration of steroids prior to delivery, the administration of inotropes in the first 72 hours, and gender were not related to hypoglycemia. Neonatal hypoglycemia was not a risk factor for mortality in the Neonatal Intensive Care Unit (Relative Risk 0.91 P=1.00).
CONCLUSION:
This is the first report of incidence of hypoglycemia in premature infants <33 weeks. Hypoglycemia in premature infants <33 weeks gestation is common and risk factors include IUGR and hypertension in pregnancy. Protective factors against hypoglycemia included labour before birth and potentially the administration of antenatal magnesium sulphate.
TABLE 1.
Relative Risk for Hypoglycemia in the premature infant <33 weeks
| RR | p-value | |
|---|---|---|
| IUGR | 2.39 | 0.003 |
| Hypertension in pregnancy | 1.84 | 0.008 |
| Labour | 0.36 | <0.0001 |
| Magnesium sulphate | 0.67 | 0.095 |
| Antenatal steroids | 1.02 | 1.00 |
| Male Gender | 0.92 | 0.75 |
| Inotropes | 0.73 | 1.00 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e86–e87.
Abstract
BACKGROUND:
The OptEC trial aims to evaluate the effectiveness of oral iron in young children with non-anemic iron deficiency (NAID). The initial sample size calculated for the OptEC trial ranged from 112–198 subjects (56–99 per group). Given the uncertainty regarding the standard deviation (SD, S1 =15) used to calculate the sample, an internal pilot study was conducted.
OBJECTIVES:
The objectives of this internal pilot were to obtain a reliable estimate of the standard deviation (S2) for the primary outcome of the OptEC trial; to recalculate the sample size of the OptEC trial using the estimates generated from the internal pilot; and to assess the adherence rate and causes of non-adherence in children enrolled in the pilot study.
DESIGN/METHODS:
The first 30 subjects (15 per group) enrolled into the OptEC trial constituted the internal pilot study. The primary outcome of the OptEC trial is a formal developmental assessment called the Early Learning Composite (ELC), assessed at baseline and four months following intervention. For estimation of the SD, descriptive statistics of the four month follow-up ELC scores were assessed within each intervention group. The observed SD within each group was then pooled to obtain an estimated SD (S2) of the ELC. Recalculation of the sample size was performed using analysis of covariance (ANCOVA) method. Adherence rate was calculated using a self- reported rate of missed doses of the study intervention.
RESULTS:
The new estimate of the SD of the ELC was found to be 17.40 (S2). Using a significance level of 5%, power of 80%, S2 = 17.40 and effect estimate (Δ) ranging from 6–8 points, the new sample size based on ANCOVA method ranged from 32–56 subjects (16–28 per group). Adherence rate ranged between 14% and 100% with 44% of the children having an adherence rate ≥86%.
CONCLUSION:
This type of design allows data-driven recalculation of the sample size of randomized trials. Application of the ANCOVA method increases the statistical power while reducing the number of subjects required for a trial. Adherence was found to be adequate to meet the objectives of the OptEC trial.
Paediatr Child Health. 2015 Jun-Jul;20(5):e87.
Abstract
BACKGROUND:
Physical activity in early childhood may be important for the prevention of childhood obesity, although it is unknown if parent-reported physical activity and sedentary behavior are valid in preschoolers.
OBJECTIVES:
The objectives of this study were to validate parent-reported physical activity and sedentary behavior using accelerometry in young children.
DESIGN/METHODS:
From 2013 to 2014, 117 healthy children (ages 0–5) were recruited to wear Actical accelerometers for seven days. Average daily physical activity was defined as the sum of activity ≥100 counts per minute, and sedentary behavior as the sum of activity <100 counts/min, during waking hours. Parents reported daily physical activity (including unstructured free play in and out of school, and structured activities) and sedentary behaviours (including screen time, stroller time, time in motor vehicle). Spearman correlation tests with 95% confidence intervals, and Bland-Altman plots were used to assess the validity of parent-reported measures compared to directly measured accelerometer data.
RESULTS:
The correlation between parent-reported and directly measured total physical activity was ρ=0.39 (95% CI 0.19, 0.56). The correlations between types of physical activity (unstructured activity in and outside of school/daycare, and structured activity) and accelerometer were ρ=0.30 (0.09, 0.49); ρ=0.42 (0.23, 0.58); ρ=0.26 (0.05, 0.46), respectively. Parent-reported and objectively measured total sedentary behaviour were not correlated, ρ=0.10 (−0.12, 0.33).
CONCLUSION:
Parent-reported measures of unstructured free play and structured activity may be valid for the relative measurement of physical activity among children less than 6 years of age. Further research is needed to adequately capture sedentary behavior in young children.
Paediatr Child Health. 2015 Jun-Jul;20(5):e87.
Abstract
BACKGROUND:
There is little detailed epidemiologic and clinical data about tuberculosis (TB) disease in children in Canada.
OBJECTIVES:
To characterize the epidemiologic, clinical, and treatment data for all cases of TB in children under age 15 in Canada through the Canadian Pediatric Surveillance Program’s (CPSP) Childhood Tuberculosis Study. The initial results of the three year study presented here includes cases from September 2013 to October 2014.
DESIGN/METHODS:
TB cases were identified through a monthly form sent by the CPSP to approximately 2500 active pediatricians, pediatric subspecialists, and select non-pediatricians who manage childhood TB. For cases meeting inclusion criteria, a detailed questionnaire was sent to collect clinical, epidemiological, and treatment data, followed by 6-month follow-up surveys until six months after treatment completion.
RESULTS:
Of 70 unique incident cases reported, 34 cases both met inclusion criteria and returned a detailed questionnaire. Selected demographic data is shown in Table 1.
Intrathoracic TB was reported in 32/34 (94%) of cases including 26 with pulmonary infection. One or more positive cultures were obtained in 13/27 (48%) of cases attempting pulmonary culture using sputum (n=7), bronchoalveolar lavage (n=1), and/or gastric aspirates (n=6). Of these, 4/12 (33%) were positive in patients younger than 5 years, 2/6 (33%) between ages 5–9, and 7/9 (78%) children 10+ years. No culture-negative specimen had a positive AFB, PCR, or AMTD. Extrathoracic TB was reported in 27% (n=9). Of these, seven cases had central nervous system involvement. One case had confirmed drug resistance to Isoniazid and Rifampicin.
CONCLUSION:
Numerous cases of childhood TB in Canada have been identified through early results from the CPSP Childhood Tuberculosis Study and detailed clinical, epidemiological, and treatment data have been obtained on these cases. This study will provide the most complete picture of childhood TB in Canada and will serve to refine practice in monitoring, detecting, and treating this infection.
TABLE 1.
Demographic Characteristics of Childhood TB in Canada
| Cases (n) | % | ||
|---|---|---|---|
| Age (N=34) | <1 | 4 | 12 |
| 1–4 | 12 | 35 | |
| 5–9 | 8 | 24 | |
| 10+ | 10 | 29 | |
| Sex (N=33) | M | 12 | 36 |
| F | 21 | 64 | |
| Ethnicity (N=34) | Canadian Born, Non-Aboriginal | 7 | 21 |
| Inuit | 10 | 29 | |
| First Nations | 10 | 29 | |
| Non-Canadian Born | 7 | 21 | |
| Area of Residence (N=34) | Central Canada | 14 | 41 |
| Western Canada | 12 | 35 | |
| Northern Canada | 8 | 24 | |
| Eastern Canada | 0 | 0 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e88.
Abstract
BACKGROUND:
It is important that paediatric residents (our future paediatricians) know how to perform pubertal examinations. Without appropriate training, there is a risk that exams are done inaccurately, patients experience unnecessary discomfort and physicians avoid warranted exams.
OBJECTIVES:
To conduct a learning needs assessment (LNA) of paediatric residents to determine their knowledge of and comfort in performing a Tanner Staging pubertal examination and to develop a learning module (LM), informed by the LNA, to address deficits identified in the LNA.
DESIGN/METHODS:
The LNA questionnaire was developed to assess residents’ previous education, experience, confidence, and knowledge related to Tanner Staging. The questionnaire underwent content and face validity testing. The LNA was administered to residents in four Canadian paediatric training programs that varied in geography and size to sample residents across Canada. The results of the LNA were analyzed using quantitative and qualitative methods to identify themes regarding knowledge and comfort.
RESULTS:
Sixty-four PGY-1 to PGY-4 residents responded. Half (51.6%) reported discomfort introducing the puberty exam to patients, and 50% reported lack of confidence in their ability to perform a puberty exam. Over half (56.3%) reported having avoided a warranted puberty exam. Of concern, avoidance rates were not statistically different between junior (PGY-1 and PGY-2) and senior (PGY-3 and PGY-4) residents (P=0.69). Over a third (39.1%) did not correctly identify the numeric scale used for Tanner Staging, and 15.6% erroneously identified Tanner Stage 0 as a component of the system. Based on provided pictures, 57.6% assigned the incorrect Tanner Stage for breast development and 67.2% assigned the incorrect Tanner Stage for pubic hair. There were no differences in performance on the knowledge based questions between senior and junior residents, or between residents who had completed an endocrine rotation (54.7%) and those who had not. Quantitative and qualitative analyses identified barriers and enabling factors for exam performance. Together all results were used to develop a case-based, web-based LM that addressed education gaps.
CONCLUSION:
This study demonstrated the importance of evaluating paediatric residents’ experiences with Tanner Staging. Residents report being uncomfortable with Tanner Staging and avoiding the puberty exam, and they have significant knowledge gaps. To address these issues, we have developed a case-based, web-based LM to help residents learn to perform accurate and compassionate pubertal exams. An important next step will be to examine the utility and effectiveness of the LM.
Paediatr Child Health. 2015 Jun-Jul;20(5):e88.
Abstract
BACKGROUND:
Type 1 Diabetes (T1D) patients present with gastrointestinal (GI) symptoms related to diabetes complications but also to other associated pathologies.
OBJECTIVES:
In order to describe GI symptoms in patients with T1D, children, adolescents and adults were assessed as part of the screening phase of the Celiac Disease & Diabetes – Dietary Intervention & Evaluation Trial (CD-DIET). Individuals aged 8–35 years with T1D duration ≥1 year completed a self-reported questionnaire – Gastrointestinal Symptom Scale (GISS) to qualify for CD serology screening (www.celia-canddiabetes.com).
DESIGN/METHODS:
GI symptoms were evaluated over the previous seven days, with an 9-item symptom questionnaire which included no symptoms, upper and lower abdominal pain, loss of appetite, nausea, loose or hard stool, vomiting and a Visual Analog Score (VAS, 0–100) to assess symptom severity. Age categories were defined as children 8–12 years, adolescents 13–18 years and adults 19–35 years.
RESULTS:
In total, 1095 patients completed the questionnaire; 283 (26%) children, 482 (44%) adolescents and 330 (30%) adults. Overall, 77% children, 79% adolescents and 79% adults reported no GI symptoms. In the group that had symptoms, adults most frequently reported lower (35%) and upper (28%) abdominal pain and loose stool (26%) while children reported lower (38%) and upper (44%) abdominal pain and nausea (26%) as main symptoms; similar to adolescents who referred lower (40%) and upper (34%) abdominal pain and nausea (13%) as main symptoms. Mean for the VAS score were low for all groups: 6.1/100 in children, 6.9/100 in adolescents and 6.2/100 for adults. In subjects reporting at least one GI symptom, a correlation between number of symptoms, severity and age group was seen, with adults reporting higher VAS scores for two symptoms (P=0.03) and ≥3 symptoms (P=0.02) compared to children.
CONCLUSION:
In conclusion, the frequency of GI symptoms was low in all groups of T1D subjects screened in clinic. The pattern of symptoms differed between the age groups and a stronger correlation was seen between number of symptoms and the severity in adults.
Paediatr Child Health. 2015 Jun-Jul;20(5):e88.
Abstract
BACKGROUND:
Prompt treatment of febrile Urinary Tract Infection is required to decrease the risk of short and long term complications. The literature supports the use of an empirical oral treatment in comparison with the usual IV treatment.
OBJECTIVES:
To compare the rate of treatment failure (fever more than 96 hours, non-compliance with follow-up, modification of empiric antibiotic before culture result, hospitalisation or positive urine culture in the following month) between patients treated with intravenous (IV) or oral empiric antibiotic and to compare the rate of adverse events and complications.
DESIGN/METHODS:
A retrospective study was conducted with patients aged 6 months to 5 years comparing the group of patient treated before and the one treated after the implementation of a new empirical ambulatory oral treatment protocol (cefixime). The IV group (ampicillin and gentamicin) included 122 patients from April 2010 to September 2011. The oral group included 111 patients from September 2011 to July 2013. Included patients needed to have a suspected UTI (presence of fever and abnormal microscopic analysis) at the presentation in the emergency department and a confirmed infection on the urine culture. Bivariate analyses were used to compare the two groups.
RESULTS:
Both groups had similar characteristics for sex, age, clinical presentation and the identified bacteria. A statistically significant difference in treatment failure was found between the two groups (P=0.04). However, when considering only hospitalisation and positive urine culture, the difference between both groups became non-significant (P=0.16). Hospitalisation rate was similar in both groups (5% vs 6%). There was no difference for the treatment adverse events (27% vs 26%) and the complications. 20% of patients in the IV group had a problem with the IV access.
CONCLUSION:
This study confirms that the advantages of administering an oral treatment for the febrile UTI outweigh the risks when appropriate clinical and laboratory follow-up are initiated.
Paediatr Child Health. 2015 Jun-Jul;20(5):e89.
Abstract
BACKGROUND:
This study was funded by our institution’s associated University’s Research Opportunities Fund. The authors have no conflicts of interest to declare.
Abdominal pain is the most frequent clinical feature of acute appendicitis, the most common pediatric condition requiring urgent surgical intervention. There is evidence, particularly in children, that analgesia is underutilized for abdominal pain. Historically, the reluctance to provide analgesia to patients was thought to be due to concerns of obscuring the diagnosis of appendicitis. In the last decade, evidence disputing this supposition has mounted. No recent studies have described pain management patterns in undifferentiated cases, reasons behind withholding analgesia, or its relationship with surgical consultation.
OBJECTIVES:
Given a decade of new evidence supporting the safety of analgesia, our objectives were to explore the current practice variation surrounding the provision of analgesia by paediatric emergency physicians, identify reasons for withholding analgesia, and evaluate the relationship of providing analgesia with obtaining surgical consultation.
DESIGN/METHODS:
We prospectively surveyed physician members of the Paediatric Emergency Research Canada (PERC) database. We collected demographic information and presented three scenarios depicting undifferentiated abdominal pain of varying severity. A modified Dillman’s Tailored Design method was used to distribute the survey, from June 15 to July 16, 2014.
RESULTS:
Our overall response rate was 75% (149/200). 52% of respondents were female and their mean age was 44 years. Most respondents completed paediatric emergency medicine fellowship training (59%) and were within 15 years of independent practice (74%). The rates of providing analgesia for the cases of renal colic, intussusception, and appendicitis were 100%, 92.1%, and 83.4% respectively, while rates of providing IV opioids were 85.2%, 12.4%, and 58.6% respectively. Across scenarios, all 61 respondents obtaining surgical consultation provided analgesia. Of respondents withholding analgesia, most (21/35 or 60%) believed that pain was not severe enough to warrant it, and only 5/35 (14.3%) indicated that analgesia would obscure a surgical condition.
CONCLUSION:
The self-reported rates of analgesic provision for acute undifferentiated pain by paediatric emergency physicians is higher than reported one decade ago and, according to self-report, surgical consultation does not negatively impact the provision of analgesia.
Paediatr Child Health. 2015 Jun-Jul;20(5):e89.
Abstract
BACKGROUND:
The evidence of the analgesic effect of oral sweet solutions has been established in neonates. However, there have been a limited number of published clinical trials in older infants.
OBJECTIVES:
To compare the efficacy of an oral sucrose solution versus placebo in reducing pain in children 1 to 3 months of age undergoing venipuncture without cannulation in the Emergency Department (ED).
DESIGN/METHODS:
A single-center, randomized, double-blind, placebo controlled clinical trial was conducted in a pediatric university-affiliated hospital ED. Infants 1 to 3 months of age requiring venipuncture were recruited. Participants were randomly allocated to receive 2 mL of 88% sucrose solution or 2 mL of a placebo solution orally, two minutes before the procedure. The primary outcome measure was the difference in pain levels during venipuncture as assessed by the Face, Legs, Activity, Cry and Consolability Pain Scale (FLACC) one minute post venipuncture vs baseline. Secondary outcome measures were the difference in pain levels using the Neonatal Infant Pain Scale (NIPS) one minute post venipuncture, crying time and variations in heart rate following the procedure.
RESULTS:
Eighty-two participants were recruited, 41 in the sucrose group and 41 in the placebo group. Both groups had similar baseline demographic and clinical characteristics, including administration of pacifier and other analgesia. The mean difference in FLACC pain scores compared to baseline was 3.67±0.62 in the placebo group vs 3.51±0.64 in the sucrose group (P=0.73). For the NIPS pain score, it was 3.00±0.49 (placebo) vs 2.90±0.47 (sucrose) (P=0.89). The difference in the mean crying time following venipuncture was not statistically significant between both groups: 96±8 seconds (placebo) vs 66±5 (sucrose) (P=0.32). No significant difference was found in the difference of participants’ heart rates one minute post venipuncture compared to baseline: 24±5 beats per minute (placebo) vs 33±6 (sucrose) (P=0.44). No significant adverse effects were reported. The overall blinding was successful.
CONCLUSION:
In children 1 to 3 months of age undergoing simple venipuncture in the ED, administration of an oral sweet solution did not statistically decrease pain scores as measured by the FLACC and NIPS scales. The participants’ heart rate variations and crying time were not significantly changed by providing sucrose instead of a placebo.
Paediatr Child Health. 2015 Jun-Jul;20(5):e89.
Abstract
BACKGROUND:
Most patients suffering from concussion present persistent symptoms at one week post injury. A systematic review showed a paucity of studies for short term outcomes following concussion. Among potential treatments, Ondansetron has shown promising results based on clinical experience and a single retrospective study.
OBJECTIVES:
The primary objective of this pilot study was to assess the clinical efficacy of one dose of oral Ondansetron to decrease post concussion symptoms at one week following concussion in children aged between eight and 17 years old.
DESIGN/METHODS:
This was a randomized, double blinded, controlled trial performed among children aged between eight and 17 years old who sustained a concussion in the previous 24 hours. Participants visiting the emergency department were randomized to receive one dose of either ondansetron or placebo. The primary outcome of interest was an increase from pre-concussion baseline of at least three symptoms from the Post Concussion Symptom Inventory (PCSI) one week following trauma. Secondary outcomes included time to full recovery, mean PCSI score, and outcomes at one month following head trauma. The primary analysis compared the proportion of participants with persistence of symptoms at one week in both groups. This was a pilot study aiming to evaluate the feasibility of the study.
RESULTS:
A total of 16 children provided informed consent and were randomized to the study medication. They all provided data for the measurement of the primary outcome at one week and one month. The proportion of children with persistent post concussion symptoms was higher in the placebo group but this did not reach statistical significance at one week (difference: 13%; 95% CI −40% to 69%) and one month (difference: 37%; 95% CI −15% to 90%).
CONCLUSION:
This pilot study demonstrated the feasibility of a randomized controlled trial to evaluate the impact of ondansetron for concussion in children. The administration of one dose of ondansetron in the first 24 hours following concussion showed a trend toward a lower proportion of post-concussion symptoms at one week and one month following intervention. Based on these results, a larger, more powerful study is necessary.
Paediatr Child Health. 2015 Jun-Jul;20(5):e90.
Abstract
BACKGROUND:
Urethral catheterization (UC) is widely performed to diagnose urinary tract infection (UTI) in febrile young children presenting to the emergency department (ED). However, little is known about risk factors associated with adverse events following this procedure.
OBJECTIVES:
To determine risk factors for adverse events following diagnostic UC in the pediatric ED.
DESIGN/METHODS:
This was a secondary analysis of a prospective cohort study conducted over a period of nine months in a tertiary care pediatric ED. Recruitment mainly occurred during week days from 9AM until 7PM. All children aged three to 24 month old with fever ≥38°C (≥100.4°F) and who had a diagnostic UC were invited to participate. Parents were contacted by phone seven to 10 days following the ED visit to answer a standardized questionnaire about adverse events potentially related to the procedure. Adverse event was prospectively defined as painful urination, genital pain, urinary retention, hematuria or UTI occurring secondary to UC. No sample size was calculated a priori because it was a secondary analysis of another study. Nonetheless, it was estimated that 40 participants experiencing at least one complication permitted to evaluate five risk factors (male sex, age, previous UC, hematuria at UC, final diagnosis of UTI). Univariate and multivariate analysis were used to calculate odds ratio (OR).
RESULTS:
240 patients were invited to participate. Among them, 219 patients accepted and were included in the study with 20 (9%) lost to follow-up. Of the 199 patients who completed the study, 110 were females (55%) and the median age was 10 months. Overall, 41 (21%) patients experienced at least one adverse event. Male sex (OR 3.99 [CI 1.84–8.61]) and age 12–23 months (OR 2.61 [CI 1.24–5.50]) were statistically associated to a higher risk of having adverse events.
CONCLUSION:
Urethral catheterization is associated to adverse events in the following week in 21% of young children. Male sex and age 12–23 months were associated with a higher risk of complications. It should be used carefully in young children especially in those with risk factors.
Paediatr Child Health. 2015 Jun-Jul;20(5):e90.
Abstract
BACKGROUND:
An important proportion of children visit the emergency department (ED) in the evening and during the week-end. This limits recruitment for research in pediatric ED because it is more challenging to hire research assistants for this time period. The PIEUVRES program involves 12 hours of formal training for first and second year medical students to become research assistants in the ED. Following their training and support from research coordinators, they are able to recruit research participants in a pediatric ED. There is very limited data about the impact of such a volunteer program on research in a clinical setting.
OBJECTIVES:
The primary objective of this study was to evaluate the additional number of children recruited by a group of medical students volunteer in the research program PIEUVRES.
DESIGN/METHODS:
This was an observational study reporting the number of children recruited by the volunteers during PIEUVRES program during the academic year of 2013–14. Volunteers worked a 6-hour recruitment shift per week during a semester. These shifts were distributed among the evenings of the week (4PM–10PM) and during the week-end (10AM–10PM). At the end of each shift they reported the number of patients approached and recruited for each of the (7 eligible) studies. During the study period, there was seven studies for which volunteers could have recruited.
RESULTS:
The volunteer program occurred from October 19th 2013 until May 11 2014. During this period, the volunteers approached a total of 692 children/families and recruited 262 participants (38%) during 184 shifts. Most patients were recruited for the five observational studies while only 3/9 and 9/38 (recruited/approached) patients were recruited for the two interventional trials. No ethical problem or complaints were received from the families in relation to their interaction with the volunteers.
CONCLUSION:
The volunteer program permitted to recruit an important amount of research participants in a pediatric emergency department. This improvement required small financial and human resources.
Paediatr Child Health. 2015 Jun-Jul;20(5):e90.
Abstract
BACKGROUND:
Fever is currently the most common reason for an emergency department (ED) visit. Parental concerns regarding dehydration and seizures, lead to significant anxiety and ED visits. With rapid advances in software development and Internet access, web-based modules (WBMs) are a feasible way to educate parents. Studies using educational WBMs on antibiotics and autism have shown increased knowledge transfer and information retention. There are currently no such interventions to educate parents about fever.
OBJECTIVES:
Our objectives were to assess caregivers’ knowledge acquisition and satisfaction with an interactive WBM for fever education.
DESIGN/METHODS:
We randomized caregivers of children presenting to the ED with a chief complaint of fever to receive education through an interactive WBM, read-only website (WEB), or standard of care handout (SOC). Primary outcome variable was the pre-post difference (gain score) on a novel questionnaire testing parental knowledge of the etiology, measurement, therapy, and complications of fever. Secondary outcome variable was parental satisfaction using a 13-item questionnaire.
RESULTS:
There were 70, 66, and 67 participants in the WEB, WBM, and SOC groups respectively. The mean (SD) caregiver age was 33 (6.7) years. Most (113/203, 55.7%) completed post-secondary education. 54/203 (26.6%) were employed in health care. Of a maximum score of 33, the mean (SD) gain scores on the knowledge questionnaire were 3.9 (4.0), 3.5 (4.2), and 0.2 (3.1) for the WBM, WEB, and SOC groups, respectively (P<0.001). Contrast analyses showed no significant differences in gain scores between WBM and WEB (P=0.55). Of a maximum score of 52, the mean (SD) parental satisfaction scores were 43 (5.2), 38.7 (8.1), and 29.9 (11.9), for the WBM, WEB, and SOC groups respectively (P<0.001). Contrast analysis showed that all groups were significantly different in terms of parental satisfaction in the following rank: WBM > WEB > SOC (P<0.01).
CONCLUSION:
The WBM and WEB educational tools lead to a significant improvement in caregivers’ knowledge of fever, and caregiver satisfaction is significantly greater with WBM. Evidence for the effectiveness of WBMs on clinically important outcomes such as ED visits could lead to widespread adoption of this intervention.
Paediatr Child Health. 2015 Jun-Jul;20(5):e91.
Abstract
BACKGROUND:
Pediatric Emergency Point-of-care Ultrasound (POCUS) has become more and more important in the emergent care of ill and injured children over the last years. No information is currently available about its adoption and integration into Canadian pediatric emergency medicine (PEM) fellowship programs.
OBJECTIVES:
The objective of this study was to describe current state as well as requests for POCUS training offered by Canadian PEM fellowship programs as perceived by both program directors and actively training fellows.
DESIGN/METHODS:
Two web-based surveys were created by the survey authors: one for fellowship program directors and one for actively training fellows. The survey was tested and refined, and posted on a web-based survey site. The links for both questionnaires were distributed to all PEM fellowship program directors in Canada for dissemination to their fellows. A modified Dillman’s method was used to maximize survey responses. Survey questions explored: current use of POCUS clinically at the training sites, existing POCUS curriculum and training opportunities, and interest in future curriculum development.
RESULTS:
A total of 9/10 (90%) fellowship program directors as well as 42/60 (70%) fellows responded. Currently a formal curriculum in POCUS is established in five of nine PEM programs. Most fellows (83%) had no training in POCUS before their fellowship but 74% reported a formal training during fellowship (FAST and focused cardiac examination mainly). Only 33% of fellows reported specific pediatric POCUS training. 50% of fellows stated using POCUS at least once a week, while directors indicated that the majority of faculty rarely uses POCUS (70%) in clinical practice. Main application in both groups is the FAST exam. For fellows and fellowship directors the major barrier in learning POCUS was the lack of trained faculty (95% and 90%, respectively), followed by faculty time, and interest in the technology. Finally, 86% of fellows described training in POCUS as very important or essential and they expressed their need for more training.
CONCLUSION:
While demand from PEM fellows is high, there is a great variability in implantation of POCUS training in Canadian PEM programs. The most important barrier in POCUS training is related to the lack of trained faculty, a fact that needs to be addressed by program directors. Canadian PEM programs should develop a conjoint standardized POCUS curriculum.
Paediatr Child Health. 2015 Jun-Jul;20(5):e91.
Abstract
BACKGROUND:
Buckle fracture of the distal radius is a very stable injury with an excellent prognosis. Evidence recommends treatment with a removable wrist splint and follow up with a primary care physician (PCP).
OBJECTIVES:
Our main objective was to determine what proportion of children with a distal radius buckle fracture who were referred to the PCP for follow up subsequently experienced specialty consultation or lacked any physician follow up. We also examined clinical outcomes and parental satisfaction.
DESIGN/METHODS:
This was a prospective cohort study at an urban, tertiary care pediatric emergency department (ED). Eligible children were 2–18 years of age diagnosed with a distal radius buckle fracture, treated with a removable splint, and referred to a PCP for follow up within two weeks of the injury. We telephoned families 28 days after their ED visit and recorded physician follow up visits and parental satisfaction with PCP follow up on a five-point categorical scale.
RESULTS:
We enrolled and completed phone follow up for 129 children. (Figure 1) The mean (SD) age was 8.2 (3.5) years, 55.8% were male, and 124 (96.1%) had a PCP. Overall, 46 (35.7%; 95% CI 27.4, 44.0) children experienced specialty consultation or lacked any physician follow up. Of the 99 seen by the PCP, 78 (78.8%) were seen within 2–3 weeks and 95 (96.0%) had one visit. Ninety-five (92.5%) parents reported being “very satisfied/satisfied” with the care they received at the PCP office for this injury. None of the distal radius fractures required specialty consultation due to clinically significant complications and all cases were reported by parents as fully recovered at phone follow up.
CONCLUSION:
Follow up of ED diagnosed distal radius buckle fractures was not successfully completed exclusively at the PCP office in approximately one-third of cases. Barriers to a higher success rate included inaccurate initial diagnosis by the ED physician, and parental and PCP perceptions of appropriate clinical indications for specialty consultation.
Paediatr Child Health. 2015 Jun-Jul;20(5):e92.
Abstract
BACKGROUND:
Sickle cell vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit, and admission in children with this condition.
OBJECTIVES:
To evaluate wheter the implementation of an oral morphine protocol has led to improved care of sickle cell disease (SCD), translated by a reduced hospitalization rate, comparing the cohort of SCD patients presenting to the ED with VOC pre and post implementation. We also aimed at evaluating if the oral route was favored for morphine administration, and if this led to quicker time of administration.
DESIGN/METHODS:
Retrospective chart review of patients with SCD followed in the hematology clinic at CHU Ste-Justine, who presented to the ED with VOC requiring opioids, in the year pre (January–June 2012) and post (January–June 2014) implementation of the oral morphine protocol. Patients with a diagnosis of VOC during the study periods were selected in the ED database. The primary objective was to evaluate the hospitalization rate before and after the implementation of the protocol. The rate of oral administration as well as the delay of administration of the first opiate dose after triage pre and post-implementation were calculated. We estimated that 35 patients per arm would be sufficiently powered to detect at least a 30% rate reduction of admissions, with a power of 80% and a significance of 0.05.
RESULTS:
Over the two periods, a total of 67 patients (35 pre and 32 post) were included: the mean age was 9.0±4.1 years. A total of 33/35 (94%) patients were admitted in pre vs 16/32 (50%) in post: a difference of 44% (95% CI 23, 61). None of the two patients discharged in pre returned within 72 hours of VOC, compared to 2/16 (12%) in post: a difference of 12% (95% CI −36, 54). In pre, 5/32 (16%) patients received their first dose orally compared to 18/32 (54%) in post: a difference of 41% (95% CI 17, 58). Surprisingly, there was no difference in the delay of administration of the first opiate dose after triage: median of 88 min (IQR 67, 119) in pre vs 83 min (IQR 59, 112) in post (difference of 5 min [95% CI −14, 27]).
CONCLUSION:
This study validates the use of our oral morphine protocol for the treatment of sickle cell VOC, by showing a significant reduction in hospitalization rates. Although a reduction in time to first opiate dose was not seen in the post protocol period favoring the oral route, it decreased the number of painful IV procedures.
Paediatr Child Health. 2015 Jun-Jul;20(5):e92.
Abstract
BACKGROUND:
The scaphoid bone is the most commonly fractured bone in the wrist, usually resulting from a fall on the outstretched hand. Clinically, these fractures present with wrist pain and tenderness of the scaphoid bone, which can be produced by palpation in the anatomical snuffbox when the wrist is ulnarly deviated, or axial loading of the first metacarpal. Complications are not uncommon, and include non-union and avascular necrosis. When a patient of any age presents with clinical scaphoid tenderness and radiographs are negative, it is common practice for the wrist to be immobilized until a definitive imaging study can be performed 10–14 days later.
OBJECTIVES:
The purpose of this study is to determine the positive predictive value of clinical scaphoid tenderness for fractures in children aged 4–11, and to look at the efficiency and practicality of the management of scaphoid fractures in children presenting at the Janeway Emergency Department, with the goal of helping to quantify the burden of this treatment strategy and perhaps give weight to the consideration of alternative approaches to this clinical presentation in children.
DESIGN/METHODS:
Approval for this study was obtained from the Health Research Ethics Authority. We conducted a retrospective chart review study of children aged 4–11, presenting to the Janeway ED within twenty-four hours of a wrist injury, with clinical suspicion sufficient to order a scaphoid x-ray, from January 1, 2009 to December 31, 2012. A total of 142 patients (145 wrists) were identified and included in the study.
RESULTS:
108 patients (111 wrists) had normal initial x-rays. Of these, 68 wrists were casted (for an average of 12 days) and 53 had a follow-up x-ray. Only two patient in this study were ultimately diagnosed with a scaphoid fracture. Based on these results, the most conservative calculation for the positive predictive value of clinical scaphoid tenderness for fractures in children aged 4–11 years is 3.8 percent.
CONCLUSION:
There is insufficient evidence to show that clinical scaphoid tenderness is a good indicator of scaphoid fractures in children aged 4–11 years. Treating suspected scaphoid fractures in young children the same as in adults (i.e. immobilization even when initial radiographs are negative) may be impractical.
Paediatr Child Health. 2015 Jun-Jul;20(5):e92–e93.
Abstract
BACKGROUND:
Trauma is the leading cause of death in children. The limitations of previous trauma mortality prediction scores include their complexity and lack of validation. In contrast, the BIG score is simple, easy to calculate, and incorporates key physiologic variables influencing trauma mortality: base-deficit, INR and Glascow Coma Scale- with encouraging validation results in Germany. However, the median age was higher than at most North American centers and other factors impacting mortality were not examined.
OBJECTIVES:
We examined the association between in-hospital mortality and the BIG score measured on Emergency Department arrival in pediatric blunt trauma patients, adjusted for age, pre-hospital intubation, volume administration and referral hospital management. We also examined the association between the BIG score and mortality in patients requiring ICU care.
DESIGN/METHODS:
A retrospective 2001–2012 trauma registry review of blunt trauma patients ≤17 years old. Charts were reviewed for in-hospital mortality, age, components of the BIG score on Emergency Department arrival, pre-hospital intubation, administration of a crystalloid bolus ≥20 mL/kg, local hospital referral and disposition.
RESULTS:
We found that 50/621 (8%) study patients died. Independent mortality predictors were the BIG score (OR 12, 95% CI 6–25), prior fluid bolus (OR 3, 95% CI 1.3–9) and prior intubation (OR 8, 95% CI 2–40). The area under the ROC curve was 0.95 (CI 0.93–0.98), with the optimal BIG cutoff of 16. With BIG <10, death rate was 1/382 (0.003, 95% CI 0.001–0.007), versus 23/209 (0.11, 95% CI 0.7–0.15) with BIG 11–25, and 26/30 (0.87, 95% CI 0.67–0.95) with BIG >25 (P<0.0001). In patients requiring the ICU, the BIG score remained predictive of mortality (OR 14.3, 95% CI 7.3–32, P<0.0001).
CONCLUSION:
The BIG score accurately predicts mortality in North American pediatric blunt trauma patients independent of age or pre-hospital interventions, identifies children with a high probability of survival (BIG ≤10) and those with highest potential of benefit from timely interventions (BIG 11–25). The BIG score is also associated with mortality in pediatric trauma patients requiring ICU care.
Paediatr Child Health. 2015 Jun-Jul;20(5):e93.
Abstract
BACKGROUND:
Pre- and post-migration exposures are unique to pediatric immigrants and may affect healthcare access and quality. Children are high users of emergency departments (ED’s). ED revisits may be a marker of access to and quality of healthcare for urgent problems. Interactions with the healthcare system for immigrant children may be hindered by differences in language or culture potentially leading to more frequent ED revisits compared with non-immigrant children.
OBJECTIVES:
To test whether being a pediatric immigrant increases the odds of unscheduled 7-day revisits to the ED compared with non-immigrant children living in urban Ontario and to test whether being from certain subgroups of immigrants increases the odds of ED revisits. These subgroups include immigrant class, native tongue upon landing in Canada, and region of origin.
DESIGN/METHODS:
This was a retrospective population-based cohort study of all immigrant and non-immigrant children, living in urban Ontario, who visited an ED between April 2003 and March 2010 (n = 3322901). We used multiple linked administrative health and demographic datasets to measure demographic variables, immigration information, ED visits and revisits, visit acuity and disposition, and hospital related data. We modeled the relationship between immigration status, immigration sub-groups and 7-day ED revisits using logistic regression models.
RESULTS:
Being a recent immigrant was associated with a significantly higher odds of ED revisit compared with non-immigrants (odds ratio 1.07; 95% CI 1.05–1.09). When biologically and clinically important covariates related to the patient, visit, and hospital were included in the adjusted model, the observed relationship between exposure groups disappeared. Within the immigrant group, the odds of revisit was not different between immigrant classes but immigrants who did not speak English or French as their native tongue had a higher odds of revisiting the ED after adjusting for socio-demographic and hospital characteristics (adjusted odds ratio 1.05; 95% CI 1.01–1.09). Differences were not observed based on region of origin.
CONCLUSION:
Immigration status was not associated with increased ED revisits but having a native tongue other than English or French was associated with increased ED revisits. These findings are relevant for improving translation services in Ontario EDs and highlight the need for further research and understanding of pediatric immigrant health systems interactions.
Paediatr Child Health. 2015 Jun-Jul;20(5):e93.
Abstract
BACKGROUND:
Young children with viral-induced wheeze pose a diagnostic challenge as there are no diagnostic tests available to differentiate bronchiolitis from reactive airway disease. Point-of-care ultrasound is an increasingly available tool for emergency physicians and may serve a role in discriminating different lung pathologies.
OBJECTIVES:
To describe lung ultrasound findings in young children with viral upper respiratory tract infections and wheeze presenting to a pediatric emergency department.
DESIGN/METHODS:
A cross-sectional study was conducted in children <2 years of age presenting with URTI symptoms and wheeze to a pediatric emergency department from October 2013 to July 2014. Prior to management, one investigator (TV) performed all point-of-care lung ultrasounds and saved 5-second video clips in each of the six lung zones. A physician (ASD) blinded to all clinical and ultrasound information reviewed the latter and provided the final interpretations used for the main outcome measure. Abnormal lung ultrasound was defined as the presence of any of the following findings: multiple B-lines, consolidations, pleural abnormalities, or absent lung slide. The treating physician remained blinded to the findings and prospectively documented discharge diagnoses. Proportion of children with abnormal lung ultrasounds were characterized and categorized abnormalities by discharge diagnoses (reactive airway disease versus other respiratory diagnoses).
RESULTS:
96 patients were enrolled (median age 11.1 months (IQR 6.7–16.1), 65% male). Ultrasound revealed an abnormality in 40/96 (41.7%) patients: multiple B-lines 32/40 (80%), consolidation 25/40 (62.5%; larger than >1 cm in 4/40 [10%]), and pleural abnormalities 8/40 (20%). When categorized per diagnosis, an abnormal lung ultrasound was found in 0/16 (0%) with reactive airway disease, which was significantly less compared to all other respiratory diagnoses: bronchiolitis 20/43 (46.5%, P=0.001), viral respiratory illness 13/29 (44.8%, P=0.001), and pneumonia 7/8 (87.5%, P<0.0001). Excellent agreement was found between raters for an abnormal lung ultrasound (kappa ± SE: 0.89±0.04).
CONCLUSION:
Over a third of young children with undifferentiated wheeze had an abnormal point-of-care lung ultrasound. Given that all children with a discharge diagnosis of reactive airway disease (compared to other respiratory diagnoses) had a normal ultrasound, the next step would be to prospectively determine if lung ultrasound might help guide clinicians with the management of children with undifferentiated viral-induced wheeze.
Paediatr Child Health. 2015 Jun-Jul;20(5):e93.
Abstract
BACKGROUND:
Chest pain is a frequent chief complaint of paediatric patients presenting to the emergency department (ED). Despite the low risk of a cardiac cause in the paediatric population, chest pain is a worrisome presentation for patients and their families, and sometimes serious underlying pathology can occur. There is no evidence based diagnostic approach, and this results in significant practice variation often with extensive investigations, both in the ED and in follow-up.
OBJECTIVES:
To establish poor predictive value and over-use of diagnostic testing in pediatric patients presenting with chest pain.
DESIGN/METHODS:
After REB approval, a chart review was conducted of all patients presenting to an urban paediatric tertiary care ED with the chief complaint of chest pain over a three year period. Charts were analyzed for sex, age at presentation, associated symptoms, past cardiac history, investigations in the ED, discharge diagnosis, and outpatient echocardiogram and Holter monitor findings.
RESULTS:
Of the 473 visits, 50 were repeat visits. The mean age at visit was 12.1 years, and mean duration of pain was 53.4 minutes. 16.9% (n=80) of patients reported past cardiac-related medical history. 64.9% (n=307) of patients received chest x-ray, but only 2.9% (n=9) had an abnormal finding. Electrocardiogram was done in 75.7% (n=358) of the patients, and 23.7% (n=85) of the results were abnormal. Troponin was done in 9.5% (n=45) of the cases, with only one abnormal result unrelated to cardiac etiology. 96.0% of patients (n=454) were discharged, and 4% (n=19) were admitted to hospital. Most causes were idiopathic (n=282, 59.6%), followed by musculoskeletal causes (n=145, 30.7%). Within six months following discharge, 75 (15.9%) patients received echocardiogram, 45 (60%) of whom had no reported cardiac history or previous investigations, and 25 had normal ECG in the ED. The echocardiograms yielded only two cases of newly diagnosed mitral valve prolapse, and one case of small patent ductus arteriosus. 50 patients (10.6%) received Holter monitoring within six months following discharge, 20 of whom had no previous cardiac history, and had normal ECGs in the ED, and the arrhythmias found on Holter monitor correlated poorly with the presenting symptoms.
CONCLUSION:
This is the largest paediatric review of chest pain in Canada in published literature. Chest pain in the paediatric population are rarely due to cardiac causes, but most patients still receive unnecessary investigations in the ED, and in their follow-up visits. An evidence based diagnostic algorithm would be useful to improve resource utilization in children presenting with chest pain.
Paediatr Child Health. 2015 Jun-Jul;20(5):e94.
Abstract
BACKGROUND:
In Canada, it is estimated that nearly one in three children are overweight or obese (Roberts et al., 2012). With a myriad of contributing factors and potential for serious long-term health consequences, overweight/obesity status constitutes an urgent and complex public health issue (Avis et al., 2014). Moreover, recent reports suggest that approximately 35–38% in American children with Autism Spectrum Disorder (ASD) are overweight or obese, higher than the general population (Sharp et al., 2014; Zuckerman et al., 2014). To date, no studies have looked at weight status among children with ASD in a Canadian population.
OBJECTIVES:
To determine the prevalence of overweight or obesity in a clinical sample of children with ASD at a tertiary care centre.
DESIGN/METHODS:
Participants were recruited within the first 12 months of receiving their diagnosis of ASD (as defined by the DSMIV-TR) as part of an international registry. The primary health care provider (e.g. nurse practitioner, developmental pediatrician, etc.) completed several baseline measures, including age, gender, height, and weight. BMI was calculated for each participant using date of birth, date assessed, gender, height, and weight using the recommended BMI calculations by the Centre for Disease Control (2000) and terminology provided by Barlow et al. (2007).
RESULTS:
Complete information was available for 130 children with ASD (108 boys). Median age of participants was 5 years, 9 months (range: two years, two months – 17 years, four months; standard deviation: 3 years, 5 months). In total, 2% of children had BMI under the 5th percentile (underweight), 55% of children had BMI within the 5th to 85th percentile (normal weight), 41% of children were at or above the 85th percentile (overweight or obese) and 21% of children were at or above the 95th percentile (obese). Using a one-sample binomial test, children and adolescents with ASD were found to be significantly different in the prevalence of overweight and obese rates compared to typically developing Canadian children and adolescents (p.05).
CONCLUSION:
These findings are in accordance with the prevalence of overweight and obese status in children with ASD in the USA but differ from typically developing Canadian children. Further monitoring is needed longitudinally to monitor the prevalence of overweight and obese children and adolescents with ASD and to provide appropriate weight-management intervention.
Paediatr Child Health. 2015 Jun-Jul;20(5):e94.
Abstract
BACKGROUND:
Adult knowledge of child development shapes their expectations and feedback to children as they learn and grow. Effective guidance of children by adults is influenced by their knowledge of child development. There are gaps in our understanding about what information and resources adults access related to child development. Research has focused on knowledge of child development among parents despite an increased acknowledgement that children are exposed to a range of adult influences.
OBJECTIVES:
To review the supports and services used by adults regarding child development, including: (1) what information sources are used, and; (2) what key people or professionals are accessed for advice about children? To determine whether these supports and services vary by parents versus non-parents, urban versus rural residence, or if the adult was a parent of a child with a special health care need (SHCN).
DESIGN/METHODS:
A telephone survey of 1,451 randomly selected adults – both parents and non-parents – was conducted in 2013 and explored parenting supports and services, and included demographic information. Data were analyzed using univariate and bivariate techniques (P<0.05).
RESULTS:
Key information sources regarding child development identified included books (68%), television/media (43%), recreation centres (41%), and the public library (38%). Key parenting supports were family members or friends (76%), family doctors or pediatricians (61%), and teachers (54%). Parents were more likely to access any resource or support than non-parents. Adults living in urban settings were more likely to use physicians, child-care providers, the public library, and phone advice services for information about children than rural adults. Parents of children with SHCN were more likely to contact teachers and developmental specialists about their children than parents of children without SHCN. Online access of information was preferred by 47%.
CONCLUSION:
Adults use a variety of information sources regarding child development, and access these resources through the internet and in various community settings or organizations. Information is also obtained from social networks including family and friends. Health service providers and educators in particular are a key source of information for adults about child development. There is an opportunity to make accessible already existing programs and services that support families and children that target both parents and non-parents using the venues, organizations and professionals identified from this survey.
Paediatr Child Health. 2015 Jun-Jul;20(5):e94.
Abstract
BACKGROUND:
The prevalence of ASD is estimated at 1 per 68 based on US surveillance data. In many cases, ASD can be accurately diagnosed at two to three years old and high risk children can be identified earlier than 24 months, but Canadian data shows a median age at diagnosis of 39 to 55 months. Despite advances in diagnosis of ASD, there is little data on ASD screening among Canadian general paediatricians.
OBJECTIVES:
The objectives of this study were to examine community paediatricians’ ASD screening practices, obtain quantitative date on the use of ASD and general developmental screening tools, and identify factors influencing paediatricians’ use of ASD screening tools.
DESIGN/METHODS:
A questionnaire was designed base on a survey by dosReis et al to assess developmental and ASD screening among general paediatricians (dosReis 2006) with questions added based on themes drawn from the investigator’s qualitative data from focus groups with community paediatricians on ASD screening. Main focus areas were quantitative data on developmental and ASD screening tools use, facilitators and barriers of ASD screening, tool characteristics that encourage their use, and collection of demographic data. After revision by community (n=5) and developmental (n=5) paediatricians, the questionnaire was piloted to n=30 general paediatricians, further refined, and distributed to all general paediatricians in a large multicultural urban centre. Descriptive statistics was used.
RESULTS:
Results from ongoing data collection showed that most respondents routinely used a developmental screening tool (95%) with the majority using the Nipissing Developmental Screen (95%) and the Rourke Baby Record (42%). 15% routinely using an ASD screening tool while most used an ASD specific screening tool (most commonly the M-CHAT) when they suspected ASD on exam, history, or if there was parental concern. Respondents were divided 50–50 in making the diagnosis of ASD in their practice while 90% agreed or strongly agreed to feeling confident in their ability to identify children with signs and symptoms of ASD. 70% of respondents felt there should be clearer guidelines on how and when to screen for ASD. As for specific ASD screening tool characteristics, the most valued were brevity, ability to be completed by a parent, and availability in multiple languages.
CONCLUSION:
This study provides critical data on developmental and ASD screening practices and identifies factors influencing physician decision making and clinical practice. Assessing factors affecting screening in primary care is vital to the future design and implementation of sustainable programs for early detection of ASD.
Paediatr Child Health. 2015 Jun-Jul;20(5):e95.
Abstract
BACKGROUND:
Young children with special health care needs (SHCN) have unique developmental challenges and require intensive parenting to reach their potential. Mothers are often the primary caregiver and interventions have aimed at increasing their knowledge of early childhood development. Previous research in high-risk populations has found that the combination of high maternal knowledge of childhood development combined with high maternal confidence correlates with competent parenting. Low knowledge combined with high confidence is felt to be more detrimental than low knowledge and low confidence.
OBJECTIVES:
To compare the knowledge and confidence levels of mothers with young children (<=6 years) who have SHCN to mothers with young children who do not have SHCN.
DESIGN/METHODS:
A telephone survey of 1452 randomly selected adults included questions regarding knowledge of early childhood development and parenting confidence. A total of 320 respondents were mothers of children 6 years of age or younger; 46 had at least one child with a SHCN and 274 did not have a child with a SHCN. High maternal knowledge was defined as answering correctly at least 50% of the questions in at least two of four developmental domains (physical, cognitive, emotional and social). High confidence were those who selected “strongly agree” at the top end of a 7-point Likert scale. Between-group comparisons were analyzed using a t-test for binomial proportions (P<0.05).
RESULTS:
About 70% of mothers in each group were found to have low knowledge. Mothers of children with SHCN were more likely to indicate high parenting confidence (54%) than mothers of children without SHCN (33%). Based on knowledge and confidence level mothers were assigned to one of four groups. A significantly greater proportion of mothers of children with SHCN had low knowledge/high confidence than mothers of children without SHCN (P=0.03).
CONCLUSION:
A greater proportion of mothers of young children with SHCN fall into the category of low knowledge and high confidence. This combination may have a negative effect on parenting success. Further research is required to determine why this combination is more prevalent among mothers of children with SHCN, and how future interventions might more effectively support parents of children with SHCN.
| No SHCN n (%) | SHCN n (%) | P | |
|---|---|---|---|
| Low Knowledge and Less Confidence | 121 (39%) | 14 (45%) | 0.97 |
| Low Knowledge and High Confidence | 72 (41%) | 19 (26%) | 0.03* |
| High Knowledge and Less Confidence | 62 (15%) | 7 (22%) | 0.89 |
| High Knowledge and High Confidence | 19 (13%) | 6 (7%) | 0.12 |
Paediatr Child Health. 2015 Jun-Jul;20(5):e95.
Abstract
BACKGROUND:
Wait times for diagnosis of autism spectrum disorders (ASD) may negatively impact outcomes by delaying access to early interventions. Community general pediatricians (CGPs) are often consulted in cases of suspected ASD, and may play a role in increasing ASD diagnostic capacity in the community setting.
OBJECTIVES:
The objective of this study was to explore the perspectives of CGPs regarding their role in the system of ASD diagnoses using qualitative methods.
DESIGN/METHODS:
We performed a phenomenological qualitative study of CGPs’ experiences with cases of suspected ASD. Two groups of CGPs were sampled to provide varying perspectives: CGPs that had referred patients with suspected ASD for a subspecialist assessment, and CGPs that regularly attended ASD educational events. Individual in-depth interviews were recorded and transcribed. Two investigators coded each interview. Thematic saturation was reached when two successive interviews did not generate new codes. Texts were analyzed using a grounded theory approach. A preliminary theoretical framework was developed, summarized and sent to participants with a request for feedback. This feedback was incorporated into the final theoretical framework.
RESULTS:
Eleven in-depth interviews were conducted (six males, five females; mean years in practice 17.1). Participants described three elements to the process of assessment: diagnostic determination, communication of the diagnosis, and management of the diagnosis. Each element contains potential barriers to assigning a diagnosis of ASD. Diagnostic determination is affected by patient factors (such as age, severity, and comorbidities), family factors (the reliability of the historian), and physician factors (such as training, access to informal expert consultation, and interest in ASD). When communicating the diagnosis, it is important that families know enough, but not too much, about ASD; families who know too much are perceived to need an “expert” opinion. Participants described a significant emotional burden and were very sensitive to the impact of the diagnosis. They feel ill equipped to deal with the fragmented service delivery system for ASD. Helping families to access services is time-consuming, poorly remunerated, and less satisfying than other areas of pediatric practice.
CONCLUSION:
Though CGPs are frequently consulted on cases of suspected ASD, they experience many barriers to making a diagnosis, leading to increased subspecialist referrals. Efforts to improve diagnostic capacity in this group must focus not only on diagnostic determination, but also on communicating the diagnosis and efficiently connecting families to resources.
Paediatr Child Health. 2015 Jun-Jul;20(5):e95–e96.
Abstract
BACKGROUND:
Assistive technology (also known as adaptive technology) refers to any product, device, or equipment, whether acquired commercially, modified or customized, that is used to maintain, increase, or improve the functional abilities of individuals with disabilities. Assistive technology promotes greater independence by enabling people to perform tasks that they had great difficulty accomplishing. The evolution of assistive products has relied on state-of-the art materials and technologies. Improving functional outcomes has been always the main purpose of assistive technologies. Some of the important developmental milestones of assistive technology are worth describing.
OBJECTIVES:
The objective of this paper is to describe the fascinating developmental trajectory of assistive technology over time.
DESIGN/METHODS:
Historical review.
RESULTS:
Assistive products and devices, like the cane, have been around since the Stone Age. During the Renaissance, prosthetics developed with the use of iron, steel, copper, and wood. Functional prosthetics began to make an appearance in the 1500s. In the 1800s modern prostheses, especially for the lower limbs, were developed to restore mobility to war combats. Hearing aids were first patented in 1890s, followed by the first Braille typewrite in 1892 and the first speech in 1936. The first electric wheelchair was developed in 1950. But a major milestone of assistive technology occurred with the development of the microprocessor electronic circuit the “chip” in 1958. Microcomputer advances have been used for the design and manufacture of several assistive technologies such as speech recognition programs, robotic aids, seating and positioning, vision adaptation softwares and mobility devices.
Legislations promoting the development and application of assistive technologies in 1970s, and the publication of the International Classification of Functioning, Disability and Health (ICF) in 2001, were major contributions. The ICF highlights the role of environmental factors like assistive technologies as facilitators of functional abilities. Consequently, professionals are encouraged to systematically consider environmental modifications when planning interventions for individuals with functional limitations, for example the introduction of virtual reality in pediatric neurorehabilitation interventions.
CONCLUSION:
In conclusion, assistive technologies provide significant enhancement to inclusive education, social participation and employment. History shows that technology has revolutionized rehabilitation interventions and the care of individuals with chronic conditions, and promises to deliver even more innovative products for years to come.
Paediatr Child Health. 2015 Jun-Jul;20(5):e96.
Abstract
BACKGROUND:
The preferred timing of a sleep-wake rhythm is considerably varied between individuals. Self described preferences for being active in the morning or evening is referred to as a chronotype and also as “morningness” or “eveningness”, respectively. Literature on adults and adolescents associate eveningness with higher proneness to emotional and behavioural problems. However, little research has been conducted in regards to the potential health affects of circadian preference in a pediatric population.
OBJECTIVES:
Hence, the objective of this study was to investigate the association between chronotype and emotion and behaviour in children.
DESIGN/METHODS:
24 typically developing elementary school children completed the Morningness and Eveningness Questionnaire (MEQ), with lower scores on the MEQ corresponding to a morningness preference and higher scores to an eveningness preference.
Externalizing and internalizing problems were measured using the Child Behavior Checklist (CBCL) and Teacher Report Form (TRF). Pearson correlation analyses were conducted between scores on the MEQ and reports on the CBCL and TRF.
RESULTS:
Results indicated that children reporting evening preference had significantly higher social problems and aggressive behaviour, as reported by parents using the CBCL. Additionally, eveningness was also significantly associated with higher internalizing problems, specifically with affective problems, and with withdrawal/depression behaviour as reported by teachers using the TRF.
CONCLUSION:
The results of this study are in line with adult and adolescent literature, suggesting children with an evening preference are more prone to emotional and behavioural problems. Understanding the potential effects of pediatric circadian tendencies is crucial to the development of successful preventative and intervention measures promoting the well being of children. Educating health care providers and parents on the importance of balancing extreme evening tendencies in their children is warranted. Additionally, integrating such information within educational curriculums in schools can help inform students about the importance of their sleep wake rhythm, and can provide them with the necessary tools for a healthy transition into adulthood.
Paediatr Child Health. 2015 Jun-Jul;20(5):e96.
Abstract
BACKGROUND:
The Pediatric Developmental Passport (Passport) is an ongoing initiative that aims to develop, assess and implement a tool that is designed to be used jointly by pediatricians and families with a child who has received a new developmental diagnosis of Autism Spectrum Disorder (ASD).
OBJECTIVES:
Previous research projects have led to the design of the Passport. The aim of this phase of the study is to pilot test the passport in a pediatric setting to determine its usability among families with a child diagnosed with ASD between 0–6 years of age.
DESIGN/METHODS:
A pragmatic randomized controlled trial was conducted. Children referred for a developmental assessment and diagnosed with ASD between 0–6 were randomized to receive the passport (intervention) or the placebo (control). All families were followed for one year. Primary outcome was time of first contact with developmental agency. Secondary outcomes included 1) length of time it takes families to meet the agency directly and 2) proportion of total recommendations accessed by families. Additional exploratory outcomes were 1) patient satisfaction and 2) impact of socio-economic status on the effect of the passport on primary and secondary outcomes.
RESULTS:
The passport is currently being evaluated at multiple pediatric sites. Preliminary results reveal forty-one percent of families were Non-Canadian born who predominantly came from Asia. Families were predominantly Caucasian (41%), Asian (29%), and African American (12%). The income status of families were evenly distributed with 29% families making less than $24000, between $50, 00–74,999 and above $100,000. Although all families in both groups accessed Applied Behavior Analysis (ABA) services, families from the passport group contacted services in significantly less time (9 days vs 14 days). The passport allowed pediatricians to discover that early intervention services and speech and language pathology (services recommended by developmental pediatricians) were more often accessed prior to a diagnosis due to community endorsement. The developmental pediatricians felt the passport helped increase their efficiency at communicating recommendations to families. All families were highly satisfied with the passport and reported it to reduce stress and anxiety.
CONCLUSION:
The passport is an innovative practical tool that has shown proof of concept and usability among families diagnosed with ASD and developmental pediatricians. Further evaluation of the passport at the general pediatric level is being planned. We would also like to adapt the passport into a mobile application or online application, as suggested by caregivers.
Paediatr Child Health. 2015 Jun-Jul;20(5):e96.
Abstract
BACKGROUND:
Controversy exists about the management of neonatal septic shock. Hydrocortisone (HC) is used during septic course in older children and adults, but has been rarely studied in neonates.
OBJECTIVES:
To describe hydrocortisone administration in septic shock in our neonatal intensive care unit and determine if variations in practice are associated with improved survival.
DESIGN/METHODS:
The effects of HC therapy for septic shock were retrospectively evaluated in neonates admitted to our unit between 2010 and 2013. Data regarding timing of HC administration and effects on survival were analysed.
RESULTS:
Thirty-five infants were treated for neonatal shock during the study period (80% culture proven sepsis). A total of 23 patients out of the 35 received HC during the course of their shock (average cumulative dose of 16±16 mg/kg). The two groups (hydrocortisone vs no-hydrocortisone) did not differ significantly in terms of gestational age (25.7±1.4 vs 26.8±1.8 weeks, P=0.68), birth weight (994±194 vs 964±371 grams, P=0.34) and age at onset of shock (12.2±18 vs 9.9±8.1 days, P=0.93). Exposure to antenatal steroids (87% vs 100%, P=054) and APGAR scores (6±2 and 6±2, P=0.69) did not differ significantly between the two groups. Patients who received hydrocortisone were less likely to survive (26 vs 83%, P=0.03) and were sicker in general (vasoactive index score 48±51 vs 10±8, P=0.000). Timing of hydrocortisone administration was on average 49±63 hours after the onset of shock. Although we noted a trend toward later hydrocortisone administration in survivors (79±92 vs 38±51 hours, P=0,26), this difference was not statistically significant. Patients that received hydrocortisone and survived had a trend toward a more prolonged hospitalisation (age at discharge 47.4±5.8 vs 42±5.3 weeks of corrected gestational age, P=0.08).
CONCLUSION:
In our centre, hydrocortisone administration in the context of neonatal septic shock tends to be early and in patients presenting with a more severe clinical picture. However, this is without any improvement in survival. Further prospective studies are needed to clarify hydrocortisone’s role in septic shock management in the term and preterm newborn.
Paediatr Child Health. 2015 Jun-Jul;20(5):e96.
Paediatr Child Health. 2015 Jun-Jul;20(5):e97.
Abstract
BACKGROUND:
Primary health care is an essential component of the health care system and has been shown to improve health outcomes (such as decreased urgent health care use) in patients with chronic conditions. Asthma is the most prevalent chronic illness in children and contributes major costs to the system with emergency room visits and hospital admissions. The federal and provincial governments had recognized the value of primary care and over a decade ago had invested millions of dollars in primary care reforms to improve quality and access for the population. Reforms introduced new models of care, such as Family Medicine Groups (FMG) and Integrated Network clinics in Quebec, as well as financial incentives for physicians to take on patients with chronic conditions but there is no evidence that these structures or incentives have been successful in prioritizing children with conditions such as asthma. Very little data exist on access to primary health care for children in Canada. It is thus pertinent to explore whether children with asthma are being prioritized in terms of access to primary care.
OBJECTIVES:
To determine the patient acceptance rates into primary care practices in Montreal for a child without asthma compared to a healthy child.
DESIGN/METHODS:
We conducted a randomized telephone audit study between July 24–October 10, 2014 in which primary care clinics in Montreal were randomized to two script scenarios. One scenario consisted of a caller posing as a mother of a four-year-old son with asthma, and the second was a mother of a healthy four-year-old son. In both cases, the caller was looking for a primary care physician for the child. We collected baseline data on the clinics, including health and social services region, clinic type (pediatrics, FMG, FMG-integrated network, non-FMG clinics). We conducted descriptive statistics (proportions) and χ2 tests to determine difference between the acceptance rates of two scenarios.
RESULTS:
Of the 257 clinics included, 30 (11.7%) were willing to accept a child. There was no significant difference between acceptance rates for a child with or without asthma (13.3% vs. 10.2%, respectively). Of the 227 clinics that would not accept the child, 45 (18.5%) said they did not accept children at all. Pediatric compared to other clinic types were more likely to accept new patients (P=0.005).
CONCLUSION:
Access to primary care in Montreal is poor. The majority (88.3%) of primary care clinics are not accepting children altogether. Children with asthma are not being prioritized in terms of access to primary care. Given the importance of primary care in children, especially those with chronic disease, policy-makers should re-examine current structures and incentives to address problems in primary care access.
Paediatr Child Health. 2015 Jun-Jul;20(5):e97.
Abstract
BACKGROUND:
Although sweet-tasting substances such as sucrose solution have been demonstrated to reduce pain in infants undergoing routine vaccine injections, they are rarely utilized in clinical practice. Oral rotavirus vaccine is administered concomitantly with injectable vaccines in two- and four-month-old infants and contains sweet-tasting substances, including sucrose. At present, there is no guidance regarding the order of administration of rotavirus relative to injectable vaccines resulting in some clinicians administering it before and others after. If analgesic, rotavirus administration could be standardized to precede injectable vaccines so as to confer the added benefit of reducing pain from subsequent vaccine injections and sucrose would not be needed.
OBJECTIVES:
The objective was to compare the analgesic effectiveness of sucrose and oral rotavirus when administered prior to injectable vaccines.
DESIGN/METHODS:
Two- and four-month-old infants receiving routine injectable vaccines (Diphtheria, Tetanus and acellular Pertussis/Inactivated Polio/Haemophilus influenza type b and Pneumococcal conjugate) were randomized to receive oral sucrose before the injectable vaccines and rotavirus (Rotarix™) afterwards or rotavirus before and sucrose afterwards. The order of injections was standardized (pneumococcal conjugate vaccine last). Parents and clinicians were blinded to order of administration and assessed pain in real time after each injection using an 11-point numerical rating scale (where 0=no pain and 10=worst possible pain). The pain score for each injection and average pain score for both injections was used in the analysis.
RESULTS:
Altogether, 120 infants participated: 60 were randomized to sucrose first. The mean age, sex and weight of infants did not differ statistically between groups (P>0.05 for all analyses). Parent pain ratings in the sucrose group vs. the rotavirus group during the 1st and 2nd vaccine injections were: 3.9 (2.6) vs. 3.0 (2.3), P=0.066; and 7.7 (2.0) vs. 6.8 (2.4), P=0.046, respectively. Clinician pain ratings were: 3.0 (2.4) vs. 2.3 (2.2), P=0.110, and 6.3 (2.3) vs. 6.1 (2.4), P=0.643, respectively. The average pain score for both injections was lower in the rotavirus group for parent ratings but not for clinician ratings: 5.8 (2.1) vs. 4.9 (2.1); P=0.032, and 4.6 (2.2) vs. 4.2 (2.1), P=0.269, respectively.
CONCLUSION:
The results demonstrated that rotavirus possesses analgesic properties. Based on the findings, rotavirus administration is recommended to precede injectable vaccines in order to obtain the added benefit of analgesia. In this context, sucrose solution is not needed. Additional research may examine if there is an additional benefit of sucrose when added to rotavirus.
Paediatr Child Health. 2015 Jun-Jul;20(5):e97–e98.
Abstract
BACKGROUND:
Many Canadian pediatric health care providers participate in the conduct and dissemination of research involving Aboriginal children. Even if they are not directly involved in research, front-line clinicians have insight into issues, both medical and sociopolitical, affecting the health of Aboriginal patients, and are uniquely positioned to highlight areas where thoughtfully conducted research could improve the health status of Aboriginal children. A community-based participatory research approach (CBPR; Minkler & Wallerstein, 2003) can identify and address the social determinants of health that impact Aboriginal children and their communities.
OBJECTIVES:
The current presentation describes a CBPR project carried out by university and First Nation community partners. In response to high rates of substance abuse in their communities, members of a First Nation community invited university researchers to form a partnership to culturally adapt, implement, and evaluate an evidence-based substance abuse and violence prevention program. The objectives of the current presentation are to (1) share evaluation findings from three years of program implementation in community schools; (2) describe how CBPR can address the social determinants of health and build the capacity of university and community partners to address important health issues; and (3) demonstrate how different research paradigms can co-exist in an ethical space that honors multiple worldviews.
DESIGN/METHODS:
Evaluation of the culturally adapted program utilized a mixed method approach. Outcome Mapping (Earl, Carden, & Smutylo, 2001), a unique participatory evaluation tool, documented changes in behaviors, relationships, actions, and activities of program stakeholders. Additionally, pre- and post- program questionnaires were distributed to students, and a linear mixed model was used to evaluate learning of program content. Finally, focus groups were conducted with community members to obtain program feedback.
RESULTS:
Outcome Mapping documented how the process of culturally adapting, implementing, and evaluating the prevention program (1) acted as a catalyst for community development, and (2) built community and academic capacity to facilitate community change. The results of pre- and post-program questionnaires indicated statistically significant improvements in student knowledge, skills, and attitudes related to substance abuse, and focus groups captured the critical importance of the program’s cultural content.
CONCLUSION:
The process of forming and maintaining a community-university partnership, as well as culturally adapting, implementing, and evaluating the effectiveness of an evidence based substance abuse and violence prevention program led to meaningful individual and community change. Implications relevant to research and practice will be discussed, and findings will be presented from the perspectives of both community and university partners.
Paediatr Child Health. 2015 Jun-Jul;20(5):e98.
Abstract
BACKGROUND:
Child sexual abuse (SA) is associated with emotional and behavioral difficulties in children such as emotion regulation (ER) deficits. Close to 50% of mothers of SA children report having themselves been sexually victimized as children, and are at risk of experiencing significant distress that could interfere with their ability to provide support.
OBJECTIVES:
Our aim was to explore the contribution of parental factors (history of sexual victimization in childhood and the current level of distress) to the prediction of SA preschoolers’ ER competencies.
DESIGN/METHODS:
The sample consisted of 153 preschoolers (M = 4.3 years; SD = 0.92) and their parents (93% maternal figure). There were 75 (14 boys) SA children and 78 (21 boys) non SA controls. Children’s ER competencies were evaluated by parents with the Emotion Regulation Checklist (ERC). Parental psychological distress was evaluated using the Psychiatric Symptom Index (PSI). The contribution of parental factors to the prediction of children’s ER competencies was tested using regression analysis. Victimisation status of the child was entered first, then the parental factors and the child’s gender.
RESULTS:
Around 32% of SA children reported a single episode of abuse, 42% more than two episodes and 26% abuse lasting for more than six months. Complete or attempted penetration was described in 47% of cases. An immediate family member was identified as the perpetrator in 53% of cases. Entering the victimisation status of the child in the regression analysis predicting scores on the emotional lability/negativity scale of the ERC gets an R2 = 0.06 F (1,141) = 9.0, P<0.01. Adding parental psychological distress resulted in a significant increment in R2 = 0.12, F(2, 140) = 9.54, P<0.001. With the addition of parental history of SA, the prediction reached R2 = 0.16, F(3, 139) = 8.66, P<0.001, and with the addition of child’s gender, the prediction reached R2 = 0.18, F(4, 138) = 7.65, P<0.001. When predicting child’s score on the emotion regulation scale of the ERC, child’s victimisation status alone gets an R2 = 0.23 F (1,141) = 41.9, P<0.001 and the only other variable adding significantly to the score prediction is child’s male gender with R2 = 0.27 F (1, 140) = 26.5, P<0.001.
CONCLUSION:
Parental factors appear to contribute to some aspects of children’s ER, namely display of exuberance, temper tantrums and emotional negativity. ER competencies being central to mental health, helping parents overcome their own distress might be helpful in fostering resilience in sexually abused preschoolers.
Paediatr Child Health. 2015 Jun-Jul;20(5):e98.
Abstract
BACKGROUND:
Child maltreatment (CM) is a widespread problem in children and youth. Pediatricians and health professionals involved may be required to interact with child welfare authorities and the court system; arenas in which they may be unfamiliar. Professionals often have little experience in reporting suspected CM and frequently don’t feel prepared to provide court testimony. Even for those specializing in CM, stress surrounding court appearances is reported. Exposure to and familiarity with this element of practice could increase comfort and competence.
Games are an established and effective teaching method. However, evidence for game-based learning among health professionals is limited.
OBJECTIVES:
To assess the satisfaction with and perceived learning from a game-based tool designed to assist with preparation for court.
DESIGN/METHODS:
A board game with content developed by an expert CM group was created. Game content, in the form of questions and tasks, reflected knowledge and skills required by the court system. Attendees at a session on ‘preparing for court’ at a national Child Maltreatment Symposium played the game for one hour. An anonymous post-session survey was completed to assess participants’ satisfaction and perceived learning. Responses to questions on a 5-point Likert scale were coded and analyzed using descriptive statistics. Qualitative comments were analyzed and grouped by emerging themes.
RESULTS:
Forty-three of the 58 players completed a survey yielding a response rate of 74%. Thirty-four respondents (79%) self-identified as a pediatrician or Child Abuse pediatrician, 9% (n=4) were trainees and 12% (n=5) were allied health practitioners. Over half of the respondents were between the ages of 25–45 (n=22). The mean number of years in practice was 19 (range 2–46). Respondents most often “agreed” that the game was: useful for learning (88%), helped link knowledge to practice (56%) and met their educational needs (68%). The vast majority of respondents “agreed” or “strongly agreed” (70%) they would participate in a similar session in the future. When asked to compare the game experience to prior educational sessions about court, respondents most often “agreed” or “strongly agreed” (81%) that the game held their attention better. Qualitative feedback, in the form of exemplar quotes also supported respondents’ satisfaction with the game as a learning tool.
CONCLUSION:
These results suggest that game-based learning is an effective and positively accepted method of learning about court. Similar game based interactive sessions may be useful for education in other areas with limited preparation options and opportunities for practical experience.
Paediatr Child Health. 2015 Jun-Jul;20(5):e98–e99.
Abstract
BACKGROUND:
An estimated 2% of children in Canada suffer mal-treatment. These children have higher rates of medical, developmental and behavioural problems, however their needs may be poorly understood and gaps in service are often identified. In September 2013, the regional pediatric hospital child maltreatment program and the local child welfare agency collaborated to open an outpatient clinic as a pilot project.
OBJECTIVES:
The goals of the clinic are to provide early, comprehensive and expert identification and intervention in cases of abuse and neglect, as well as to screen for related medical, developmental and behavioural problems. The objectives of this study are to describe the patient population and evaluate the clinic’s overall functioning, acceptability and ability to meet the above goals.
DESIGN/METHODS:
A logic model delineated the program theory and set out a framework for evaluation. Program function goals included clinical, communication and system issues. Data was collected via chart review and a clinic satisfaction survey for caregivers and child welfare workers. The data was collated and stored in REDCap. Institutional ethics review board approval was granted. Descriptive statistics are reported for the first 12 months.
RESULTS:
In the first year, 87 children were seen through 134 patient encounters. Most children were referred by child welfare workers (70%). The most common reasons for referral were physical abuse (54%), neglect (29%), trauma and behavior issues (both 14%). New diagnoses were made for 79% children with an average of 2.8 (range 1–8) per patient. Laboratory investigations were required for 58% children, diagnostic imaging for 25% and referrals to other specialized services for 56%. The clinic satisfaction survey was completed by 43 respondents. The overall experience in the clinic was rated as excellent by 86%. Only 20.5% respondents indicated that they had an excellent understanding of the child’s health needs before the clinic visit but this increased to 61.9% after the visit. All respondents felt that the new information shared was relevant for the child’s health. Most respondents (88.4%) agreed that the new information was relevant for child welfare’s involvement with the child.
CONCLUSION:
This model of care for high risk children involved with the child welfare system is innovative in our region in that the expert assessments and recommendations are created, communicated and implemented collaboratively by medical and child welfare staff. Preliminary data demonstrates that this population has a high rate of unrecognized health needs and that this model has high ratings of satisfaction by the users.
Paediatr Child Health. 2015 Jun-Jul;20(5):e99.
Abstract
BACKGROUND:
Some children with congenital heart disease (CHD) have exercise intolerance; however, the associations between their moderate-to-vigorous physical activity (MVPA) levels, gross motor skill development, and peak exercise capacity are unclear.
OBJECTIVES:
To determine whether associations between MVPA, peak exercise capacity, and gross motor skill development are influenced by patient characteristics and type of CHD.
DESIGN/METHODS:
Medical history was abstracted from medical record review. Accelerometers assessed 7-day MVPA levels. A standard cardiopulmonary exercise test using the modified Bruce protocol determined peak exercise oxygen consumption (%-predicted VO2). Gross motor skill scores (combined motor and object score) were determined using The Test of Gross Motor Development Version-2 (TGMD-2).
RESULTS:
CHD patients (n=172, 56% male, age 8±2 years) included children with a repaired atrial septal defect (ASD, n=37, MVPA=424±271 minutes/week), transposition of the great arteries (arterial switch, TGA, n=47, MVPA=416±164 minutes/week), tetralogy of Fallot (TOF, n=48, MVPA=327±141 minutes/week), and single ventricle after Fontan (SV; n=40, MVPA=301±134 minutes/week). MVPA was significantly higher for ASD/TGA versus TOF/SV (P<0.001). A higher %-predicted VO2 was associated with higher MVPA (parameter estimate [standard error]: +1.2(0.6) %-predicted VO2 per 60 minutes of MVPA, r=0.21, P=0.02). A higher gross motor skill score was associated with higher MVPA (EST: +2.1(0.7) minutes per 1% change in TGMD score, r=0.24, P=0.004). This association was marginally influenced by testing during the summer months (EST[SE]: −0.05[−0.02], P=0.01) and family-reported income (EST[SE]: −0.001[−0.0002], P=0.02). However, associations were independent of age at testing, age at repair, sex, CHD diagnosis, and on-going cardiac complications.
CONCLUSION:
Associations between MVPA, gross motor skill, and peak exercise capacity were similar for all children with CHD. Lower MVPA levels in TOF and SV patients were not associated with clinical variables. Future research should target interventions for increasing the MVPA of TOF and SV patients.
Paediatr Child Health. 2015 Jun-Jul;20(5):e99.
Abstract
BACKGROUND:
Hearing loss (HL) is a threat to normal language development. Children undergoing cardiac surgery are exposed to numerous risk factors involved in HL.
OBJECTIVES:
In this study, we aim to establish HL prevalence and risk factors in this population.
DESIGN/METHODS:
We conducted a retrospective study of children undergoing cardiac surgery before the age of one year in our institution (May 2007–June 2012). Based on local practices, patients underwent hearing testing between 1 and 5 years of age. Charts were reviewed. Collected data included: demographics, cardiac surgery information, ototoxic medication dosage and hearing testing results.
RESULTS:
Eighty-four patients (48 males) were included with a median age of 38.5 days (range: 3–363) at surgery. Seven patients (8.3%) were found to have definitive HL, four with moderate to severe HL. Neonatal screening tests had been done prior to surgery in 3/7 patients, and 2/3 were normal. HL was associated with low birth weight (under 2.2 kg, P=0.02) and low Apgar scores at 5 minutes (under 6, odds ratio: 10.7 [1.4, 83.2]). No association was found with craniofacial abnormality, genetic syndromes, ototoxic medications, mechanical ventilation or postoperative complications. The expected negative influence of higher RACHS-1 score or length of extracorporeal circulation was not confirmed. Rather, a lower RACHS-1 score and a shorter extracorporeal circulation were associated with HL (P=0.026 and 0.0002, respectively). Also, older age at surgery was associated with HL (P=0.009).
CONCLUSION:
Children undergoing cardiac surgery before one year of age are at high risk for hearing loss (8.3% compared to 0.14% in general population and 2.9% in neonatal intensive care population). A significant association was established with low birth weight and Apgar score at 5 minutes. Larger studies are needed to identify risk factors and screening recommendations.
Paediatr Child Health. 2015 Jun-Jul;20(5):e99.
Abstract
BACKGROUND:
Children with congenital heart defects (CHD) are at increased risk for the health consequences of a sedentary lifestyle. We know CHD children are more sedentary than healthy peers, but need to identify the specific areas of deficit in order to development optimal supports and interventions.
OBJECTIVES:
This cross-sectional study evaluated the physical literacy (capacity for an active lifestyle) of children with CHD and compared their results to those of healthy peers.
DESIGN/METHODS:
Children (8 to 12 years) completed the Canadian Assessment of Physical Literacy. Standardized protocols assessed daily behavior (daily steps, sedentary time), physical competence (motor skill, aerobic and muscular endurance, strength, flexibility, body composition), motivation (adequacy, predilection) and knowledge (activity, fitness, skill) domains. Children with CHD, a convenience sample assessed at a cardiac clinic, were compared (t-tests) to healthy peers assessed in local schools. Statistical significance was P<0.012 (.05/4 physical literacy domains).
RESULTS:
Participants were 37 children with CHD (35% female, 10.0±1.3 yrs) and 963 healthy children (55% female, 10.1±0.9 yrs). CHD patients tended to have a higher proportion of males (P=0.02) and were more likely to be tested during the spring/summer (P<0.001). Total Canadian Assessment of Physical Literacy score (P=0.45) and the motivation (P=0.77) and knowledge (P=0.48) domains did not differ between groups (see Table). Physical competence (P=0.03) tended to be lower and daily behavior (P=0.07) tended to be higher among CHD patients. Within the physical competence domain, core body strength (plank isometric hold, P<0.001) was significantly lower and motor skill tended to be lower (obstacle course, P=0.03) among CHD patients. Within the daily behavior domain, CHD patients performed more daily activity (pedometer step counts, P<0.001) and tended to report more sedentary behavior (screen time, P=0.016).
CONCLUSION:
The results of this study suggest that children with CHD have a similar overall capacity for a healthy active lifestyle (i.e., physical literacy) compared to healthy peers. Their motivation for, and knowledge of physical activity are similar. Motor skill, sedentary behavior and muscular endurance measures may identify children with CHD most at risk for an inactive lifestyle. The higher daily activity among CHD patients suggests that study volunteers may have been those who were already more active. Future research should evaluate a larger randomized, representative sample of CHD patients and the impact of interventions to promote core muscular endurance, motor skill, and decreased sedentary behaviour.
Paediatr Child Health. 2015 Jun-Jul;20(5):e100.
Abstract
BACKGROUND:
Kawasaki Disease (KD) is the leading cause of acquired heart disease in developed countries. Coronary artery aneurysms (CAA) develop in up to 30% of patients not treated before 10 days of fever. Affirmative KD diagnosis can be confusing in the absence of a confirmatory test or pathognomonic finding, especially when clinical criteria are incomplete (iKD). Recently, NT-proBNP has been shown to be a reliable adjunctive diagnostic test in acute KD.
OBJECTIVES:
The goal of this study was to assess the performance of the algorithm with respect to coronary artery outcome (aneurysm, dilation, or occult dilation).
DESIGN/METHODS:
We retrospectively tested a new diagnostic algorithm to aid in diagnosis based on NT-proBNP (Z-score for age), coronary artery dilation (CAD) at onset, and abnormal serum albumin or CRP. Coronary dilation is defined as a coronary artery Z-score>2.5. Occult dilation is defined as variation in time of the coronary artery Z-score>2 standard deviation points, but within the normal range (<2.5). For example, a patient with a coronary artery Z-score of −1.0 at diagnosis, and of 1.5 at three months follow-up would qualify as occult dilation.
RESULTS:
The algorithm was tested on 81 consecutive KD patients who had NT-proBNP on admission at our institution between 2008 and 2013. Age at diagnosis was 3.2±2.6 years, with a median of five diagnostic criteria (range 3–6), of whom 31/81 (38.3%) had iKD. Aneurysms occurred in 16/81 (19.8%); higher prevalence in iKD, 12/31 (38.7%) versus 4/50 (8.0%) (P=0.001). CAD affected 35/81 (43.2%), and 30/81 (37.0%) had occult CAD. With the algorithm, 80/81 (98.8%) were to be treated: based on high NT-proBNP alone for 54/81 (66.7%), on onset CAD for 13/81 (16.0%), and on high CRP or low albumin for 13/81 (16.0%) (Figure 1). Results were similar when the algorithm was applied to patients with complete or incomplete criteria. The only patient “not-to-treat” with the algorithm had iKD and transient occult CAD.
CONCLUSION:
This NT-proBNP based algorithm proved efficient to identify and treat patients at risk of coronary involvement, despite an apparent selection bias of CA involvement. This paves the way for a prospective validation trial of the algorithm.
Figure 1).
Application of the algorithm to patients with KD and CAA, CAD, oCAD. cKD: complete Kawasaki; iKD: incomplete Kawasaki; CA: coronary artery; CAD: coronary artery dilatation; oCAD: occult coronary artery dilatation
Paediatr Child Health. 2015 Jun-Jul;20(5):e100.
Abstract
BACKGROUND:
Survival rates after neonatal Complex Cardiac Surgery (CCS) for congenital heart disease (CHD) have increased. Surviving children face neurodevelopmental and neuromotor challenges. While neuro-cognitive difficulties have been reported; little research has been done on motor impairments. Permanent non-progressive motor impairments are cerebral palsy (CP) and acquired brain injury (ABI), including stroke. Major Neuromotor Disability (MND) is the umbrella term used here to include CP and ABI.
OBJECTIVES:
1) To calculate the rate of MND among 4.5-year survivors, 2) To describe MND among 4.5-year survivors according to the current CP definition and classification, 3) To determine potentially modifiable acute care predictors that might lead to a reduction in the frequency of MND.
DESIGN/METHODS:
This prospective inception cohort study included 549 children with CHD of ≤6 weeks of age at the time of their first CCS requiring cardio-pulmonary bypass at the Stollery Children’s Hospital, 1996–2009. Groups included those with only one CCS, mostly bi-ventricular CHD, and those with more than one CCS, predominantly single ventricle defects. After 4.5 years, 105 (19.1%) children had died, 24 (5.4%) were lost to follow up, and 420 survivors received multidisciplinary assessment. The frequency of MND is given as percentage (95% confidence interval [CI]) of assessed survivors. Operative and peri-operative predictors of MND were analyzed using univariate and multiple logistic regression analysis, expressed as odds ratios (OR) with 95% CI.
RESULTS:
MND occurred in 25 (5.95%) (CI 3.7%, 8.2%) of 420 4.5-year survivors; for one CCS, 4.2%(CI 2.3%, 6.1%) and more than one, 9.8% (CI 7%, 12.6%). MND occurred in 10.3% (CI 7.4%, 13.2%) of those with single ventricle defects. Unilateral MND was found in 18(72%); spasticity in 20(80%). According to the multiple regression model, statistically significant independent OR for MND are: age in days at first surgery, 1.079 (CI: 1.037, 1.123) (P<0.001); and prior to first surgery, highest plasma lactate (mmol/L), 1.129 (CI: 1.032, 1.235) (P=0.008) and highest inotrope score, 1.020 (CI: 0.997, 1.040) (P=0.054) (marginal significance). Adjusting for the presence of these predictors, OR for MND is 3.569 (CI: 1.467, 8.687) (P=0.005) if more than one CCS is needed.
CONCLUSION:
MND is not uncommon among survivors after CCS, especially for those children needing more than one surgery. OR for MND is 1.08 for each day the neonatal CCS is delayed and 1.13 for each mmol/L of plasma lactate elevation in the pre-operative period at first surgery. Identification of these potentially modifiable predictors may assist in reducing the frequency of MND after life-saving CCS. This information will improve counselling for families of these children.
Paediatr Child Health. 2015 Jun-Jul;20(5):e100–e101.
Abstract
BACKGROUND:
Early Developmental Intervention (EDI) is known to have long-term positive outcomes across developmental domains. Gastrostomy feeding is indicated in children with swallowing difficulties to prevent aspiration and lung disease; and to enhance growth and nutrition.
OBJECTIVES:
To compare the proportion of different types of developmental delay in Complex Cardiac Surgery (CCS) survivors with and without gastrostomy feeding tube, in order to determine if the presence of gastrostomy in infants after CCS identifies the need for EDI.
DESIGN/METHODS:
387 survivors requiring early CCS with cardiopulmonary-bypass at the Stollery Children’s Hospital (2004–2012) were assessed at 21+ 3 months of age with the Bayley Scales of Infant and Toddler Development, 3rd edition and the Adaptive Behavior Assessment System-II: self-care skills and General Adaptive Composite (GAC). Delay was determined by scores >2 SD below mean. Fisher Exact test compared groups.
RESULTS:
Ninety-four (24.3%) of survivors had gastrostomy. In comparison to those without gastrostomy (n=293) cognitive delay occurred in 21 (22.3%) vs. 12 (4.1%); language, 32 (34%) vs. 38 (13%); motor, 28 (29.8%) vs. 13 (4.4%); all P<0.001. Children with gastrostomy had 6.6 times more delay on the GAC, and five times more delay on self-care skills than those without.
CONCLUSION:
The presence of gastrostomy in this population strongly suggests CCS survivors should be referred for EDI. The major contribution of this study is a simple way to enhance prompt identification of at risk survivors after CCS in order to maximize the benefits of EDI.
Paediatr Child Health. 2015 Jun-Jul;20(5):e101.
Abstract
BACKGROUND:
Increasingly expensive therapies are becoming available for “orphan” diseases. For example, ivacaftor given orally targets and corrects the dysfunctional cell membrane protein in cystic fibrosis (CF), but only in individuals who carry one of several rare genetic CF mutations. Ivacaftor is priced at $300,000 CDN per patients over 6 years of age, per year, for life. Ivacaftor does not cure CF, but is associated with increased lung function, quality of life and body weight. It may slow disease progression, but it will not be known for many years if it does this more effectively than the present, burdensome, approach.
OBJECTIVES:
To analyse the legal processes and ethical landscape in the Canadian Health Care System relative to provision and funding of expensive therapies for Canadian children with orphan diseases.
DESIGN/METHODS:
A scoping review was conducted to understand the extent of the orphan drug issue in Canada and globally. News articles, government websites and peer-reviewed journals were reviewed to understand the approval process. Moral and ethical theories regarding fairness in the allocation of resources for minorities were reviewed, and a legal analysis was conducted to determine if the current policy for orphan drug allocation could be at risk of a tortious claim.
RESULTS:
The exorbitant cost of orphan drugs impacts public and private insurers worldwide. Canada has no national pharmaceutical strategy nor any orphan drug legislation. A proposed (in 2012) federal framework to address orphan drugs, has not yet been implemented. In Alberta, decisions to cover orphan drugs for a particular patient are made on a case-by-case basis under two dedicated programs. The process seems to lack clarity and transparency, and lobbying and political pressure seem to play a role.
CONCLUSION:
The threat of growing orphan drug costs to overall health budgets is real. We found no legal or ethical justification for automatic funding of these effective, but expensive therapies. We do find strong ethical reasons for a national framework, with agreed criteria and processes, including appeal processes and budgets. However, legal and ethical analyses both support the necessity of the process being transparent.
Paediatr Child Health. 2015 Jun-Jul;20(5):e101.
Abstract
BACKGROUND:
Severe combined immune deficiency (SCID) is caused by an array of genetic disorders resulting in a diminished adaptive immune system due to impaired T and/or B lymphocytes. To prevent transmission of infections in SCID patients, standardized infection control precautions should be implemented. Although such policies have been described for other vulnerable pediatric populations such as hematopoietic stem cell transplant (HSCT) and oncology patients, SCID-specific infection control policies have not yet been described.
OBJECTIVES:
To describe SCID-specific infection control precautions internationally, and from this descriptive data, propose future evidence-based research for SCID infection control practices/guidelines.
DESIGN/METHODS:
A survey regarding SCID-specific isolation protocols was disseminated online through clinical immunodeficiency organizations. Descriptive data were collected and analyzed using SelectSurvey and Microsoft Excel. Our institutional Research and Ethics Board approved the study, and participant consent was obtained at the beginning of each survey.
RESULTS:
73 responses were obtained, with 54% of responses from the United States, 14% from Canada, and the remainder from 14 other countries. Only 50% of respondents had a SCID-specific infection control protocol at their center. Most physicians (88%) received training on these protocols, but only 54% of nurse practitioners (NPs) and 46% of nurses received training.
The majority (89%) of SCID inpatients are admitted to private rooms, with HEPA filters in 57% of rooms, positive pressure airflow in 46% and anterooms in 54%. Required personal protective equipment (PPE) for staff included non-sterile gowns (66%), surgical masks (72%) and non-sterile gloves (62%). 48% of respondents do not require caregivers to wear PPE if the patient is not contagious. Most centers (62%) allow visitors, but with visitor restrictions.
There was significant variability regarding indications for discharge of a clinically well SCID patient: 31% would not discharge home, 11% had no restrictions for discharge, while the remainder allow clinically well SCID patients to be home under certain conditions, such as requiring that they live close (31%) and no visitors are allowed (33%).
CONCLUSION:
Significant variability of SCID-specific infection control precautions was found between different treatment centers in Canada and internationally. There is little evidence-based data regarding the safest environment to prevent infection in SCID patients, and it must be considered that protocols instituted will have significant impact on infection risk, family well-being, the child’s development and cost of care. Further multi-center research is required to determine the safest and healthiest environment for these children, in order for evidence-based SCID-specific infection control protocols to be implemented.
Paediatr Child Health. 2015 Jun-Jul;20(5):e101.
Abstract
BACKGROUND:
The World Health Organization lists artificial tanning beds as a class one physical carcinogen. Tanning bed use is associated with a 75% increased risk of cutaneous malignant melanoma if used before the age of 35. In 2012, the Manitoba government announced a parental consent law that requires minors to have a guardian present or sign a permission form for children and youth to use artificial tanning equipment. This law falls below the national standards as set by the Canadian Pediatric Society (CPS); furthermore, parental consent laws have been shown to be ineffective at changing commercial tanning exposure in youth.
OBJECTIVES:
Our group of senior pediatric residents worked on a project advocating for a complete ban of commercial tanning use for all youth under the age of 18 in Manitoba.
DESIGN/METHODS:
The first component of the project focused on community education. Residents presented to middle and high school students about the harmful consequences of tanning, and created educational pamphlets that were made available at several general pediatric clinics. The second component of our project focused on legislative change and public forum advocacy. Residents engaged with the media to bring awareness to the general public about the risks of artificial tanning. A petition calling for a complete ban of artificial tanning for minors was also created. This petition, which included over 1000 signatures, along with evidence supporting a full ban for artificial tanning was presented to the Manitoba Ministers of Health and Healthy Living in an invited forum to advocate for legislative change.
RESULTS:
These efforts were successful and resulted in the recent proposed legislation calling for a full ban on artificial tanning for minors; this is expected to pass into Manitoba law in the spring of 2015.
CONCLUSION:
This project serves as an example of how physicians can promote the health of their patients via community education, collaboration with public health experts, and involvement in local government.
Paediatr Child Health. 2015 Jun-Jul;20(5):e102.
Abstract
BACKGROUND:
Both the CPS and the Royal College require pediatricians to be strong advocates for the health and well being of their patients. Although pediatric residents are taught to identify the need for advocacy, they are given few opportunities for and required rarely to take an active role in advocacy. Since 2009, the pediatric residency program at the University of Manitoba required PGY3 residents to collaboratively complete a group health advocacy project.
OBJECTIVES:
To describe the success of a yearly, collaborative resident-driven health advocacy project.
DESIGN/METHODS:
Each PGY3 cohort of pediatric residents is required to work collaboratively to identify a health need and respond to that need by developing and implementing an advocacy project. The residents are provided with faculty supervisors, dedicated time, and start-up funds. A business plan with objectives, timeline, and measureable outcomes is required by September 1 with an interim report by December 31. A final written report is required by June 30 along with a group presentation at Pediatric Grand Rounds.
RESULTS:
During the past five years, each cohort successfully developed, implemented and completed a unique advocacy project (Table 1). Four projects relate directly to position statements from the CPS with two focusing on areas of provincial deficiency outlined in the CPS Status Report 2012. For three projects, residents lobbied the provincial government for legislative change, successfully resulting in three new legislations.
CONCLUSION:
A collaborative resident-driven health advocacy project is possible and has been highly successful. Provided with the time and minimal resources, each cohort of pediatric residents has developed and completed relevant and unique projects. The short term and long term impact of the projects has been immense.
| Year | Project Title | Objectives | Outcome |
|---|---|---|---|
| 2009 | Pearly Whites | Improve children’s access to toothbrushes and toothpaste during in-patient stay | Weekly in-patient Caries-Risk-Assessment along with distribution of fact sheets and toothbrush tote Education of caregivers and health care personnel about oral health |
| 2010 | Smart Seat, Safe Ride | Promote booster seat education Lobby for legislative change | Education booths about booster seats at shopping malls Lobbying efforts resulted in legislative change mandating booster seat use |
| 2011 | Preventing Injury Through Promotion and Distribution of Bike Helmets | Distribute and promote use of bicycle helmets | Received Advocacy Grant from CPS. Distributed 900 helmets at inner-city schools, recreation centres, and physicians’ offices. Lobbying efforts resulted in legislative change mandating bicycle helmets for children |
| 2012 | Transgender Youth and Promotion of Gender Dysphoria Assessment and Action for Youth (GDAAY) | Advocate for and promote access to health care resources for transgender youth. | Developed promotional material about GDAAY program Presentation to school divisions, pediatricians, and residency programs about resources Creation and maintenance of website on GDAAY program |
| 2013 | Banning Tanning | Raise awareness of harmful effects of tanning. Advocate for legislative change banning use of tanning equipment in children |
Presentation at high schools on harmful effects of artificial tanning Lobbying efforts resulted in introduction of legislation banning use of commercial tanning equipment by children. |
Paediatr Child Health. 2015 Jun-Jul;20(5):e102.
Abstract
BACKGROUND:
Exclusive breastfeeding is the optimal method of infant feeding for the first six months of life for both term and preterm infants. Several trials have shown the beneficial effect of peer and/or professional support on the duration of breastfeeding up to six months. Although many well-established programs exist that provide this support in-person or via telephone, the Internet is a relatively new means to deliver breastfeeding support. Yet, mothers have a vast presence online and a clear desire to seek healthcare information on the Internet. The availability and accessibility of interactive communication technologies via the Internet provide the opportunity for developing new methods of healthcare delivery.
OBJECTIVES:
To provide peer and professional breastfeeding support to first time mothers through a secure website in order to increase exclusive breastfeeding rates at six months post-hospital discharge.
DESIGN/METHODS:
This study uses information technology to deliver an innovative and cost-effective way to support breastfeeding mothers. MAVINS was designed to have four arms: (1) text, pictorial, and video evidenced-based breastfeeding educational resources; (2) an interactive discussion forum for mothers that is monitored and facilitated by a lactation consultant; (3) the capacity for data collection; and (4) an online baby journal for text and photo entries.
RESULTS:
Over a 5-month period from October 2013 to and March 2014 a total of 200 first time mothers who delivered a healthy tem baby were recruited and followed to six months post-hospital discharge. Exclusive breastfeeding data at six months was obtained from 125/200 mothers and compared to statistics Canada data, the results are shown in the table.
CONCLUSION:
Our new online breastfeeding support clinic has the potential to improve access to specialized professional breastfeeding support in combination with interactive peer support. This new innovative online clinic can be readily implemented to all regions in Canada with reliable Internet access, with the potential to significantly impact the health of all Canadian infants and their families.
TABLE.
Comparison of Exclusive Breastfeeding Mothers from MAVINS Study and Statistics Canada 2010–13 Data for Ontario Mothers
| Group | Exclusive Breastfeeding | Total N | Percent | Z-ratio |
|---|---|---|---|---|
| MAVINS | 76 | 125 | 60.8% | - |
| Statistics Canada | ||||
| 2010 | 168,065 | 581,540 | 28.9% | 7.87** |
| 2011 | 156,055 | 571,630 | 27.3% | 8.41** |
| 2012 | 119,946 | 535,473 | 22.4% | 10.30** |
| 2013 | 208,722 | 626,793 | 33.3% | 6.52** |
| 4-year total | 652,788 | 2,315,436 | 28.2% | 8.10** |
**
p < 0.0001, two-tailed.
Paediatr Child Health. 2015 Jun-Jul;20(5):e103.
Abstract
BACKGROUND:
Necrotizing enterocolitis (NEC) is a complex disease with a multifactorial etiology affecting 8–10% of all very low birth weight (VLBW) infants. Variability in the incidence of NEC, even in the same unit has been noted throughout the year; however, seasonal variability in the rate of NEC has not been explored.
OBJECTIVES:
To assess the seasonality of stage 2/3 NEC among preterm infants <30 weeks gestation.
DESIGN/METHODS:
Data from participating NICUs in the Canadian Neonatal Network of preterm infants of <30 weeks gestation and birth weight of <1500 grams admitted between January 2010 to December 2013 were retrospectively reviewed. We excluded infants with major congenital anomalies. Rates of NEC during the warmer six months (May–October) were compared to rates from the cooler six months (November–April) and incidence rate ratio (IRR) with 95% CIs was calculated for all NEC and NEC associated with infection (diagnosed within +2 days of NEC).
RESULTS:
Of the total 7676 eligible infants, 291 (3.8%) developed NEC during warmer months and 211 (2.8%) developed NEC during the rest of the year. Baseline characteristics are as reported in the Table. NEC associated with infection was lower in warmer months. The results of IRR are also reported in the table. There was an increase in the incidence of NEC over the study period (63.3/1000 patients in 2010 vs. 77.5/1000 patients in 2013).
CONCLUSION:
The incidence rate of NEC during the warmer months was higher compared to the rest of the year. The reason for this higher incidence is unclear. Further research to confirm or refute these findings is needed. In addition, higher vigilance may be needed during warmer months.
| Variable | NEC during warmer months (N=291) | NEC during the rest of the year (N=211) | P |
|---|---|---|---|
| GA, Mean (SD) | 26.0 (1.7) | 26.0 (1.7) | 0.92 |
| SGA (%) | 28 (10) | 18 (9) | 0.69 |
| BW (grams), Mean (SD) | 890 (232) | 885 (245) | 0.82 |
| Antenatal steroid (%) | 256 (91) | 184 (89) | 0.35 |
| Chorioamnionitis (%) | 61 (29) | 44 (27) | 0.76 |
| Umbilical artery catheters (%) | 177 (61) | 137 (65) | 0.35 |
| Inotropes during first 3 days (%) | 48 (16) | 46 (22) | 0.13 |
| PDA (%) | 175 (61) | 140 (66) | 0.18 |
| Age at NEC, Mean (SD) | 27.6 (19.7) | 27.8 (21.4) | 0.92 |
| Infection within 2 days of NEC (%) | 37 (13) | 41 (19) | 0.04 |
| Incidence Rate of NEC, IR (95% CI) | IRR (95% CI) |
Paediatr Child Health. 2015 Jun-Jul;20(5):e103.
Abstract
BACKGROUND:
Previous studies have well documented the uptake of tobacco and alcohol in adolescence and young adulthood. However, little is known on their early initiation and use even if these are associated to several adverse outcomes.
OBJECTIVES:
To document early initiation and use of tobacco and alcohol, and to characterize the transition from initiation to use of these substances throughout the passage from childhood to the teenage years.
DESIGN/METHODS:
As part of the ongoing Québec Longitudinal Study of Child Development (QLSCD), self-reported data on substance initiation during the past year (yes/no) were collected from a national representative sample (n=1,558) of young Quebecers (48.6% males) at 10, 12 and 13 years of age (between 2008 and 2011) while data on active use of tobacco and alcohol during the last 30 days (yes/no), and binge drinking in the past year (yes/no) were collected at ages 12 and 13. The between-year movement of consumption status was described using Markov modeling with survey-specific sample weight.
RESULTS:
Throughout the ages, an increase in substance initiation and use were obtained. Weighted frequencies were of 1.4%, 6.5% and 16.6% for tobacco, and of 1.1%, 9.8% and 25.7% for alcohol initiation at ages 10, 12 and 13 respectively. At ages 12 and 13, 1.0% and 4.5% reported to be smokers, while 0.9% and 4.2% were alcohol users, and 2.9% and 10.2% experienced binge drinking. None of 10-year initiated youths were users at age 12, but 24.0% and 15.7% of 12-year initiated youths respectively became tobacco and alcohol users at age 13. In addition, 43.6% and 59.5% of users of tobacco and alcohol at age 12 were still users one year later and 52.5% of youths reproduced binge drinking from ages 12 to 13.
CONCLUSION:
A number of participants from our cohort reported to be initiated to tobacco or alcohol as early as at the end of their childhood even though few already became users or showed risky behaviors such as binge drinking. Taking into consideration that for several kids early initiation rapidly develops into sustained use, and because approximately half of them maintain their habits later on, the turning from child to teen represents a strategic window to start tackling tobacco and alcohol use among youths; much younger that one would expect.
Paediatr Child Health. 2015 Jun-Jul;20(5):e103–e104.
Abstract
BACKGROUND:
In the past decades, caffeinated products (CP) use, among which energy drinks are at the forefront, has known a lighting growth among youths. With established yet limited potential effects on specific physical tasks, these products, as others, may appeal to adolescents looking for a way to increase their sport performance. Sparse data exist on the use of ergogenic substances among youths and how CP may now not be limited to a subset of athletes.
OBJECTIVES:
To evaluate the relative importance of CP consumption at ergogenic purpose, among other substances, and to explore its possible determinants among sport-practicing adolescents (SA).
DESIGN/METHODS:
Using data issued from a wider cross-sectional study based on a representative sample of adolescents aged 16–20 years in the French-speaking part of Switzerland (2009–10), 894 SA were asked over a list of 24 items which substances they had used in the past 12 months in order to enhance their sport performance. Age, gender, socioeconomic level (high/other), presence of chronic condition (y/n), type of sport involvement (competitive/leisure), weekly hours devoted to sports (≤3.5, 3.6–10.5, 10.6–17.5, >17.5), and nature of their principal sport practice (endurance/other) were inquired and viewed as possible determinants of ergogenic substance use. In addition to descriptive statistics on ergogenic substance use, significant variables (P<0.05) at the bivariate level between CP use and its possible determinants were subsequently included in a multivariate logistic regression (results given as Adjusted Odds Ratio: AOR [95% CI]).
RESULTS:
73.4% of SA reported the use of at least one substance to increase their sport performance in the past year. CP were the most commonly used substances cited (55.1%), followed by sports drinks (50.8%), vitamins (25.4%), analgesics (11.2%), and protein-based products (10.2%). At the bivariate level, older participants, males, SA without chronic condition and those devoting more time to sports showed a higher rate of CP use. Only males (AOR=1.63 [1.24–2.15]) and SA without chronic condition (AOR=2.22 [1.36–3.61]) remained significant determinants of CP use in the multivariate analysis.
CONCLUSION:
CP have now reached the top of the chart of ergogenic substances used by SA in French-speaking Switzerland, an observation that remains to be established in other parts of the world. Describing that some youths use CP at ergogenic purpose in a higher proportion, regardless of the type, nature and intensity of their sport practice, should make us ponder the importance of performance for certain subgroups and question how this behaviour has now become mainstream.
Paediatr Child Health. 2015 Jun-Jul;20(5):e104.
Abstract
BACKGROUND:
About 10% of people claim to have a penicillin allergy. In the current literature, most patients with negative skin tests can tolerate oral doses of penicillin and only 1.2% of patients experience IgE-mediated reactions. Verifying a penicillin allergy is important because it reduces patient exposure to other antibiotics that are associated with increased patient morbidity and healthcare costs.
OBJECTIVES:
The aim of this study is to report the validity of self-reported penicillin allergies in paediatric patients presenting to an allergy clinic as determined by the results of subsequent skin testing, intradermal testing and 5-day oral dose challenges of penicillin.
DESIGN/METHODS:
This is a retrospective chart review of 284 patients who presented to an allergy clinic for penicillin allergy assessment. Data was collected from patients who received skin testing, intradermal testing and 5-day oral dose challenges of penicillin from April 2011 to December 2014. Data collected includes: demographics (patient age, sex, date of birth, ethnicity); history of asthma; known allergies; family history of penicillin allergies; medical comorbidities; details on the previous penicillin allergic reaction (age, dose, route, indications for use, symptoms, treatment); any repeated exposure to penicillin; reason for allergy test; results of skin test, intradermal and 5-day oral challenge; and symptoms experienced in relation to the allergy tests. This study is associated with low risk ethics as all patient identifying information will be undisclosed.
RESULTS:
8.0% (23 of 284) of self-reported penicillin allergies reacted positively to allergic testing as determined by a positive skin test, intradermal testing or 5-day oral challenge. There were eight reactions to skin and intradermal testing. Five patients reacted within 24 hours of ingestion of the first dose of oral challenge, which could be attributed to an IgE-mediated allergic reaction. 12 patients had a delayed reaction with a rash occurring 24 hours after initial ingestion penicillin. Of the oral challenges, the reactions included seven with hives, 12 with a rash, and none with any cardiopulmonary compromise.
CONCLUSION:
In our community paediatric population, of those reporting a penicillin allergy, only 8.0% were proven to be allergic. Of these, the majority had a delayed reaction to penicillin, which typically only involved a rash. Penicillin allergy testing is important as it can help determine whether patients should actually be avoiding penicillin. This can help reduce patient morbidity associated with increased hospital stay and antibiotic-resistant infections.
Paediatr Child Health. 2015 Jun-Jul;20(5):e104.
Abstract
BACKGROUND:
EVOH is a relatively common neuroimaging finding in infants and young children who are investigated for macrocephaly. These children typically have non-progressive enlargement of ventricular and extra-axial subarachnoid spaces. Different terms have been used interchangeably many of which include the term “benign”.The association of developmental problems in some of these children begs the question as to whether or not this is indeed a “benign” condition.
OBJECTIVES:
To study the neurodevelopmental status of children with macrocephaly and EVOH at presentation.
DESIGN/METHODS:
A retrospective study of children with macrocephaly and radiologically confirmed EVOH performed by chart review completed by a developmental paediatrician and neuroimaging review by pediatric neuroradiologist. Neurodevelopmental status established by neurodevelopmental examination conducted by pediatric neurologist in the Neurodevelopmental Clinic. 295 patient reports reviewed. 209 reports excluded (93 had clear comorbid neurological, developmental and genetic condition, 73 were multiple reports on a single patient and duplicate entries, 22 were head ultrasound reports only, 13 had no interpretable data, eight had no documented neurodevelopmental clinic visits). 86 children with macrocephaly and EVOH confirmed by head CT and/or MRI were eventually identified.
RESULTS:
Eighty six children (67 male) with EVOH were identified. Twenty four (28%) had mild to moderate neuro-developmental deficits including: motor (gross and fine), communication, social and adaptive. Most of the children with neurodevelopmental deficits were males (23/24). Preliminary analysis revealed no significant association (P=0.467) between developmental deficits and the degree of ventriculomegaly or extra-axial CSF space enlargement. Nearly one-third of children with macrocephaly and EVOH have mild-moderate deficits, but there appear to be no neuroimaging findings that predict the presence of neurodevelopmental problems. Males with macrocephaly and EVOH appear to be particularly susceptible to developmental problems.
CONCLUSION:
EVOH might not necessarily be “benign” in affected children. Children with EVOH merit close neurodevelopmental surveillance in order to institute timely developmental interventions for attainment of as normal a developmental trajectory as possible. The neurobiological mechanisms behind EVOH and the long term neurodevelopmental outcomes with standardized neurodevelopmental testing merits further prospective study.
