Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach.

BACKGROUND: In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania. METHODS: A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required. RESULTS: Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a "normal" process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery. CONCLUSION: Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

Kidney and blood pressure abnormalities 6 years after acute kidney injury in critically ill children: a prospective cohort study.

BACKGROUND: Acute kidney injury (AKI) in pediatric intensive care unit (PICU) children may be associated with long-term chronic kidney disease or hypertension. OBJECTIVES: To estimate (1) prevalence of kidney abnormalities (low estimated glomerular filtration rate (eGFR) or albuminuria) and blood pressure (BP) consistent with pre-hypertension or hypertension, 6 years after PICU admission; (2) if AKI is associated with these outcomes. METHODS: Longitudinal study of children admitted to two Canadian PICUs (January 2005-December 2011). Exposures (retrospective): AKI or stage 2/3 AKI (KDIGO creatinine-based definition) during PICU. Primary outcome (single visit 6 years after admission): presence of (a) low eGFR (<90 ml/min/1.73 m2) or albuminuria (albumin to creatinine ratio >30 mg/g) (termed "CKD signs") or (b) BP consistent with ≥pre-hypertension (≥90th percentile) or hypertension (≥95th percentile). RESULTS: Of 277 children, 25% had AKI. AKI and stage 2/3 AKI were associated with 2.2- and 6.6-fold higher adjusted odds, respectively, for the 6-year outcomes. Applying new hypertension guidelines attenuated associations; stage 2/3 AKI was associated with 4.5-fold higher adjusted odds for 6-year CKD signs or ≥elevated BP. CONCLUSIONS: Kidney and BP abnormalities are common 6 years after PICU admission and associated with AKI. Other risk factors must be elucidated to develop follow-up recommendations and reduce cardiovascular risk.

A single gestational weight gain recommendation is possible for all classes of pregnant women with obesity.

OBJECTIVES: Obesity is a known risk factor for adverse pregnancy outcomes; however, appropriate gestational weight gain (GWG) may mitigate these risks. We investigated whether the singular 2009 Institute of Medicine (IOM) GWG guidelines were appropriate for all women with obesity, or whether separate recommendations were needed by class. METHODS: This cross-sectional study of pregnant women with obesity used 2014 U.S. birth certificate data (N=646,642) and included only term pregnancies. Adjusted log-binomial regression models examined the relative risk of adverse maternal, obstetric, and neonatal outcomes for pregnant women with class I-III obesity who: lost weight during pregnancy, gained below IOM guidelines, or gained above IOM guidelines, compared to women who gained within IOM guidelines. RESULTS: Most women (55.1; 95% CI: 55.0-55.3) gained above IOM guidelines. As BMI severity increased, significantly fewer women had excessive GWG (Class I: 61.6%, 95% CI: 61.4-61.7; II: 50.7%, 95% CI: 50.4-50.9; III: 41.1%, 95% CI: 40.8-41.4). All classes of women with obesity who lost weight during pregnancy or gained below had a significantly decreased risk for caesarean delivery (RR (95% CI) class I: 0.92 (0.90-0.94); II: 0.91 (0.89-0.93); III: 0.92 (0.90-0.93)) and large-for-gestational age (LGA) births (class I: 0.80 (0.77-0.83); II: 0.76 (0.73-0.78); III: 0.73 (0.70-0.75)), but significantly increased risk of small-for-gestational age (SGA) births (class I: 1.34 (1.26-1.43); II: 1.38 (1.28-1.49); III: 1.35 (1.24-1.46)). CONCLUSION: The observed pattern of association was the same for all obese classes, hence evidence supports a possible singular GWG recommendation for all women with obesity, regardless of class.

Hypophosphatemia is Prevalent among Preterm Infants Less than 1,500 Grams.

OBJECTIVE: This article identifies the prevalence and associated factors of hypophosphatemia (HP) in very low birth weight (VLBW) infants in the first week of life. STUDY DESIGN: Prospective exploratory cohort study of 106 consecutive VLBW infants admitted to neonatal intensive care at Foothills Hospital, Calgary, Canada. HP was defined as at least one measurement of serum phosphate < 1.5 mmol/L (4.5 mg/dL). RESULTS: Seventy-seven percent (82/106) of the VLBW infants had HP, with significantly higher prevalence in infants < 1,000 g (94%) compared to infants ≥ 1,000 g (61%) (p < 0.001). Hypophosphatemic infants had lower birth weight (p < 0.001), gestational age (p < 0.001), and their increase in phosphate intake was slower (p = 0.003). Respiratory distress syndrome (RDS) (p = 0.002), intraventricular hemorrhage (IVH) ≥ grade III (p = 0.020), and hyperglycemia (p = 0.013) were more frequent among hypophosphatemic infants, especially among those < 1,000 g. Mortality, seizures, arrhythmias, and need for transfusion were not different between groups. Birth weight modified the association between RDS, IVH, hyperglycemia, and HP. CONCLUSION: HP was ubiquitous among infants < 1,000 g and highly prevalent among those weighing 1,000 to 1,500 g. While the direction of effect was not clear, RDS, IVH, and hyperglycemia were associated with HP. Prevention of HP in these physiologically immature neonates might improve neonatal outcomes.

Missed opportunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania.

BACKGROUND: Despite the significant benefits of early detection and management of pregnancy related complications during antenatal care (ANC) visits, not all pregnant women in Tanzania initiate ANC in a timely manner. The primary objectives of this research study in rural communities of Geita district, Northwest Tanzania were: 1) to conduct a population-based study that examined the utilization and availability of ANC services; and 2) to explore the challenges faced by women who visited ANC clinics and barriers to utilization of ANC among pregnant women. METHODS: A sequential explanatory mixed method design was utilized. Household surveys that examined antenatal service utilization and availability were conducted in 11 randomly selected wards in Geita district. One thousand, seven hundred and nineteen pregnant women in their 3rd trimester participated in household surveys. It was followed by focus group discussions with community health workers and pregnant women that examined challenges and barriers to ANC. RESULTS: Of the pregnant women who participated, 86.74% attended an ANC clinic at least once; 3.62% initiated ANC in the first trimester; 13.26% had not initiated ANC when they were interviewed in their 3rd trimester. Of the women who had attended ANC at least once, the majority (82.96%) had been checked for HIV status, less than a half (48.36%) were checked for hemoglobin level, and only a minority had been screened for syphilis (6.51%). Among women offered laboratory testing, the prevalence of HIV was 3.88%, syphilis, 18.57%, and anemia, 54.09%. In terms of other preventive measures, 91.01% received a tetanus toxoid vaccination, 76.32%, antimalarial drugs, 65.13%, antihelminthic drugs, and 76.12%, iron supplements at least once. Significant challenges identified by women who visited ANC clinics included lack of male partner involvement, informal regulations imposed by health care providers, perceived poor quality of care, and health care system related factors. Socio-cultural beliefs, fear of HIV testing, poverty and distance from health clinics were reported as barriers to early ANC utilization. CONCLUSION: Access to effective ANC remains a challenge among women in Geita district. Notably, most women initiated ANC late and early initiation did not guarantee care that could contribute to better pregnancy outcomes.

The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from oMakoti in uMgungundlovu District, South Africa.

INTRODUCTION: In response to revisions in global and national policy in 2011, six-month isoniazid preventive therapy (IPT) became freely available as a preventive measure for people living with HIV in the uMgungundlovu District of KwaZulu-Natal province, South Africa. Given a difference in uptake and completion by sex, we sought to explore the reasons why Zulu women were more likely to accept and complete IPT compared to men in an effort to inform future implementation. METHODS: Utilising a community-based participatory research approach and ethnographic methods, we undertook 17 individual and group interviews, and met regularly with grassroots community advisory teams in three Zulu communities located in uMgungundlovu District between March 2012-December 2016. FINDINGS & DISCUSSION: Three categories described women's willingness to initiate IPT: women are caregivers, women are obedient, and appearance is important. The findings suggest that the success of IPT implementation amongst clinic-utilising women of uMgungundlovu is related to the cultural gender norms of uMakoti, isiZulu for "the bride" or "the wife." We invoke the cultural concept of inhlonipho, meaning "to show respect," to discuss how the cultural values of uMakoti may conflict with biomedical expectations of adherence. Such conflict can result in misinterpretations by healthcare providers or patients, and lead some patients to fear the repercussions of asking questions or contemplating discontinuation with the provider, preferring instead to appear obedient. We propose a shift in emphasis from adherence-focussed strategies, characteristic of the current biomedical approach, to practices that promote patient agency in an effort to offer IPT more appropriately. IMPLICATIONS: Building on existing tools, namely the harm reduction model and the use of mini-ethnography, we provide guidance on how to support women to participate as agents in the decision to initiate or continue IPT, decisions which may also impact the health and choices of the family.

Tuberculosis Contact Screening and Isoniazid Preventive Therapy Among Children Under 5 in the Mbeya and Songwe Regions, Tanzania.

INTRODUCTION: The World Health Organization (WHO) recommends contact screening and initiation of isoniazid preventive therapy (IPT) for children under 5 years of age exposed to a sputum smear-positive (SS+) tuberculosis (TB) source case. We conducted this study in order to assess implementation of these recommendations in southwestern Tanzania. METHODS: We conducted this cross-sectional study from June to August 2015 in 12 selected health facilities in the Mbeya and Songwe regions of Tanzania. Adult SS+ pulmonary TB patients living in the same household as children under 5 were enrolled. Structured questionnaires were used to obtain sociodemographic information and details about screening and intervention activity related to contact children under 5. Data were analysed using Stata version 11.0. RESULTS: We enrolled 257 index cases, who collectively had 433 contact children under 5. The median age of the index cases was 34 years (interquartile range 28 to 41) and 52.9% were male. Out of 433 contacts, 31 (7.2%) were screened for TB, of whom 7 (22.6%) were treated for presumptive TB. Among those screened, 24 were not diagnosed with TB, of whom only 8 (33.3%) received IPT. CONCLUSION: Low uptake of TB contact screening and IPT administration among eligible children under 5 was observed in this study. Health-care workers should be sensitized to screening of household contacts of adults with SS+ TB and initiate IPT in those who are eligible.

Early-Onset Invasive Candidiasis in Extremely Low Birth Weight Infants: Perinatal Acquisition Predicts Poor Outcome.

BACKGROUND: Neonatal invasive candidiasis (IC) presenting in the first week of life is less common and less well described than later-onset IC. Risk factors, clinical features, and disease outcomes have not been studied in early-onset disease (EOD, ≤7 days) or compared to late-onset disease (LOD, >7 days). METHODS: All extremely low birth weight (ELBW, <1000 g) cases with IC and controls from a multicenter study of neonatal candidiasis enrolled from 2001 to 2003 were included in this study. Factors associated with occurrence and outcome of EOD in ELBW infants were determined. RESULTS: Forty-five ELBW infants and their 84 matched controls were included. Fourteen (31%) ELBW infants had EOD. Birth weight <750 g, gestation <25 weeks, chorioamnionitis, and vaginal delivery were all strongly associated with EOD. Infection with Candida albicans, disseminated disease, pneumonia, and cardiovascular disease were significantly more common in EOD than in LOD. The EOD case fatality rate (71%) was higher than in LOD (32%) or controls (15%) (P = .0001). The rate of neurodevelopmental impairment and mortality combined was similar in EOD (86%) and LOD (72%), but higher than in controls (32%; P = .007). CONCLUSIONS: ELBW infants with EOD have a very poor prognosis compared to those with LOD. The role of perinatal transmission in EOD is supported by its association with chorioamnionitis, vaginal delivery, and pneumonia. Dissemination and cardiovascular involvement are common, and affected infants often die. Empiric treatment should be considered for ELBW infants delivered vaginally who have pneumonia and whose mothers have chorioamnionitis or an intrauterine foreign body.

Bisphenol A exposure and children's behavior: A systematic review.

Bisphenol A (BPA) is an endocrine disrupting chemical used to synthesize polycarbonate plastics and epoxy resins. Previous research suggests that exposure to it can alter children's behavior. The objective of this study is to conduct a systematic review of the existing literature, examining associations between prenatal and childhood BPA exposure and behavior in children up to 12 years of age. We searched electronic bibliographic databases (MEDLINE, PubMed, EMBASE, PsycINFO, CINAHL, and ERIC), reference lists of included articles, and conference abstracts (American Psychiatric Association, American Academy of Neurology, Pediatric Academic Societies, and International Society of Environmental Epidemiology). We included original studies reporting on the association between prenatal and childhood BPA exposure that measured BPA metabolites in urine and children's behavioral outcomes. From 2811 citations, 11 articles met our inclusion criteria. Descriptive analyses indicated that prenatal exposure to maternal BPA concentrations were related to higher levels of anxiety, depression, aggression, and hyperactivity in children. BPA exposure in childhood was associated with higher levels of anxiety, depression, hyperactivity, inattention, and conduct problems. Limited observational evidence suggests an association between both prenatal and childhood exposure to BPA and adverse behavioral outcomes in children. Prospective cohort studies are needed to clarify these associations.

Determinants of developmental outcomes in a very preterm Canadian cohort.

OBJECTIVES: Identify determinants of neurodevelopmental outcome in preterm children. METHODS: Prospective national cohort study of children born between 2009 and 2011 at <29 weeks gestational age, admitted to one of 28 Canadian neonatal intensive care units and assessed at a Canadian Neonatal Follow-up Network site at 21 months corrected age for cerebral palsy (CP), visual, hearing and developmental status using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). Stepwise regression analyses evaluated the effect of (1) prenatal and neonatal characteristics, (2) admission severity of illness, (3) major neonatal morbidities, (4) neonatal neuroimaging abnormalities, and (5) site on neurodevelopmental impairment (NDI) (Bayley-III score < 85, any CP, visual or hearing impairment), significant neurodevelopmental impairment (sNDI) (Bayley-III < 70, severe CP, blind or hearing aided and sNDI or death. RESULTS: Of the 3700 admissions without severe congenital anomalies, 84% survived to discharge and of the 2340 admissions, 46% (IQR site variation 38%-51%) had a NDI, 17% (11%-23%) had a sNDI, 6.4% (3.1%-8.6%) had CP, 2.6% (2.5%-13.3%) had hearing aids or cochlear implants and 1.6% (0%-3.1%) had a bilateral visual impairment. Bayley-III composite scores of <70 for cognitive, language and motor domains were 3.3%, 10.9% and 6.7%, respectively. Gestational age, sex, outborn, illness severity, bronchopulmonary dysplasia, necrotising enterocolitis, late-onset sepsis, retinopathy of prematurity, abnormal neuroimaging and site were significantly associated with NDI or sNDI. Site variation ORs for NDI, sNDI and sNDI/death ranged from 0.3-4.3, 0.04-3.5 and 0.12-1.96, respectively. CONCLUSION: Most preterm survivors are free of sNDI. The risk factors, including site, associated with neurodevelopmental status suggest opportunities for improving outcomes.

Early childhood language outcomes after arterial switch operation: a prospective cohort study.

BACKGROUND: Developmental and language outcomes at 2 years of age of children who had arterial switch operation (ASO) for transposition of the great arteries 2004-2010 are described. METHODS: In this prospective cohort study, 91/98 (93 %) children who underwent ASO were assessed at 2 years of age with the Bayley Scales of Infant & Toddler Development-3rd Edition. Outcomes were compared by patient and perioperative variables using bivariate and multivariate regression analyses to identify predictors of language delay. RESULTS: Infants without ventricular septal defect (VSD) (n = 60) were more likely to be outborn (73 vs 58 %, p = 0.038), require septostomy (80 vs 58 %, p = 0.026), have a shorter cross clamp time (min) (62.7 vs 73.0, p = 0.019), and a lower day 1 post-operative plasma lactate (mmol/L) (3.9 vs 4.8, p = 0.010). There were no differences in cognitive, motor and language outcomes based on presence of a VSD. Language delay (<85) of 29 % was 1.8 times higher than the normative sample; risk factors for this in multivariate analyses included <12 years of maternal education (AOR 19.3, 95 % CI 2.5-148.0) and cross-clamp time ≥70 min (AOR 14.5, 95 % CI 3.1-68.5). Maternal education <12 years was associated with lower Language Composite Scores (-20.2, 95 % CI -32.3 to -9.1). CONCLUSIONS: Outcomes at 2 years of age in children who undergo ASO are comparable to the normative sample with the exception of language. There is a risk of language delay for which maternal education and cross-clamp duration are predictors. These findings suggest that focused post-operative early language interventions could be considered.

Prediction of Late Death or Disability at Age 5 Years Using a Count of 3 Neonatal Morbidities in Very Low Birth Weight Infants.

OBJECTIVE: To evaluate bronchopulmonary dysplasia (BPD), serious brain injury, and severe retinopathy of prematurity (ROP) as predictors of poor long-term outcome in very low birth weight infants. STUDY DESIGN: We examined the associations between counts of the 3 morbidities and long-term outcomes in 1514 of 1791 (85%) infants with birth weights of 500-1250 g who were enrolled in the Caffeine for Apnea of Prematurity trial from October 1999, to October 2004, had complete morbidity data, and were alive at 36 weeks postmenstrual age (PMA). BPD was defined as use of supplemental oxygen at 36 weeks PMA. Serious brain injury on cranial ultrasound included grade 3 and 4 hemorrhage, cystic periventricular leucomalacia, porencephalic cysts, or ventriculomegaly of any cause. Poor long-term outcome was death after 36 weeks PMA or survival to 5 years with 1 or more of the following disabilities: motor impairment, cognitive impairment, behavior problems, poor general health, deafness, and blindness. RESULTS: BPD, serious brain injury, and severe ROP occurred in 43%, 13%, and 6% of the infants, respectively. Each of the 3 morbidities was similarly and independently correlated with poor 5-year outcome. Rates of death or disability (95% CI) in children with none, any 1, any 2, and all 3 morbidities were 11.2% (9.0%-13.7%), 22.9% (19.6%-26.5%), 43.9% (35.5%-52.6%), and 61.5% (40.6%-79.8%), respectively. CONCLUSIONS: In very low birth weight infants who survive to 36 weeks PMA, a count of BPD, serious brain injury, and severe ROP predicts the risk of a late death or survival with disability at 5 years.

Risk factors for positional plagiocephaly and appropriate time frames for prevention messaging.

OBJECTIVE: To determine potential risk factors for developing positional plagiocephaly in infants seven to 12 weeks of age in Calgary, Alberta. METHODS: A prospective cohort design was used. Healthy term infants (n=440), seven to 12 weeks of age, from well-child clinics at four community health centres in Calgary, Alberta were assessed by the primary author and a registered nurse research assistant using Argenta's plagiocephaly assessment tool. Parents completed a questionnaire surveying risk factors. RESULTS: The incidence of positional plagiocephaly was estimated to be 46.6%. The following risk factors were identified using multiple logistic regression: right-sided head positional preference (OR 4.66 [95% CI 2.85 to 7.58]; P<0.001), left-sided head positional preference (OR 4.21 [95% CI 2.45 to 7.25]; P<0.001), supine sleep position (OR 2.67 [95% CI 1.58 to 4.51]; P<0.001), vacuum/forceps assisted delivery (OR 1.88 [95% CI 1.02 to 3.49]; P=0.04) and male sex (OR 1.55 [95% CI 1.00 to 2.38]; P=0.05). CONCLUSION: Advice to vary infants' head positions needs to be communicated to parents/guardians well before the two-month well-child clinic visit. This could occur in the prenatal period by prenatal care providers or educators, or during the neonatal period by postpartum and public health nurses. Prevention education may be emphasized for parents/guardians of male infants and infants who have had assisted deliveries.

OBJECTIF: Déterminer les facteurs de risque potentiels de plagiocéphalie positionnelle chez les nourrissons de sept à 12 semaines à Calgary, en Alberta. MÉTHODOLOGIE: Dans une cohorte prospective, des nourrissons à terme et en santé (n=440) de sept à 12 semaines provenant de cliniques d'enfants en santé de quatre centres de santé communautaire de Calgary, en Alberta, ont été évalués par l'auteur principal et une infirmière adjointe à la recherche au moyen de l'outil d'évaluation de la plagiocéphalie d'Argenta. Les parents ont rempli un questionnaire pour déterminer les facteurs de risque. RÉSULTATS: L'incidence de plagiocéphalie positionnelle a été évaluée à 46,6 %. Les facteurs de risque suivants ont été déterminés au moyen de la régression logistique multiple : préférence positionnelle de la tête à droite (RC 4,66 [95 % IC 2,85 à 7,58]; P<0,001), préférence positionnelle de la tête à gauche (RC 4,21 [95 % IC 2,45 à 7,25]; P<0,001), position de sommeil en décubitus dorsal (RC 2,67 [95 % IC 1,58 à 4,51]; P<0,001), accouchement assisté par ventouses ou forceps (RC 1,88 [95 % IC 1,02 à 3,49]; P=0,04) et sexe masculin (RC 1,55 [95 % IC 1,00 à 2,38]; P=0,05). CONCLUSION: Il faut conseiller aux parents ou aux tuteurs de modifier la position de la tête du nourrisson bien avant le rendez-vous à la clinique pour enfants en santé à deux mois. Ces conseils pourraient être donnés pendant la période prénatale par les dispensateurs ou les éducateurs de soins prénatals ou par des infirmières postnatales ou des infirmières de santé publique pendant la période néonatale. On peut donner des conseils de prévention aux parents ou aux tuteurs des nourrissons de sexe masculin et de ceux qui ont eu un accouchement assisté.

The incidence of positional plagiocephaly: a cohort study.

OBJECTIVE: The objective of this study was to estimate the incidence of positional plagiocephaly in infants 7 to 12 weeks of age who attend the 2-month well-child clinic in Calgary, Alberta, Canada. METHODS: A prospective cohort design was used to recruit 440 healthy full-term infants (born at ≥37 weeks of gestation) who presented at 2-month well-child clinics for public health nursing services (eg, immunization) in the city of Calgary, Alberta. The study was completed in 4 community health centers (CHCs) from July to September 2010. The CHCs were selected based on their location, each CHC representing 1 quadrant of the city. Argenta's (2004) plagiocephaly assessment tool was used to identify the presence or absence of plagiocephaly. RESULTS: Of the 440 infants assessed, 205 were observed to have some form of plagiocephaly. The incidence of plagiocephaly in infants at 7 to 12 weeks of age was estimated to be 46.6%. Of all infants with plagiocephaly, 63.2% were affected on the right side and 78.3% had a mild form. CONCLUSIONS: To our knowledge, this is the first population-based study to investigate the incidence of positional plagiocephaly using 4 community-based data collection sites. Future studies are required to corroborate the findings of our study. Research is required to assess the incidence of plagiocephaly using Argenta's plagiocephaly assessment tool across more CHCs and to assess prevalence at different infant age groups. The utility of using Argenta's plagiocephaly assessment tool by public health nurses and/or family physicians needs to be established.

Risk factors for preterm birth and small-for-gestational-age births among Canadian women.

BACKGROUND: Preterm births (PTB) and small-for-gestational-age (SGA) births are distinct but related pregnancy outcomes, with differing aetiologies and short and long-term morbidities. Few studies have compared a broad array of predictors among these two outcomes. The purpose of this study was to compare risk factors for PTB and SGA births using a national sample of Canadian women. METHODS: We analysed data from the Canadian Maternity Experiences Survey (n = 6421). Mothers were ≥ 15 years of age, gave birth to a singleton infant and were living with their infant at the time of the interview (between 5 and 14 months post-partum). Backward stepwise multivariable logistic regression models were constructed for each outcome. RESULTS: Risk profiles for the two outcomes had both differences and similarities. Risk factors specific to PTB were education less than high school, having a previous medical condition, developing a new medical condition or health problem during pregnancy, being a primigravida, or being a multigravida with a previous PTB or a previous miscarriage or abortion. Risk factors unique to SGA were low pre-pregnancy body mass index (<18 kg/m(2) ), smoking during pregnancy and being a recent immigrant. Risk factors for both outcomes included low weight gain during pregnancy (<9.1 kg), short stature (<155 cm) and reporting life as 'very stressful' in the year prior to birth of the baby. CONCLUSION: A greater understanding of the risk factors related to PTB and SGA may help to reduce the prevalence of these conditions and the associated risk of infant mortality and morbidity.

The 'picky eater': The toddler or preschooler who does not eat.

The majority of children between one and five years of age who are brought in by their parents for refusing to eat are healthy and have an appetite that is appropriate for their age and growth rate. Unrealistic parental expectations may result in unnecessary concern, and inappropriate threats or punishments may aggravate a child's refusal to eat. A detailed history and general physical examination are necessary to rule out acute and chronic illnesses. A food diary and assessment of parental expectations about eating behaviour should be completed. Where the child's 'refusal' to eat is found to be related to unrealistic expectations, parents should be reassured and counselled about the normal growth and development of children at this age.

La majorité des enfants de un à cinq ans pour qui les parents consultent parce qu'ils refusent de manger sont en bonne santé et ont un appétit qui convient à leur âge et à leur rythme de croissance. Les attentes irréalistes des parents peuvent donner lieu à des inquiétudes inutiles, et les menaces et punitions déplacées peuvent aggraver le refus de manger de l'enfant. Les médecins doivent procéder à une anamnèse détaillée et à un examen physique général pour écarter une maladie aiguë ou chronique. Ils doivent demander un journal alimentaire et évaluer les attentes des parents à l'égard du comportement alimentaire. Lorsque le « refus de manger ¼ de l'enfant semble lié à des attentes irréalistes, il faut rassurer les parents et leur donner des conseils sur la croissance et le développement normaux des enfants de cet âge.

Mortality after neonatal cardiac surgery: Prediction from mean arterial pressure after rewarming in the operating room.

OBJECTIVE: To examine the predictive contribution of mean arterial pressure after rewarming to > or =34 degrees C in the operating room to mortality after cardiac surgery in infants < or =6 weeks old. METHODS: In this prospective inception cohort study, 70 consecutive infants who had open cardiac surgery with deep hypothermic circulatory arrest when < or =6 weeks old in the years 1996 to 1999 had follow-up to 5 years of age. Demographic, preoperative, operative, and postoperative variables were recorded prospectively. The previously unexplored variables of lowest mean arterial pressure in the operating room after rewarming to 34 degrees C were recorded retrospectively from anesthesia records. Predictor variables for death were examined using univariate and multivariate analyses. RESULTS: Deep hypothermic circulatory arrest time, re-cardiopulmonary bypass in the operating room, duration of mean arterial pressure below 40, 35, 30, and 25 mm Hg after rewarming in the operating room, time for lactate to return to < or =2 mmol/L postoperatively, and cardiopulmonary resuscitation were significantly associated with death at 1 and 5 years of age on univariate analysis. Multivariate stepwise forward logistic regression analysis found the duration of mean arterial pressure after rewarming below 30 mm Hg (odds ratio 1.094; 95% confidence interval 1.033-1.158) and cardiopulmonary resuscitation (odds ratio 13.800, 95% CI 3.062-62.194) were significant predictors of death by 5 years of age. Stepwise multiple regression using pre- and intraoperative variables accounted for 30.1% of the variability related to mean arterial pressure < or =30 mm Hg after rewarming. CONCLUSION: In these infants, low mean arterial pressure after rewarming in the operating room, even for brief times, is significantly associated with death.

Clinical correlations and pulmonary function at 8 years of age after severe neonatal respiratory failure.

OBJECTIVES: The aim of this study was to determine the pulmonary sequelae of severe neonatal respiratory failure. STUDY DESIGN: This was a multicenter, prospective study. Fifty-four survivors of neonatal respiratory failure (oxygenation indices >25 on two occasions), completed pulmonary function testing at 8 years of age. Thirty-one (57%) received extracorporeal membrane oxygenation (ECMO). Pulmonary outcome was based on spirometry and lung volume data. Pulmonary outcome for each diagnostic and treatment group is reported as mean and as percent predicted. Individually subjects were also classified based on spirometry, as either normal, obstructed (defined as forced expiratory volume (FEV(1)) in 1 sec:forced vital capacity (FVC) of <80 % predicted, or with reduced FVC (FCV of <80% predicted) with normal FEV(1)/FVC. Risk for adverse outcome was determined using univariate analysis. RESULTS: Mean FVC, FEV(1) and FEV(25-75) were reduced in the total cohort. The reduction was greatest in the subgroup with CDH and the group treated with ECMO. Assessed individually, 54% of subjects had normal spirometry and lung volumes, 19% airflow obstruction, and 27% reduced FVC. Poorer pulmonary outcome was linked to ECMO, congenital diaphragmatic hernia (CDH), birth weight for gestational age <10th percentile, duration of hospitalization, or need for prolonged supplemental oxygen. CONCLUSION: Neonates with severe respiratory failure due to CDH or needing ECMO and small for gestation are at increased risk of poorer pulmonary outcome and require close follow-up.

Intermediate-term outcomes of the arterial switch operation for transposition of great arteries in neonates: alive but well?

OBJECTIVES: This interprovincial inception cohort study outlines the operative and intermediate outcomes of all neonates at a single institution with a broad referral area who underwent the arterial switch operation for transposition of great arteries, including complex types. Predictors of outcome are explored. METHODS: A total of 88 consecutive neonates underwent the arterial switch operation between 1996 and 2004 with full-flow (150 mg/kg/min) cardiopulmonary bypass with selective deep hypothermic circulatory arrest. Overall and event-free survivals were calculated. Health and neurodevelopment (Bayley Scales of Infant Development II) were assessed at 18 to 24 months of age. Univariate and multivariate analyses, sensitivity, and specificity were determined to identify preoperative, intraoperative, and postoperative factors associated with mental and/or motor delay. RESULTS: There was 1 operative mortality (1.1%). At the average 4-year follow-up, survival was 98.9% and freedom from reintervention was 93.2%. Eighty-five children were assessed. Three were excluded because of unrelated postoperative diagnoses. For the remaining 82, mean scores were 89 +/- 17 (49-118) for mental skills and 92 +/- 15 (49-125) for motor skills. Anatomic complexity, cardiopulmonary bypass, and deep hypothermic circulatory arrest times were not associated with developmental outcome. Preoperative variables of low gestational age and high preoperative lactate correctly classified 84.1% of mentally and/or motor-delayed children. CONCLUSION: Transposition of great arteries, including complex types, can be corrected with low surgical risk and good intermediate survival; however, neurodevelopmental outcome is a concern. These data suggest that although anatomic complexity may not affect late outcome, there may be potentially modifiable preoperative factors that can be optimized to improve developmental outcomes.