bluuebunny/crossref_metadata_2025_split huggingface dataset:
82 Management of Very Severe Iron Deficiency Anemia: Is Transfusion Always Necessary?
Authors: Ramic Lana , Speckert Matthew , Leung Elaine , Boggs Samantha 
Published: September 2023

Abstract

Background
Paediatric iron deficiency anemia (IDA) is a common condition in Canadian children; however, little is known about the natural history of extreme cases. This deficit makes it challenging to determine how to approach management when these patients present acutely to the emergency department (ED).

Objectives
To describe the clinical features and management of children presenting to the ED with very severe IDA with hemoglobin &lt; 40 g/L.

Design/Methods
Retrospective chart reviews were performed for paediatric patients with IDA and hemoglobin &lt; 40 g/L over a 5-year period (June 2017 – June 2022) at a Canadian tertiary care children’s hospital.

Results
Chart reviews were completed for 19 patients. The mean case rate was 3.1 patients annually (SD 2.14) with 11(58%) presenting in 2021–2022. Patients were young (median age 24 months; IQR 18–32) and predominantly female (79%). Nutritional deficiencies were the most common etiology (n=16, 84%). Median presenting hemoglobin was 25 g/L (IQR 22–36 g/L). The most common clinical features documented at presentation were pallor (n=19, 100%), tachycardia (n=17, 89%), and systolic ejection murmur (n=14, 74%). Thirteen (68%) patients had a ferritin measured in ED, 11(58%) had a chest x-ray, four (21%) had a lactate measured. One (5%) patient had an echocardiogram, and four (21%) had bedside cardiac ultrasounds documented. Eight (42%) patients with median hemoglobin 35 g/L (IQR 25–36 g/L) were managed without blood transfusion (PO iron only: n=3, 16%; IV iron only: n=5, 26%). Of the 11 (63%) patients who received blood, 2 (18%) had transfusion-related adverse events, with one patient undergoing intubation for transfusion-associated circulatory overload while admitted. All patients (100%) were initiated on oral iron supplementation. Ten patients (53%) received intravenous (IV) iron (dose 5–7 mg/kg) with one experiencing a mild reaction. Fifteen patients (79%) were hospitalized, with two (10%) admitted directly to the Paediatric Intensive Care Unit. Median duration of hospitalization was 5 days (IQR 2–9 days). Patients followed after transfusion-free management (n=5) demonstrated median hemoglobin increase of 21 g/L (IQR 20–32 g/L) within 12 days. No patient returned to the ED for anemia within 30 days.

Conclusion
Paediatric patients with very severe IDA do not always require transfusion. Some patients were effectively managed with IV iron alone. Investigation and management of these patients appears heterogenous. Given the risks of blood transfusion and the increased availability of IV iron, guidelines outlining evidence-based management of severe IDA are needed. These guidelines should promote optimization of iron therapy and guide judicious administration of blood transfusion.
84 Late-onset Anemia in Neonates with a Positive Direct Coombs Test: A Retrospective Descriptive Study
Authors: Tremblay Arnaud , Thibault Marlène , Racette Christine 
Published: September 2023

Abstract

Background
Hemolytic disease of the newborn is a well-known phenomenon in paediatrics. It occurs when maternal blood group antibodies cross the placenta and react with the fetus’ red blood cells, ultimately leading to their destruction. Late-onset anemia occurs between 7-90 days of life. Its incidence is not well defined in the literature; however, it can lead to deleterious outcomes. Some experts recommend a complete blood count assessment within the first month of life in all newborns with a positive direct Coombs test (DCT).

Objectives
This study aimed to describe the screening practices and epidemiology of late-onset anemia in infants with a positive DCT in a tertiary-care paediatric centre.

Design/Methods
We performed a retrospective descriptive study that included all newborns of ≥ 35 weeks of gestational age with a positive DCT born between January 1st 2018 and December 31st 2020. Patients were identified retrospectively through the blood bank records and were excluded if they were transferred from another centre or if they had significant comorbidities.

Results
A total of 284 patients were included. Forty percent had an ABO incompatibility, 30.6% a Rhesus incompatibility, 24.3% more than one incompatibility, 2.5% rare incompatibilities, and 2.1% had undetermined incompatibility. During their neonatal hospitalization, 74 patients (26.1%) required phototherapy, 4 patients (1.4%) received IVIG and 2 patients (0.7%) received red blood cells transfusions. Three patients (1.1%) were discharged with iron supplements. As for screening practices, 47 patients (16.5%) were prescribed a follow-up hemoglobin assessment at discharge. On chart review, hemoglobin value was available in the first 3 months of life in 72 patients (25.4%), showing late-onset anemia in 20 of these infants (27.8%). Among possible risk factors to encounter late-onset anemia, neither DCT positivity intensity nor type of blood incompatibility had any statistical significance. Newborns who required phototherapy had an OR of 3.37(1.16-9.85) to develop late-onset anemia. This OR was 10.89(2.50-47.32) for those who were anemic during their neonatal period, 2.68(0.16-45.07) for those who received IVIG, and 8.03(0.08-759.44) for those transfused in the neonatal period. Outpatient hemoglobin measurements during the first three months of life led to 6 patients (2.1%) being prescribed iron supplements and one patient (0.4%) receiving a red blood cells transfusion.

Conclusion
This study showed that late-onset anemia is relatively common among newborns with a positive DCT. However, this phenomenon is not routinely screened in our centre and further studies are needed to determine its clinical significance and best screening practices.
89 Frequency and Impact of PANDAS/PANS Diagnosis in Canada
Authors: Goren Rachel , Shouldice Michelle , Kronenberg Sefi 
Published: September 2023

Abstract

Background
Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS/PANS) are defined by abrupt onset and episodic course of neuropsychiatric symptoms associated with infection. There are challenges in the application of published diagnostic criteria, and the frequency of diagnosis is unknown. To date, there is little data on clinical practice patterns in diagnosis, assessment and treatment.

Objectives
The aim of this study was to estimate and characterize the frequency and impact of the diagnostic label of PANDAS/PANS in Canada.

Design/Methods
Through established CPSP methodology, over 2,800 paediatricians and subspecialists were surveyed for children seen in the previous month who had received the diagnostic label of PANDAS/PANS. Respondents completed a detailed questionnaire on demographics, clinical presentation, diagnostic evaluation and interventions.

Results
Between December 1, 2019 and November 30, 2021, 84 reported cases received the diagnosis of PANDAS/PANS. The majority were female (48/84, 57%), with mean age of symptom onset 9.4 years (range 3 to 16 years). Of the 84 cases, 82% (69/84) had OCD and/or acute food refusal, 39% (33/84) had tics and 32% (27/84) had both OCD and tics. Symptom onset was described as sudden in 22% of cases. The vast majority of cases had at least two neuropsychiatric symptoms (80/84, 95%). Infection was associated with symptom onset (22/84, 26%) or exacerbation (25/84, 30%) in less than one-third of cases. Healthcare utilization included emergency-department visits (29/84, 35%) and inpatient admissions, both medical (8/84, 10%) and psychiatric (8/84, 10%). Three quarters (52/68, 76%) of cases had five or more health care visits since symptom onset and 31% (24/78, 31%) accessed more than five health care providers. Medical treatments were provided in 95% (80/84; antibiotics, NSAIDS, steroids, IVIG or rituximab), 95% (80/84) received psychological and/or psychiatric treatments, and more than 50% (42/84) of patients saw a complementary/alternative health provider. Almost all cases (84/85) experienced significant negative impacts, including family stress, mental health concerns, or conflict (54/84, 64%); school absences (43/84, 51%); and withdrawal from activities/friends (33/84, 39%). In forty-one percent (33/81) of cases, there was a significant discrepancy in the certainty of diagnosis, with families significantly more certain than reporting physicians.

Conclusion
PANDAS/PANS are rare diagnoses, associated with a significant burden on children, families and the healthcare system. In reported cases, there was significant practice variation in diagnosis, assessment and treatment, with frequent uncertainty about the diagnosis. Education and clinical practice guidelines are needed, targeting a range of practitioners.
96 Foreign Body Aspiration in Children: A Review of the Public Health Prevention Guidelines by Analyzing the Circumstances of Choking Episodes in a Canadian Tertiary Centre from 2006 to 2020
Authors: Veilleux Justine , Daigneault Patrick , Bellavance Sandrine 
Published: September 2023

Abstract

Background
Choking and foreign body aspiration are major causes of morbidity and mortality in infants and young children. To prevent choking episodes and their complications, many associations, from the Canadian Paediatric Society to National Public Health Institutes, have suggested prevention guidelines for parents and health professionals. They specify what types of food should be restricted in young children, such as nuts and raw hard vegetables, and give advice on surveillance. Yet, every year, children are admitted to our centre following a choking episode that requires a bronchoscopy under general anesthesia.

Objectives
Our objective was to identify the risks factors associated with choking episodes in children and compare them with actual prevention guidelines to determine if public health recommendations are still adequate.

Design/Methods
This retrospective study included all patients, from 0 to 17 years old, who presented to our tertiary centre between April 2006 and December 2020 and underwent a bronchoscopy under general anesthesia for a suspicion of foreign body aspiration. Data on demographic characteristics of the patients, the circumstances of the episodes and on severity criteria were collected from the patients’ electronic files and compared to the prevention guidelines.

Results
One-hundred and ninety-one patients with a history of suspected foreign body aspiration were included. Among them, 101 had a positive bronchoscopy. Close to 65% of patients were boys. The mean age at presentation was 31,5 months. Food was the most common type of foreign body, causing 73,3% of all choking episodes. Close to 70% of those choking episodes involved nuts, seeds or raw hard vegetables. 84,5% of those events happened at home, and 79,4% of choking episodes happened under the surveillance of one or both parents. Thirty patients ended in the paediatric intensive care unit where they spent an average of 6,47 days.

Conclusion
Our results show that most choking episodes in children result from a non-respect of actual recommendations. They involve types of food and circumstances that are already restricted by the prevention guidelines. It highlights the need for better parent education and should inspire clinicians to make some time to address choking hazards with families.
98 Seeing the Unseen– A Retrospective Review of the Demographic Characteristics of a Place-based, Inner-City Social Paediatrics Program
Authors: So Judy , Sun Sunny , Kim Annie , Nemati Saina , Kim Michelle , McIntosh Gwyneth , Pikksalu Kristina , Loock Christine , Carwana Matthew 
Published: September 2023

Abstract

Background
Social paediatrics is a holistic approach to child and youth health that considers the society and environment the child lives in, and aims to address social determinants of health (SDoH) to improve health equity. Place-based social paediatrics clinics minimize health disparities through outreach programs, navigational support, and facilitating access to specialty care services. This model of care was developed in the past few decades as it became widely accepted that SDoH and adverse childhood events have a direct impact on child health. Typical clinic demographics and most prevalent care needs are not well described.

Objectives
Identify key demographic features and common diagnoses seen by a social paediatrics program’s primary and specialty care services.

Design/Methods
Ethical approval was obtained from institutional REB. A retrospective chart review of patients accessing the program between Jan 1, 2018 and April 30, 2021, with no additional exclusion criteria, was conducted. Demographic information, factors influencing SDoH, and past medical history were collected. Basic descriptive statistics were used for analysis of the data collected.

Results
144 charts have been reviewed to date. The mean age in years at initial assessment was 6.22 (0.07–25.84). The most commonly documented ethnicity was Indigenous (30%), followed by Latinx (8%) and Middle Eastern (8%); 45% of patients were unspecified, as race is not consistently collected in Canadian health records. Poverty was mentioned as an issue in 52 (36%) patients’ charts, ministry involvement noted in 29 (20%), and substance use in 45 (31%) of households. 74 (51%) of charts had evidence of at least one adverse SDoH (e.g. financial and/or housing instability, food insecurity) that could negatively influence health equity. The most frequently documented diagnoses were skin disorders (38%), ADHD (31%), upper respiratory tract infections (29%), learning disability (27%), and speech delay (25%). Developmental disorders were diagnosed in 79 (55%) patients and 45 (31%) had at least one incidence of being seen by a nurse practitioner or general paediatrician for a mental health concern.

Conclusion
Place-based, equity-oriented social paediatrics clinics see more socially and developmentally complex individuals than traditional paediatric clinics or community health programs. Data analysis of the population seen by our inner-city program found 55% and 31% of patients had developmental and mental concerns, respectively. This suggests that clinicians planning or working in similar programs should be prepared to support neurodevelopmental, mental health, and common medical conditions (e.g. skin disorders and infections).
100 Exploring the Experiences of Refugee Claimant Youth and their Caregivers with Navigating Healthcare in Canada
Authors: Newbube Chioma , Parmar Puneet , Suleman Shazeen , Taylor Martha 
Published: September 2023

Abstract

Background
In 2022 alone, 27,000 refugee claimants entered Canada, seeking protection. Although refugee claimants are ineligible for provincial health insurance programs, the Interim Federal Health Program (IFHP) provides coverage for basic medical care and supplemental services. However, previous studies have shown that only 24% of paediatricians are registered for IFHP, suggesting limited access for refugee claimant youth (RCYs), who are already at increased risk of poor health outcomes. It is important to understand the perspectives and needs of RCYs and their caregivers to develop interventions to improve their access to care, but to date, no study has examined their experiences directly.

Objectives
This study aims to explore how RCY, their caregivers, service providers and health care providers understand and utilize the healthcare system after arrival in Canada.

Design/Methods
This was a qualitative study that was rooted in community-based participatory action methodology. In-depth interviews (IDIs) were conducted with RCYs (age 10-18), their caregivers, community service providers (ie. settlement workers) and health care providers (HCPs) that worked with RCYs in a large urban Canadian city in English, and with an interpreter, recorded and transcribed. Transcripts were coded using inductive coding methods, and analyzed within and across stakeholder groups using thematic analysis.

Results
A total of 27 IDIs were conducted (8 HCPs, 9 community service providers, 5 caregivers, and 5 RCYs). Youth and their caregivers had little to no understanding of how the healthcare system operated in Canada, including how IFHP provided coverage. Most explained that their limited knowledge about the healthcare system was provided informally through social contacts, or their community service providers, who in turn expressed limited understanding of IFHP coverage and difficulty finding IFHP registered providers. Although healthcare providers similarly found IFHP difficult to navigate, they did not appreciate how little RCYs and their families understood the healthcare system, nor the difficulties placed on community service providers. RCYs stated that a youth-oriented, multi-lingual resource that explained how to access care in Canada would be a useful tool to help them feel empowered to advocate for themselves and their families.

Conclusion
Although policies exist to provide coverage for medical care for RCYs, there are many barriers that prevent them from accessing care, including limited knowledge of the system and few navigational supports. Our findings suggest that working with RCY themselves to co-develop a youth-centred approach to understanding the healthcare system may increase youth empowerment and access to care.
101 The Impact of Sociodemographic Factors on Youth Academic Achievement During the COVID-19 Pandemic in Ontario, Canada
Authors: Freeman Sloane , Minhas Ripudaman , Hove Jennifer , Guimonda Timothy 
Published: September 2023

Abstract

Background
The COVID-19 pandemic interrupted education and widened socioeconomic disparities. In Ontario, schools were closed for 28 weeks, longer than any other state, province, or territory in North America. School interruptions and remote learning are known to have short and long-term negative effects, which differ by socioeconomic status, on students’ academic outcomes.

Objectives
The objective of this study was to determine whether the COVID-19 pandemic was associated with a greater achievement gap between disadvantaged and non-disadvantaged secondary students in Ontario, Canada.

Design/Methods
We conducted a population-based observational study comparing scores from Ontario’s Education Quality and Accountability Office (EQAO) standardized Grade 9 Assessment of Mathematics from 2018-19 (pre-COVID year) and 2020-21 (COVID year). Our outcome measure was the EQAO Grade 9 Assessment of Mathematics dot scores. The primary analysis used a mixed-effects multilevel model (with random effects for school board) to calculate the interaction between year and neighborhood family income on math scores (difference in income slope between years) while controlling for confounders. Secondary analyses examined other risk factors (e.g. parental education, newcomer status, and lone-parent home) and their impact during the pandemic.

Results
In the COVID year, 3,485 of 42,920 eligible Ontario Grade 9 students (8.1%) participated in the EQAO Grade 9 Assessment of Mathematics from 38 of 72 school boards. In the pre-COVID year, within those same 38 school boards, 42,640 of 43,230 eligible Grade 9 students (98.6%) participated in the math assessment. We found that in the pre-COVID year, every one standard deviation increase (or decrease) in mean log-adjusted neighborhood income resulted in a mean increase (or decrease) in test score of 0.088 (95% CI, 0.078 to 0.097; p&lt;0.0001). The effect of income on test score decreased in the COVID year (delta between years, -0.047, 95% CI, -0.060 to -0.033; p&lt;0.0001).

Conclusion
This population-based observational study demonstrated that neighborhood family income impacted academic performance less in the COVID year compared to the pre-COVID year. The impact of other sociodemographic factors on academic achievement were also modified in the COVID year compared to pre-COVID. Determining how sociodemographic risk factors affected academic achievement during the pandemic may help inform educational recovery strategies and improve educational outcomes for children facing social inequities.
C4 (Clinical Case) Vascular Ehlers-Danlos Syndrome in the Paediatric Population: A Case Report of an Internal Bleed Caused by Ruptured Pseudoaneurysm
Authors: Alkindi Nour , Andijani Abdurahman , Zavalkoff Samara , Muchantef Karl 
Published: September 2023

Abstract

Introduction/Background
Ehlers-Danols syndrome (EDS) is a connective tissue disease characterized by joint hypermobility, skin hyperextensibility and tissue fragility. EDS has six types. Type IV EDS: vascular EDS (vEDS), is rare but also the most malignant.

Case Description
We report a 15-year-old boy with a previous history of spontaneous colon perforation and two left shoulder dislocations. He presented with sudden onset abdominal pain, vomiting, dizziness, and lethargy with a Glasgow coma scale of 13. His abdomen was soft but mildly tender. He had a capillary refill of 3 seconds with cold extremities, was found to be in a hypotensive shock state requiring resuscitation with fluids and inotropes, as well as intubation and mechanical ventilation. His hemoglobin dropped by 30 g/L in 6 hours. Therefore, an abdominal ultrasound was done, revealing an intrabdominal hematoma. CT scan of the abdomen confirmed a ruptured fusiform pseudoaneurysm of the accessory left hepatic artery. This was successfully managed by coil embolization, see F1 and F2, below. Genetic workup was positive for the pathogenic COL3A1 gene that presents phenotypically as Ehlers-Danlos syndrome, particularly type IV.

Discussion
COL3A1 encodes pro-alpha1 chains of type III collagen. Inheritance is autosomal-dominant. It can present as a de novo variant with a negative family history, as was the situation for our patient. Estimated affected people with de novo variant vEDS is 33%-50%. Clinical diagnosis of vEDS involves one major and several minor criteria (2017). Major criteria include arterial aneurysms, dissection, or rupture; intestinal rupture; uterine rupture during pregnancy; family history of vEDS. Minor criteria include easy bruising; thin skin and visible veins; facial characteristics including prominent eyes, narrow nasal bridge, thin lips; club foot, congenital hip dislocation; inguinal hernia and pneumothorax. Our patient had two elements from the major criteria: arterial pseudoaneurysm and intestinal rupture.

Conclusion
vEDS has high morbidity and mortality due to the risk of spontaneous internal organ/vessel injury. This can be mitigated by increased awareness of systemic manifestations of vEDS and a high index of suspicion by both primary care and emergency physicians. Once diagnosed, surveillance is crucial, including regular blood pressure monitoring, frequent non-invasive imaging to identify emerging vascular lesions, and pregnancy counselling for potential uterine rupture and avoiding trauma, collision sports, and lifting heavy items.