Evidence for changing guidelines for routine screening for retinopathy of prematurity

CONTEXT: Existing guidelines recommended by the Canadian Pediatric Society (CPS) and American Academy of Pediatrics (AAP) for routine screening for retinopathy of prematurity (ROP) remain controversial. OBJECTIVE: To determine whether current guidelines for routine screening for ROP should be changed. DESIGN: We examined data that were collected as part of a larger study of 14 neonatal intensive care units (NICUs) in Canada. We examined the effect of strategies using different birth weight (BW) and gestational age (GA) criteria for routine ROP screening, and performed a cost-effectiveness analysis. SETTING: The 14 NICUs (except one) are regional tertiary level referral centres serving geographic regions of Canada, and include approximately 60% of all tertiary-level NICU beds in Canada. PATIENTS: This large cohort included all 16 424 infants admitted to 14 Canadian NICUs from January 8, 1996, to October 31, 1997. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Treatment for ROP. RESULTS: The most cost-effective strategy was to routinely screen only infants having a BW of 1200 g or less. This included all infants treated for ROP (except 1 outlier at 32 weeks GA and 1785 g BW), at a marginal cost per additional person with improved vision of $513 081 for screening patients between 28 weeks GA and 1200 g BW, compared with $1 800 039 and $2 075 874 for using the current AAP and CPS guidelines, respectively (cryotherapy outcomes). Results for laser therapy were similar, but costs were slightly lower. This strategy reduced the number of infants screened under the current CPS guidelines by 46%. CONCLUSION: Screening only infants having a BW of 1200 g or less is the most cost-effective strategy for routine ROP screening.     

Routine procedures for examination of stool and blood for parasites

The diagnosis of a parasitic infection depends upon demonstration of the organism in stool, blood, or tissue specimens, and a variety of relatively simple procedures is available for this purpose. In this article, the author describes those procedures that are most frequently used on a routine basis.     

Screening for retinopathy of prematurity

The CRYO-ROP study confirmed the success of treatment for ROP and made screening mandatory. National based screening has been influenced by the varied incidence of disease in developed and developing countries. Most ophthalmologists in developed countries screen infants born between 1000 and 1500 g and between 28 and 31 weeks gestation post menstrual age. The 1984 classification has been updated to highlight the importance of plus disease. The ETROP study findings have resulted in earlier treatment and elevated the importance of screening. Measures such as nesting may help to reduce infant distress during examination. It is important for neonatal units to have an agreed policy on screening and both neonatologist and neonatal nurses have an invaluable role. Diagnostic retinal imaging and telemedicine may have an increasing role in future screening. Timely and accurate screening is the most important first step as earlier treatment results in improved visual prognosis.     

Evaluation of the Glucometer Elite XL device for screening for neonatal hypoglycaemia

To prevent persistent neurodevelopment and physical growth deficits in neonatal care, it is mandatory to determine blood glucose levels as quickly and precisely as possible, preferably using micro-methods. However, most commercially available instruments have not been validated and approved for this purpose. The aim of this study was to validate the Glucometer Elite XL, a newly developed device for point-of-care testing (POCT). In samples from 869 newborn infants, glucose levels were simultaneously measured by the Glucometer Elite XL in whole blood and by an accepted clinical laboratory method in haemolysed blood using the ECA 2000 device. An acceptable method agreement was found between the POCT and the ECA 2000 method (mean difference 0.013 mmol/l, SD 0.69). As determined by regression analysis (Passing-Bablok), the slope was 1.086 with a y-intercept of –0.4 mmol/l ( r =0.959, P <0.05). The differences between measurement pairs of both assays versus the haematocrit were negligible. With a cut-off for hypoglycaemia at 2.6 mmol/l glucose in haemolysed blood, the sensitivity of the POCT device was 0.63 and specificity was 0.98. Raising the cut-off of the Glucometer Elite XL to 3.2 mmol/l, the sensitivity and specificity incremented to 1.0 and 0.89, respectively. Conclusion:The Glucometer Elite XL instrument can be recommended for point-of-care blood glucose measurement in newborn infants if its character as a screening method is taken into account. To compensate deviating results, we advise to shift its cut-off for hypoglycaemia recognition to a safe threshold of 3.2 mmol/l. However, hypoglycaemia has to be confirmed by a valid glucose measurement in the clinical laboratory.     

Parent-reported quality of preventive care for children at-risk for developmental delay

ObjectiveTo compare preventive care quality for children at risk and not at risk for developmental, behavioral, or social delays.MethodsUsing the 2007 National Survey of Children’s Health (n = 22,269), we used the Parents’ Evaluation of Developmental Status (PEDS) questionnaire to identify children ages 10 months to 5 years who were at risk for delays. We examined parent-reported quality measures to evaluate whether care was comprehensive, coordinated, family-centered, effective in providing developmental surveillance and screening, and provided within a medical home. Bivariate and multivariate analyses were used.ResultsTwenty-eight percent of children were at-risk for delay, with 17% at moderate risk and 11% at high risk. Greater proportions of children at high, moderate, and no/low risk had a usual source of care (89%–96%) and a personal doctor/nurse (91%–94%); smaller proportions of children underwent a standardized developmental screening (16%–23%) and had parental developmental concerns elicited from their doctor (47%–48%). In adjusted analyses, moderate-risk and high-risk children were less likely than no/low-risk children to receive needed care coordination (adjusted odds ratio [AOR] for high risk 0.33, 95% confidence interval [95% CI] 0.24–0.46) and referrals (high risk AOR 0.40, 95% CI 0.25–0.65), family-centered care (high-risk AOR 0.47, 95% CI 0.36–0.62), and to have a medical home (high-risk AOR 0.41, 95% CI 0.32–0.54).ConclusionsOur findings may reflect either poorer quality of care provided to at-risk children, or higher level of parental need that routine visits are not currently meeting. For at-risk children, enhanced screening and detection followed by targeted increases in communication and follow-up may help clinicians better anticipate families’ needs.