bluuebunny/crossref_metadata_2025 huggingface dataset:
Dual hydration of oceanic lithosphere
Authors: Zhang Fan , Lin Jian , Zhu Rixiang , Zhang Xubo , Zhang Jiangyang , Zhou Zhiyuan
Published: September 2023

Water input budget of global oceanic lithosphere at different tectonic settings are quantitatively estimated. The results indicate that the hydration at subduction zone is fundamentally essential to plate dynamics and water cycle of the Earth.
Challenges and approaches of single-crystal Ni-rich layered cathodes in lithium batteries
Authors: Hu Jiangtao , Wang Hongbin , Xiao Biwei , Liu Pei , Huang Tao , Li Yongliang , Ren Xiangzhong , Zhang Qianling , Liu Jianhong , Ouyang Xiaoping , Sun Xueliang
Published: September 2023

High energy density and high safety are incompatible with each other in a lithium battery, which challenges today's energy storage and power applications. Ni-rich layered transition metal oxides (NMCs) have been identified as the primary cathode candidate for powering next-generation electric vehicles and have been extensively studied in the last two decades, leading to the fast growth of their market share, including both polycrystalline and single-crystal NMC cathodes. Single-crystal NMCs appear to be superior to polycrystalline NMCs, especially at low Ni content (≤60%). However, Ni-rich single-crystal NMC cathodes experience even faster capacity decay than polycrystalline NMC cathodes, rendering them unsuitable for practical application. Accordingly, this work will systematically review the attenuation mechanism of single-crystal NMCs and generate fresh insights into valuable research pathways. This perspective will provide a direction for the development of Ni-rich single-crystal NMC cathodes.
Breast Cancer-Related Financial Toxicity in Sri Lanka: Insights From a Lower Middle-Income Country With Free Universal Public Healthcare
Authors: Ranawaka Sarith , Gunarathna Sathika , Gunasekera Sanjeeva , Booth Christopher M , Jalink Matthew , Carson Laura M , Berry Scott , Gyawali Bishal , Seneviratne Sanjeewa , Wijeratne Don Thiwanka
Published: September 2023

Financial toxicity (FT) describes either objective or perceived excess financial strain due to a cancer diagnosis on the well-being of patients, families, and society. The consequences of FT have been shown to span countries of varied economic tiers and diverse healthcare models. This study attempts to describe FT and its effects in a lower- to middle-income country delivering predominantly public nonfee-levying healthcare. This was a cross-sectional study involving 210 patients with breast cancer of any stage (I to IV), interviewed between 6 and 18 months from the date of diagnosis. Financial toxicity was highly prevalent with 81% reporting 3 or more on a scale of 1 to 5. Costs incurred for travelling (94%), out-of-hospital investigations (87%), and consultation fees outside the public system (81%) were the most common contributors to FT. Daily compromises for food and education were made by 30% and 20%, respectively, with loss of work seen in over one-third. Greater FT was seen with advanced cancer stage and increasing distance to the nearest radiotherapy unit (P = .008 and .01, respectively). Family and relatives were the most common form of financial support (77.6%). In conclusion, FT is substantial in our group, with many having to make daily compromises for basic needs. Many opt to visit the fee-levying private sector for at least some part of their care, despite the availability of an established public nonfee-levying healthcare.
Des expériences négatives de l’enfance à la santé relationnelle précoce : les conséquences pour la pratique clinique
Authors: Williams Robin C
Published: September 2023

Les enfants grandissent et se développent dans un environnement de relations. Des relations sécuritaires, stables et bienveillantes contribuent à consolider la résilience et à atténuer les répercussions des expériences négatives. La promotion de la santé relationnelle en pratique clinique recentre l’attention accordée aux expériences négatives de l’enfance sur les expériences positives de l’enfance. Cette approche, qui évalue les forces et les atouts d’une famille, peut être intégrée à la fois aux rendez-vous réguliers de l’enfant en santé et aux soins surspécialisés. Il est optimal de réaliser de telles interventions pendant la période prénatale ou le plus rapidement possible avant l’âge de trois ans, mais il n’est jamais trop tard pour les entreprendre. Le présent document de principes décrit comment les cliniciens peuvent adopter une approche de santé relationnelle lors de chacune de leurs rencontres médicales s’ils comprennent ce qu’est le stress toxique et ses effets sur le cerveau en développement, les relations familiales et le développement de l’enfant; à quel point les relations, expériences et comportements positifs peuvent en atténuer les effets et renforcer la résilience; quels sont les signes observables de la santé relationnelle et des risques relationnels dans les interactions entre les parents et l’enfant; quelles sont les caractéristiques de relations thérapeutiques de confiance avec les familles et comment en optimiser les avantages par les échanges et la pratique clinique.
2 Excessive Exercise among Youth with a New Diagnosis of Restrictive Eating Disorder before and during the COVID-19 Pandemic
Authors: Coret Alon , Agostino Holly , Tritt Ashley , Moubayed Dina , Chadi Nicholas
Published: September 2023

Background

During the COVID-19 pandemic, Canadian youth with anorexia nervosa (AN) and atypical anorexia nervosa (AAN) presented at higher rates with more severe illness. This trend was found to be more pronounced in Canadian jurisdictions where public health measures included full school closures and confinement. Disease severity in AN is multifactorial, however, excessive exercise can be associated with more severe illness. Due to closures, many adolescents turned to unregulated exercise regimes within their homes. The contribution of excessive exercise to the rise of new onset AN during the pandemic remains unknown.

Objectives

To determine the rate of excessive exercise among newly diagnosed adolescents with AN/AAN during the COVID-19 pandemic compared to the five preceding years.

Design/Methods

This was a secondary analysis of a prospectively collected intake registry of all new diagnoses of AN and AAN completed between January 1st, 2015, and November 30th, 2020 at two large, urban, tertiary paediatric hospitals in Quebec. Baseline demographic information and clinical assessment variables were collected based on standardized assessment forms. Excessive exercise was self-reported and defined as >10 hours per week of moderate or vigorous physical activity at the time of diagnosis. Medical hospitalization within 1 week of assessment was used as a marker of medical severity. The primary outcome of excessive exercise was compared between the period of pandemic public health preventive measures (March 2020 to November 2020) and the pre-pandemic period (January 2015 to February 2020). Variables were compared before and during the pandemic using Chi square testing.

Results

Overall, 817 patients with new diagnoses of AN/AAN met inclusion criteria during the study period (pre=647; during=170), with 40 patients (pre=34/647 and during =6/170) excluded due to missing data on exercise frequency. Overall, median patient age was 15.9 (IQR 13.8-16.9) years; 93% female; and 59% diagnosed with AAN. During the pandemic, mean hospitalization rate increased from 2.2 to 7.2 patients per month (p=0.001). Hospitalization within one week of diagnosis increased from 23% to 40% (136/613 vs. 65/16; p=0.001). The rate of excessive exercise did not differ before versus during the pandemic overall (27% vs. 24%; p=0.48) nor in patients requiring admission (40/136 [29%] vs. 23/65[36%]; p=0.39).

Conclusion

Excessive exercise in isolation does not appear to explain the increased rate and severity of new AN/AAN diagnoses since the pandemic in this cohort. Further studies are needed to better elucidate other drivers which may have contributed to the severity of eating disorders during this period.
9 “The Child's Voice”: Perceptions of Healthcare Systems for Children Aged 8-12 Referred for Neurobehavioural Concerns: A Focus Group Study
Authors: Schatz Ryan , Gander Dr Sarah , Campbell Sarah , Flood Kate , Fana Natalia , Lunney Sarah
Published: September 2023

Background

Providing children with a voice to tell their story and to fully participate in the plan of care has not been commonly reported in the literature. Paediatric health assessments traditionally rely on caregiver opinions and the interpretation of the child’s view rather than the child’s first voice perspective.

Objectives

This study focused on the experiences of children seeing a paediatrician primarily for neurobehavioural issues, such as autism and attention-deficit hyperactivity disorder (ADHD). The study was designed to provide children with the opportunity to share their thoughts directly rather than through a caregiver.

Design/Methods

This study, approved by the Horizon Health Network Research Ethics Board, used a qualitative design. 11 children between 8-12 years of age were recruited. These children were interviewed across three focus groups conducted using a semi-structured approach. The interview questions focused on emotions and opinions surrounding their care. Discussions were primarily led by the children. Focus groups were transcribed and analyzed using the six phases of inductive thematic analysis.

Results

Three overarching themes were identified: trust, boredom, and resolution (Figure 1). Trusting in their parent’s ability to communicate for them and regarding the doctor as an expert appeared as two subthemes. Children also reported feeling substantial levels of boredom at appointments, although “missing school” and “getting a treat” were reported as positives. Despite these feelings of boredom, many children expressed that the doctor provided them with a feeling of change or resolution, and that their visits were addressing their problems and needs.​ They also report disagreement may be perceived as being ungrateful for the help. Overall, children felt trust in their physician and parental intentions, along wit feeling positive about results. However, children’s views of their care are possibly influenced by the belief that decisions will be made for them, regardless of their voice. When children disagree with care, they may not voice this because of possibly perceived negative consequences.

Conclusion

Children must have a voice to ensure that we meet them ‘where they are’ as care providers and make goals and plans tailored to their needs, regardless of parent or physician bias or opinion. This is a cornerstone to upholding the Rights of the Child and ensuring patient-centred care. ​
14 Comorbidities Affecting Children with Autism Spectrum Disorder: A Retrospective Chart Review from the Main Referral Site for ASD Evaluation in Manitoba
Authors: Burns Jessy , Phung Ryan , McNeill Shayna , Hanlon-Dearman Ana , Ricci M Florencia
Published: September 2023

Background

Autism Spectrum Disorder (ASD) is a developmental disorder characterized by deficits in social interaction/communication, restricted interests and repetitive behaviours. Recent discussions have emerged worldwide regarding a possible “overly-inclusive” diagnosis of ASD, adding heterogeneity around presentation/etiology and comorbidities.

Objectives

This study aimed to determine the frequency and characteristics of comorbidities among children diagnosed with ASD in Manitoba, and to evaluate differences in presentation between those with and without medical comorbidities. As comorbid neurodevelopmental disorders such as global developmental delay (GDD) and attention-deficit yyperactivity disorder (ADHD) are common in children with ASD, these were not included as “medical comorbidities” and were studied separately.

Design/Methods

We conducted a retrospective chart review of >2000 electronic charts at the main referral site for children <6 years requiring evaluation for ASD in Manitoba. All children aged 0-5 years diagnosed with ASD at this site between May 2016 to September 2021 were identified. X2 and t test were used to compare groups.

Results

Of the total of 1858 children identified, 1459 (78%) were male, 252 (13.5%) were born prematurely, 504 (27%) had ≥1 medical comorbidity. Most common medical comorbidities were neurological (12.7%) and allergies/eczema (6.1%). Comorbid GDD was diagnosed in 428 (23%). Age of referral to RCC and age of diagnosis did not differ between groups. Medical comorbidities were more common among preterm children (31% vs. 26%, p:<0.01) and children with comorbid GDD (35% vs. 18.6%, p:<0.01). There was no significant difference in overall presence of medical comorbidities by sex (29.5% vs. 26.6%, p: 0.25); however, girls had a statistically significant higher incidence of neurological comorbidities, e.g. cerebral palsy, epilepsy, hypotonia NYD (16% vs. 12%, p:0.03).

Conclusion

Results of this study are consistent with previous studies, which note high comorbidity rates among children with ASD. The high rates of associated neurological conditions, GDD, and prematurity add heterogeneity to this group and may relate to the reported “overly-inclusive” diagnosis. This study will be used as a catalyst for guiding further prospective studies in the area.
20 Developmental Outcomes of a Cohort of Preschool Children Requiring Craniosynostosis Surgery in Manitoba
Authors: Ripstein Yael , Ricci M Florencia , Pylypjuk Christy
Published: September 2023

Background

Historically in Manitoba, all children with craniosynostosis were referred to the Child Development Clinic (CDC) for neurodevelopmental evaluation, because craniosynostosis has been associated with developmental delay. However, due to heightened volume pressures, the CDC recently decided to limit the number of referrals accepted for evaluation of children with craniosynostosis.

Objectives

To inform best practices for neurodevelopmental screening, this study aims to describe the developmental outcomes of preschool children requiring craniosynostosis surgery in Manitoba.

Design/Methods

In this historical chart review of the CDC electronic medical record, the developmental outcomes of patients who were assessed at CDC for surgically managed craniosynostosis between July 1st, 2016 and December 1st, 2021 were described. Developmental quotients across Motor, Cognitive and Language domains were collected, and patients were categorized as Normal, Mild Delay in 1 Area or Delay in ≥2 Areas. Demographic and medical characteristics were collected, and descriptive statistics were used to describe and compare outcomes between groups.

Results

Out of a total of 67 children, 18% (n=12) demonstrated developmental delays in ≥2 areas, 23.9% (n=16) demonstrated mild developmental delays in one area, and 58.2% (n=39) were developmentally appropriate across all areas. Presence of genetic syndrome (p<0.001), suture type (p=0.011), and parental SES score (p=0.028) were significantly associated with developmental delay in ≥2 areas. Odds ratios for genetic syndrome and SES score were 218.352 (95% CI 6.843, 6967.766) and 0.857 (95% CI 0.766, 0.959) respectively. 11.9% (n=8) of children were referred to Children’s Disability Services, 5 of whom had syndrome involvement.

Conclusion

To target children at highest risk for developmental delay, we suggest that children with craniosynostosis be referred for neurodevelopmental evaluation if they have multisutural craniosynostosis, suspicion or confirmed genetic syndrome, or an identified developmental concern by primary care physician screening.
23 Association between Autism Spectrum Disorder and Parental Immigration among a Cohort of Preschool Children in Manitoba
Authors: Phung Ryan , Burns Jessy , Fridell Mara , Hanlon-Dearman Ana , Narvey Stefanie , Ricci M Florencia
Published: September 2023

Background

Recent data indicate that rates of autism spectrum disorder (ASD) are increasing and therefore, studies exploring risk factors for ASD that can further support early diagnosis and intervention are needed. A link between immigration and autism has been made by several international studies, but despite high rates of immigration, a Canadian study examining this association has not been conducted.

Objectives

To determine the proportion of children diagnosed with ASD at Manitoba’s primary autism referral site (the only publicly funded site for ASD evaluation of children <6 years of age) that were born to immigrant parents, and compare it with the known proportion of immigrants in Manitoba. Also, to compare demographic and clinical characteristics of children whose parents are immigrants with those whose parents were born in Canada.

Design/Methods

We conducted a retrospective chart review of >2000 electronic records that identified all children <6 years diagnosed with ASD at the referral site between May 2016 and September 2021. Data on parental immigration, demographics, diagnostic evaluation, and medical history was collected. Descriptive statistics were used to compare the relative proportion of children with ASD from immigrant parents with the proportion of immigrants in Manitoba based on 2016 census data.

Results

A total of 1865 children were diagnosed with ASD during the study period. The mean age at referral and diagnosis was 2.81 (SD 1.26) years and 3.88 (SD 2.90) years respectively; 78% were male and 13.5% were born preterm. The proportion of children with ASD from immigrant parents (36%) was greater than the expected proportion (18.3%) of immigrants based on Manitoba census data (p < 0.001). The most common countries of origin of immigration were the Philippines (30.7%), India (11.6%), Nigeria (8.6%), and Ethiopia (6.4%). Overall, children of immigrants were younger at referral (2.71 years, SD = 0.98 versus 2.91 years, SD = 1.43; p <0.001), less likely to have a family history of ASD (17.1% versus 35.6%; p = <0.001) and less likely to have comorbidities (46.8% versus 53.9%; p <0.001) including global developmental delay (18% versus 27.6%; p <0.001).

Conclusion

At Manitoba’s primary autism referral site, there was a greater proportion of children diagnosed with ASD born to immigrant parents than expected when compared to the Manitoba population. Overall, children of immigrants were younger, less likely to have comorbidities, developmental delay, and a family history of ASD. Future prospective studies are required to better understand the complex relationship between immigration and ASD diagnosis.
31 Iron Deficiency in Formula-fed Very Preterm Infants: Do We Need to Revise Recommendations for Iron Supplementation?
Authors: Power Grace , Stratas Alexandra , Landry Carmen , Morrison Lisa , Kulkarni Ketan , Campbell-Yeo Marsha , Singh Balpreet , Higgins Michelle , Ghotra Satvinder
Published: September 2023

Background

Preterm infants are at risk for iron deficiency (ID). The Canadian Paediatric Society (CPS) recommends iron supplementation of 2 to 3mg/kg/day for breastfed (BF) preterm infants born <2 kg. Additional iron supplementation is not recommended if these infants are primarily formula-fed (FF) with iron-rich formula, since formula is thought to provide enough iron. However, these recommendations are not universally accepted.

Objectives

To investigate how feeding type influences the iron status of very preterm infants (VPI) at 4 to 6 months corrected age.

Design/Methods

A retrospective population-based cohort study was conducted using a provincial database of all VPI (<31 weeks gestational age) born in Nova Scotia from 2005-2018. Information about feeding type, iron intake from formula, and supplemental iron therapy at 4- to 6-month follow-up was extracted, as were neonatal variables. Two groups were compared using chi-square and unpaired t-tests.

Results

392 infants were studied (gestational age: 23-30 weeks). Of these, 285 were exclusively FF with iron-rich formula, and 107 were exclusively or partially BF. Neonatal variables were comparable between the two groups. An elemental iron intake of >2 mg/kg/day was obtained from formula alone in only 20.4% of FF infants. FF infants were less likely to receive additional iron supplements. However, total iron intake (from formula and supplements) was higher in FF infants. Despite this, 36.8% of infants in FF group developed ID, versus 20.6% in the BF group (Table 1).

Conclusion

Most VPI fail to receive elemental iron of >2 mg/kg/day from formula alone. ID is significantly more prevalent in FF infants than in BF infants, despite higher iron intake. Our findings do not support the current CPS guidelines.
37 Improving Bronchiolitis Management at B.C. Children’s Hospital: Standardizing Care Through a Pre-printed Order
Authors: Chen-Mack Riley , Seaton Claire , McLaughlin Tom , Balleny Rosa
Published: September 2023

Introduction/Background

Bronchiolitis is the most common cause of hospital admissions during the first year of life. There is significant variation in the management of this disease. Despite supportive care being the hallmark of treatment, investigations and other treatments are commonly prescribed. Standardizing care for bronchiolitis leads to decreased resource utilization and improved patient outcomes. Pre-printed orders can standardize care and improve compliance with evidence-based medicine.

Objectives

To determine whether a pre-printed order (PPO) would influence length of stay and specific medication use (corticosteroids, antibiotics, bronchodilators) for patients admitted to B.C. Children’s Hospital (BCCH) with a diagnosis of bronchiolitis.

Design/Methods

We implemented a pre-printed order (PPO) for inpatient management of bronchiolitis at B.C. Children’s Hospital (BCCH), then conducted a retrospective chart review of children admitted to BCCH with a discharge diagnosis of bronchiolitis. We compared primary and secondary outcomes between the pre-PPO (November 24, 2017 to December 31, 2019) and post-PPO (September 22, 2021 to April 12, 2022) periods. The primary outcome was length of stay (LOS) in days, and secondary outcomes included the prescription of specific medications.

Results

A total of 584 patients were included in the retrospective chart review: 436 patients were from the pre-PPO period and 148 patients were from the post-PPO period. There was no difference in the LOS between the pre-PPO and post-PPO periods: median LOS was 3.00 days (2.00 to 5.00 days) and 3.00 days (2.00 to 5.00 days) in the pre- and post-PPO periods, respectively (p = 0.88). There was a decrease in prescribed antibiotics, from 36.7% to 24.7% (OR = 0.56, 95% CI = 0.37 to 0.86, p = 0.01). Additionally, there was a decrease in prescribed salbutamol, from 41.5% to 29.3% (OR = 0.58, 95% CI = 0.39 to 0.87, p = 0.01). There was no significant difference in rates of PICU admission between the pre- and post-PPO periods (23.6% vs. 26.4%, OR = 1.16, 95% CI = 0.75 to 1.76, p = 0.5).

Conclusion

The implementation of a PPO for inpatient management of bronchiolitis did not affect length of stay or PICU admissions. However, there was significant reduction in prescribed antibiotics and salbutamol (both reduced in the post-PPO period). Our results suggest that a pre-printed order can improve antimicrobial stewardship and reduce unnecessary medication use, when managing a common paediatric disease.

Graph Example for antibiotic/salbutamol and PICU
43 Far from Home: The Impact of Geographic Distance from Tertiary Paediatric Hospitals on Family Expenses and Experiences
Authors: Buuren Asia , Van Udall Britt , Carwana Matthew
Published: September 2023

Background

Many individuals living in rural and remote communities are required to travel to urban centres to receive essential health care. These experiences may be especially complex for children and their families. Despite this, there is a lack of available literature on the experiences of children and families travelling to receive care at tertiary paediatric hospitals in Canada, specifically regarding associated costs and psychosocial impacts.

1.Objectives: Analyze tertiary hospital-based administrative data to quantify the number of admissions and length-of-stay for families living > 50 km from the hospital.

2.Describe the costs and psychosocial impacts of hospitalization on families living > 50 km from the hospital.

Design/Methods

Ethics approval was obtained. Family partners were involved in all aspects of the study design. We obtained a de-identified data set describing the length of stay and home community of paediatric patients admitted to our paediatrics unit. Descriptive statistics were produced to determine the relevant study population and inform subsequent data analyses. A cross-sectional survey was distributed to interested caregivers admitted to our paediatrics team. Participants were offered a $20 gift card as remuneration. The survey included optional questions to assess participant demographics, costs associated with hospitalization, and subjective stress levels. Descriptive statistics were reported.

Results

Administrative data analysis described 2,758 admissions to a paediatric tertiary hospital from January 1, 2021 to December 31, 2021. Patients from rural and remote communities were 9.54% of total admissions. Regression models found a strong statistical relationship between length of stay and distance from the tertiary centre (Pearson chi2 coefficient 58.9, p < 0.001).

A total of 39 caregivers filled out the cross-sectional survey. 75% (n=29) of participants were from local communities and 25% (n=10) were from rural and remote communities. 82% (n=32) of hospital stays were unplanned. 54% (n=21) of participants paid out-of-pocket transportation costs and 13% (n=5) paid out-of-pocket accommodation costs. 82% (n=32) of participants had co-travellers. 20% (n=8) of participants reported difficulty paying for hospital-associated costs and 10% (n=4) had to borrow money to do so.

Conclusion

To our knowledge, this study is the first to look at the psychological and socioeconomic barriers facing families travelling to a tertiary paediatric hospital in Canada. Patients from outside the local area had increased odds of longer length of stay and participants described a variety of stressors associated with hospitalization. We hope to translate this data into evidence-based interventions to better support these families.
47 Clinical Approach to Febrile Urinary Tract Infections in Young Children Presenting to the Paediatric Emergency Department: A Retrospective Study of National Guideline Compliance
Authors: Morin Frances , Desai Neil
Published: September 2023

Background

Antimicrobial resistance is one of the greatest threats to global health. Antibiotic overuse drives antimicrobial resistance. Suspected urinary tract infection (UTI) is a key area of over-prescribing in many clinical settings but has not been investigated in the paediatric emergency department (ED).

Objectives

Here, we explore compliance with national UTI management guidelines in a paediatric emergency department setting and characterize patient and provider factors associated with guideline non-compliance.

Design/Methods

We performed retrospective chart review of patients ages 60 days to 36 months, discharged with a diagnosis of UTI from a single, urban, tertiary care paediatric emergency department (PED) with a diagnosis of UTI. Random visits were chosen using a computer algorithm. Primary outcomes were: 1) proportion of patients receiving guideline-compliant investigation and treatment, and 2) the proportion of children whose antibiotic prescriptions were appropriately adjusted upon return of urine culture and antibiotic susceptibilities (C&S). The guideline was the Canadian Paediatric Society statement on management of UTI, as well as the BC Children’s Hospital institutional UTI management guideline. Descriptive statistics and odds ratios between associations were calculated.

Results

We reviewed 402 charts. The proportion of infants receiving guideline-compliant testing and treatment was 25.9% (95% CI: 21.8-30.4%). Of those who were prescribed antibiotics, 79.6% (95% CI: 74.7-83.8%) received a first-line recommended agent and 58.9% (95% CI: 53.8-63.8%) received fully compliant therapy with respect to agent, dose, duration, and frequency. 19.4% (15.4-24.2%) of patients who were prescribed empiric cephalexin received an inappropriately high total daily dose. The proportion of patients receiving age-appropriate testing method was 52.2% (95% CI: 47.4-57.1). Febrile children were more likely to receive age-appropriate urine sample collection by catheterized sample (OR: 2.77 95% CI: 1.81-4.25) compared with afebrile children. Ultimately, 50.7% (95% CI: 40.4-49.6%) of patients discharged with a diagnosis of UTI and prescription for antibiotic met diagnostic criteria for UTI based on urinalysis and culture results. Of patients whose C&S mandated a change in therapy, 60.8% (95% CI: 55.8-65.7%) had their agent changed or discontinued.

Conclusion

Paediatric emergency medicine physicians frequently order inappropriate investigation and empiric treatment of UTI in young children. Discontinuation of empiric antibiotics in culture-negative children may be an impactful stewardship intervention in the PED.
69 A Population-based Study of Parent-reported Health Outcomes at Preschool Age of Children Born Very Preterm
Authors: MacDonald Sydney , Ghotra Satvinder , Stratas Alexandra , Campbell-Yeo Marsha , Synnes Anne , Shah Prakesh , Sandila Navjot
Published: September 2023

Background

Most existing literature on health status (HS) and health-related quality of life (HRQL) of preterm survivors focuses on late childhood, adolescent, and adult age, with only a small body of data on preschool age children. Little is known about the relationship between parent-reported HS outcomes and standardized neurodevelopmental outcomes measured in preterm survivors at preschool age.

Objectives

To present parent-reported HS outcomes at 36 months of age in a population-based cohort of very preterm survivors and compare parent-reported subjective outcomes to standardized neurodevelopmental outcomes measured by clinicians at the same age.

Design/Methods

Infants <31 weeks’ gestation born between April 2014 and June 2016 were prospectively followed through the Perinatal Follow-Up Program and enrolled in a population-based database. HS was measured using the Health Status Classification System for Pre-School Children questionnaire, completed by parents when children reached 36 months’ age. At the same age, neurological examination and standardized developmental assessments were completed by clinicians, using the Bayley Scales of Infant and Toddler Development – III to determine neurodevelopmental impairment (NDI). NDI was categorized as none, “mild”, or “significant" (moderate or severe cerebral palsy, Bayley-III <70, blind or required hearing aid). Inter-rater reliability between the physician and parent scores was assessed using Cohen’s weighted kappa coefficient.

Results

Of 118 children included, there were 47 and 71 children born in <28 and ≥28 weeks’ gestational age, respectively. At 36 months’ age, 73.7% had a parental health concern, mild in >50% and severe in only 8.5%. The most affected HS attributes were language (46.6%) and self-care (39.0%). Nearly 75% of the participants did not meet the criteria for NDI. Of 11 (9.3%) children with significant NDI at 36 months’ age, all parents reported moderate (36.4%) or severe (63.6%) health concerns. Conversely, of 26 (22%) children with parents reporting moderate to severe health concerns, 11 (42.3%) met the criteria for significant NDI (Table 1). Weighted Kappa coefficient was 0.33 (CI=0.20,0.046).

Conclusion

Most parents expressed at least one concern for their preschool-aged child born preterm. Despite high parental concern, most children did not meet the criteria for NDI via clinician assessment. Overall, there was fair agreement between parental concerns and clinician-reported outcomes.
71 Trends, Practice Patterns, and Opportunities for Improvement in Postnatal Steroids Use for Bronchopulmonary Dysplasia – Eleven Years Observational Study
Authors: Kanagaraj Uthaya Kumaran , Shivananda Sandesh , Tan Jason
Published: September 2023

Background

Postnatal steroids (PNS) use in preterm infants improves pulmonary function in a select subset of patients but can potentially increase the risk of spontaneous intestinal perforation and cerebral palsy. Despite national guidelines, reducing intra-centre variation and demonstrating responsible stewardship in PNS use have been challenging.

Objectives

To describe (i) PNS type, regimen, time of initiation, use over time, and identify opportunities for improving practices in the use of PNS for bronchopulmonary dysplasia (BPD); (ii) outcome at discharge for infants who received PNS.

Design/Methods

We conducted a retrospective observational study in a quaternary NICU that included infants born at <33 weeks gestational age who received PNS to prevent or treat BPD between 2011 and 2021. We initially identified all infants who received PNS from the pharmacy registry, followed by demographic, PNS use details, and outcome data collection from the Canadian Neonatal Network (CNN) database, discharge summaries and, occasionally, by reviewing individual charts.

Results

The mean (SD) gestational age and birth weight of 184 eligible infants were 25(24-26) weeks and 720(625-841) grams respectively. Based on timing of first course of PNS, 2(1.1%), 93(50.5%), 85(46.2%), and 4(2.2%) infants received PNS in early (E) (< 7 days), early evolving (EE) (7-28 days), late evolving (LE) (29 days – 36 + 6 weeks PMA), and established (Es) (≥ 37 weeks) phases, respectively. 157 (85.3%) infants received dexamethasone and 22 (12%) received hydrocortisone as the first PNS course. Infants in the EE group, when compared with the LE group, received more days and higher cumulative dose of PNS 13(10-28) vs. 10(10-16) p= 0.04, and 24(24-60) vs. 24(24-25) hydrocortisone equivalents in milligrams/kilograms, p=0.01, respectively. Two common regimens used at our centre were 10-day Dexamethasone: A Randomized Trial (DART) and 22-day tapering doses of hydrocortisone (STOP-BPD). Deviation from published protocols based on duration (±20%), dose (±10%) or timing was 66.7% and 33.3% with hydrocortisone and dexamethasone use. Dexamethasone usage remained stable, but a small increase in hydrocortisone use and the cumulative PNS dose received occurred over time. Survival, survival without major morbidity, moderate to severe BPD, and technology dependence at discharge were 87%, 1.6%, 90.8% and 66.9%, respectively. Identified opportunities for improvement were: adapting national guidelines to local context, creating order sets to reduce deviations, and using this study’s outcomes during PNS decision-making conversations with family.

Conclusion

Variation in the use of hydrocortisone was higher than for dexamethasone, and cumulative dose received per infant increased over time. Potential interventions to reduce variation in PNS use and optimize decision- making were identified.
73 Milking of the Cut-Cord during Stabilization of Very Preterm Infants: A Randomized Controlled Trial (The MoCC Study)
Authors: El-Naggar Walid , Mitra Souvik , Abeysekera Jayani , Disher Tim , Woolcott Christy , Hatfield Tara , McMillan Douglas , Dorling Jon
Published: September 2023

Background

Delayed cord clamping (DCC) for at least 30-60 seconds after birth has been recommended as the standard of care for most preterm infants. However, DCC can be contraindicated or not optimal in certain situations (for example, in cases of interrupted placental circulation). Milking of the long-cut cord (MoCC) while providing stabilization and supporting breathing of the infant after birth is proposed as an alternative to DCC.

Objectives

To investigate the feasibility of MoCC during stabilization of very preterm infants after birth.

Design/Methods

This parallel-group, randomized controlled trial was conducted at IWK Health, which is a tertiary care perinatal centre in Halifax, Canada. Infants born to eligible, consenting women presenting in preterm labor at <32 weeks’ gestation were randomized to the MoCC group (where the infant received 30 seconds of DCC while initial resuscitation steps were taken by the obstetric provider, followed by milking of the long-cut cord one time over 10 seconds, with breathing supported by the neonatal team) or to the current standard of care group. For these infants, DCC for 30-60 seconds depended on whether the baby was breathing at birth or not. Primary outcome was feasibility in terms of percentage recruitment, intervention compliance, safety, and study completion. Short-term clinical outcomes were collected. Analysis was by intention-to-treat.

Results

Fifty infants were randomized to either MoCC (25) or DCC (25) (see Figure below). Baseline characteristics were similar. All infants completed the study. One infant in the MoCC group and five infants in the DCC group did not receive the allocated intervention. Median (IQR) time to cord milking was 62 seconds (54, 99) and median (IQR) length of the cut cord milked was 20 cm (14, 29). MoCC was not associated with adverse effects when compared with DCC (see Table).

Conclusion

Milking the long-cut cord one time after 30 seconds of DCC, while supporting breathing, was feasible and not associated with adverse effects. A large randomized controlled trial is required to assess the efficacy of this approach for clinical outcomes. MoCC may be especially useful when immediate clamping is indicated.

Potential competing interests

Dr. El-Naggar has served as a consultant for Aerogen Pharma Limited and is a site investigator of its funded study: A Partially-Blind, Randomized, Controlled, Parallel-Group, Dose-Ranging Study to Determine the Efficacy, Safety and Tolerability of AeroFactTM (SF-RI 1 surfactant for inhalation combined with a dedicated drug delivery system) in Preterm Infants at Risk for Worsening Respiratory Distress Syndrome.
74 “Dental Care for Children with Disability Is Not Considered Essential Care”: Perspectives of Parents and Dentists
Authors: Jaworski Magdalena , Cadorel Hugo , Janvier Annie , Asselin Marie-Ève
Published: September 2023

Background

Oral health is often overlooked in the medical care for children with disabilities. While recommendations exist, these take little account of the daily reality of the main stakeholders: parents and dentists.

Objectives

Our goal was to explore the perspectives of parents and dentists regarding dental care for children with special needs, and contrast their lived experience with recommended best practices.

Design/Methods

14 participants were recruited from a tertiary paediatric health centre to participate in semi-structured interviews: 9 parents of children with special needs (cerebral palsy, craniofacial anomalies, autism spectrum disorder) and 5 paediatric dentists. Interviews were conducted virtually in 2021. The participants were asked about oral health prevention, accessibility and treatment. The interviews were analyzed using qualitative methodology.

Results

Based on a thematic analysis of the content of the interviews, we identified several issues encountered by our participants in the context of the dental health of children with special needs. There were mainly issues of accessibility: ‘I work in the field and yet it was so difficult to find a dentist for my own child with disabilities’; financial barriers: ‘His dental needs are not covered because they are deemed aesthetic’; and geographical: ‘I am lucky, I have to drive 30 minutes to her appointments, but others need to drive for hours’. Parents also described difficulties in prevention: ‘I didn’t know how to care for his teeth; I used my own common sense’. The dentists emphasized the importance of communication: ‘I wish dentists were a part of the multidisciplinary healthcare team’. Also, sensitive questions regarding ethical issues, such as protective stabilization and general anesthesia were candidly answered by the majority of interviewees who accepted these practices as essential: ‘It [stabilization] is not easy to accept, but we know it is necessary’, and ‘I prefer getting the treatments done in one appointment [necessitating anaesthesia]’. These practices, in contrast, are deemed more problematic in the medical literature.

Conclusion

Dental care and prevention is essential since oral and dental problems can cause significant pain and distress. There is a significant gap between what “ought to be done” and the reality of families. Despite this, several practical recommendations emanated from the interviews that can be turned into actionable items in practice.
76 Injury-related Paediatric Emergency Department Visits during the First 2 Years of the COVID-19 Pandemic
Authors: Groulx-Boivin Emilie , del Giorgio Francesca , Gravel Jocelyn , Drouin Olivier
Published: September 2023

Background

The onset of the COVID-19 pandemic was associated with a decrease in injury-related paediatric emergency department (ED) visits. However, the longitudinal impact of COVID-19 on paediatric injury beyond the first 6 months of the pandemic is not well established.

Objectives

To quantify the impact of COVID-19 and associated public health measures on injury-related paediatric ED visits during the first two years of the pandemic and determine whether children of all ages were similarly affected.

Design/Methods

We conducted a longitudinal observational study of injury-related ED visits at a large paediatric tertiary care centre before and during the COVID-19 pandemic. We used negative binomial regression to assess the impact of the first two years of the pandemic (Year 1: March 2020-February 2021; Year 2: March 2021-February 2022) on the monthly incidence of injury-related ED visits and risk of hospitalization from injury. Secular time-trends and seasonality were accounted for by modelling the pre-pandemic trend using a 4-year historical control (April 2016-February 2020). In a secondary stratified analysis, changes in monthly incidence of injury-related ED visits were assessed by age group (0-4, 5-11, and 12-17 years).

Results

Of 458,799 ED visits during the 6-year study period, 21,644 (4.7%) were associated with injuries. The distribution of age categories, acuity of presentation, and frequency of hospitalization were similar between the pre-pandemic and pandemic periods (see Table below). Injury-related paediatric ED visits reached a low (−49%) in March 2020 (IRR 0.51, 95% CI 0.43-0.60), and a peak (+50%) in January 2021 (IRR 1.50, 95% CI 1.33-1.68) relative to historical controls (see Figure). All three confinement periods were associated with an initial reduction in injury-related ED visits and followed by a rapid increase in visits. Fluctuations in injury-related ED visits were found to differ between age groups. While there was evidence of no change among preschoolers 0-4 years old, there was a 52% reduction in visits at the onset of the pandemic in children ages 5-11 (RR 0.48, 95% CI 0.35-0.65) and an 87% reduction in children ages 12-17 (RR 0.13, 95% CI 0.06-0.23) followed by a surplus of cases among the 5- to 11-year-olds in January 2021 (+53%; RR 1.53, 95% CI 1.25-1.85) and March 2021 (+48%, RR 1.48, 95% CI 1.21-1.80).

Conclusion

The consequences of COVID-19 on paediatric injury extend far beyond the first few months of the pandemic. Understanding changes in the incidence of paediatric injury around confinement periods may assist in the development of injury prevention strategies.
78 Nitrous Oxide Use for Children Experiencing Painful Procedures: A Survey of Canadian Paediatric Emergency Physicians’ Knowledge, Attitudes, and Practices
Authors: Hudson Summer , Jain Raagini , Osmond Martin , Poonai Naveen , Trottier Evelyne D , Ali Samina
Published: September 2023

Background

Nitrous oxide (N2O) is an inhaled analgesic/anxiolytic gas with ample evidence supporting its safety and efficacy in children. However, its prevalence of use remains low, while its indications in paediatric emergency departments (EDs) across Canada remain unknown. Optimization of safe and appropriate of N2O use in this setting requires an understanding of paediatric emergency providers’ knowledge, attitudes, and practice patterns surrounding its use.

Objectives

We aimed to characterize physicians’ perceptions and current site-specific processes and procedures surrounding N2O use to understand differences between current evidence and clinical practice and standardize care for children undergoing distressing procedures.

Design/Methods

This cross-sectional survey was distributed electronically to all physician members of Paediatric Emergency Research Canada (PERC) from February to April 2021. Survey items pertained to N2O availability, comfort with N2O use, and perceived barriers/facilitators to its use. Further, a PERC representative from each site completed a site-specific inventory of N2O policies and procedures.

Results

Response rate was 67.8% (156/230), with 53.2% (83/156) women; 66.6% (104/156) had paediatric emergency subspecialty training, and mean clinical experience was 14.7 years (SD 8.6). 40.0% (6/15) of sites had N2O available in the ED, and 83.3% (5/6) of these institutions had written policies and/or procedures in place for N2O use in the ED. Overall, 48.7% (76/156) of physicians reported using N2O in their clinical practice. The most common indications for use were fracture/dislocation reduction (69.7%, 53/76), wound closure (60.5%, 46/76), and incision and drainage (59.2%, 45/76). The most common perceived barriers to N2O included concerns about ventilation/scavenging systems (71.2%, 57/80) and unfamiliarity with equipment (52.5%, 42/80). The most common perceived facilitators were N2O availability in the ED (73.0%, 114/156) and clinical experience with N2O (71.7%, 112/156). Of the 51.3% (80/156) physicians who reported not using N2O, 93.7% (75/80) did not have access available at their site; notably, 77.3% (58/75) indicated a desire to have access to N2O.

Conclusion

Despite evidence to support its use, only half of paediatric emergency physicians in Canada currently use N2O as a tool for treating children’s procedure-related pain and distress. Increasing availability of necessary equipment, protocols, and clinical training surrounding N2O use in children may improve clinicians’ abilities to better manage children’s acute pain and distress in the ED, and other clinical contexts.