bluuebunny/crossref_metadata_2025 huggingface dataset:
5 Extremely Low Gestational Age Neonates and Resuscitation: Perspectives of Canadian Neonatologists
Authors: Wood Stacie , Cheng Anita , Coughlin Kevin
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Resuscitation care planning for extremely low gestational age neonates (ELGANs) continues to be one of the most complex, ethically charged areas within paediatrics.

Objectives

This study sought to determine the current attitudes and practices of neonatologists in Canada, and to assess the moral distress associated with resuscitation decisions in the ELGAN population and current practices in an era of improved neonatal outcomes. It also aimed to explore the perspectives of adopting a shared decision-making approach, where further data with regard to best interests and prognosis are gathered in an individualized manner.

Design/Methods

This was a descriptive study employing an electronic survey constructed in REDCap®. The survey was distributed to neonatologists working in Level III NICUs across Canada and responses were collected from March to May 2020.

Results

65 total survey responses were received. 78% of neonatologists expressed at least some moral distress when parents request non-resuscitation between 24 weeks 0 days and 24 weeks 6 days. Prognostic uncertainty with regard to individualized long-term outcome in an era with increased chances of morbidity-free survival was the most prominent factor identified as contributing to moral distress. 70% felt they would feel less moral distress deciding about goals of care after assessing the baby’s response to an initial trial of resuscitation at birth, and preferred an individualized approach to palliation decisions based on postnatal course and assessment, rather than making the decision based primarily on gestational age.

Conclusion

While most current practices support the option of non-resuscitation for infants born at less than 25 weeks, there is growing evidence of moral distress among Canadian neonatologists that suggests the consideration of resuscitation at 24 weeks and above is a more realistic approach in the current era of improved outcomes. Furthermore, our results suggest that Canadian neonatologists are ethically more comfortable developing plans for care postnatally, with more evidence to support prognostication, instead of antenatally, based solely on gestational age.
7 Efficacy of Pharmacologic Therapy for Patent Ductus Arteriosus Closure in Preterm Newborns According to Their Gestational Age-Specific Z-Score for Birth Weight
Authors: Srivastava Ankur , Soraisham Amuchou , Murthy Prashanth , Kaur Sharandeep , Kamaluddeen Majeeda , Thomas Sumesh , Stritzke Amelie , Al-Awad Essa , Mohammad Khorshid
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Preterm infants who are also intrauterine growth restricted (IUGR) experience more frequent and earlier hemodynamic consequences of patent ductus arteriosus (PDA). This may be related to altered levels of prostaglandins or altered number or sensitivity of their receptors in IGUR infants. Few studies have examined the efficacy of pharmacologic therapy (non-steroidal anti-inflammatory drugs [NSAIDs]: indomethacin, ibuprofen, or acetaminophen) for PDA closure among preterm infants based on their degree of IUGR with differing results.

Objectives

Primary: To determine if the degree of IUGR [defined by birth weight (BW) z-score] affects the efficacy of pharmacologic PDA closure and rate of surgical PDA ligation in preterm infants. Secondary: To compare the side effects of NSAIDs and neonatal outcomes based on the severity of IUGR.

Design/Methods

This retrospective cohort study included infants of < 30 weeks’ GA, admitted to a tertiary neonatal intensive care unit (NICU) between 2010 and 2018, with hemodynamically significant PDA and treated with NSAIDs. Infants with major congenital anomalies, those who received prophylactic Indomethacin and those who died in the first 48 hours were excluded. Birth weight (BW) z-scores were calculated using Olsen nomograms and classified into 3 categories: z-score > −0.5 (normal), z-score −0.5 to −2.0 (mild to moderate growth restriction), z-score <−2 (severe IUGR). We compared responses to NSAID treatment and PDA ligation. Multivariate logistic regression analysis was done to examine the association of BW z-score and response to pharmacological therapy and subsequent surgical PDA ligation.

Results

Of the 1511 eligible infants, 769 (51%) had a diagnosis of PDA. Of 517 included infants, 323 (62.5%) had BW z-score >− 0.5, while 154 (29.8%) had z-scores − 0.5 to −2.0 and 40 (7.7%) had z-score < −2. Table 1 shows their demographic characteristics. Efficacy of first course of NSAIDs was not different among these birth weight groups (Table 2). There was no difference in the side effects and neonatal morbidities amongst the three groups (Table 2). Multivariate logistic regression analysis after controlling for GA, gender, antenatal steroids, C-section, and SNAP II showed that the odds of PDA ligation was significantly higher among infants with BW z-score < −2 (aOR 2.68, 95% CI 1.13- 6.36) but not among infants with z-score −0.5 to−2.0 (aOR 1.41, 95% CI 0.84, 2.39) as compared to z-score >-0.5.

Conclusion

Preterm severe IUGR infants with z-score < −2 have an associated increased risk of PDA ligation following pharmacologic treatment as compared to normally grown infants.
9 The Burden of Bronchopulmonary Dysplasia and Pulmonary Vascular Disease in Premature Infants
Authors: de Carvalho Nunes Gabriela , Wutthigate Punnanee , Simoneau Jessica , Renaud Claudia , Dancea Adrian , Beltempo Marc , Altit Gabriel
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Extremely premature infants are at a high risk of bronchopulmonary dysplasia (BPD) and BPD-associated pulmonary hypertension (PH). Prolonged patency of the ductus arteriosus (PDA) may worsen PH; however, due to the lack of evidence supporting improvement in outcomes after strategies to promote ductal closure, our center has adopted a strict non-intervention policy since 2013.

Objectives

Assess PH prevalence and severity, as well as the impact of BPD on echocardiographic parameters of cardiac performance.

Design/Methods

Retrospective cohort of infants <29 weeks gestational age at birth, admitted between 2015 and 2019, and without genetic/congenital anomalies. Measurements from the echocardiography acquired closest to 36 weeks were done by masked experts. Severe BPD was defined as positive pressure support at 36 weeks. PH was defined as an estimated systolic pulmonary pressure (SPAP) ≥40 mmHg or an abnormal septal curvature by eccentricity index (EI) (>1.3).

Results

Out of 387 infants, 222 were included, of which 27 (12%) were categorized as severe BPD and 78 (35%) had PH. Severe BPD was associated with lower birth weight (704±214 vs 842±229g, p<0.01), longer hospitalization (median 138 [IQR 108-167] vs 103 [IQR 86-125] days, p<0.01) and longer mechanical ventilation duration (median 82 [IQR 33-107] vs 17 [IQR 2-32] days, p<0.01), with no difference in gestational age at birth. Severe BPD was associated with PH (70% vs 43%, p<0.01). The combined outcome of death (after the 36 weeks echocardiography) or severe BPD was associated with PH (68% vs 30%, p<0.01), smaller left ventricle length in diastole (2.8±0.5 vs 3.0±0.5 cm, p=0.03), decrease in the tricuspid annular plane systolic excursion (0.7±0.2 vs 0.9±0.2 cm, p<0.01), abnormal EI (1.31±0.25 vs 1.17±0.18, p<0.01) and smaller right ventricle fraction area change (41.3±5.8 vs 47.8±7.6%, p<0.01), without a significant increase on SPAP (35±21 vs 35±14, p=0.15). Other echocardiographic markers were similar.

Conclusion

In the context of a PDA non-intervention policy, a third of our population was affected by PH at 36 weeks. Furthermore, those with severe BPD or death had signs of RV dysfunction (despite similar SPAP estimate), indicating that the effect of BPD on pulmonary vascular remodelling and cardiac function may be underestimated.
15 2020 CaRMS Residency Match Confirms Popularity of Pediatrics
Authors: Rowan-Legg Anne , Zucker Marc
Published: October 2021

Primary Subject area

Medical Education

Background

Longitudinal data about the interest in, and competitiveness of, pediatric postgraduate training in Canada has not been reported.

Objectives

1. To describe the results of the 2020 CaRMS pediatric residency match with respect to application rates, first-choice discipline choices, and succesful match rates by gender. 2. To examine the trend of these indices over the past decade.

Design/Methods

Data from the 2020 Canadian Residency Matching Service (CaRMS) pediatric residency match was evaluated and compared over the past decade. Residency match data from other programs was also used for some comparison reporting.

Results

Of a total pool of 2998 Canadian medical graduate (CMG) applicants in 2020, 305 (10.2%) applied to pediatrics, and 17 of these latter applicants (5.6%) applied solely to pediatrics. In the first iteration CaRMS match, pediatrics was the first-choice discipline for 177 CMG applicants (6.0% of all first choices). Pediatrics has been consistent as a first-choice discipline over the years: 5.9% (2017), 5.5% (2015), and 6.1% (2013). Of the 155 first-year positions offered in pediatrics this year, all were filled.

Of those CMGs who matched to pediatrics in 2020, the specialty was the first-choice discipline for 128 applicants (92.8%) and the second-choice discipline for 9 applicants (6.5%). There were clear gender differences noted. Pediatrics accounted for 8.3% of female and 3.2% of male first-choice disciplines. Of the 135 females whose first-choice discipline was pediatrics, 101 matched to that first choice (74.8%). Of the 41 males whose first-choice discipline was pediatrics, 26 matched to that first choice (63.4%). Since 1995 (at CaRMS’ inception), the rates of first-choice discipline choice by gender have been quite stable (Table 1), with females consistently higher than males, while the first-choice discipline matching rate by gender have varied (Figure 1).

Forty CMG applicants whose first-choice discipline was pediatrics matched to an alternate discipline choice and nine went unmatched, suggesting that pediatrics continues to be a competitive discipline. The pediatric rate of first-choice discipline matching to another alternate choice of 22.6% (40/177) is comparable to Anesthesia (22.1%; 34/154), Ophthalmology (26.7%; 20/75), and Otolaryngology (20.9%; 9/43).

Conclusion

Pediatrics continues to be a top specialty choice for graduates of Canadian medical schools, according to data from the 2020 CaRMS match. There are gender differences noted in the choice of pediatrics as a first-choice discipline, and in the successful match rate to pediatrics programs. The rate of successful first-choice discipline matching by gender have varied over time, with the past two years showing significantly greater matching success for females. These trends in the CaRMS pediatric data have implications on discipline recruitment and the pediatric workforce in Canada, and merit further exploration.
17 Decannulation Following Tracheostomy in Children: A Systematic Review
Authors: Verma Rahul , Mocanu Cora , Shi Jenny , Miller Michael , Chiang Jackie , Wolter Nikolaus , St-Laurent Aaron , Amin Reshma
Published: October 2021

Primary Subject area

Respirology

Background

Despite the large morbidity and potential mortality associated with tracheostomy tube decannulation failure, there are currently no consensus guidelines on pediatric tracheostomy decannulation. This has led to wide practice variation that is largely based on expert option. This is the largest review of pediatric decannulation protocols.

Objectives

To systematically review the literature on existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes.

Design/Methods

Five online databases were searched for relevant studies from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Independent reviewers extracted data, including patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted, including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location and length of observation period, and clinical outcomes were also collected. Quality assessment of included studies was performed using the Newcastle-Ottawa Scale (NOS) tool. Descriptive statistical analyses were performed.

Results

Twenty-three studies with 1328 children were included (Figure 1). Tracheostomy indications included upper airway obstruction at a well-defined anatomic site (37%), upper airway obstruction not at a well-defined site (13%), and need for long-term ventilation (50%). Bronchoscopy was routinely used in 96% of protocols. Tracheostomy tube modifications in the protocols included capping (83%), downsizing (57%), and fenestrations (9%). Measurements of gas exchange in the protocols included polysomnography (72%), oximetry (61%), blood gases (17%), and capnography with end-tidal CO2 (17%). After tracheostomy decannulation, children in 92% of protocols were transitioned to room air, and 38% of protocols used non-invasive ventilation. Most children (76%) were observed in hospital for 48 hours or less. Of all decannulation attempts, 79% were successful. Overall risk of bias in included studies was low.

Conclusion

The absence of clear evidence-based guidelines in pediatric tracheostomy decannulation has led to large variability in clinical practice. Most protocols include bronchoscopy, tube modifications, gas exchange measurements, and brief hospital admission. Polysomnography plays an integral role in assessing the majority of children for tracheostomy removal. Evidence-based guidelines to standardize pediatric tracheostomy care remain an urgent priority.
23 Pulmonary Hypertension Associated with Bronchopulmonary Dysplasia and Neurodevelopmental Outcomes: A Systematic Review and Meta-Analysis
Authors: Thomas Soumya , Murthy Prashanth , Soraisham Amuchou , Lodha Abhay
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Pulmonary Hypertension (PH) is estimated to occur in 1 in 4 infants with Bronchopulmonary Dysplasia (BPD). The impact of PH in infants with BPD on their neurodevelopmental (ND) outcomes is uncertain.

Objectives

This systematic review aims to evaluate whether PH in infants with BPD is associated with ND delay.

Design/Methods

A systematic literature search was performed to identify studies that reported ND outcomes of infants with BPD (based on NIH definition) and PH (based on echocardiographic findings of PH at 36 weeks PMA). The primary outcome was ND delay in infants with pulmonary hypertension associated with BPD compared with BPD alone. Standardized developmental tests evaluated ND outcomes at 18-24 months corrected age (CA) and three years of age. Quality assessment of the studies was done using the Newcastle-Ottawa Quality Assessment for Cohort studies.

Results

Three retrospective cohort studies met the inclusion criteria. Two studies reported ND outcomes based on Bayley Scales of Infant and Toddler Development-III Edition in cognitive, language, and motor domains at 18-24 months CA (Table 1 and Figure 1). One study reported outcomes at 3 years, including overall developmental delay (Kyoto Scale of Psychological Development [KSPD] scores < 70) and cerebral palsy. The quality of all 3 studies was rated between good, fair, and poor. Pooled data from the 2 studies reporting outcomes at 18-24 months showed no difference between the 2 infant groups for Bayley cognitive score < 85 (Odds ratio [OR]: 3.78; 95% CI 0.87-16.52), Bayley language score < 85 (OR: 1.19; 95% CI0.57-2.49), and Bayley motor score < 85 (OR: 2.04; 95% CI 0.89-4.67). At 3 years of age, children in the BPD-PH group had an increased risk of developmental delay (DQ < 70 in all areas) compared with the BPD group (OR: 4.37; 95% CI 1.16-16.46), but no difference in the risk of cerebral palsy (OR: 0.57; 95%0.03-12.39).

Conclusion

PH in BPD is not associated with a developmental delay compared to BPD alone at 18-24 months CA. However, a single study showed infants in BPD-PH had delayed development at 3 years of age. A large prospective cohort study with longer multidisciplinary follow-up is required to confirm this.
32 Accidental ingestions of cannabis in children pre- and post-legalization: Perspectives from a Canadian paediatric hospital
Authors: Coret Alon , Rowan-Legg Anne
Published: October 2021

Primary Subject area

Public Health and Preventive Medicine

Background

Cannabis is one of the most prevalent recreational substances worldwide. In 2018, Canada legalized the use of recreational cannabis. Cannabis is available in numerous forms, including a wide range of ingestible forms (baked goods, candies, gummies, etc.). This increasing availability and palatability of cannabis – coupled with a rise in the concentration of tetrahydrocannabinol (THC; the psychoactive component of cannabis) in many products – has made children particularly vulnerable. Research has demonstrated rising cases of pediatric accidental cannabis exposures, primarily in U.S. states, but there is a paucity of Canadian data.

Objectives

We sought to: i) Characterize the frequency and clinical features of children presenting with accidental cannabis ingestions to a Canadian tertiary pediatric hospital; and ii) Compare the rates and presentations in the pre- and post-legalization periods.

Design/Methods

A retrospective chart review of Emergency Department visits at the Children’s Hospital of Eastern Ontario (Ottawa, ON) between March 2013 and September 2020 was undertaken, with institutional ethics approval sought. Inclusion criteria were: (i) Age < 13 years; and (ii) Accidental cannabis ingestion, as identified by specific ICD-10 diagnostic codes (T40.7, X42). Data collected from each chart included basic demographics; type and quantity of cannabis ingested; timing and location of ingestion; vital signs and Glasgow Coma Scale (GCS) rating at triage; presenting symptoms; investigations and procedures performed; as well as length of stay in hospital. Data were analyzed using descriptive statistical methods.

Results

A total of 39 patients met inclusion criteria (23 male; 59%). The mean age of presentation was 5.2 years (± 3.3; range 1 month–12 years). The vast majority of visits (32/39; 82%) occurred in the last two years of data collection (i.e., after legalization of recreational cannabis in Canada in October 2018). A total of 15 patients (38%) required admission to hospital, with a mean length of stay of 1.3 (± 1.0) days. Details about each patient’s presenting symptoms, investigations, and disposition were analyzed.

Conclusion

Our data from a Canadian tertiary pediatric centre confirms an increased rate of unintentional cannabis ingestions among young children, particularly post-legalization. This is of significant public health concern. An understanding of the clinical presentation of cannabis intoxication, as well as advocacy for safe storage strategies is prudent for parents, pediatric providers, and public health policymakers.
42 The accuracy and clinical implications of point-of-care testing in children
Authors: Morin Chelsea , Füzéry Anna K , Senthiselvan Ambikaipakan , Gowrishankar Manjula
Published: October 2021

Primary Subject area

Nephrology

Background

Point-of-care testing (POCT) is commonly used at our institution to gather data quickly for sick patients, including electrolytes, glucose, and hemoglobin. Serum electrolytes, hemoglobin, and glucose are the gold standard of testing, but the results often lag POCT by a significant time period. Management decisions are made on the results returned by POCT. Thus, it is imperative to determine the accuracy of POCT at our institution.

Objectives

Determining whether POCT is an accurate and clinically appropriate method to measure electrolytes, glucose, and hemoglobin compared to standard serum testing.

Design/Methods

This study retrospectively reviewed 128 consecutive patients either assessed in the emergency department or admitted prior to November 1, 2019 who had both POCT and serum electrolytes (+/- glucose, hemoglobin, and lactate) performed within 4 hours of each other. A sample size of 128 was required to determine a difference of 3 mmol/L in sodium for an effect size of 0.5, with 0.05 level of significance and 80% statistical power. Patient demographics and additional labs drawn within 4 hours of POCT were extracted. Paired t-tests were used to compare values between serum testing and POCT for each patient. Secondary kappa coefficient analyses were performed to look at agreement within clinically-determined normal ranges. POCT was performed on Radiometer ABL835 FLEX analyzers, and serum testing on Beckman Coulter DxC 800 analyzers.

Results

There were 56 males and 72 females; age range 0.01–17.93 years. There were statistically significant differences between POCT and serum values for all electrolytes and hemoglobin, with POCT over-estimating, but not for glucose (Table 1). Within clinically determined normal ranges, there was substantial agreement between POCT and serum potassium, glucose, and hemoglobin, and fair agreement for sodium and bicarbonate (Table 2).

Conclusion

Our study highlights the importance of verifying abnormal POCT electrolytes and hemoglobin with serum values. Even when POCT values are normal, clinically significant hyponatremia and hypokalemia may not be detected, and when abnormal, hypernatremia and hyperkalemia may be overestimated. In patients with dysnatremia, if diagnosed with serum sodium and monitored with POCT (or vice versa), there is potential for incorrect diagnosis and/or rate of correction with clinical impact. Thus, when following electrolytes and hemoglobin values in a patient, POCT and serum should not be interchanged, and if there is clinical suspicion for these to be abnormal, verification with serum is warranted. Our study is limited to the specific POCT analyzer used, and behaviour of another analyzer may be different.
44 It’s All About That Trach! Using a Modified Delphi Approach to Developing Pediatric Tracheostomy Teaching Tools
Authors: Shah Prachi , Kherani Tamizan , Hicks Elizabeth (Anne)
Published: October 2021

Primary Subject area

Medical Education

Background

Pediatric tracheostomy care is intimidating; regular and emergency care are critical skills. Tracheostomy care training is vital for pediatric patients who have multiple people involved in their care and are fully dependent on their tracheostomy tubes for breathing. An Alberta team is developing an informational tool, the “Tracheostomy Journey”, to help families and health care providers understand and communicate clearly about pediatric tracheostomy. A needs assessment identified consistent, universal, multimodal teaching and communication tools for families, trainees, and hospital and home care providers as a primary need. Consistency in training will also improve communication between caregivers and families.

Objectives

The main objective of this study was to develop shareable pediatric tracheostomy care and management teaching materials for health care professionals and families. The goals of such information are to ensure checks and balances, provide universal, consistent and cohesive teaching content to all caregivers, set expectations, and promote effective communication.

Design/Methods

A modified Delphi approach provided structured development of training modules using existing diverse teaching materials. Participants were asked to focus on safe, consistent pediatric tracheostomy care. Two components were to: 1) Update and consolidate basic hospital discharge checklists for families; 2) Formalize current unstructured emergency training while building new resources to teach families, staff, and trainees through goal-oriented simulations.

Results

We consolidated 7 Home Care tracheostomy care checklists and developed 24 simulations to teach specific care skills, incorporating input from multiple stakeholders to consolidate and unify content. Participants included primary care and subspecialty physicians (Respirology, Otolaryngology, Pediatric and Neonatal Intensive Care), home care, nursing, respiratory therapy, trainees, and families. The teaching materials emphasize inclusive, acceptable skill and confidence-building as well as mastery. Each module includes a scenario, preceptor script, and debriefing materials. Scripting is designed for future video adaptation, to allow review. Pilot evaluation with trainees included knowledge and confidence assessment before and after training, after training specifically addressed the question: “Do they address the goal?”.

Conclusion

Training materials were developed by an expert team via a modified Delphi process and met the intended goals of being accessible, acceptable, inclusive, and effective at teaching and consolidating the skills of those involved in pediatric tracheostomy care. These tools are ready to employ and are anticipated to improve teaching and communication for families and trainees caring for children with tracheostomy.
49 Exploring parental acceptability of universal psychosocial screening in the pediatric emergency department
Authors: Atwal Amanbir , Virk Punit , Wright Bruce , Doan Quynh
Published: October 2021

Primary Subject area

Mental Health

Background

Mental health concerns among children and adolescents presenting to the emergency department (ED) are on the rise. Universal screening can facilitate early identification and management of these concerns, mitigating significant long-term morbidity and mortality. The efficacy of psychosocial screening in the ED is not only determined by accurate identification of concerns, but by downstream resource-seeking behaviours to address these concerns. For many children and adolescents, parents hold a key role in determining their access to care. Thus, parental attitudes and perceptions of psychosocial screening may influence resource-seeking behaviours and predict a youth’s ability to access support.

Objectives

Given the limited understanding of parental perceptions of psychosocial screening in the ED, we aimed to qualitatively explore parents’ attitudes towards screening with MyHEARTSMAP, an electronic self/proxy administered psychosocial screening tool. We also quantified resource-seeking behaviours and explored barriers to seeking care.

Design/Methods

This was a nested qualitative study conducted during the 30-day follow-up period of a larger prospective cohort study. Eligible youth and their accompanying parent/guardian completed a self/proxy psychosocial screen using MyHEARTSMAP. Youth who screened positive were provided with recommendations and resources for support.

30 days (+ 5 days) after their ED visit, parents participated in semi-structured follow-up interviews to share their attitudes, perceptions, and thoughts around the screening and care-seeking process.

Results

Of the 171 participants requiring resources for support, 124 (72.5%; 95% CI 65.2-79.1%) completed the follow-up interview. Most parents endorsed positive perceptions of the screening process, describing it as an “eye-opening” process that “sparked conversation”.74.2% (95% CI 65.6-81.6%) of participants also agreed with the support recommendations they received during their ED visit.

In terms of resource seeking, as displayed in Figure 1, only 41 participants (33.1%; 95% CI 24.9-42.1%) attempted to access support services. Other families felt identified concerns were mild and “not serious enough” to warrant resources, though many expressed an intention to seek care if the concerns escalated.

Conclusion

Parental perceptions of psychosocial screening in the ED were favourable and encouraging, with a majority of participants expressing an understanding and appreciation of the process. This lends support to the implementation of universal psychosocial screening in the ED. Despite positive attitudes towards screening, only a fraction actually attempted to access care. This incongruence may reflect the persisting view that mental health holds low priority and suggests a need for increased education on the importance of seeking timely mental health care.
52 Cultivating Learner-centeredness in a Time of Rupture: Lessons from the Shift to Virtual Pediatric Academic Half Day during the COVID-19 Pandemic
Authors: Remington Mia , Schrewe Brett , Carwana Matt , Kadoura Basil
Published: October 2021

Primary Subject area

Medical Education

Background

The COVID-19 pandemic has significantly disrupted the postgraduate learning environment. In light of public health recommendations and the need to offer safe learning environments, many programs have drawn upon virtual technologies to continue delivery of formal academic curricula. Despite widespread use, however, little is currently known as to how trainees view these changes.

Objectives

The authors sought to explore resident perceptions on the COVID-19-influenced shift from in-person to virtual academic half day (AHD) delivery.

Design/Methods

A cross-sectional survey was created and distributed to 51 pediatric residents who participated in virtual AHD at a university-affiliated Canadian program distributed across three sites, from March to June 2020. Survey responses were obtained confidentially through a secure, online platform (REDCap). Descriptive statistics and inductive thematic analysis were used to analyze responses to close-ended questions and narrative comments, respectively.

Results

Response rate was 60.8%. Residents reported statistically significant improvement in their attitudes towards virtual AHD across all metrics collected. Areas most strongly rated included increased trainee engagement and overall satisfaction with virtual delivery, in part due to increased relevance of content. Factors enabling participation included educationally safe interactions and a more comfortable and flexible learning environment.

Conclusion

These results suggest that the transition to virtual AHD was generally well received. During an uncertain time, when trainee vulnerability is heightened, the need to explicitly attend to educational issues of relevance, engagement, safety, and comfort are crucial. Further, given the rapid and reactive pivots to new curricular strategies in the wake of COVID-19, it is incumbent upon programs to incorporate resident feedback to ensure a learner-centred environment is maintained.
64 Association of 24-hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants
Authors: Debay Anthony , Shah Prakesh , Lodha Abhay , Shivananda Sandesh , Redpath Stephanie , Seshia Molly , Dorling Jon , Lapointe Anie , Canning Rody , Strueby Lannae , Beltempo Marc
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Medical team composition at the delivery of high-risk neonates may contribute to better outcomes. The presence of 24-hour (h) in-house staff neonatologist (NN) may improve delivery room (DR) care practices and outcomes.

Objectives

To assess if 24-h in-house NN coverage is associated with better care practices and outcomes among inborn infants born < 29 weeks GA.

Design/Methods

Cross-sectional cohort study of 2476 inborn infants born at 23-28 weeks gestation, admitted in 2014-2015 to Canadian Neonatal Network level 3 NICUs with a maternity unit that participated in a 2015 survey on NICU coverage. Exposures were classified using survey responses based on the most senior provider offering 24-h in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders with generalized estimating equations to account for clustering within each site.

Results

Among the 28 participating NICUs, most senior providers ensuring 24-h in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). Infants’ characteristics are shown in Table 1. No NN/fellow coverage and 24-h fellow coverage were associated with higher odds of infants receiving DR chest compressions or epinephrine compared to 24-h NN coverage (adjusted odds ratio [AOR] 4.72, 95% CI 2.12-10.6 and AOR 3.33, 95% CI 1.44-7.70, respectively) (Table 2). 24-h fellow coverage was associated with higher odds of normothermia (36.5°C-37.2°C) on admission (AOR 2.26, 95% CI 1.51-3.37) compared to 24-h NN coverage (Table 2). Rates of mortality or major morbidity did not differ significantly among the three groups: NN, 63% (249/395); fellow, 64% (1092/1700); no NN/fellow, 70% (266/381). Compared to 24-h NN coverage, 24-h fellow coverage was associated with lower odds of mortality (AOR 0.62, 95% CI, 0.43-0.88) (Table 2).

Conclusion

24-h in-house NN coverage was associated with lower rates of DR chest compressions or epinephrine use; however, it was not associated with death and/or major morbidity. These results are from a survey linked cohort, and data on the actual presence of individuals in NICU/resuscitation is unknown. Future prospective research on care providers present in the NICU, and its impact on outcomes, is needed.
65 Complication rate of cuffed versus uncuffed PICC lines placed by interventional radiology in pediatric patients
Authors: Al Bandari Maria , Donnellan John , Tavares Filomena
Published: October 2021

Primary Subject area

Paediatric Radiology

Background

Peripherally inserted central catheters are commonly used in pediatrics to offer stable access for administering prolonged courses of antibiotics, chemotherapy, parenteral nutrition, or other intravenous fluids.

Objectives

To assess the complication rates of cuffed versus uncuffed PICCs in a pediatric tertiary referral centre.

Design/Methods

Research ethics board approval was sought and granted. A dual arm study design was employed with a retrospective chart review of PICCs inserted between June 2017 - June 2018, and a prospective chart review of PICCS inserted between January 2019 - June 2019 at a large tertiary pediatric referral center. Data collected from the electronic record included age, weight, and diagnosis. Line type, size, location, insertion and removal dates, and indications were recorded. Primary outcome was removal of PICC after completion of therapy or premature removal due to the following complications: infection, thrombosis, or mechanical failure (defined as catheter breakage, blockage, or dislodgement).

Results

The study included 266 patients. Across all patients weighing < 10 kg, 90.5% of those with cuffed PICCs and 65% of those with uncuffed catheters completed therapy. The predominant complication resulting in premature removal was mechanical failure, but this was only observed in patients with uncuffed catheters (25%). Infection was also observed only in uncuffed catheters (10%), and thrombosis (4.8%) was only in the cuffed lines. For patients weighing ≥ 10 kg, 86% of those with cuffed PICCs and 77.2% with uncuffed catheters completed therapy. More complications were observed in uncuffed catheters (infection 7.7%, mechanical failure 6.6%, thrombosis 5%). Infection resulting in premature removal occurred in 7% of cuffed catheters. There was no reported mechanical failure or thrombosis in the cuffed group. The distribution of diagnoses was relatively homogenous between the groups for most diagnoses. However, there was a higher percentage of oncology patients in the uncuffed group (23%) than the cuffed group (7%) due to the need for power-injectable lines, which were not available in a cuffed variant during this study.

Conclusion

All-cause pediatric PICC-associated complications rate in the neonate group for patients < 10kg in the uncuffed group is 35% and in the cuffed group is 4.8%. Whereas in the pediatric group ≥ 10kg, all-cause pediatric PICC-associated complications rate in the uncuffed group is 19.3% and in the cuffed group is 7%. There were no mechanical complications in the cuffed group and the vast majority of lines made it to completion of therapy. This work supports utilization of cuffed PICC lines in selected pediatric patients.
66 Long-term survival and neurodevelopmental outcomes of very-preterm infants born in Canada between 2009 and 2016
Authors: Ricci M Florencia , Shah Prakesh , Moddemann Diane , Alvaro Ruben , Ng Eugene , Lee Shoo K , Synnes Anne
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Quality improvement programs across Canadian Neonatal Network (CNN) sites have led to increased neonatal survival without major neonatal morbidity among infants born extremely preterm. The next step is to determine if such activities impact longer-term survival and neurodevelopmental outcomes.

Objectives

This cohort study aimed to compare death or significant neurodevelopmental impairment (sNDI) (Bayley-III scores < 70, severe cerebral palsy, blind, or hearing aided) at 18-24 months corrected age among infants born < 29 weeks’ gestation admitted to CNN sites, between 2 Epochs: 1 (2009-2012) and 2 (2013-2016). Secondary objectives included death or neurodevelopmental impairment (NDI) (Bayley-III < 85, any cerebral palsy, visual or hearing impairment), death, sNDI, NDI, and components of neurodevelopmental impairment.

Design/Methods

Only sites with ≥ 70% follow-up rates were included. Differences in maternal-infant characteristics and neonatal morbidities were assessed by Pearson Chi-square and Student t-test testing. Adjusted odds ratios with 95% CIs were calculated for outcome change between the 2 Epochs, accounting for patient characteristic differences in the model.

Results

Study population included 4426 children; Epoch 1: 1895 (43%) and Epoch 2: 2531 (57%). In Epoch 2, more mothers received MgSO4 (56.3% vs. 28.4%; p<0.01), antibiotics (69%vs.65.3%; p 0.01) and delayed cord clamping (37.1% vs. 31.3%; p 0.02), and fewer infants had SNAP-2 (illness severity score) >20 (30.7% vs. 35.2%; p<0.01) or late-onset sepsis (23.3% vs. 26.9%; p 0.01). See Table 1.

Conclusion

Significant reductions in rate of death or sNDI, and in visual and hearing impairment, were identified between Epoch 2 to Epoch 1. An increase in poor cognitive outcome rates requires further study.
68 COVID-19 in children: A case series
Authors: Kukreti Vinay , Sakran Mahmoud , Tsimelkas Sarah , MacDonald Jessie , Wadhwa Anupma
Published: October 2021

Primary Subject area

Community Paediatrics

Background

The COVID-19 pandemic has had an overwhelming impact worldwide. Studies on pediatric populations remain limited, as the burden of disease in pediatric patients appears to be low at this time.

Objectives

To further describe clinical characteristics and severity of disease of confirmed pediatric COVID-19 patients seen and evaluated in a community-based hospital.

Design/Methods

A retrospective chart review of positive COVID-19 patients ≤ 18 years seen in COVID clinic or in the Emergency Department (ED) between April and December 2020 was performed. The results of nasopharyngeal swabs were confirmed using real-time reverse-transcription-polymerase chain reaction (RT-PCR) assays. A descriptive analysis of illness severity, performed via Excel 2019, was based on clinical presentation, laboratory data, and chest x-ray imaging. The categories of illness severity were: asymptomatic, mild, moderate, severe or critical.

Results

A total of 53 positive COVID-19 patients were enrolled in this study, which consisted of 24 (45.3%) males and 29 (54.7%) females. The median age was 7.5 years (2.4-12.8). The majority of patients presented with mild symptoms (64.2%), with fever and cough being the main symptoms in 20 (37.7%) and 16 (30.2%) cases, respectively. Other symptoms included sore throat (15.1%), diarrhea (13.2%), headache (9.4%), runny nose (7.5%) and abdominal pain (7.5%). The remaining patients (35.8%) were asymptomatic. Of note, one patient (1.9%) presented with COVID toes requiring referral to a tertiary centre, and one (1.9%) was diagnosed with acute appendicitis. A history of contact with a confirmed COVID-19-positive family member was present in 43 (81.1%) patients, and 6 (11.3%) reported a history of recent travel. Laboratory tests were performed in 7 (13.2%) patients, and chest x-rays were performed in 9 (17%). There were no abnormalities detected in either, other than an elevated CRP seen in one patient with appendicitis. Two (3.8%) patients were admitted, including the patient with appendicitis who developed a perforation and was later transferred to a tertiary care centre to undergo an appendectomy. The majority of patients (96.2%) were discharged home.

Conclusion

All patients either presented with mild symptoms or were asymptomatic. Fever and cough were the most common presenting symptoms. Due to this, the vast majority of patients were discharged home. The infection in the majority of patients could be traced to a positive family contact. Our findings are consistent with what has been observed previously in our centre as well as worldwide.
72 Identifying Perinatal and Neonatal Factors Associated with Autism Spectrum Disorder among Preterm Infants Born < 29 Weeks’ Gestation
Authors: Busque Andrée-Anne , Jabbour Elias , Patel Sharina , Couture Élise , Garfinkle Jarred , Khairy May , Claveau Martine , Beltempo Marc
Published: October 2021

Primary Subject area

Neonatal-Perinatal Medicine

Background

Preterm infants born <29 weeks’ gestational age (GA) are at risk for autism spectrum disorder (ASD), typically diagnosed at age >2 years. Perinatal and neonatal factors, including interventions and morbidities during neonatal intensive care unit admission, may contribute to the risk of ASD among these infants.

Objectives

We aimed to assess the incidence of and risk factors for, ASD among preterm infants born < 29 weeks’ GA.

Design/Methods

<29 weeks’ GA admitted 2009-2017 to two tertiary NICUs and followed ≥18 months at the Neonatal Follow-Up Clinic. Primary outcome was ASD defined as a confirmed diagnosis using standardized testing or suspected diagnosis at >18 months of corrected age. Patient data and 18-month developmental outcomes were obtained from the local Canadian Neonatal Follow Up Network database and from chart review. Stepwise logistic regression was used to identify significant perinatal, neonatal, and socio-economic factors associated with ASD.

Results

Among 300 eligible infants, 47 (15.7%) developed ASD (Figure 1, Table 1). Mean follow-up duration was 3.9 ± 1.4 years and mean age at diagnosis was 3.7 ± 1.5 years. Male sex (adjusted odds ratio [aOR] 4.63, 95% CI 2.12, 10.10), small for gestational age status (aOR 3.03, 95% CI 1.02, 9.01), maternal age ≥ 35 years at delivery (aOR 2.22, 95% CI 1.08, 4.57), and tobacco use in utero (aOR 5.67, 95% CI 1.86, 17.29) were significantly associated with ASD. Major neonatal morbidities (retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, late-onset sepsis, severe neurological injury) were not associated with ASD. Among infants with a complete 18-month corrected age developmental assessment and later diagnosed with ASD, 46% (19/41) did not have significant neurodevelopment impairment (Bayley-III < 70, deafness, blindness, or cerebral palsy).

Conclusion

ASD is a significant morbidity among infants born < 29 weeks’ GA. ASD was associated with infant and prenatal risk factors but not with neonatal morbidities or socio-economic factors. These findings emphasize the need for ASD evaluation among preterm infants < 29 weeks and for reporting developmental outcomes beyond 18-months corrected age.
73 Off-label use and safety of drug use in vascular anomalies
Authors: Gariépy-Assal Laurence , Marcoux Simon , Coulombe Jerome , Powell Julie , Essouri Sandrine , McCuaig Catherine , Dubois Josée , Kleiber Niina
Published: October 2021

Primary Subject area

Clinical Pharmacology and Toxicology

Background

Vascular anomalies (VA) represent a heterogeneous group of disorders associated with an abnormal development and proliferation of blood and/or lymphatic vessels displaying variable clinical presentations and severity. Infantile hemangiomas, venous, and lymphatic malformations, for example, are commonly encountered in children. Other, less frequent diagnostics include Klippel-Trenaunay syndrome and PIK-3CA-related overgrowth spectrum (PROS). Severe phenotypes can alter organ function and/or lead to pain and chronic functional impairment, and are associated with significant morbidity and mortality. Management includes surgical, interventional radiology, and pharmacologic modalities. Drugs are administered by systemic (e.g., oral, intravenous) or local (topical, intralesional) routes, or by sclerotherapy (endovascular or percutaneous venous, lymphatic, or arterial injection). Off-label drug use is common in pediatrics and in rare diseases, two characteristics applying to vascular anomalies (VA). Off-label use is associated with an increased risk of adverse drug reactions.

Objectives

To quantify off-label drug use in VA and assess its safety.

Design/Methods

A guidelines search was conducted to extract a list of drugs used in VA management. The labelling status and safety of each drug was assessed based on the product monograph, Micromedex, and the FDA data. A drug was considered to have significant safety concerns if a black box warning (the FDA’s most stringent warning dedicated to serious or life-threatening risks) or if a serious adverse drug reaction was reported in at least 1% of the patients (leading to hospitalization, congenital malformation, persistent or significant disability or incapacity, life-threatening condition, or death).

Results

Among 87 drugs, 13 were unlicensed and 73 off-label. Figure 1 describes the reason for considering the 73 drugs off-label. Among 74 licensed drugs, only the oral solution of propranolol hydrochloride (Hemangeol®) for the treatment of infantile hemangiomas (IH) is approved. 98.9% of the drugs are used off-label or unlicensed. Except infantile hemangioma, all other VA are exclusively treated with off-label drugs. Significant safety issues concerned 73% of the drugs and were more frequent among systemic than locally delivered drugs (Figure 2).

Conclusion

This first study determining the rate of off-label drug use in vascular anomalies shows that off-label drug use in VA is the rule and not the exception. Significant safety concerns are common. It is needed to carefully weigh risk and benefits for every patient when using systemic and local treatments carrying safety concerns. Patients and families should be openly informed and involved in the decision-making process.