[Show abstract][Hide abstract] ABSTRACT: Background:Rhesus (Rh) disease and extreme hyperbilirubinemia (EHB) result in neonatal mortality and long-term neurodevelopmental impairment, yet there are no estimates of their burden.Methods:Systematic reviews and meta-analyses were undertaken of national prevalence, mortality, and kernicterus due to Rh disease and EHB. We applied a compartmental model to estimate neonatal survivors and impairment cases for 2010.Results:Twenty-four million (18% of 134 million live births ≥32 wk gestational age from 184 countries; uncertainty range: 23-26 million) were at risk for neonatal hyperbilirubinemia-related adverse outcomes. Of these, 480,700 (0.36%) had either Rh disease (373,300; uncertainty range: 271,800-477,500) or developed EHB from other causes (107,400; uncertainty range: 57,000-131,000), with a 24% risk for death (114,100; uncertainty range: 59,700-172,000), 13% for kernicterus (75,400), and 11% for stillbirths. Three-quarters of mortality occurred in sub-Saharan Africa and South Asia. Kernicterus with Rh disease ranged from 38, 28, 28, and 25/100,000 live births for Eastern Europe/Central Asian, sub-Saharan African, South Asian, and Latin American regions, respectively. More than 83% of survivors with kernicterus had one or more impairments.Conclusion:Failure to prevent Rh sensitization and manage neonatal hyperbilirubinemia results in 114,100 avoidable neonatal deaths and many children grow up with disabilities. Proven solutions remain underused, especially in low-income countries.
Pediatric Research 12/2013; 74 Suppl 1:86-100. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To survey current practices among different types of medical practitioners in Ontario to assess if national guidelines for screening and management of neonatal hyperbilirubinemia were being followed.
An anonymized, cross-sectional survey distributed by mail and e-mail.
From each group (general practitioners, family medicine practitioners, and pediatricians), 500 participants were randomly selected, and all 390 registered midwives were selected.
Compliance with national guidelines for screening, postdischarge follow-up, and management of newborns with hyperbilirubinemia.
Of the 1890 potential respondents, 321 (17%) completed the survey. Only 41% of family physicians reported using national guidelines, compared with 75% and 69% of pediatricians and midwives, respectively (P < .001). Bilirubin was routinely measured for all newborns before discharge by 42% of family physicians, 63% of pediatricians, and 22% of midwives (P < .001). Newborn follow-up was completed within 72 hours after discharge by 60% of family physicians, 89% of pediatricians, and 100% of midwives. Management of neonatal hyperbilirubinemia differed significantly (P < .001), with 91% of family physicians, 99% of pediatricians, and 79% of midwives correctly managing a case scenario according to the guidelines.
The management of jaundice varied considerably among the different practitioner types, with pediatricians both most aware of the guidelines and most likely to follow them. Increased knowledge translation efforts are required to promote adherence to the jaundice management guidelines across all practitioner types, but particularly among family physicians.
Canadian family physician Medecin de famille canadien 08/2013; 59(8):e379-86. · 1.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Although numerous evidence-based and feasible interventions are available to treat pain from childhood vaccine injections, evidence indicates that children are not benefitting from this knowledge. Unrelieved vaccination pain puts children at risk for significant long-term harms including the development of needle fears and subsequent health care avoidance behaviours. Parents report that while they want to mitigate vaccination pain in their children, they lack knowledge about how to do so. An evidence-based clinical practice guideline for managing vaccination pain was recently developed in order to address this knowledge-to-care gap. Educational tools (pamphlet and video) for parents were included to facilitate knowledge transfer at the point of care. The objectives of this study were to evaluate usability and effectiveness in terms of knowledge acquisition from the pamphlet and video in parents of newly born infants. METHODS: Mixed methods design. Following heuristic usability evaluation of the pamphlet and video, parents of newborn infants reviewed revised versions of both tools and participated in individual and group interviews and individual knowledge testing. The knowledge test comprised of 10 true/false questions about the effectiveness of various pain management interventions, and was administered at three time points: at baseline, after review of the pamphlet, and after review of the video. RESULTS: Three overarching themes were identified from the interviews regarding usability of these educational tools: receptivity to learning, accessibility to information, and validity of information. Parents' performance on the knowledge test improved (p<=0.001) from the baseline phase to after review of the pamphlet, and again from the pamphlet review phase to after review of the video. CONCLUSIONS: Using a robust testing process, we demonstrated usability and conceptual knowledge acquisition from a parent-directed educational pamphlet and video about management of vaccination pain. Future studies are planned to determine the impact of these educational tools when introduced in clinical settings on parent behaviors during infant vaccinations.
[Show abstract][Hide abstract] ABSTRACT: Despite the implementation of screening guidelines to identify infants at risk for hyperbilirubinemia, chronic bilirubin encephalopathy (CBE) continues to be reported worldwide in otherwise healthy infants. The incidence of CBE in Canada is unknown. The objectives of this study were to establish the incidence of CBE in Canada and identify epidemiological and medical risk factors associated with its occurrence.
Data on infants were collected prospectively through the Canadian Pediatric Surveillance Program. Infants born between January 1, 2007 and December 31, 2008 were included if they either had symptoms of CBE and a history of hyperbilirubinemia, or if they presented in the newborn period with severe hyperbilirubinemia and an abnormal MRI finding as per the reporting physician.
During the study period, 20 cases were identified; follow-up data were available for 14 of these. The causes for the hyperbilirubinemia included glucose-6-phosphate dehydrogenase deficiency (n = 5), sepsis (n = 2), ABO incompatibility and other red blood cell antibodies (n = 7). Fifteen infants had abnormal brain MRI findings during the neonatal period. At follow-up, 5 infants developed classic choreoathetoid cerebral palsy, 6 had spectrum of neurologic dysfunction and developmental delay (as described by the reporting physician), and 3 were healthy.
CBE continues to occur in Canada at an incidence that appears to be higher than previously reported.
[Show abstract][Hide abstract] ABSTRACT: Potocki-Lupski syndrome is a genomic disorder caused by duplication of 17p11.2. It is characterized by failure to thrive, intellectual disability, hypotonia, and behavioral difficulties. Structural renal anomalies have been observed in <10% of affected individuals. We present detailed clinical and molecular data on six patients with Potocki-Lupski syndrome, two of whom had renal abnormalities, and investigate the prevalence of kidney abnormalities in the mouse model for the syndrome. In contrast to affected humans, the mouse model does not demonstrate a renal phenotype. Comparison of the duplicated segment in patients with Potocki-Lupski syndrome and the renal phenotype and the syntenic duplicated region in the mouse model allowed us to suggest a 0.285 Mb critical region, including the FLCN gene that may be important for development of renal abnormalities in patients with this duplication.
American Journal of Medical Genetics Part A 05/2012; 158A(7):1579-88. · 2.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Organisms causing early-onset neonatal sepsis (EONS) have consistently changed over time. The distribution of organisms in EONS helps to influence the appropriate type of antibiotic prophylaxis strategy during labor and the antibiotics used in neonates with suspected sepsis.
To compare the organisms distribution for EONS between 2003 and 2008 for infants admitted to neonatal intensive care units (NICUs) in Canada. Data were retrieved from infants with a positive bacterial blood or cerebrospinal fluid culture in the first 72 h after birth who were admitted to NICUs participating in the Canadian Neonatal Network from 2003 to 2008. Comparisons of incidence rate, demographics and causative organisms were carried out between earlier cohort (2003 to 2005) and later cohort (2006 to 2008).
A total of 405 infants had positive blood and/or cerebral spinal fluid cultures over the study period. The EONS rate was 6.8/1000 admissions (n=24969) in the earlier cohort compared with 6.2/1000 admissions (n=37484) in the later cohort (P=0.36). Rate of clinical chorioamnionitis was higher in the later cohort (38 vs 26%; P=0.02). For term infants, coagulase-negative Staphylococcus (CONS) (2.4/1000) followed by group B Streptococcus (GBS) (1.9/1000) were the most common organisms identified. For preterm infants, CONS (2.5/1000) followed by Escherichia coli (2.6/1000) were the most common organisms identified. There was a significant reduction in GBS EONS over time (P<0.01) and a trend toward an increase in other organisms.
Although the rate of EONS among neonates admitted to NICUs has not changed, the pattern of infection has changed over the past 6 years. With the increased use of prophylactic antibiotics to mothers, careful surveillance of the changing trend of bacterial organisms among neonates is warranted.
Journal of perinatology: official journal of the California Perinatal Association 04/2011; 31(12):794-8. · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Severe neonatal hyperbilirubinemia continues to occur in healthy newborns. Recent guidelines have supported using transcutaneous devices in estimating bilirubin levels. Previous studies using these devices are limited.
Newborns requiring serum bilirubin level measurements before hospital discharge were recruited prospectively. The agreement between a transcutaneous bilirubin (TCB) and total serum bilirubin (TSB) level was assessed. Sensitivity analysis was conducted.
A total of 430 infants were enrolled. Correlation between the values was high (Pearson's correlation coefficient 0.83; Lin's concordance coefficient 0.81 [95% CI 0.77 to 0.84]; P<0.001). The mean (± SD) TSB level was 194±60 μmol/L. The TCB measurement tended to overestimate the value (mean difference 12.7), with wide 95% limits of agreement (-52 μmol/L to 77 μmol/L). Sensitivity and specificity analysis of TCB values allowed estimation of clinically important TSB levels.
The TCB correlated, but was imprecise in predicting TSB. TCB values can be used at the time of discharge to safely plan care for jaundiced infants if the limits of agreement are considered and clinical judgment is maintained.
Paediatrics & child health 03/2011; 16(3):141-5. · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Canada the incidences of Fetal Alcohol Spectrum Disorder (FASD) is estimated to be in 1 in 100 live births caused by prenatal exposure to alcohol, the disorder is the leading cause of developmental and cognitive disabilities among Canadian children and its effects are life lasting. No research has attempted to describe the experience of living with FASD from the perspective of Canadian children.
The main purpose of this study was to describe the children's experience of living with FASD.
A qualitative method was used to examine the children's experiences. Twenty-two (22) children, aged 6 to 18 years, living in urban and rural communities across Canada participated in an unstructured in-depth interview. Data was analysed using Colaizzi's qualitative method.
For all children in this study, living day-to-day with FASD meant feeling different. Within this construct knowing the disability; feeling alone-feeling supported, and overcoming the disability were dominant themes which emerged.
Implications for practice and research have been described.Keywords: Fetal Alcohol Spectrum Disorder, children's experience, qualitative research.
The Canadian journal of clinical pharmacology = Journal canadien de pharmacologie clinique 01/2011; 18(3):e475-85.
[Show abstract][Hide abstract] ABSTRACT: In neonatal mammals, arginine is synthesized in the enterocyte, with either proline or glutamate as the dietary precursor. We have shown several times in piglets that proline is the only precursor to arginine, although in vitro evidence supports glutamate in this role. Because of this uncertainty, we performed a multitracer stable isotope study to determine whether proline, glutamate, or both are dietary precursors for arginine in enterally fed human neonates. Labeled arginine (M + 2), proline (M + 1), and glutamate (M + 3) were given enterally to 15 stable, growing preterm infants (GA at birth 30-35 wk) at 1-3 wk postnatal age. Enrichment in urine of the tracer amino acids and the M + 1 and M + 3 isotopomers of arginine were measured by LC-tandem mass spectrometry to determine the contribution of proline and glutamate to arginine synthesis. Plateau enrichments of arginine and proline tracers were measurable in urine. Urinary glutamate enrichment was not detected. Conversion of proline to arginine was detected. However, the M + 3 isotopomer of arginine, which would have been synthesized from glutamate, was not detected. We conclude that, in contrast to the current consensus in the literature based on in vitro studies, proline is the major contributor to arginine synthesis in human preterm infants.
Pediatric Research 01/2011; 69(1):46-50. · 2.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe and compare infants with severe hyperbilirubinemia, who presented with and without abnormal neurological findings and to identify associated risk factors.
Data on infants with severe hyperbilirubinemia (>425 μmol l(-1) and/or received exchange transfusion) were collected prospectively through the Canadian Paediatric Surveillance Program (CPSP) from 2002 to 2004. Cases were categorized into two groups on the basis of information provided by the reporting physician: neurologically normal or abnormal. Demographic characteristics were compared and univariate logistic regression was performed to identify factors associated with acute neurological abnormalities in infants.
Of the initial cohort of 258 infants, 32 (12.4%) were identified to have neurological abnormalities. Infants in the highest peak bilirubin level group (>550 μmol l(-1)) had the greatest risk of acute neurological abnormalities. The mid range (451 to 550 μmol l(-1)) and lowest level (450 μmol l(-1)) groups were less likely to have abnormalities (odds ratio (OR)=0.174; P=0.0013 and 0.402; P=0.0613, respectively). Exchange transfusion and presentation within the first 2 days of age were positively associated with abnormal neurological findings in infants (OR=3.332, P=0.003 and OR=2.572, P<0.0001, respectively).
In this national cohort of infants with severe hyperbilirubinemia, a significant percentage of infants developed acute bilirubin encephalopathy. Long-term neurodevelopmental follow-up is necessary to determine the incidence of permanent neurological sequelae.
Journal of perinatology: official journal of the California Perinatal Association 12/2010; 31(6):392-6. · 1.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the acceptability and feasibility of administering seasonal influenza vaccinations in an antenatal clinic setting.
All patients were approached during the study period by a dedicated nurse in the antenatal clinic and offered the seasonal influenza vaccine. The nurse was employed in the antenatal clinic for a two-week period in the fall of 2007 and had no tasks other than to approach patients and to offer and administer the vaccine. The proportion of women accepting the vaccine and the most common reasons for refusal were determined.
Not counting multiple visits by the same patient, there were 631 patient visits during the study period, and 266 (42%) women agreed to receive the vaccine. The most common reasons for refusal were already having received the vaccine or not wanting to be vaccinated during pregnancy.
In Canada, most obstetricians do not administer vaccines in their offices. By implementing an influenza vaccination program in our antenatal clinic, we accomplished the immunization of almost one half of all patients seen during the study period. Prenatal care providers should routinely offer influenza vaccines as a means to increase vaccination rates among pregnant women.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 08/2010; 32(8):745-8.
[Show abstract][Hide abstract] ABSTRACT: Immunosuppressant therapy is essential in the prevention of organ transplant rejection.
To evaluate the long-term neurodevelopmental outcomes of children following in utero ciclosporin (cyclosporine) exposure after maternal renal transplantation.
A cohort study with matched controls using a prospectively collected database was conducted to assess neurocognitive and behavioral outcomes using standardized measures. Thirty-nine children exposed in utero to ciclosporin therapy following maternal renal transplantation were assessed (15 single pregnancies, 24 multiple pregnancies) and compared with 38 matched unexposed children. Intelligence, visuomotor abilities, and psychologic adjustment were measured using the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Beery Developmental Test of Visual-Motor Integration (VMI-4) and the Wide Range Assessment of Visual Motor Abilities (WRAVMA), and the Child Behavior Checklist (CBCL), respectively. Statistical analysis, including regression, was performed to determine the significant predictors for the main outcome, full-scale IQ (FIQ).
There were no significant differences in FIQ, verbal IQ (VIQ), performance IQ (PIQ) or behavioral outcomes between exposed and unexposed children or between single and multiple delivery groups. Thirty-three percent of exposed children were premature versus 0.5% in unexposed controls (p < 0.01). Prematurity was associated with low birthweight, high rates of perinatal complications, and instrumental deliveries. Relative to full-term children, premature, low birthweight children in the ciclosporin-exposed group had significantly lower FIQ and VIQ scores (101.04 vs 111.31 [p = 0.008] and 102.31 vs 113.08 [p = 0.021], respectively). Maternal IQ and socioeconomic status were positive and significant predictors for children's IQ (p < 0.001 and p = 0.03, respectively). There were no statistically significant differences in exposed children's IQ who were and were not breastfed.
In this cohort, there was no association between in utero exposure to ciclosporin and long-term neurocognitive and behavioral development in children after maternal renal transplantation. Maternal IQ and socioeconomic status are positive predictors for children's intelligence. However, maternal renal transplantation and associated co-morbidity is associated with higher rates of premature delivery and consequent poorer neurocognitive and behavioral outcomes. Proper management of maternal morbidity and improved obstetric care may improve the child's profile.
[Show abstract][Hide abstract] ABSTRACT: To determine whether providing an information pamphlet in the antenatal clinic improves women's knowledge about influenza and vaccine recommendations during pregnancy.
An information pamphlet was distributed in the antenatal clinic during the fall of 2007. A cross-sectional survey was carried out in women on the postpartum floor in the fall of 2006 and again in the fall of 2007 (before and after implementation of the pamphlet) to assess women's knowledge. Results were compared to assess knowledge transfer.
Knowledge improved with the use of the educational pamphlet. Most women in both years (>90%) correctly answered that influenza is a serious infection. However, significantly more women in 2007 correctly answered that pregnant women have a higher risk of complications from influenza (34.6% in 2007 vs. 12.1% in 2006, P < 0.001), that the influenza vaccine is safe for use during pregnancy (80.2% vs. 55.2%, P < 0.001) or breastfeeding (75.3% vs. 60.3%, P = 0.001), and that the vaccine does not cause birth defects (90.1% vs. 79.3%, P = 0.04). After implementation of the information pamphlet, a significantly higher proportion of women knew the correct recommendations for influenza vaccination during pregnancy (63.2% vs. 39.7%, P < 0.001). Vaccination rates increased from 19% in 2006 to 56% in 2007.
Providing an information pamphlet in the antenatal clinic improved pregnant women's knowledge about influenza and vaccine safety during pregnancy and about recommendations for influenza vaccination during pregnancy. Knowledge transfer in this area may help to increase vaccination rates.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 03/2010; 32(3):232-7.
[Show abstract][Hide abstract] ABSTRACT: We wished to assess pregnant women's knowledge of influenza, vaccine safety during pregnancy and breast feeding, and the recommendations for use of the influenza vaccine in pregnancy.
We performed a cross-sectional survey of postpartum women during influenza season in 2006.
Pregnant women's overall knowledge of these subjects was poor. Most women (95%) knew that influenza is highly contagious, but almost 90% incorrectly believed that pregnant women have the same risk of complications as non-pregnant women. Only one half of the women were aware of national recommendations for vaccination during pregnancy and that the vaccine is safe during pregnancy and breast feeding, and 80% incorrectly believed that the vaccine can cause birth defects. Only 20% of women had been offered the vaccine during the current pregnancy or a prior pregnancy.
Pregnant women's knowledge about influenza vaccine recommendations and safety during pregnancy is poor. There is substantial room for improvement among prenatal care providers in both patient education and offering the vaccine.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 03/2009; 31(2):120-5.
[Show abstract][Hide abstract] ABSTRACT: There are currently few studies describing the use of high-fidelity (hi-fi) simulation in teaching neonatal resuscitation. Traditionally, residents are certified in the neonatal resuscitation program (NRP) after successful completion of a multiple-choice written examination and demonstration of skills during a hands-on 'mega-code'. In the present study, the use of a hi-fi simulation mannequin was compared with a standard plastic mannequin when teaching the megacode portion of the NRP.
In the present pilot study, 15 first-year residents were randomly assigned to demonstrate neonatal resuscitation knowledge, with either the hi-fi mannequin (SimBaby, Laerdal Medical Corporation, USA) or a traditional plastic mannequin (ALS Baby, Laerdal Medical Corporation, USA). A written evaluation was conducted before and after the intervention. Each pair of residents experienced the two scenarios. Video performance was then assessed and compared.
Residents randomly assigned to the hi-fi mannequin rated the experience higher (31+/-3.3 versus 27+/-3.5; P=0.026), and required less redirection from instructors during the megacode (scenario 1: 4.5+/-1.7 versus 15+/-6.9; P=0.015 and scenario 2: 1.8+/-1.3 versus 9.3+/-2.5; P=0.0009) than those who were randomly assigned to the plastic mannequin. Residents randomly assigned to the hi-fi mannequin did not have improved written scores or improved intubation times.
The present pilot study demonstrated that a hi-fi mannequin can be used as part of an educational program, such as the NRP. The use of this technology in neonatal resuscitation training is well-received by learners and may provide a more realistic model for training. Further work is required to clarify its role in task performance and team training.
Paediatrics & child health 02/2009; 14(1):19-23. · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: It is estimated that more than 20% of pregnant women worldwide consume alcohol. Current research suggests that alcohol intake of seven or more standard drinks (one standard drink = 13.6 grams of absolute alcohol) per week during pregnancy places the baby at risk of serious, lifelong developmental and cognitive disabilities. Psychological and educational interventions may help women to reduce their alcohol intake during pregnancy.
To determine the effectiveness of psychological and educational interventions to reduce alcohol consumption during pregnancy in pregnant women or women planning pregnancy.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2008), CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), CINAHL (1982 to November 2007), Counsel.Lit (1980 to November 2007), PsycLIT (1974 to November 2007) and PsycINFO (1967 to November 2007) and checked cited references from retrieved articles.
Randomized controlled trials examining the effectiveness of psychological and educational interventions for reducing consumption of alcohol among pregnant women, or women planning for pregnancy.
At least two review authors independently extracted information from the results sections of the included studies.
Four studies met the inclusion criteria (715 pregnant women), and reported on at least one of the outcomes of interest. We performed no meta-analyses as the interventions and outcomes measured in the studies were not sufficiently similar. For most outcomes there were no significant differences between groups; and results relating to abstaining or reducing alcohol consumption were mixed. Results from individual studies suggest that interventions may encourage women to abstain from alcohol in pregnancy. There was very little information provided on the effects of interventions on the health of mothers and babies.
The evidence from the limited number of studies suggests that psychological and educational interventions may result in increased abstinence from alcohol, and a reduction in alcohol consumption among pregnant women. However, results were not consistent, and the paucity of studies, the number of total participants, the high risk of bias of some of the studies, and the complexity of interventions limits our ability to determine the type of intervention which would be most effective in increasing abstinence from, or reducing the consumption of, alcohol among pregnant women.