Canadian Paediatric Society Guidelines Research Articles

Criteria for discharge of preterm infants from Canadian neonatal intensive care units.

Initial discharge from a neonatal intensive care unit (NICU) to home is a crucial milestone that impacts preterm infants, their families, and NICUs. Standardized discharge programs individualized for family needs can ensure a safe transfer of care to parents, decrease the length of stay and hospital costs, and improve parents' satisfaction. To assess the degree of variability in the current discharge criteria of preterm infants less than 34weeks' gestation among Canadian NICUs, explore different institution-specific guidelines and degree of adherence to the Canadian Paediatric Society (CPS) guidelines. A clinical representative of each of the 117 level 2-4 Canadian NICUs was contacted via email to participate in an anonymous survey link regarding the discharge criteria of preterm infants. Responders from ninety-eight NICUs (84%), representing all Canadian provinces, completed the survey. Most were nurse practitioners (43%) and neonatologists (31%) with > 5years of experience (87%). Level 3 and 4 NICUs represented 63% of responses. Units varied widely in many discharge criteria and in their adherence to CPS guidelines. Most of the units (81%) lack written discharge guidelines; 60% do not have a dedicated discharge coordinator, and 45% do not have a post-discharge clinic. Only 25% routinely teach parents CPR and only half of the surveyed units provide parental support programs. Conclusion: There is a significant heterogeneity in discharge practices of preterm infants among Canadian NICUs. This survey provides a basis for benchmarking and knowledge sharing. What is Known: • Discharging preterm infants from the NICU impacts preterm infants, their families, and NICUs. • All efforts should ensure a safe transfer of care to parents, decrease the length of stay, better utilize resources, and improve parents' satisfaction. What is New: • The discharge criteria of preterm infants vary widely among NICUs. • This survey provides benchmark information and exposes the need to better standardize discharge practices and the subsequent support for infants and parents.

72 Criteria for Discharge of Preterm Infants in Canadian Neonatal Intensive Care Units

Abstract Background Discharging to home is a milestone that impacts preterm infants, their parents, and the neonatal intensive care units (NICU). Standardized discharge programs that are individualized for family needs can ensure a safe transfer of care to parents, decrease the length of hospital stay and costs, and improve parental satisfaction. Objectives To assess the degree of variability in discharge criteria for preterm infants <34 weeks’ gestation across Canadian NICUs, explore different institution-specific guidelines, and evaluate the degree of adherence to Canadian Paediatric Society (CPS) guidelines. Design/Methods A clinical representative for each of 117 level 2, 3 and 4 Canadian NICUs was contacted via email to participate in an anonymous survey link (OPINIO) regarding their discharge criteria for preterm infants. French and English versions of the survey were available. Results Ninety-eight respondents (83.7%), representing all Canadian provinces and the NWT, completed the survey (Figure 1). The majority of the responders were nurse practitioners (42.8%) and neonatologists (30.7%) with >5 years of experience (87%). 63% of responses came from level 3 and 4 NICUs. Most respondents (80.6%) lacked written guidelines in their units for discharging preterm infants. 60.2% did not have a dedicated discharge coordinator, and 45% did not have a post-discharge clinic. Table 1 summarizes the different discharge practices. Conclusion There is a significant heterogeneity in discharge practices for preterm infants in Canadian NICUs, despite the presence of CPS guidelines. This survey provides a basis for benchmarking and knowledge-sharing, but more research is needed to guide best evidence-based practice. Potential competing interests Dr. El-Naggar served as a consultant for Aerogen Pharma Limited and is a site investigator of its funded study: A Partially-Blind, Randomized, Controlled, Parallel-Group, Dose-Ranging Study to Determine the Efficacy, Safety and Tolerability of AeroFactTM (SF-RI 1 surfactant for inhalation combined with a dedicated drug delivery system) in Preterm Infants at Risk for Worsening Respiratory Distress Syndrome.

31 Iron Deficiency in Formula-fed Very Preterm Infants: Do We Need to Revise Recommendations for Iron Supplementation?

Abstract Background Preterm infants are at risk for iron deficiency (ID). The Canadian Paediatric Society (CPS) recommends iron supplementation of 2 to 3mg/kg/day for breastfed (BF) preterm infants born <2 kg. Additional iron supplementation is not recommended if these infants are primarily formula-fed (FF) with iron-rich formula, since formula is thought to provide enough iron. However, these recommendations are not universally accepted. Objectives To investigate how feeding type influences the iron status of very preterm infants (VPI) at 4 to 6 months corrected age. Design/Methods A retrospective population-based cohort study was conducted using a provincial database of all VPI (<31 weeks gestational age) born in Nova Scotia from 2005-2018. Information about feeding type, iron intake from formula, and supplemental iron therapy at 4- to 6-month follow-up was extracted, as were neonatal variables. Two groups were compared using chi-square and unpaired t-tests. Results 392 infants were studied (gestational age: 23-30 weeks). Of these, 285 were exclusively FF with iron-rich formula, and 107 were exclusively or partially BF. Neonatal variables were comparable between the two groups. An elemental iron intake of >2 mg/kg/day was obtained from formula alone in only 20.4% of FF infants. FF infants were less likely to receive additional iron supplements. However, total iron intake (from formula and supplements) was higher in FF infants. Despite this, 36.8% of infants in FF group developed ID, versus 20.6% in the BF group (Table 1). Conclusion Most VPI fail to receive elemental iron of >2 mg/kg/day from formula alone. ID is significantly more prevalent in FF infants than in BF infants, despite higher iron intake. Our findings do not support the current CPS guidelines.

Neonatal hypoglycemia and the CPT1A P479L variant in term newborns: A retrospective cohort study of Inuit newborns from Kivalliq Nunavut.

Neonatal hypoglycemia (NH) in the first days of life can largely be prevented by recognizing those at risk and managing accordingly. The CPT1A P479L variant is prevalent in northern Indigenous populations and is a possible risk factor for hypoglycemia. We report on NH incidence in the Kivalliq region of Nunavut, where all Inuit newborns are screened for NH. We reviewed clinical charts of 728 Inuit newborns from Kivalliq (January 1, 2010 to December 31, 2013) for blood glucose (BG) levels and infant/maternal characteristics, linking to CPT1A genotype; 616 newborns had BG data from 2 to 48 hours of life. NH was defined using Canadian Paediatric Society guidelines (≤2.0 mmol/L at 2 hours, <2.6 mmol/L at 2 to 48 hours). NH was documented in 21.4% overall, 24.4% of at-risk newborns and 19.5% of term newborns with no risk factors (≥37 weeks gestation, term-NRF). NH was documented in 22.0% of CPT1A P479L homozygous, 19.8% of P479L heterozygous and 4.8% of noncarrier term-NRF newborns. With multivariable logistic regression, the adjusted ORs for developing NH in term-NRF newborns was 4.97 for CPT1A P479L homozygotes (95% confidence interval [CI]:0.65-38.35, P=0.19) and 4.71 for P479L heterozygotes (95% CI:0.57-37.89, P=0.15). Term-NRF newborns had a higher NH incidence than previously reported, similar to that for at-risk newborns, possibly due to the CPT1A P479L variant. Since only Inuit newborns from Kivalliq are screened for NH, further study of long-term outcomes of NH in this population and the role of the P479L variant are warranted to determine if neonatal BG screening is indicated in all Inuit newborns.

The palivizumab patchwork: Variation in guidelines for Respiratory Syncytial Virus prevention across Canadian provinces and territories.

Respiratory Syncytial Virus is the leading cause of hospitalization for lower respiratory tract infection in young children. The only preventive intervention is an anti-Respiratory Syncytial Virus (RSV) monoclonal antibody (palivizumab, Synagis) administered as monthly intramuscular injections during the winter. Recommendations for palivizumab use have been published by the Canadian Paediatric Society (CPS) and other agencies. We sought to determine if there was interjurisdictional variation in eligibility for palivizumab across provinces and territories and in comparison to CPS recommendations, as well as the nature of this variation. Eligibility criteria were obtained from personnel coordinating provincial and territorial programs and from public governmental websites. All 13 jurisdictions provided information about their palivizumab eligibility policies. No province or territory (PT) follows CPS guidelines exactly and substantial heterogeneity exists among jurisdictions. All PT jurisdictions provide prophylaxis in the first year of life to infants with hemodynamically significant congenital heart disease or chronic lung disease on ongoing therapy for those conditions, and to premature children in remote areas. In general, PTs had more liberal policies than the CPS, offering palivizumab to a wide range of children with conditions such as cystic fibrosis, Down syndrome or to moderately premature children with risk factors. Substantial variation in PT criteria for RSV prevention exists in Canada, and no jurisdiction follows CPS criteria exactly. Variability in subnational policy may reflect access to human or material resources, varying interpretation of evidence for efficacy, variation in epidemiology, the effect of local pressures, or advocacy.

Palivizumab Prophylaxis for infants 29 to 32 weeks gestation at birth: A 10-year audit from Vancouver Island using BC Guidelines.

After initially recommending palivizumab (PVZ), a monoclonal antibody against respiratory syncytial virus (RSV) for all infants 29 to 32 weeks at birth if <6 months age at season start, the American Academy of Pediatrics (AAP) and Canadian Paediatric Society (CPS) guidelines were revised. British Columbia was the only jurisdiction in North America to restrict eligibility for this group to those with additional risk factors, long before the change in national recommendations. To determine the risk for first season RSV admission for 29 to 32-week gestational age (GA) infants admitted to Victoria Neonatal Intensive Care Unit (NICU) that either received or were denied PVZ prophylaxis. Descriptive cohort study of infants eligible for prophylaxis according to earlier CPS guidelines. Instead, BC guidelines for prophylaxis were applied and data for Vancouver Island infants were collected over 10 consecutive RSV seasons. We followed 423 infants. Three hundred and thirty-six (79%) did not receive prophylaxis, of which 10 (3.0%; 95% confidence interval [CI] 1.4% to 5.4%) had an RSV hospitalization before the end of April during their first RSV season versus 3 admissions from 87 (3.5%; 95% CI 0.7% to 10%) infants who received prophylaxis. Our risk factor approach to RSV prophylaxis for infants born at 29 to 32 weeks GA resulted in a low (average incidence=3.1%) rate of RSV hospitalization. Our approach would offer considerable cost savings to RSV prophylaxis programs that continue to offer routine prophylaxis beyond 28/29 weeks GA at birth.

P132: Trampoline park safety perceptions of caregivers of patients presenting to the paediatric emergency department in London, Ontario

Introduction: Trampoline injuries are frequent complaints of children presenting to paediatric emergency departments (PED) in Canada. The medical community has recognized the danger of recreational trampoline use, with the Canadian Paediatric Society (CPS) formally recommending against their use. A new type of trampoline recreation has recently emerged in the form of trampoline parks. Trampoline parks are dangerous, with similar rates of injury as backyard trampolines, and an increased likelihood of injuries warranting hospital admission. No current Canadian governmental or industry regulations exist for trampoline parks. This study aimed to determine the public perspective of trampoline park safety in order to provide a basis for addressing the current lack of safety recommendations around trampoline parks. Methods: Parents/caregivers of children seeking care in the PED were approached to participate in a survey regarding trampoline safety. Parents/caregivers of patients with severe injury/illness were excluded. Survey questions included demographics, safety perceptions of both home trampolines and trampoline parks, as well as awareness of the CPS statement regarding trampoline use. The survey was completed in the Research Electronic Data Capture System. Results: To date, 68 participants have completed the survey. 66% of participants (45/68) were aware of the new trampoline parks recently opening in the community. 31/68 (46%) of participants had allowed their child to visit a trampoline park. A comparison of the perception of the relative safety of trampoline parks found that 31% of participants (21/67) considered home trampolines “safe/very safe” while 39% of participants (26/66) considered trampoline parks “safe/very safe.” The median [IQR] age at which participants thought children could safely play at trampoline parks was 10 [3-15]. 43% of participants (29/67) thought the current CPS statement about backyard trampolines should apply to trampoline parks, and 93% of participants (62/67) thought the Ontario government should institute mandatory standards for trampoline parks. Conclusion: Trampoline parks are a significant emerging source of paediatric injury. Trends in preliminary data suggest that participants consider trampoline parks to be safer than backyard trampolines, and perceive that young children can safely participate in trampoline park activities. Should final survey data analysis support these trends, a call for adjustment of CPS guidelines and public policy should proceed.

PREPAREDNESS OF CANADIAN PHYSICIAN OFFICES FOR PAEDIATRIC EMERGENCIES

Abstract BACKGROUND Studies in the US have demonstrated that many primary care staff and offices are inadequately prepared for paediatric emergencies. Although the Canadian Paediatric Society (CPS) recently reaffirmed their “Guidelines for Paediatric Emergency Equipment and Supplies for a Physician’s Office”, no evaluation has been made regarding the impact of publishing these recommendations, or on the state of preparedness for paediatric emergencies in family physician offices. OBJECTIVES The aim of this study was to evaluate awareness of and adherence of family physicians in Ontario to the CPS guidelines on preparedness for paediatric emergencies. DESIGN/METHODS We conducted a province-wide, cross-sectional survey of 749 randomly selected family physicians. Participants were asked to complete a 14-question survey regarding clinic characteristics, incidence of paediatric emergencies, and preparedness of the clinic in the case of a paediatric emergency. Ethics approval was obtained from the regional Ethics Review Board. RESULTS 94 physicians responded to our survey (response rate of 13.1%). 68.1% of respondents reported seeing more than 10 children per week, and 59.6% and had experienced at least one paediatric emergency in the past year. The proportion of physicians reporting paediatric emergencies within the last year increased with the number of children seen - 37.9% of physicians who saw fewer than 10 children per week reported an emergency, compared to 100.0% of those who saw more than 40 children per week. Only 4.3% respondents reported that they were unaware of the CPS guidelines on paediatric emergency preparedness. Although 85.1% of respondents were aware of the guidelines, only 10.6% of respondents had read them. Of the physicians who were aware of but had not read the guidelines, 2.5% engaged in mock code sessions, 27.8% were up-to-date on Paediatric Advanced Life Support (PALS), 1.3% had written protocols outlining safe transport of children to hospitals, and 41.8% stocked half or more of the recommended supplies. In comparison, of the physicians who had read the guidelines, 20.0% engaged in mock code sessions, 50.0% were up-to-date on PALS, 10.0% had written protocols, and 70.0% stocked half or more of the recommended supplies. CONCLUSION A large proportion of respondents had experienced at least one paediatric emergency in the past year, but were overall underprepared. There was a discrepancy between physicians who were aware of the CPS guidelines on emergency preparedness (85.1%), and those who have actually read them (10.6%), though offices with the latter were more adherent to the guidelines’ recommendations. It will be important for CPS to consider how to further advocate for paediatric emergency preparedness in clinics that see children regularly.

ANTIBIOTIC USE FOR INPATIENT BRONCHIOLITIS: DID NATIONAL GUIDELINES CHANGE PRACTICE?

Abstract BACKGROUND Millions of infants and young children are affected by bronchiolitis annually around the globe. This viral lower respiratory tract infection often results in hospital admissions, thus impacting the cost of the healthcare system. Because of its heterogeneous clinical presentation, inpatient management practices amongst paediatricians varies widely. The publication of national guidelines by the Canadian Paediatric Society (CPS) in 2014 was aimed at decreasing the use of unnecessary investigations and therapies for inpatient management of bronchiolitis. OBJECTIVES To evaluate the levels of antibiotic prescriptions and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. DESIGN/METHODS This study is a single-centre retrospective chart review of inpatients with confirmed cases of bronchiolitis. We included children with no other relevant co-morbidities, aged 1- 24 months, who were admitted from November 2011 – October 2016. We excluded those who were born less than 35 weeks gestational age and patients with chronic complex medical problems. Our inclusion and exclusion criteria mirrored those used in the CPS guidelines. Those admitted prior to December 2014 were analysed in the pre-guidelines cohort and the remaining were placed in the post-guidelines cohort. The main outcome was antibiotic prescription during the hospital stay. Secondary outcomes included the frequency of chest x-rays, nasopharyngeal swabs, and blood cultures. RESULTS 131 patients were included in the first (pre-guideline) cohort and 71 in the second (post- guideline) cohort. The overall initiation of antibiotics was almost equal in both cohorts, regardless of whether a chest x-ray was ordered (p=1.000). There was no significant difference in the number of chest x-rays ordered between cohorts (p=0.099). The percentage of patients discharged on antibiotics were significantly lower in the second cohort (p=0.018). More antibiotics were discontinued after a viral cause was isolated in the second cohort (p=0.001). The gender distribution, mean age and mean length of stay were almost equivalent between the cohorts. CONCLUSION Our study did not show a significant change in antibiotic prescription despite the release of national guidelines. We found that isolating a viral aetiology often leads to the discontinuation of antibiotics. This study emphasizes the need for local antimicrobial stewardship initiatives to reduce the use of unnecessary antibiotics.

P153: Preparedness of Canadian physician offices for paediatric emergencies

Introduction: Background: Studies in the US have demonstrated that many primary care staff and offices are inadequately prepared for paediatric emergencies. Although the Canadian Paediatric Society (CPS) recently reaffirmed their Guidelines for Paediatric Emergency Equipment and Supplies for a Physicians Office, no evaluation has been made regarding the impact of publishing these recommendations, or on the state of preparedness for paediatric emergencies in family physician offices. Objectives: The aim of this study was to evaluate awareness and adherence of family physicians in Ontario to the CPS guidelines on preparedness for paediatric emergencies. Methods: We conducted a province-wide, cross-sectional survey of 749 randomly selected family physicians. Participants were asked to complete a 14-question survey regarding clinic characteristics, incidence of paediatric emergencies, and preparedness of the clinic in the case of a paediatric emergency. Ethics approval was obtained from the regional Ethics Review Board. Results: 104 physicians responded to our Ontario survey (response rate of 14.8%). 71.2% of respondents reported seeing more than 10 children per week, and 58.7% and had experienced at least one paediatric emergency in the past year. The proportion of physicians reporting paediatric emergencies within the last year increased with the number of children seen - 37.9% of physicians who saw fewer than 10 children per week reported an emergency, compared to 85.7% of those who saw more than 40 children per week. 85.6% of respondents reported that they were unaware of the CPS guidelines on paediatric emergency preparedness. Only 9.6% of respondents were aware of the guidelines, and even fewer, 3.8% had read them. Of the physicians who were unaware of the guidelines, 4.5% [CI=0.2, -0.09] engaged in mock code sessions, 29.2% [CI=0.2, 0.2] were up-to-date on Paediatric Advanced Life Support (PALS), 1.1% [CI=0.03, -0.01] had written protocols outlining safe transport of children to hospitals, and 50.6% [CI=0.4, 0.6] stocked half or more of the recommended supplies. In comparison, of the physicians who were aware of the guidelines, 14.3% [CI=0.3, -0.04] engaged in mock code sessions, 35.7% [CI=0.1, 0.6] were up-to-date on PALS, 7.1% [CI=0.2, -0.06] had written protocols, and 78.6% [CI=0.8, 0.8] stocked half or more of the recommended supplies. Conclusion: A large proportion of respondents had experienced at least one paediatric emergency in the past year, but were overall underprepared. The majority of respondents, 85.6%, were not aware of the guidelines, compared to 9.6% who were aware of them. However, offices with the latter were more adherent to the guidelines recommendations. It will be important for CPS to consider how to further advocate for paediatric emergency preparedness in clinics that see children regularly.

Implementation of the Canadian Paediatric Society's hyperbilirubinemia guidelines: A survey of Ontario hospitals

In 2007, the Canadian Paediatric Society (CPS) published guidelines aimed at preventing severe hyperbilirubinemia. To determine whether hospitals had implemented these guidelines; to investigate how guideline-recommended care is organized; and to understand the factors influencing guideline implementation. The present study was an online survey conducted from December 2011 to May 2012 of all Ontario hospitals offering maternal-newborn services. A total of 97 of 100 eligible hospitals responded. Seventy-seven of the 97 (79%) respondents reported having implemented universal neonatal bilirubin screening. Among these hospitals, hospital-based postdischarge follow-up was reported more frequently than follow-up at community-based locations: hospital laboratory (n=40 [52%]), mother-baby care unit (n=32 [42%]), outpatient clinic (n=25 [33%]), primary care provider in community (n=19 [25%]) and community laboratory (n=8 [10%]). The CPS guidelines were the most frequently reported factor influencing implementation (n=74 [96%]). The survey provides valuable insight into the impact of a complex guideline in Canada's largest province. There was heterogeneity in how hospitals organized services, but there was a notable trend toward hospital-based postdischarge care. The shift to hospital-based care runs counter to current health policy directions and highlights the lack of integration among health care sectors. The majority of Ontario hospitals implemented universal bilirubin screening following the release of the CPS guidelines. Further analysis is needed to determine the impact that the guidelines and the differences in implementation have had on clinical outcomes and the utilization of health services.

Palivizumab use among children with congenital heart disease in Quebec: Impact of Canadian guidelines on clinical practice

Palivizumab has been shown to reduce the risk of hospitalization caused by respiratory syncytial virus in children with congenital heart disease (CHD). Guidelines published in 2003 by the Canadian Paediatric Society (CPS) stated that children younger than 24 months with hemodynamically significant CHD should be considered for up to five monthly doses of palivizumab during the winter season. To assess the impact of CPS guidelines on the use of palivizumab in children with CHD. Clinical information was reviewed on all patients with CHD who were prescribed palivizumab in 2002-2003 and 2003-2004 and who were followed by one of four paediatric cardiovascular programs in the province of Quebec. Palivizumab was prescribed to 45 children in 2002-2003 and to 146 children in 2003-2004. The number of children receiving more than five doses increased from 10 of 45 (22%) in 2002-2003 to 57 of 128 (45%) in 2003-2004 (P=0.008). One hundred seventeen of 146 children (80%) receiving palivizumab in 2003-2004 met the CPS guidelines versus 38 of 45 children (84%) in 2002-2003 (ie, before the guidelines were published) (P=0.66). Patients not meeting CPS criteria were older than 24 months at the time of the first dose, had hemodynamically insignificant CHD or had lesions adequately corrected by surgery. The number of children with CHD receiving palivizumab prophylaxis increased significantly following the publication of CPS guidelines. The majority of children were eligible for palivizumab according to the current CPS criteria. More patients received more than five doses in 2003-2004 than in 2002-2003.

Net cost of palivizumab for respiratory syncytial virus prophylaxis during the 1998/99 season in northern Alberta.

Palivizumab has been shown to decrease respiratory syncytial virus (RSV) hospitalization rates in preterm infants and infants with chronic lung disease. The objective of the present study was to determine whether the use of palivizumab during the 1998/99 RSV season would have resulted in a cost-saving in infants discharged from Edmonton hospitals. A retrospective study of RSV hospitalizations was performed by contacting parents and reviewing hospital lists. The net cost of using palivizumab was determined by comparing the cost of giving the drug from November 1, 1998 to April 1, 1999 with the cost of potentially averted medical transports and hospitalizations. One hundred fifty-nine infants discharged from Edmonton hospitals who met the Canadian Paediatric Society's criteria for receiving palivizumab during the 1998/99 RSV season were studied. The cost of using palivizumab in these 159 study infants would have been $753,300. The infants had 21 RSV hospitalizations and required four medical transports. The estimated cost of RSV hospital-based care for these infants was $168,888. Assuming a drug efficacy of 39% in infants with chronic lung disease and 78% in infants born before 33 weeks' gestation with no chronic lung disease, $121,147 of these costs could have been averted if palivizumab had been used. The net cost to the health care system of using palivizumab, as recommended in the Canadian Paediatric Society guidelines, in study infants in northern Alberta during the 1998/99 RSV season would have been $632,153.