bluuebunny/crossref_metadata_2025 huggingface dataset:
ADHERENCE TO THE PECARN PEDIATRIC HEAD INJURY RULE IN TWO CANADIAN EMERGENCY SETTINGS
Authors: Gariepy Martin , Gravel Jocelyn , Turcotte Stéphane , Légaré France , Melnick Edward , Hess Erik , Witteman Holly , Lelaidier-Hould Lania , Truchon Catherine , Sauvé Louise , Plante Patrick , Lesage Nathalie , Archambault Patrick
Published: May 2018

BACKGROUND

Head computerized tomography (CT) increases the risk of cancer in children and should be carefully prescribed to paediatric patients with head injury. The Pediatric Emergency Care Applied Network (PECARN) validated a rule to identify children at risk of a clinically important traumatic brain injury (TBI) needing a head CT.

OBJECTIVES

The objective was to evaluate adherence to the PECARN rule as a function of CT overuse (defined as a prescribed CT when not recommended by the rule) and underuse rates (no CT performed when recommended) in two Canadian emergency departments (EDs).

DESIGN/METHODS

We conducted a retrospective chart review of children under 17 years of age seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma center. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with a head trauma. Mandatory inclusion criteria were (1) that the head trauma occurred in the 24 hours prior to arrival to the ED, (2) a GCS over 13 and (3) and at least one sign or symptom of minor TBI. Patients with a special condition that could have influenced the decision to order a head CT were automatically excluded. When a patient did not receive a head CT when recommended by the rule, we reviewed medical records to determine if the patient has returned to the ED after his discharge within the next 30 days.

RESULTS

1546 eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%) respectively from sites 1 and 2 had a head CT performed. For the younger group (< 2), both overuse and underuse rates were below 3%. For the older group, overuse rates were higher in site 2 (9.3% (95%CI:4.8–17%) vs. 1.2% (95%CI:0.2–6.5%) (P=.03)) and there was no difference in underuse rates (22% (95%CI:6.3–55%) vs 39% (95%CI:18–65%) (P=.65)). For children who did not receive a head CT when recommended, none returned to the ED for a related complication.

CONCLUSION

Overall, even if there may be slightly more overuse of head CTs in the Level II trauma center, results showed an excellent agreement with the PECARN rule when CT was not recommended. However, results also showed a deviation when CT was recommended, where a higher portion of patients than expected did not receive a head CT. Reasons to explain this behaviour will need further exploration.
Knowledge, attitudes, and practices regarding opioid use in the pediatric emergency department
Authors: Fowler Megan , Ali Samina , Gouin Serge , Drendel Amy , Poonai Naveen , Jun Esther , Sivakumar Mithra , Dong Kathryn
Published: May 2018

BACKGROUND

Inadequate pain management in children is ubiquitous in the emergency department (ED). Inadequate pain management in children can have both short and long term detrimental effects. As the current national opioid crisis has highlighted, physicians are caught between balancing pain management and the risk of long term opioid dependence.

OBJECTIVES

This study aimed to describe paediatric emergency physicians’ (PEPs) willingness to prescribe opioids to children in the ED and at discharge, perceived knowledge regarding common fears and myths about opioid use, management approach to hypothetical scenarios of varying musculoskeletal injury (MSK-I) pain in children, and perceived facilitators and barriers to prescribing opioids.

DESIGN/METHODS

A unique survey tool was created using published methodology guidelines. Information regarding practices, knowledge, attitudes, perceived barriers, facilitators and demographics were collected. The survey was distributed to all physician members of Pediatric Emergency Research Canada (PERC), using a modified Dillman’s Tailored Design method, from October to December 2017.

RESULTS

The response rate was 49.7% (124/242); 53% (57/107) were female, mean age was 43.6 years (+/- 8.7), and 58% (72/124) had paediatric emergency subspecialty training. The most common first line pain medication in the ED was ibuprofen for mild, moderate and severe MSK-I related pain (94.4% (117/124), 89.5% (111/124), and 62.9% (78/124), respectively). For moderate and severe MSK-I pain, intranasal fentanyl was the most common opioid for first (35.5% (44/124) and 61.3% (76/124), respectively) and second line pain management (41.1% (51/124) and 20.2% (25/124), respectively). 74.8% (89/119) of PEPs reported that an opioid protocol would be helpful, specifically for morphine, fentanyl, and hydromorphone. Using a 0–100 scale, physicians minimally worried about physical dependence (13.3 +/-19.3), addiction (16.6 +/-19.8), and diversion of opioids (32.8+/-26.4) when prescribing short-term opioids to children. They reported that the current opioid crisis minimally influenced their willingness to prescribe opioids (30.0 +/-26.2). Physicians reported rarely (36%; 45/125) or never (28%; 35/125) completing a screening risk assessment prior to prescribing opioids.

CONCLUSION

Intranasal fentanyl was the top opioid for all MSK-I pain intensities. PEPs are minimally concerned regarding dependence, addiction, and the current opioid crisis when prescribing short-term opioids to children. There is an urgent need for evidence regarding the dependence and addiction risk for children receiving short term opioids in order to create knowledge translation tools for ED physicians. Opioid specific protocols in the ED would likely improve physician comfort in responsible and adequate pain management for children.
IMPLEMENTATION AND EVALUATION OF A DKA ORDER SET IN A PEDIATRIC TERTIARY CARE HOSPITAL: A QUALITY IMPROVEMENT INITIATIVE
Authors: Flood Kayla , Nour Munier , Cattell Vicki , Holt Tayna , Seifert Blair , Rozdilsky Janlyn , Inman Mark
Published: May 2018

BACKGROUND

Diabetic ketoacidosis (DKA) is a common clinical presentation in new and previously diagnosed paediatric patients with type 1 diabetes. In contrast to other Canadian tertiary paediatric hospitals, our center lacked a physician-endorsed evidence-informed care pathway for management of DKA. In the absence of a standardized approach to DKA, variability in patient management and outcomes were observed. This project was a quality improvement initiative that sought to develop and pilot a paediatric DKA order set.

OBJECTIVES

Our primary aim was to attain broad clinical uptake of the order set at our tertiary care center over a 12-month period. Secondary aims included improved standard-of-care DKA management: appropriate fluid bolus volume and maintenance rates; initial potassium management; and timely dextrose supplementation.

DESIGN/METHODS

A paediatric multidisciplinary collaborative was created to examine evidence for the development and implementation of a DKA order set. Implementation of the order set involved department wide education, targeted end-user education, and quarterly end-user review. A modified plan-do-study-act (PDSA) cycle guided by end-user feedback and early clinical outcomes allowed progressive order set modifications.

RESULTS

A retrospective chart review of fifty paediatric patients presenting to our center between April 2014 and September 2016 (pre-implementation) was compared to thirty paediatric patients presenting in DKA during the post-implementation phase (September 2016 – September 2017). There were no statistically significant differences in demographic and clinical characteristics between the groups. We achieved 83% uptake of the order set for patients presenting to our tertiary center and 67% uptake for patients transferred from peripheral centers. Improvements in DKA management included: appropriate intravenous (IV) maintenance fluid rates (20% vs. 48.3%, p=0.008), earlier administration of potassium to IV fluids (66% vs. 93.1%, p=0.006); appropriate potassium chloride dosing (40 mmol/L) to IV fluid (40% vs. 79.3%, p=0.0007) and earlier addition of IV dextrose (67.4% vs. 93.1%, p=0.009). No differences in moderate to severe hypokalemia (< 3.0 mmol/L), hypoglycemia (<4.0 mmol/L) or clinically suspected cerebral edema occurred.

CONCLUSION

Implementation of a DKA order set in a tertiary hospital required identification of key stakeholders, formation of a multidisciplinary team, and the development of an evaluation process. There was an observed increase in physician order set uptake and DKA management practice improvements. Future goals involve expanding the implementation and evaluation process to regional and remote centers and analyzing the impact on resource utilization.
VARIABILITY IN EMERGENT MANAGEMENT OF DIABETIC KETOACIDOSIS IN PEDIATRICS: A RETROSPECTIVE CHART REVIEW
Authors: Thawer Zoyah , Saleh David , Gregoire Keith
Published: May 2018

BACKGROUND

Variability in the management of paediatric diabetic ketoacidosis (DKA) has been well described in the literature. Although there are many paediatric DKA management guidelines available at tertiary care centres, there seems to be a lack of familiarity with these in some community hospitals, leading to management inconsistent with evidence-based clinical practice.

OBJECTIVES

Our objectives were to review the management of paediatric patients who present in DKA, identify those that received initial emergent treatment not consistent with current guidelines, and track associated complications.

DESIGN/METHODS

Forty-seven charts of paediatric patients admitted to our institution (including patients transferred from peripheral hospitals) from January, 2012 to July, 2017 were identified by ICD-10 codes containing “ketoacidosis”. Primary outcome measures for inadequate management included major risk factors for cerebral edema - IV insulin boluses, IV bicarbonate boluses, hypo-osmolar IV fluid administration and non-NPO status - as well as inappropriate IV fluid boluses>10mL/kg, insulin infusion initiated within the first hour after IV fluids were initiated, and inadequate potassium replacement.

RESULTS

At least one area of inadequate management occurred at a rate of 74.5% with no significant difference between community hospitals and our tertiary centre. The most common parameter was inadequate replacement of potassium (44.7%), followed by receiving an IV fluid bolus>10mL/kg (40.4%). Twenty-three percent of patients received inadequate management that included a treatment-related major risk factor for cerebral edema. The most common complication was hypoglycemia (BG<4.0mM; 14.9%) and there were no cases of cerebral edema or patients that received a CT head. Though the mean time to insulin infusion initiation was 4.0 hours at outside centres and 2.8 hours at our tertiary centre, the difference was not statistically significant (p=0.26). However, there was a statistically significant difference in time to correction of acidosis, with correction of DKA happening more quickly at our tertiary centre (9.5h compared to 12.7h at outside centres; p=0.03).

CONCLUSION

Optimal paediatric DKA management continues to be a challenge despite the presence of multiple, evidence-based guidelines. Gradual resuscitation with appropriate fluids appears to be the most common area in which variability exists in community and tertiary care centres.
Use of a daily rounding checklist on the Clinical Teaching Unit improves interdisciplinary communication around discharge
Authors: Remington Michaela , Kong Cynthia
Published: May 2018

BACKGROUND

As the care needs of the paediatric inpatient population become increasingly complex, demands for hospitalization and efficient patient flow have resulted in the need for increased attention to discharge processes. Inefficient discharges impact flow throughout the healthcare system, extend length of stay, increase health care costs and decrease patient satisfaction. As a large inpatient service with high staff turnover, our Clinical Teaching Unit (CTU) experiences considerable variability in approach to discharge planning. Prior work at our institution has recognized inconsistent practice and gaps in communication around discharge planning as challenges to efficient patient discharge.

OBJECTIVES

Using quality improvement (QI) methodology, we aimed to decrease discharge delays on CTU, by implementing a process to identify and document patient specific discharge criteria. By focusing on discharge criteria, we sought to improve communication regarding discharge goals and patient readiness between care members, encouraging early discharge planning.

DESIGN/METHODS

We implemented a standardized CTU rounding checklist for use during daily inpatient rounds. On this checklist, physicians were instructed to document clear, patient-specific discharge criteria. Use of the checklist was encouraged through multiple avenues, including announcements at educational events, real time feedback on use to the front-line care teams and a monthly competition between resident teams. Through Plan-Do-Study-Act (PDSA) cycles, we collected feedback from the multidisciplinary team, and the checklist underwent multiple iterations to optimize use. CTU inpatient rounds were observed weekly and outcome, process and balance measures were collected.

RESULTS

With implementation of the checklist, a cultural shift towards explicit, thoughtful discussion of discharge criteria and planning was observed on daily patient rounds. Identification of patient specific discharge criteria increased from less than 30% to over 90% after implementation of the checklist. The purposeful documentation of discharge criteria received positive nursing feedback, and nursing awareness of discharge goals improved from 20–30% to over 70%. Improvements were sustained over a six-month period.

CONCLUSION

This QI project utilized a daily rounding checklist to engage care teams in purposeful conversations around discharge on rounds. By documenting patient-specific discharge criteria, interdisciplinary communication was improved and bedside nurses felt better informed of discharge goals.

Future project directions include the development of diagnosis specific standardized discharge criteria, exploration of specific discharge barriers, and identification of institution-specific resources that may help alleviate these delays to further improve discharge efficiency.
Improving appropriateness of oxygen saturation monitoring in paediatric patients with acute respiratory illness: a QI initiative
Authors: Parisien Brigitte , Cheng Daryl , Marano Maria , Johnstone Julie , Carmichael Nicole , Al-Maawali Ali , Gamulka Beth
Published: May 2018

BACKGROUND

Oxygen saturation monitoring (OSM) is a key aspect of clinical care in paediatric patients with acute respiratory disease. It is commonplace in the assessment of children with bronchiolitis, asthma and pneumonia and serves as a proxy for illness severity. However, there is a paucity of standardized guidelines around appropriate pulse oximetry and OSM use in these patients. Some preliminary evidence shows that intermittent pulse oximetry is as safe as continuous oximetry monitoring in children with bronchiolitis. Furthermore, inappropriate OSM may lead to overdiagnosis and overtreatment of mild hypoxia with no demonstrable clinical improvement and therefore contribute to prolonged length of stay.

OBJECTIVES

As part of The Choosing Wisely campaign, our aim is to increase the appropriate use of OSM in paediatric inpatients with asthma, bronchiolitis or pneumonia in our center to 90% by April 2018.

DESIGN/METHODS

Appropriate monitoring is defined as intermittent OSM when a patient is off oxygen for >2 hours and continuous OSM whilst the patient is receiving supplemental oxygen. A 4 week pre-intervention baseline chart review showed 62% (23/37) had appropriate OSM. Series of interventions along the hierarchy of effectiveness were then chosen to improve the main outcome measure:

• Educational sessions oriented at medical and nursing staff were provided to guide evidence-based practice and to reinforce the use of specific orders around OSM;

• Visual cues were used in strategic locations to remind medical staff of appropriate OSM and to prompt discussion during ward rounds;

• Weekly reminders and performance updates were displayed and electronically circulated to medical and nursing staff.

Post-intervention data collection occurred via convenience sampling by project leaders from December 2017 to April 2018. A PDSA cycle approach was used to modify interventions.

RESULTS

OSM appropriateness increased to 78% (56/72) in the first 4 weeks post-initial interventions. There were no negative impacts on balancing measures. We anticipate an ongoing graded increase in appropriateness across the study period triggered by collective staff awareness and synergistic interventions.

CONCLUSION

This QI initiative will improve the appropriate use of OSM in patients admitted for bronchiolitis, pneumonia or asthma at our paediatric tertiary hospital without increasing the number of patient safety events or admissions to the intensive care unit. Further interventions are planned to ensure greater uptake and sustainability.
NEONATAL FOLLOW-UP IN CANADA. A NATIONAL SURVEY
Authors: Albaghli Fawaz , Synnes Anne , Girardi Alberta , Church Paige , Ballantyne Marilyn
Published: May 2018

BACKGROUND

The Canadian Neonatal Follow-Up Network (CNFUN) was developed in 2008 to facilitate collaboration in research by providing a national database and implemented standardized neurodevelopmental assessments at 18 and 36 months corrected ages for babies born <29-week gestational age. Previous Canadian surveys showed a large variability in neonatal follow-up practices. This is the first Canadian national survey since the establishment of CNFUN.

OBJECTIVES

To describe the current status of neonatal follow-up services in Canada and to evaluate the impact of CNFUN by comparing the results of the current survey to a 2006 survey. Proportions are compared using chi square, p value < 0.006 adjusted for multiple comparisons.

DESIGN/METHODS

All 26 Level-III University Affiliated Neonatal Follow-up programs in Canada belonged to CNFUN and were invited to participate in this comprehensive online survey. Questions were based on previous survey results, current literature and discussion amongst the investigators.

RESULTS

23/26 (88%) of invited programs completed the survey. Scope of service: All programs provided neurodevelopmental screening and referral for intervention. Data collection, training and education were provided by most programs (>80%). Therapeutic interventions were offered by a smaller number of programs (>50%). Type of Assessments: The use of Bayley Scales of Infant and Toddler Development increased significantly since 2006. For speech and language, adaptive behavior, and psychological standardized assessments tools a large variation remains. Follow-Up Schedule: Most programs offer between 5 to 7 follow-up visits. There remains a great variability in the timing of visits. Eligibility Criteria: The use of gestational age eligibility criteria, the inclusion of up to 29 weeks, and the expansion to include additional neurologic, cardio-respiratory, and fetal diagnosis has increased since 2006.

CONCLUSION

CNFUN was associated with a clinically important, statistically non-significant standardization. Non-preterm eligibility criteria have increased. Marked variability in Neonatal follow-up practices persist. Standardized follow-up has potential benefits of including facilitating multi-centered research, site benchmarking, and continuity of care for families who move.
HIGH SYSTEMIC BLOOD PRESSURE IN PRETERM INFANTS WITH BRONCHOPULMONARY DYSPLASIA AND LONG-TERM OUTCOMES
Authors: Cayouette Florence , Spénard Sarah , Lapointe Anie , Dorval Véronique , Sommer Julie , Nuyt Anne-Monique
Published: May 2018

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a known risk factor for neurodevelopmental impairment in preterm infants. BPD is also associated with an increased incidence of high systemic blood pressure (HBP). However, it is not known if a diagnosis of HBP in BPD patients relates to later neurodevelopmental outcomes.

OBJECTIVES

We aimed to determine the incidence of neonatal HBP diagnosis in a cohort of preterm infants born <29 weeks of gestational age (GA) with BPD. The secondary objective was to assess if a concomitant diagnosis of BPD and HBP influences neurodevelopmental outcomes at 18 months.

DESIGN/METHODS

We performed a single center retrospective study using data from medical charts. All infants born <29 weeks GA admitted to our level-IV neonatal intensive care unit between January 2010 and December 2012 diagnosed with BPD at 36 weeks of corrected GA were included. Patients transferred before 36 weeks of corrected GA, that died before 18 months or had congenital anomalies were excluded. Patients were classified in the HBP group if HBP was a documented diagnosis in the chart. The control group was the remaining patients with BPD at 36 weeks corrected GA but without HBP. Severe neurodevelopmental impairment at 18 months was defined as either any Bailey-III score <70, cerebral palsy or severe hearing or visual impairment. Descriptive statistics for prenatal and postnatal patients’ characteristics were analyzed. Logistic regression was performed for factors associated with long-term disability. Level of significance was determined as a p value <0.05.

RESULTS

During the study period, 337 preterm infants <29 weeks of GA were identified and after exclusions, 98 newborns met the criteria of BPD at 36 weeks corrected GA. Mean GA and mean birth weight were 26.7 ± 1.7 weeks and 882 ± 199 g respectively. The majority were males (57%) and received antenatal steroids (87.8%). We identified twenty-five newborns (25.5%) with a diagnosis of HBP. Demographic data was similar between the 2 groups. 56% of the HBP group received a post-natal course of steroids, compared to 36% for the control group (p 0.07). The neurodevelopmental outcome at 18 months was similar between the two groups (p 0.54) and was not influenced by the presence of a HBP diagnosis after regression analysis (p 0.8).

CONCLUSION

The diagnosis of HBP was frequent in our cohort of preterm infants born <29 weeks GA with BPD but did not seem to be related to long-term neurodevelopmental outcomes.
GLUTATHIONE ADDITION TO PARENTERAL NUTRITION PREVENTS PULMONARY OXIDATIVE STRESS AND HYPO-ALVEOLARIZATION IN NEWBORN GUINEA PIG
Authors: Lavoie Jean-Claude , Mohamed Ibrahim
Published: May 2018

BACKGROUND

Parenteral nutrition (PN) is contaminated by peroxides, which induce oxidative stress (oxidized redox potential) and hypoalveolarization in lungs of newborn animals. In human premature newborns, PN is associated to an oxidized redox potential and to a greater prevalence of bronchopulmonary dysplasia (BPD). Peroxides are detoxified by glutathione that is deficient in preterm infants. Hypothesis: Improving glutathione level in premature infants prevents BPD development caused by oxidative stress.

OBJECTIVES

Assess dose-response effect of glutathione added in PN on alveolarization index and pulmonary redox potential of glutathione (specific oxidative stress marker for peroxides) in newborn guinea pigs.

DESIGN/METHODS

At day 3 of life, through a jugular catheter, guinea pigs (N=55) received PN (dextrose, amino acids, lipids, vitamins, electrolytes) enriched in glutathione (0, 50, 120, 165, 270, 370, 650 μg GSSG/kg/d). GSSG was used rather than GSH because it has a better stability in PN and similar efficiency in vivo. A control group (no manipulation, fed by mouth) served as reference. After 4 days, lungs were taken for determination of GSH, GSSG, redox potential (capillary electrophoresis) and alveolarization index (AI) (number of intercepts between a 1 mm line and histological structures); higher is AI, higher is the number of alveoli. Data (mean±sem) from animals on PN were compared by ANOVA, p<0.05.

RESULTS

There was no difference in the alveolarization index between groups receiving doses ranging from 0 to 120 μg/kg/d (25.9 ± 0.6 intercepts/mm) and between those with doses ranging between 165 and 650 μg/kg/d (30.5 ± 0.6 intercepts/mm). However, the difference between the lowest (0–120 μg/kg/d) and the highest doses (165–650 μg/kg/d) was highly significant (p<0.001). The control AI value was 29.4 ± 1.2 intercepts/mm. Increasing GSSG in PN has allowed a significant (r2=0.47; p<0.001) reduction of redox potential, from oxidized status of -205 ± 2 in PN without GSSG to -215 ± 2 mV with the highest dose (650 μg/kg/d); control = -222 ± 3 mV. GSSG in PN was also associated with a decreasing GSSG values (r2=0.49; p<0.001), from 0.84 ± 0.10 in PN without GSSG to 0.38 ± 0.06 nmol/mg prot with the highest dose (650 μg/kg/d); control = 0.35 ± 0.07 nmol/mg prot. There was no effect on GSH (mean value of 29 ± 1 nmol/mg prot).

CONCLUSION

Addition of glutathione into PN prevents pulmonary oxidative stress. The dose-response curve suggests a specific minimal dose of GSSG to maintain the alveolar integrity. Lower doses were inefficient whereas higher doses are unnecessary, as the index of alveolarization reached a plateau with a mean value similar to that one observed in the control group. This pre-clinical study brings basic data that will serve for the clinical phase I-II study that we are starting soon.
NEURODEVELOPMENTAL OUTCOMES AT 4–10 YEARS OF AGE IN CHILDREN BORN AT 22–25 WEEKS GESTATIONAL AGE: AN UPDATED META-ANALYSIS
Authors: Ding Sharon , Daboval Thierry , Lemyre Brigitte , Barrowman Nick , Moore Gregory
Published: May 2018

BACKGROUND

Published data on long-term outcomes are an important resource for clinicians to support expectant parents making perinatal care decisions.

OBJECTIVES

To update our 2013 meta-analysis with data from recently published, high quality cohorts of 22–25 wk GA infants using relevant definitions of neurodevelopmental disability (NDD).

DESIGN/METHODS

We used a peer-reviewed electronic search and grey search. Two authors independently reviewed cohorts published after May 2012 with the following inclusion criteria: born ≥1995 in a developed nation, assessed for NDD at 4–10 yrs; prospective data collection, <30% loss to follow-up, consistent definitions for moderate-to-severe (M-S) NDD as per those from EPICure; and results reported by GA. We contacted authors for clarification. Random-effects meta-analysis was used to provide pooled proportions at each GA. Weighted regression was used to examine the relationship between GA and NDD within each study. I2 was used to assess heterogeneity.

RESULTS

From 2481 titles, 20 full-text articles were reviewed and six (added to the nine from 2013) met inclusion criteria. High heterogeneity at higher GA and wide CIs at lower GA persisted. Results showed rates of M-S NDD in school-age survivors were: 42% (95%CI 23,64%; I2 0%) at 22 wks; 41% (95%CI 31,52%; I2 30%) at 23 wks; 32% (95%CI 25,39%; I2 44%) at 24 wks; and 23% (95%CI 18,29%; I2 60%) at 25 wks GA. The new analysis continued to show a significant decrease in likelihood of M-S NDI between each GA wk (8.1% decrease per wk (95%CI -11.8, -4.5%, p<0.001) but not for likelihood of severe NDD (2.7% decrease per wk (95%CI -6.6, 1.3%), I2 45%, p=0.18).

CONCLUSION

This high quality data can be used by physicians to support parents during the decision-making process for their infant. Heterogeneity and a small sample size at 22 wk GA remains a concern in the interpretation of the data.
INVESTIGATING THE PHOTOTHERAPY THRESHOLDS IN PRETERM INFANTS
Authors: Jegathesan Thivia , Sgro Michael , Shah Vibhuti , Campbell Aidan , Campbell Douglas
Published: May 2018

BACKGROUND

Currently there are limited guidelines for the management of hyperbilirubinemia in preterm infants. Current guidelines are limited to individual sites and are consensus-based opinions. The current decrease in chronic bilirubin encephalopathy in preterm infants is a result of liberal use of phototherapy that are not based on evidence from a large dataset of preterm infants. The pattern of bilirubin levels in preterm is unclear and currently based on clinical judgement. Nomograms in term infants has been proven to be beneficial and effective in reducing unnecessary treatment of hyperbilirubinemia. A nomogram designed for preterm infants would allow health professionals to quantify risk based on evidence based methods and reduce the number of test done on preterm infants.

OBJECTIVES

The objectives of this study are 1) To determine photherapy thresholds in preterm infants and 2) To determine the normative pattern of bilirubin values in preterm infants.

DESIGN/METHODS

A multi-site retrospective chart review of preterm infants ≤ 35 weeks gestation born between January 2012- November 2017 was conducted. The following data was collected; all TSB, postnatal hours of age, duration of phototherapy, infant characteristics (gestational age, birth weight, outcomes) and maternal history (inter and anter partum medication). TSB samples prior to the initiation of phototherapy were analyzed per hour and stratified by gestational age groups.

RESULTS

A total of 330 preterm infants were included in the retrospective review (50 24-28 weeks gestation, 100 29-32 weeks gestation, and 180 33–35 weeks gestation). The mean peak bilirubin in infants 33-35 week gestation was 198 umol/L at 4 days. These infants were started on phototherapy at a mean age of 89 hours. At 24 hours of age these infants’ bilirubin was 104 umol/L (72-189umol/L). The mean peak bilirubin in infants 29–32 weeks gestation was 181umol/L at 5 days. At 24 hours of age the mean bilirubin was 109 umol/L. Finally in infants 24–28 weeks gestation the mean peak bilirubin was 127 umol/L at 4 days. These infants were started on phototherapy at 44 hours of age.

CONCLUSION

Bilirubin values in preterm infants is hetergenous across gestional ages. Phototherapy treatment thresholds are lower in preterm infants between 24–28 weeks gestation. A nomogram for preterm infants maybe possible in infants between 29–35 weeks. Further research is required to determine hour specific bilirubin levels in preterm infants.
COMPARING WAIT TIMES OF SINGLE-MOTHER AND TWO-PARENT HOUSEHOLDS ACCESSING DEVELOPMENTAL SERVICES THROUGH SCHOOL-BASED HEALTH CLINICS
Authors: Gunaseelan Vinusha , Aiyadurai Ramanan , Freeman Sloane
Published: May 2018

BACKGROUND

Families in inner-city neighborhoods experience socioeconomic challenges that inhibit access to healthcare providers who could detect development concerns in children. Additionally, studies show low-income, single motherhood to be a significant risk factor for childhood developmental issues.

With wait times for developmental assessments and publicly funded services ranging from 9 to 18 months, children may not receive diagnosis and support in a timely manner. School-based health clinics (SBHCs) are easy access points for children to receive necessary services, such as diagnoses and management of health and developmental concerns especially for inner city children facing barriers to health care access.

OBJECTIVES

To measure the efficacy of SBHCs in alleviating barriers to developmental services for children from inner-city, single-mother households, by comparing wait times to children from two-parent households.

DESIGN/METHODS

A retrospective chart review of 700 children from two inner-city SBHCs was conducted over 7 years. Family demographic data were collected through the registration process and analyzed. Wait times for developmental assessments were determined from the first developmental concern to assessment by a developmental paediatrician. Independent t-tests were used to compare wait times for children from single-mother households to children from two-parent households.

RESULTS

The mean age of children seen was 6.9 years (two-parent households) and 7.6 years (single-mother households). 35% of children from single-mother households (n=169), and 36% of children from two-parent households (n=369) received referrals to the SBHC developmental paediatrician. The mean wait times were 129.08 days for single-mother households, and 105.81 days for two-parent households. No significant difference was found in wait time from first developmental concern to seeing a developmental paediatrician (p>0.05).

CONCLUSION

The SBHC program is a novel healthcare delivery model alleviating barriers to developmental healthcare access for both single-mother and two-parent families. Wait times experienced by SBHC users to see developmental specialists were shorter than the times reported in the literature. The lack of significant difference in wait times between children from single-mother and two-parent households demonstrates how SBHCs alleviate barriers to single-mother households as effectively as two-parent households.
EVALUATING THE PREDICTIVE VALIDITY OF THE NIPISSING DISTRICT DEVELOPMENTAL SCREEN IN PRIMARY CARE SETTINGS AT THE 18-MONTH HEALTH SUPERVISION VISIT
Authors: Gunaseelan Vinusha , Parkin Patricia , Bayoumi Imaan , Jiang Patricia , Medline Alexandra , Osmond Michael , Birken Catherine , Maguire Jonathon , Borkhoff Cory
Published: May 2018

BACKGROUND

The Canadian Paediatric Society (CPS) recommends that every Canadian physician caring for young children provide an enhanced 18-month well-baby visit including the use of a developmental screening tool, such as the Nipissing District Developmental Screen (NDDS). The Province of Ontario implemented an enhanced 18-month well-baby visit specifically emphasizing the NDDS, which is now widely used in Ontario primary care. However, the diagnostic accuracy of the NDDS in identifying early developmental delays in real-world clinical settings is unknown.

OBJECTIVES

To assess the predictive validity of the NDDS in primary care for identifying developmental delay and prompting a specialist referral at the 18-month health supervision visit.

DESIGN/METHODS

This was a prospective longitudinal cohort study enrolling healthy children from primary care practices. Parents completed the 18-month NDDS during their child’s scheduled health supervision visit between January 2012 and February 2015. Using a standardized data collection form, research personnel abstracted data from the child’s health records regarding the child’s developmental outcomes following the 18-month assessment. Data collected included confirmed diagnoses of a development delay, specialist referrals, family history, and interventions. Research personnel were blind to the results of the NDDS. We assessed the diagnostic test properties of the NDDS with a confirmed diagnosis of developmental delay as the criterion measure. The specificity, sensitivity, positive predictive value, and negative predictive value were calculated, with 95% confidence intervals.

RESULTS

We included 255 children with a mean age of 18.5 months (range, 17.5–20.6) and 139 (55%) were male. 102 (40%) screened positive (1+ flag result on their NDDS). A total of 48 (19%) children were referred, and 23 (9%) had a confirmed diagnosis of a developmental delay (speech and language: 14; gross motor: 4; autism spectrum disorder: 3; global developmental delay: 1; developmental delay: 1). The sensitivity was 74% (95% CI: 52–90%), specificity was 63% (95% CI: 57–70%), positive predictive value was 17% (95% CI:10–25%), and the negative predictive value was 96% (95% CI: 92–99%).

CONCLUSION

For developmental screening tools, sensitivity between 70%-80% and specificity of 80% have been suggested. The NDDS has moderate sensitivity and specificity in identifying developmental delay at the 18-month health supervision visit. The 1+NDDS flag cut-point may lead to overdiagnosis with more children with typical development being referred, leading to longer wait times for specialist referrals among children in need. Future work includes investigating the diagnostic accuracy of combining the NDDS with other screening tools.
THE ROLE OF DEVELOPMENTAL TOXICANTS AND SOCIO-ECONOMIC STATUS ON CONGENITAL HEART DISEASE IN URBAN AND RURAL ALBERTA
Authors: Ngwezi Deliwe , Hornberger Lisa , Serrano-Lomelin Jesus , Nielsen Charlene , Fruitman Deborah , Vargas Alvaro Osornio
Published: May 2018

BACKGROUND

Evidence is emerging suggesting associations between environmental pollutants, socio-economic status (SES) and congenital heart disease (CHD); however, it is still inconclusive. Furthermore, it has been documented in environmental injustice studies that people with low socio-economic status are disproportionately vulnerable to environmental hazards and therefore are victims of a double jeopardy.

OBJECTIVES

We sought to explore the effect of exposure to groups of developmental toxicants (DTs) and SES on CHD development in urban and rural Alberta.

DESIGN/METHODS

We identified 2,413 CHD cases and postal codes (PC) from echocardiographic databases (2003–2010). We used previously defined groups of DTs comprised of: 1- organics and gases, 2-organics and 3-heavy metals. Exposure was assigned to each PC as the sum of the product of multiplying amounts of DTs (tonnes) emitted from any industrial facility within 10 km radius during the whole study period, by the inverse distance from the facility to the centroid of the PC. Exposures were categorized into deciles from 1(lowest) to 10 (highest) for group 1 DTs and tertiles (1=lowest to 3 =highest), for groups 2 and 3 DTs and the SES index. Poisson regression models were used to calculate risk ratios and 95% CI, adjusted for SES index or DTs and traffic-related surrogates (NO2, PM2.5).

RESULTS

Adjusted Effect of DT Exposure: Group 1 DT showed increased risk in urban and rural regions in the 10th decile of exposure, aRR=1.85(1.5, 2.3) and 2.67(1.04, 6.8, respectively). Group 2 DT risk was increased only in urban 3rd tertile, RR=1.45(1.3, 1.6). Group 3 DTs were associated with an increased risk in urban and rural regions in the 3rd tertile of exposure [aRR=1.16(1.04, 1.3), and 2.8(1.14, 7.1, respectively)].

Adjusted Effect of SES: SES was independently associated with an increased risk of CHD in urban lowest tertile, [aRR=1.13(1.0, 1.3)] and rural lowest and middle SES tertile, [aRR=2.9(1.9, 4.8) and 1.6(1.1, 2.6), respectively].

CONCLUSION

High exposures to groups of DTs and SES were independently associated with an increased risk of CHD in urban and rural Alberta. This suggests that neighborhood SES in Alberta does not impose a disproportional exposure to DTs. Furthermore, SES had a greater impact in rural compared to urban regions. We would like to explore for interactions between the SES and DT exposures and to determine if there is environmental injustice in Alberta.
USE OF UNSAFE TEETHING REMEDIES IN A MID-SIZE CITY: A SURVEY
Authors: Abdulsatar Farah , Taheri Sepideh , Miller Michael
Published: May 2018

BACKGROUND

Various remedies are available to parents for relieving teething symptoms in their infants and toddlers. Some remedies, such as amber necklaces, have no evidence of their efficacy, yet are being widely marketed and increasingly used across North America. On the contrary, teething necklaces are unsafe, corroborated by recent reports of suffocation accidents and death attributed to their use. There is no published literature on the prevalence of teething remedies and what may determine parents’ choices.

OBJECTIVES

The primary objective was to assess the prevalence of unsafe teething remedies, especially teething necklaces. The secondary objective was to determine any association between the use of unsafe teething remedies and (a) socioeconomic status (SES), and (b) maternal education.

DESIGN/METHODS

Children aged 12–18 months in a mid-sized Canadian city visiting their primary care providers for routine well-baby checks were included. Children aged <12 or >18 months and those with chronic medical conditions were excluded. Parents completed a survey about their child’s teething symptoms and the remedies used to relieve them. Unsafe remedies were based on recommendations published by the Canadian Paediatric Society and American Academy of Pediatrics. They included oral-numbing gels, necklaces (Amber and Hazelwood), and liquid-containing teething rings.

RESULTS

Out of 130 surveys, 123 were included for statistical analysis due to missing data. Mean (SD) infant age was 14.47 (2.56) months, and mean (SD) age at first tooth was 6.92 (2.00) months. Overall, 98% of families used teething remedies with 67% of them using unsafe remedies. Of these families, 27% used Amber and 5% used Hazelwood necklaces. 28% of families used more than one unsafe remedy. No significant correlations were found between unsafe remedy use and SES or maternal education. However, a significant negative correlation was noted between SES and use of oral-numbing gels (Spearman’s rho = -0.23, p=0.01).

CONCLUSION

This study showed that a majority of parents are using unsafe teething remedies for their infants including Amber teething necklaces, despite lack of evidence to support their efficacy and recommendations against their use. Use of unsafe teething remedies transcends SES and education level. With recent reports of child injury and death associated with their use, the findings of this survey support the need for a new approach to parental education about the safety of teething remedies.
Examining access to Psychoeducational Assessments by Socioeconomic factors for children with behavioral referrals
Authors: Gander Sarah , Campbell Sarah
Published: May 2018

BACKGROUND

The psycho-educational assessment (PEA) is often recommended in behavioural presentations in children. The PEA assesses cognitive ability and detects any learning disabilities which may be the direct cause, or comorbidity, of a behavioral problem. This essential tool directs the child and family to appropriate treatment or intervention, and is critical for the school to design effective programming for the child. However, access to this assessment is quite variable. Some students may receive the PEA from a school psychologist if it has been established that other interventions have proven ineffective, but may experience long wait times. This study looked at a group of behavioural referrals at a local paediatric clinic to determine how many children had received a PEA, and if access seemed to be affected by their socioeconomic status (SES).

OBJECTIVES

• To identify how many of these behavioural referrals have also received PEAs.

• To understand the SES distribution among the children receiving behavioural referrals.

• To determine if children with higher SES status are more likely to have received PEAs.

DESIGN/METHODS

All behavioural referrals at this clinic are subject to an intake interview with a clinic nurse, who gathers a detailed medical, social and family history. This includes a list of previously accessed services and resources, including the PEA. Socioeconomic status was defined by the Quintile-Annual-Income-Per-Person-Equivalent (QAIPPE) associated with the dissemination area (DA) of the family residence. Patients were divided into these quintiles to determine the number of referrals from each quintile, and the percentage of children from each quintile that had received a PEA.

RESULTS

More than half of the referrals (51.2%; n=342) come from families living in DAs of the two lowest income quintiles. Of those children living in neighbourhoods in the two highest income quintiles, 27% had received the PEA prior to referral, as compared to 12.6% of those children living in the three lower income quintile neighbourhoods.

CONCLUSION

This demonstrates that children from low income neighbourhoods are receiving more behavioural referrals but are less likely to have received a PEA. This is a barrier to delivering timely and effective service as many children will wait over a year for their paediatric appointment only to find that they may have been better serviced elsewhere. Improving access to the PEA would improve the treatment of this population and help eliminate duplication and unnecessary service provision.
(MED) RESIDENT SATISFACTION IN CANADIAN PEDIATRIC RESIDENT CONTINUITY CLINICS
Authors: El-Korazati Adila , Peebles Erin , Miller Michael , Babic Bojana
Published: May 2018

BACKGROUND

Resident continuity clinics (RCCs) provide an opportunity for residents to gain experience with longitudinal care in an outpatient setting. RCCs have become a part of almost all recognized residency training programs across specialties in North America. However, the structure, function, and effectiveness of RCCs vary widely.

OBJECTIVES

To determine resident perspective on the structure and function of paediatric RCCs and investigate which factors were associated with resident satisfaction with paediatric RCCs.

DESIGN/METHODS

A qualitative survey of Canadian paediatric resident trainees was conducted to assess their RCC experience. The survey was administered through the REDCap© database and distributed through the Canadian Pediatric Program Directors Consortium in June-July 2016.

RESULTS

There were 127 respondents. Approximately 40% participated in RCCs. The majority of respondents were likely to recommend RCCs to other programs. The most common structure reported was a monthly half-day clinic overseen by an academic paediatrician. Referrals were mainly from inpatient wards, emergency department or family physicians. The majority of residents were satisfied with their experience (n=33, 71.7%). Participants in resident-run RCCs had more positive views compared to participants in staff-run RCCs (all U≥25.0, p≤0.009). Contributing factors to a positive RCC experience included patient-resident continuity, being viewed as the main care provider, and learning to make independent management decisions.

CONCLUSION

Almost all respondents felt that RCCs should be part of paediatric residency training. Further research is needed to determine the optimal structure for paediatric RCCs. Understanding our current training environment is an important precursor for informing program leadership and national policymakers who wish to improve ambulatory care training