bluuebunny/crossref_metadata_2025_split huggingface dataset:
Successful Implementation of a Change in Practice to Optimize Timing of Umbilical Cord Clamping in Preterm Neonates: A Quality Improvement Initiative
Authors: Irvine L , Abou Mehrem A , Singhal N , Thomas S , Cooper S 
Published: September 2022

Abstract
BACKGROUND: Natural, also known as delayed, umbilical cord clamping (NCC) is recommended for at least 60 seconds (s) in preterm infants. However, changing the institutional guidelines only may not result in satisfactory adoption and change in practice.
OBJECTIVES: To determine if a structured multidisciplinary educational approach during the implementation of the new guideline of NCC in pre-term infants will result in over 50% compliance rate.
DESIGN/METHODS: The evidence supporting NCC was presented in a grand round to all health care providers involved in maternal-newborn care. A multidisciplinary team comprised of neonatologists, obstetricians, neonatal nurse practitioners, respiratory therapists and nurses developed NCC clinical practice guideline. Local champions at each of the 4 city hospitals were identified to create change in culture and establish lines of open communication between disciplines. Following completion of education of all staff involved in delivery room care, formal implementation of NCC began October 2013 for gestational age (GA) 33-35 weeks, January 2014 for GA ≥28 weeks, and April 2014 for GA ≥26 weeks. Data were collected from October 2013 until April 2015.
RESULTS: Table 1 shows the compliance rates and the proportion of infants who received NCC ≥45s. In addition, we found that 18% of infants 26-32 weeks GA deemed eligible for NCC, received cord clamping at &lt;45s to facilitate resuscitation.
CONCLUSION: Compliance with practice change can be successfully achieved through a structured team approach, establishing open lines of communication, and frequent feedback to the front line members. Further research may lead to more infants qualifying for and resuscitated during NCC.
Assessment of Gluten Exposures in Children with Celiac Disease
Authors: Brill H , Dowhaniuk J , Cheng J , Pai N , Mileski H , Tutelman P , Saab J 
Published: September 2022

Abstract
BACKGROUND: Celiac Disease (CD) is one of the most common chronic diseases of childhood. A strict, lifelong gluten-free diet (GFD) remains the sole treatment for CD. Reports of accidental or intentional ingestion of gluten are common, but little is known about the sources or context of such exposures.
OBJECTIVES: We sought to ascertain the self-reported causes for gluten exposure for children with Celiac Disease.
DESIGN/METHODS: Parents of children with biopsy-proven CD followed at McMaster Children’s Hospital were asked to review a 22-item questionnaire listing sources, situations and causes of gluten exposure for their child. The questionnaire encompassed both intentional and unintentional gluten exposures and was developed through consultation with Registered Dietitians and Faculty in the Division of Pediatric Gastroenterology at McMaster Children’s Hospital. Children independently completed a similar 21-item questionnaire adapted for pediatric use. Participants were invited to describe any additional sources or circumstances leading to gluten consumption not captured in the questionnaire.
RESULTS: A total of 123 families participated in the study with a median of 32 months on a GFD. A minimum of one cause of gluten exposure was selected by 65% of parents and 60% of children. Restaurant dining was identified as a source of gluten consumption by 39% of parents, due to a lack of knowledge of the GFD by restaurant staff or poor labeling of menu items. Other commonly selected items on the parent questionnaire included: difficulty while traveling (13%), to avoid exclusion at social events (12%), and a lack of negative symptoms following gluten exposure (9%). Few parents identified cost (2%), or the availability of gluten-free food as a concern (5%). Children most commonly identified restaurant eating (32%), and the lack of any negative symptoms from eating gluten as the main causes of gluten exposure (14%). In this study population, 11% of children acknowledged consuming gluten because they felt left out at either home, school or with friends.
CONCLUSION: This study provides information about the common causes of gluten exposure for children with CD in Ontario, Canada. Restaurant dining and travel were the most commonly identified sources of gluten ingestion. Our study highlights the need for improved menu labeling and education of restaurant staff, requiring both policy changes and dialogue with food service industries. While availability of gluten-free products has greatly improved, exclusion from social activities remain a concern for both children and their parents. Further qualitative studies may build on these identified themes to better understand challenges families face with the GFD.
Hiv-Exposed but Uninfected Infants: Identifying Developmental Delay and the challenges faced in Accessing Developmental Services from a Canadian Tertiary Centre
Authors: Abdulwahab K , Olson L , Adjudani A , Pakzad Z , Alimenti A , Sauvé L 
Published: September 2022

Abstract
BACKGROUND: Children born to HIV-positive mothers but are HIV uninfected (HEU) are at increased risk for adverse developmental outcomes. The literature suggests that the increased risk is more related to social determinants of health rather than effects of perinatal exposures to HIV and antiretrovirals. Developmental screening and early referral do result in improved outcomes and so HEUs should benefit from anticipatory guidance and early specialist referral.
OBJECTIVES: We aimed to identify the rate of development screening, identification and referral of developmental concern, and referral completion in a provincial family-centered HIV clinic caring for 20-30 HIV exposed newborns per year and secondarily identify barriers to referral completion.
DESIGN/METHODS: We conducted a retrospective review of all of the HEU cared for at this outpatient clinic born between January 1, 2008 and June 30, 2013 to examine the frequency of developmental concerns, referral rates for children with documented concerns, and referral outcomes.
RESULTS: We reviewed 112 subjects: 64 (57%) male; 87 (77%) born at term (&gt;37 weeks). 78 (66%) of the families had one or more social vulnerabilities (parental ill health apart from HIV, poverty, limited literacy, limited English language skills, etc), including 43 (38%) who had some involvement with child protection services. 104 (92.8%) had at least one documented developmental assessment using standardized tools. Among these 104, 46 (44.2%) were noted to have a developmental concern and of those, 40 (87.0%) were referred to at least one developmental service provider or general pediatrician. There were a total of 43 referrals to developmental service providers; 58.1% occurred at time of study completion, and 60.0% for which recommendations were formally communicated. Of 36 referrals to general pediatricians, 69.4% had occurred, 92.0% of which recommendations communicated back to the clinic. Barriers to referral completion included inability to contact caregivers (7.3%), patient no-show (13.0%), waiting lists (23.2%), and other (56.5%).
CONCLUSION: The large majority of patients were screened and referred when indicated, but a significant number of patients either were not assessed by the secondary provider, or no information was communicated back to the clinic. Multiple barriers at the clinic, patient, and referral centre level were identified. The discrepancy in referral completion between developmental service provider referrals and general pediatrician referrals, may further highlight the difficulty HEU families have navigating our provincial developmental services. Future work will examine how to overcome these barriers in a vulnerable population.
DESCRIPTION D’UNE COHORTE RÉTROSPECTIVE DE PATIENTS PÉDIATRIQUES ATTEINTS DE THROMBOPÉNIE IMMUNE AIGUË
Authors: Hendriks MC , Toussaint MP , Michon B , Veilleux-Lemieux M 
Published: September 2022

Abstract
BACKGROUND: La thrombopénie immune (TPI) aiguë est une condition fréquente dont la prise en charge demeure controversée. Les lig-nes directrices suggèrent de traiter les enfants présentant des saignements modérés ou sévères avec des corticostéroïdes ou des immu-noglobulines (IVIg).
OBJECTIVES: L’objectif principal est de décrire des patients pédiatriques atteints de TPI aiguë. Les objectifs secondaires sont de décrire les effets indé-sirables et les répercussions sur les soins associés au traitement par IVIg.
DESIGN/METHODS: Il s’agit d’une étude de cohorte rétrospective par révision de dossiers. Les patients inclus sont âgés entre 1 et 17 ans, atteints de TPI aiguë et ont été traités dans notre établissement du 2004-01-01 au 2014-06-01. La classification des saignements est définie selon celle utili-sée dans les lignes directrices.
RESULTS: Les 88 patients ont un âge moyen de 6.9 ans. À l’arrivée, 87/88 (98,9%) patients présentaient des saignements : 5/87 (5,7%) sévères, 24/87 (27,6%) modérés, 58/87 (66,7%) mineurs ou légers et aucun saigne-ment menaçant la vie (comme une hémorragie intracrânienne). Les pla-quettes initiales moyennes étaient de 11,0×109/L et 63/88 (71,6%) patients avaient un taux ≤10×109/L. Initialement, 77/88 (87.5%) patients ont été traités : 62/77 (80,5%) avec des IVIg, 8/77 (10,4%) avec des corticosté-roïdes et 3/77 (3,9%) avec les deux traitements combinés. 40/88 (45%) patients ont reçu plus d'un traitement, dont 23/40 (57,5%) en moins de 48 heures. 5/77 (6,4%) patients ont reçu une transfusion de plaquettes. Une réponse au traitement initial a été obtenue chez 62/77 (80,5 %) patients. Une TPI chronique s’est développée chez 15/88 (17,0%) patients. Parmi les patients ayant reçu des IVIg au moins une fois, 42/74 (56,8%) ont présenté des effets indésirables associés à ce produit sanguin dont 10/42 (23,8%) des nausées, 28/42 (66,7%) des vomissements et 31/42 (73,8%) des céphalées. Ceux-ci sont associés à une imagerie cérébrale chez 5/88 (5,7%) patients (toutes normales).
CONCLUSION: Notre étude démontre le caractère mineur des saigne-ments à la présentation initiale du patient avec TPI. Ceci appuie les lig-nes directrices qui limitent le nombre de patients traités. Malgré cette présentation par des saignements surtout mineurs ou légers, un grand nombre de patients est traité dans notre milieu et plus de 80% le sont avec des IVIg. Cette pratique semble associée à des effets indésirables et investigations supplémentaires, ce qui devrait être pris en compte lors du choix du traitement initial.
Predictors of Unintentional Injuries in Paediatric Immigrants in Ontario
Authors: Saunders N , Macpherson A , Guttmann A 
Published: September 2022

Abstract
BACKGROUND: Unintentional injury is a frequent reason for emergency department visits and is the leading cause of death for Canadian children. Injury is associated with a number of socio-demographic variables but it is not known whether being an immigrant changes this risk.
OBJECTIVES: To examine the association between family immigrant status and unintentional injury; and to test this relationship within immigrants by refugee status.
DESIGN/METHODS: Retrospective population-based cross-sectional study of children ages 0 to 14 years residing in Ontario, Canada from 2008 to 2012, using linked health administrative databases and Citizenship and Immigration Canada’s Permanent Resident Database. The main exposure was immigration status (immigrant or child of an immigrant vs. Canadian born). Secondary exposure was refugee status. Main outcome measure was unintentional injury events (emergency department visits, hospitaliza-tions, deaths), annualized. Data were analyzed using Poisson regression models to estimate risk ratios (RR) for unintentional injuries.
RESULTS: There were 11 464 317 injuries per year. Non-immigrant children sustained 12051 injuries/100 000 and immigrants had 6837 injuries/100 000, annually. In adjusted models, immigrants had a significantly lower risk of injury compared with non-immigrant children (RR 0.60; 95% confidence interval [CI] 0.57, 0.63). Overall, the most materially deprived neighbourhood quintile was associated with a higher rate of injury (RR 1.13; 95% CI 1.07, 1.02, quintile 5 vs. 1) whereas within immigrants, material deprivation was associated with a lower rate of injury (RR 0.96; 95% CI 0.94, 0.98, quintile 5 vs. 1). Other predictors of injury included age (0 to 4 years: RR 0.84; 95% CI 0.81, 0.88; 5 to 9 years: RR 0.70; 95% CI 0.67, 0.73), male sex (RR 1.30; 95% CI 1.26, 1.35), and rural residence (RR 1.50; 95% CI 1.43, 1.57). Injury rates were lower in immigrants across all types of unintentional injuries. Within immigrants, refugees had a higher risk of injury compared with non-refugees (RR 1.12; 95% CI 1.10, 1.14). This risk was particularly high for motor vehicle accidents (RR = 1.58; 95% CI 1.46, 1.71) and scald burns (RR 1.23; 95% CI 1.11, 1.35).
CONCLUSION: Risk of unintentional injury is lower among immigrants compared with Canadian-born children. These findings support a healthy immigrant effect. Socioeconomic status has a different effect on injury risk in immigrant and non-immigrant populations, suggesting alternative causal pathways for injuries in immigrants. Risk of unintentional injury is higher in refugees versus non-refugee immigrants, highlighting a population in need of targeted injury prevention strategies.
Burning the Midnight Oil: A Focus Group Study of Medical Student Night Call Preferences
Authors: Scott O , Novak C , Lee J , Forbes K 
Published: September 2022

Abstract
BACKGROUND: Call is an integral component of clerkship, providing unique clinical and educational opportunities. Recently, traditional call has been the subject of scrutiny, resulting in changes to call requirements. Canadian Pediatric clerkships currently employ a variety of call modalities, including night float, evening call, and overnight call.
OBJECTIVES: To explore the impact that call modalities have on medical students, and elucidate preferences.
DESIGN/METHODS: We conducted focus groups of 5-7 medical students each. Participants were asked about their experiences with various call systems during clerkship. Verbatim transcripts were analyzed independently by 2 team members using grounded-theory. All codes were further reviewed by the Principal Investigator.
RESULTS: Thirty-eight students participated in 6 focus groups. Four over-arching themes were identified as influencing call preferences: (1) Educational value, including patient volume and variety, hands-on experience, and teaching; (2) Quality of life, including fatigue/burn-out, ability to maintain a healthy lifestyle, and free time; (3) Continuity and quality of patient care; (4) Contribution to professional identity and acquisition of CanMEDS roles. Overnight call was described as a “rite of passage”, contributing to improved time management skills, a sense of collegiality, and self-perception as future physicians. With traditional call, post-call days provide opportunity to maintain well-being, although some believe 24-hour shifts impair ability to learn. Moreover, this call modality results in the lowest patient continuity of care. With regard to night float, most students appreciate focused call duties, and enjoy consistency with residents, resulting in greater bonding and teaching. However, they have difficulty adjusting to a nocturnal schedule, and lament missing daytime educational activities during call week. Evening call has the fewest patient encounters, least teaching, and worst fatigue and burn-out. Nonetheless, this call modality has the best patient continuity of care with no loss of daytime work. Students designated overnight call and night float as their preferred modalities, with evening call being unanimously rated least favourite. Students believe that specific goal-setting, and feedback from residents and staff are lacking across all call modalities.
CONCLUSION: Students emphasize educational value and quality of life as important determinants of their call experience. Interestingly, acquisition of professional attributes and continuity of care play an important role in determining call preferences. We suggest that integrating the above elements and introducing a formal “call curriculum”, may make the clerkship call experience more standardized and beneficial to medical students, facilitating their growth as medical professionals.
Long-Term Effects of Saline Boluses in Very Preterm Infants (VPI)
Authors: Aslam A , Vincer M , Allen A , Imanullah S , Connell C O’ 
Published: September 2022

Abstract
BACKGROUND: Normal saline bolus is commonly used in clinical practice for treating hypotension in term and preterm neonates during resuscitation in early life despite the paucity of high quality evidence supporting this practice.
OBJECTIVES: To determine the effects of normal saline boluses given within seven days of birth in VPI less than 31 weeks at 18 to 36 of months corrected age.
DESIGN/METHODS: This is a retrospective population-based cohort analysis of the use of saline boluses from January 2006 to December 2010, of VPI from Halifax County. The outcomes at 18-36 months corrected age were extracted from the Perinatal Follow-Up Program (PFUP) database. This program is dedicated to the care and monitoring of infants who were VPI, very low birth weight or those who had brain injury at birth. It includes the evaluation of long-term developmental outcomes, multidisci-plinary services including rehabilitation, dietetics and social services. Primary Outcome: To assess the incidence of death, cerebral palsy, language, cognitive delay, hearing impairment requiring the amplification, or bilateral blindness at the corrected 18-36 months of VPI who did or did not receive normal saline boluses. Secondary Outcome: To assess patent ductus arteriosus(PDA), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), periventricular leucomalacia, necrotizing enterocolitis (NEC) and retinopathy of prematurity (ROP) between VPI who did or did not receive normal saline boluses. Inclusion criteria: VPI from Halifax County admitted to the NICU at the IWK Health Centre, Halifax, Nova Scotia, Canada between January 2006 to December 2010. Exclusion criteria: Infants with major congenital anomalies and who were not offered resuscitation in the delivery room and expected to die.
RESULTS: The regression analysis indicated that there was no difference in terms of death or disability between those who received saline bolus 15 (53.6%) versus those who did not receive saline boluses 45 (34.6%), [OR 2.17 (0.94, 5.05) p = 0.07]. Although univariate comparisons between the two groups showed significant differences in rates of PDA, severe IVH, NEC, cystic PVL, BPD and ROP, but after controlling for the influences of birth weight, APGAR score at 1 minute, admission BP and hemoglobin, bolus treatment was not significantly related to any of these outcomes
CONCLUSION: In the current study no significant difference was found between the two groups in terms of long term neurodevelopmental outcomes and short term outcomes were significantly different only in univari-ate comparisons. Given the limitations of this retrospective study, a randomized controlled trial to evaluate the effects of normal saline boluses use during early life on neurodevelopment outcomes is warrented.
Antenatal, Perinatal and Neonatal Factors Associated with Periventricular White Matter Injury in Very Preterm Infants
Authors: Ghotra S , Vincer M , Allen V , Khan N , Kuhle S 
Published: September 2022

Abstract
BACKGROUND: Although survival outcome in preterm infants has reached nearly 90%, long-term motor and cognitive disability and cerebral palsy in survivors remain an important concern. Periventricular white matter injury (WMI) is the major form of brain injury underlying these neurological morbidities. Cystic periventricular leukomalacia (cPVL) and porencephaly contribute significantly to poor long-term neurodevelopmen-tal outcomes. Currently, there is no definitive therapy available to treat cPVL or porencephaly. The management mainly lies in identification of associated risk factors and their prevention. Most studies on risk factors of cPVL are limited in their retrospective case-control design and sample size, and have an inherent selection bias with the use of hospital-based data.
OBJECTIVES: To identify risk factors for cPVL and porencephaly in a population-based cohort of very preterm infants.
DESIGN/METHODS: A retrospective population-based cohort study was conducted at the at the IWK Health Centre, Halifax, Nova Scotia, using data derived from the provincial Perinatal Follow-Up Program (PFUP) database. The PFUP database contains patient data for all pre-term infants born at a gestational age (GA) of &lt;31 weeks in Nova Scotia since 1993. Infants born at 22 to 30 weeks from 1993 to 2013 (21 years) were included in the study. Infants with severe congenital malformations or chromosomal anomalies or who died in the first 6 weeks of life were excluded. Information on potential risk factors (divided into 3 groups: antenatal, perinatal and neonatal) as well as the presence or absence of cPVL and porencephaly diagnosed by cranial ultrasound at 6 weeks of age were extracted. Variables with a P value of &lt; 0.20 in the univariate analysis were entered in the multivariate model using a backwards selection procedure.
RESULTS: Of 1184 infants found eligible for the study, 87 (7.4%) had cPVL or porencephaly. Mean GA and birth weight were 27.9 weeks and 1133 g, respectively. The gestational age-adjusted prevalence of cPVL or porencephaly did not decrease over time (p=0.07). In multivariable logistic regression analysis, chorioamniotis (OR 2.2, 95% CI 1.1-4.3), antenatal steroids (OR 0.33, 95% CI 0.18-0.61), admission hypothermia (OR 1.8, 95% CI 1.1-2.9), ventilator support (OR 4.8, 95% CI 1.4-16.9), and non-coagulase negative staphylococcal (OR 2.4, 95% CI 1.2-4.9) and fungal (OR 5.2, 95% CI 1.4-18.6) infections were independently associated with cPVL or porencephaly in the final model.
CONCLUSION: This population-based cohort study has identified a number of clinically relevant factors associated with cPVL or porenceph-aly in very preterm infants. The findings have important implications in the delivery of perinatal and neonatal care to reduce the incidence of WMI and consequent, neurological morbidity.