The developmental paediatrician and neonatal follow-up

Recent advances in modern perinatal and neonatal intensive care have led to an increase in the survival of premature infants. This increased survival, unfortunately, has not been accompanied by an improvement in neurodevelopmental outcomes. Premature infants, especially those with an extremely low birth weight (less than 1000 g) or those born at less than 28 weeks’ gestation, are at increased risk of major disabilities and complex, ‘low severity’ dysfunctions that have significant, lasting effects on their school function, academic performance and behaviour, as well as on family function. Neonatal follow-up programs provide a number of functions to centres providing neonatal intensive care, including quality assurance and audits, research and follow-up clinical care to neonatal intensive care unit survivors and their families. The challenge for neonatal follow-up programs is to meet the often competing objectives of providing clinical services to children and their families while providing quality assurance and audits, and high-quality long-term outcome research components, given the available resources. There is also a need for ongoing research to develop and evaluate effective postdischarge intervention programs to improve the long-term outcome of prematurity and other neonatal complications. Developmental paediatricians – with their background and training in the provision of specialized health care to children and their care-givers with respect to developmental and psychosocial well-being, and in conducting developmental and behavioural disabilities research – play a valuable role in the follow-up assessment and care of neonatal intensive care unit graduates, and strengthen the multidisciplinary research groups necessary to assess long-term outcomes and the effects of perinatal and postdischarge interventions.     

Child and youth mental health: Integrated health care using contemporary competency-based teams

Mental health teams have long been the foundation for mental health services provided to children and youth. Changes in professional practices, the emergence of evidence-based care, the importance of integrating mental health into primary health care delivery, the decrease in professional ‘ownership’ of mental health care competencies and other factors now challenge the traditional structure and function of these teams. New and novel frameworks will be needed to address mental health care needs for problems that do not require ‘traditional’ mental health service interventions, to enable integration of mental health care into usual health services, to promote specialist mental health care delivery for those in need, and to facilitate the development and translation of mental health research into practice. In all of these new team structures, the active participation of young people and their families will be necessary.     

Severe injury mechanisms in two paediatric trauma centres: Determination of prevention priorities

BACKGROUND

To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.

METHODS

The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.

RESULTS

A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.

CONCLUSION

The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.     

Comprehensive primary care follow-up for premature infants

Advances in perinatal and neonatal care have led to an increased incidence of survival of premature infants. Although most premature infants have normal outcomes, they are at increased risk for morbidity and mortality and require comprehensive primary care follow-up after they are discharged from the hospital. This article will review guidelines for general follow-up of premature infants and the associated problems related to prematurity. General follow-up is performed by the pediatric nurse practitioner, with subspecialty consultant referrals as needed. Knowledge of the problems of prematurity and treatment regimes will assist the pediatric nurse practitioner in providing high-quality care to these high-risk infants.     

Educational outcome of neonatal intensive care graduates.

Studies of developmental outcome of neonatal intensive care unit graduates have generally been limited to the first 2 to 3 years of life, with outcome determined by psychometric tests. This study followed neonatal intensive care unit graduates born 1975 through 1983 (n = 457) into the public school system and compared their educational outcomes with those of newborn nursery graduates (n = 656). Outcomes were evaluated by placement in four academic categories: regular classroom, academic problems, speech/language impairment, and major impairment. Educational outcomes for children of both groups were essentially the same. Their placement in the four academic categories were equally affected by nonmedical variables, primarily income (below/above poverty level), race, and sex. Seventy percent of poverty-level children were in one of the three problem categories, compared with 40% of children above poverty level. Neither neonatal intensive care unit treatment nor low birth weight were major predictors of educational outcome. The only clear-cut neonatal intensive care unit effect occurred among children born with sensory or physical impairments. Therefore, in order to reduce poor educational outcomes, follow-up and intervention programs should be targeted primarily to children with diagnosable handicaps and from minority, low-income families.     

Supporting caregivers of children born prematurely in the development of language: A scoping review

BackgroundInfants born prematurely can display impairments that negatively impact the early years of their development. Compared to their peers born at term, preterm children have higher risks of cerebral palsy, sensory deficits, learning disabilities, cognitive and language deficits, as well as difficulties related to attention and behaviour. Following discharge, parents of preterm children are often supported through neonatal follow-up programs or by community health care practitioners. Through assessment and consultation, professionals foster parental resilience by teaching them about their child’s development. Research shows a large volume of literature on improving outcomes for preterm infants, but less attention has been given to the impact and potential importance of education of parents regarding the care they provide from the home.ObjectiveA scoping review was completed to determine the best practices for early intervention in premature children regarding the development of language skills during the preschool years.MethodsThe review followed the guidelines for the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).ResultsFour general themes emerged from the review and included the importance of providing (1) parental training in the care of an infant born prematurely during neonatal intensive care unit stay; (2) education on the development of language and the importance of parental responsiveness; (3) provision of activities to support child language learning; and (4) overall and ongoing monitoring and support by qualified health professionals.ConclusionsThe conclusions drawn will provide guidance to health care professionals regarding the education of parents on best practices for stimulating language development in their child.     

Unintentional exposure of young children to camphor and eucalyptus oils

BACKGROUND:

Essential oils, such as camphorated and eucalyptus oils, are volatile oils that can be absorbed by mouth and through the skin; if ingested orally by children, they can be harmful, even life-threatening.

OBJECTIVE:

To determine the frequency of essential oil ingestion among children in Toronto, Ontario.

METHODS:

Charts from December 1995 through March 1997 at the Ontario Regional Poison Information Centre, The Hospital for Sick Children, Toronto were reviewed to collect information on calls about essential oil ingestion, and a search of MEDLINE articles from 1966 to 1998 was conducted using the key words: ‘camphor’, ‘eucalyptus’, ‘paediatric’, and ‘poisoning’.

RESULTS:

Callers to the Poison Information Centre reported that 251 children had ingested an essential oil or product: eucalyptus oil 50 children; camphorated oil 18 children; VapAir (Drug Trading, Canada) vaporizing liquid 93 children; and Vicks VaporRub (Procter & Gamble, Canada) 90 children. The most common symptoms were cough, vomiting and cough associated with vomiting. Two children had seizures but recovered. The MEDLINE search found 18 reports of paediatric ingestion of the oils or oil products. The main symptoms were vomiting, lethargy, coma and seizures. One child died.

CONCLUSION:

Although widely used by health care consumers, essential oils and the products that contain them can be harmful when ingested by children. Further education for parents and other caregivers about the risks involved in exposure to these products is required.     

Allocation of health care resources in the neonatal and perinatal area �CCPS Symposium 1996

There have been publically expressed concerns about the costs and allocation of neonatal and perinatal health care resources in Canada and elsewhere for the past 15 years. This paper reports information from a symposium held during the 1996 Canadian Paediatric Society (CPS) annual meeting sponsored by the CPS Section on Perinatal Medicine. Experts in perinatal epidemiology, health care economics, public policy and finance, and consumer perspectives on the outcomes of neonatal and perinatal intensive care explored the following questions: How should the need for health care resources in the neonatal and perinatal area be objectively determined? When there are competing needs between the maternal-newborn area and other areas, how should these be rationalized? What evidence should be used (or should be available) to support the present use of resources? What evidence should be available (or is needed) to change or introduce new uses of resources? The conclusions indicated that there are no generally accepted methods to determine the allocation of health care resources but that considerations need to include population characteristics, desired outcomes, achievable results, values, ethics, legalities, cost-benefit analyses and political objectives. Information from families and adolescents who required the use of high technology and/or high cost programs will contribute individual, family and societal values that complement cost-efficacy analyses.     

Dietary patterns of Chinese puerperal women and their association with postpartum weight retention: Results from the mother–infant cohort study

Dietary intake may affect maternal health, but it remains unclear about puerperal dietary intake and its association with maternal health. This study investigated the dietary patterns and their related factors and association with postpartum weight retention (PPWR) in Chinese puerperal women. Participants were from the mother–infant cohort study, in which both mothers and infants were followed up from childbirth to the next 2 years, in seven cities around China. Maternal puerperal dietary patterns were derived by a food frequency questionnaire and principal component analysis (PCA) within 1 month postpartum. PPWR was assessed by the difference of weight at 42 days and 6 months postpartum minus the pre‐pregnancy weight. Of 503 postpartum women, four dietary patterns were identified, including ‘plant food’ pattern (rice and vegetables as dominant foods), ‘diverse’ pattern (starchy roots, fruit, livestock meat and aquatic products), ‘traditional northern’ pattern (poultry, eggs and soup) and ‘marine‐flour’ pattern (flour, coarse food grains and marine fish). The diverse pattern was associated with professional puerperal family care and counselling service (p < .05). PPWRs at 42 days and 6 months postpartum were 6.37 and 4.70 kg averagely. The plant food dietary pattern tended to be associated with higher 42‐day PPWR (β = .105, p < .05), and diverse pattern was associated with lower 6‐months PPWR (β = −.137, p < .05). Conclusively, this study presented four dominant dietary patterns in Chinese postpartum women and showed a lower PPWR in adherence to diverse dietary pattern. The results would provide evidence to furtherly guide dietary practice and improve maternal health.     

Networks in Canadian paediatric surgery: Time to get connected

There has been a recent trend of improved outcomes for most infants born with surgically correctable congenital malformations, despite the fact that current surgical treatment is not standardized, with wide variations in practice among institutions. Because care for these infants is multidisciplinary, it is difficult to ascertain with clarity the specific role of neonatal surgery in determining outcomes. Moreover, the lack of validated measures of illness severity for most complex congenital malformations makes risk adjustment difficult. For these reasons, the utility of randomized controlled trials in determining best surgical practice in neonatal surgery for congenital malformations is impractical, and another means of deriving medical evidence to justify ‘optimal’ treatment is necessary.The Canadian Paediatric Surgical Network (CAPSNet) was developed specifically to address these issues. Patterned after the highly successful Canadian Neonatal Network, CAPSNet collects standardized data on every case of gastroschisis and congenital diaphragmatic hernia evaluated in the 16 referral perinatal centres in Canada. These centres serve as provincial referral centres for perinatal care, and, therefore, the data set created is population-based for gastroschisis and congenital diaphragmatic hernia in Canada. In addition to neonatal data fields recorded in the Canadian Neonatal Network, CAPSNet collects specific prenatal data, and details on surgical treatment and outcomes within each of the 16 participating centres. It is hoped that by using advanced analytical techniques, including outcomes modelling and multiple logistic regression analysis of risk-adjusted outcome variations by type of surgery performed, optimal treatment paradigms will be identified that will lead to further outcome improvement in babies born with complex birth defects.     

Viral infections acquired during neonatal intensive care and lung function of preterm infants at follow-up

Yuksel B, Greenough A. Viral infections acquired during neonatal intensive care and lung function of preterm infants at follow-up. Acta Pzdiatr 1994;83:117–18. Stockholm. ISSN 0803–5253
Respiratory function was assessed at a median postnatal age of seven months in seven infants born prematurely who suffered from chronic lung disease and had a proven viral infection while on the neonatal unit (study group). The results were compared with those of seven infants with chronic lung disease who were gestational age- and gender-matched but who did not have a viral infection (controls). Six of the study group and two controls were symptomatic at follow-up. Airways resistance was significantly higher ( p < 0.04) and specific conductance significantly lower ( p < 0.05) in the study group compared with the controls. We conclude in premature infants with chronic lung disease that viral infections acquired in the neonatal nursery are associated with impaired lung function at follow-up.     

Iron deficiency anemia among children: Addressing a global public health problem within a Canadian context

Despite current Canadian pre- and perinatal nutrition programs, the prevalence of both iron deficiency and iron deficiency anemia (IDA) is very high among young Aboriginal children from Canada’s remote north. The major risk factors for IDA include prolonged consumption of evaporated cow’s milk, chronic infection and prolonged exclusive breastfeeding. In the present article, the authors discuss IDA as a significant public health problem in Canadian Aboriginal communities. Whereas the prevalence of IDA in Canadian children is between 3.5% and 10.5% in the general population, in two Northern Ontario First Nations communities and one Inuit community, the anemia rate was 36%, with 56% having depleted iron stores. Traditional methods of preventing IDA, including targeted fortification, dietary diversification and supplementation, have not solved the problem. The authors’ research group at The Hospital for Sick Children in Toronto, Ontario, conceived of the strategy of ‘home fortification’ with ‘Sprinkles’ – single-dose sachets containing micronutrients in a powder form, which are easily sprinkled onto any foods prepared in the household. In Sprinkles, the iron (ferrous fumarate) is encapsulated within a thin lipid layer to prevent the iron from interacting with food. Sprinkles have been shown to be efficacious in the treatment of anemia in many developing countries. Their use in Aboriginal communities to treat and prevent anemia is described in the present paper. The authors believe that children in Aboriginal communities across Canada would potentially benefit if Sprinkles were incorporated into Health Canada’s current distribution system, in combination with a social marketing strategy to encourage their use.     

Developmental outcome of neonatal intensive care: what questions are we asking?

Recent neonatal intensive care outcome studies are asking more focused research questions and incorporating, at least implicitly, pathogenetic models. A few have grappled with the complex issues of health-related quality of life and functional outcomes and the many factors that affect these outcomes. The need to evaluate high-risk obstetrics is increasingly recognized. Studies of risk factors for neurodevelopmental outcomes provide valuable insights into mechanisms of and recovery from central nervous system injury. Ongoing study of the efficacy and effectiveness of interventions must continue amid concern about availability of family and developmental support for increasing numbers of survivors of high-risk obstetric and neonatal intensive care.     

Estimation of bilirubin using BiliChek?, a transcutaneous bilirubin measurement device: Effects of gestational age and use of phototherapy

BACKGROUND

Heel puncture to obtain bilirubin measurements is painful for infants and distressing for parents. Transcutaneous bilirubin measurement using BiliChek (Respironics, USA) is easily performed in any setting. Reliable transcutaneous testing should decrease the number of painful procedures in otherwise well infants, reduce the volume of phlebotomy losses in ill newborns, and reduce the need for hospital or specialized clinic visits after discharge.

OBJECTIVE

To correlate bilirubin measurements using the transcutaneous device BiliChek with ‘gold standard’ serum measurements in well term infants, and in ill term and preterm infants admitted to the authors’ neonatal intensive care unit.

METHODS

The study consisted of two phases. In phase 1, informed consent was obtained from mothers of 99 healthy, full-term infants not receiving phototherapy to perform both serum and transcutaneous bilirubin measurements at the time of heel puncture for routine neonatal screening. In phase 2, 56 infants in the neonatal intensive care unit had a total of 99 transcutaneous readings performed at the time serum bilirubin measurements were ordered for clinical reasons by the attending staff. The operators of the transcutaneous device, who were unaware of the serum bilirubin levels, performed readings within 1 h of the heel puncture.

RESULTS

Using a Bland-Altman comparison in the well term infants, the transcutaneous measurements were −32.2 μmol/L to +31.2 μmol/L (1.96 SD); however, 79 (79.8%) of the transcutaneous measurements were within 15 μmol/L of the serum measurements. The variation in preterm infants was greater at −69.6 μmol/L to +62.0 μmol/L, and only 49 (49.5%) were within 15 μmol/L. For infants receiving phototherapy, the variation was −76.3 μmol/L to +49.5 μmol/L, but improved to −40.4 μmol/L to +31.0 μmol/L if an area of skin was patched for testing, approximating the group not receiving phototherapy.

CONCLUSIONS

Transcutaneous bilirubin measurements obtained with the BiliChek instrument were accurate for measuring bilirubin levels in term jaundiced infants not receiving phototherapy and in those receiving phototherapy if an area of skin was patched. The instrument was not as sensitive in the small sample of preterm infants, and a larger study is required before recommending the use of this instrument in this population.     

Neonatal follow-up programs in Canada: A national survey

BackgroundA 2006 Canadian survey showed a large variability in neonatal follow-up practices. In 2010, all 26 tertiary level Neonatal Follow-Up clinics joined the Canadian Neonatal Follow-Up Network (CNFUN) and agreed to implement a standardized assessment (including the Bayley Scales of Infant and Toddler Development-III (Bayley-III) at 18 months corrected age for children born < 29 weeks’ gestation. It is unknown whether the variability in follow-up practices lessened as a result.ObjectivesTo describe the current status of neonatal follow-up services in Canada and changes over time.MethodsA comprehensive online survey was sent to all tertiary level CNFUN Follow-up programs. Questions were based on previous survey results, current literature, and investigator expertise and consensus.ResultsRespondents included 23 of 26 (88%) CNFUN programs. All sites provide neurodevelopmental screening and referrals in a multidisciplinary setting with variations in staffing. CNFUN programs vary with most offering five to seven visits. Since 2006, assessments at 18 months CA increased from 84% to 91% of sites, Bayley-III use increased from 21% to 74% (P=0.001) and eligibility for follow-up was expanded for children with stroke, congenital diaphragmatic hernia and select anomalies detected in utero. Audit data is collected by > 80% of tertiary programs.ConclusionCare became more consistent after CNFUN; 18-month assessments and Bayley-III use increased significantly. However, marked variability in follow-up practices persists.     

Paediatricians,social media and blogs: Ethical considerations

The use of blogs, Facebook and similar social networking sites is rapidly expanding and, when compared with e-mail, may be having a significantly different impact on the traditional doctor-patient relationship. Characteristics specific to these online platforms have major implications for professional relationships, including the ‘Facebook effect’ (the relative permanence of postings) and the ‘online disinhibition effect’. The present practice point illustrates relevant ethical considerations and provides guidance to paediatricians and others concerning the prudent professional and personal use of social networking media.     

Neonatal personnel in Canada

Although the need for trained personnel to care for neonates with complex needs is recognized, there has been no systematic analysis of present or future personnel requirements. The Canadian Paediatric Society’s Neonatal-Perinatal Medicine Section sponsored a symposium on neonatal personnel, inviting four Canadian experts to address issues related to future needs. Areas addressed included neonatal nurse practitioners providing increased patient care in some parts of the country as resident involvement in neonatal intensive care decreases, the extended roles of other health care personnel and increased direct patient care by neonatologists. There is no approved method to determine personnel needs, but paediatric department heads have indicated that the number of neonatologists needed is substantially greater than available funding allows. Considering economic factors and the need to educate perinatal care providers, it is important to assess present and future needs to ensure that quality care can be provided.     

Improved neonatal survival and outcomes at borderline viability brings increasing ethical dilemmas

With improvements in neonatal intensive care over the past five decades, the limits of viability have reduced to around 24 weeks' gestation. While increasing survival has been the predominant driver leading to lowering the gestation at which care can be provided, these infants remain at significant risk of adverse long-term outcomes including neuro-developmental disability. Decisions about commencing and continuing intensive care are determined in partnership with parents, considering the best interests of the baby and the family. Occasionally, clinicians and parents come to an impasse regarding institution or continuation of intensive care. Inevitably, these ethical dilemmas need to consider the uncertainty of the long-term prognosis and challenges surrounding providing or withdrawing active treatment. Further reduction in the gestational age considered for institution of intensive care will need to be guided by short- and long-term outcomes, community expectations and the availability of sufficient resources to care for these infants in the neonatal intensive care unit and beyond.