Evidence based pediatrics - part 1 ppt

Dele Davies, MD, MSc, FRCPC Director, Child Health Research Unit Alberta Children’s Hospital Associate Professor Departments of Pediatrics, Microbiology and Infectious Diseases and The H

E VIDENCE -B ASED

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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and prac- tice at the time of publication However, since research and regulation constantly change clinical stan- dards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications This is particularly important with new or infrequently used drugs.

Adelle Roberta Atkinson, RN, BSc, MD,

IWK Grace Health Centre

Professor and Chair, Department of

Pediatrics

Dalhousie University Medical School

Halifax, Canada

H Dele Davies, MD, MSc, FRCPC

Director, Child Health Research Unit

Alberta Children’s Hospital

Associate Professor

Departments of Pediatrics, Microbiology

and Infectious Diseases and

The Hospital for Sick Children

Assistant Professor of Pediatrics

Dalhousie UniversityHalifax, Canada

Darcy L Fehlings, MD, MSc, FRCPC

Hospital for Sick ChildrenBloorview MacMillan CentreAssistant Professor in PediatricsUniversity of Toronto

Toronto, Canada

Brian M Feldman, MD, MSc, FRCPC

Staff RheumatologistThe Hospital for Sick ChildrenClinical Chief, Arthritis TeamBloorview MacMillan CentreAssistant Professor

University of TorontoToronto, Canada

Mark E Feldman, MD, FRCPC

Chief of Pediatrics

St Joseph’s Health CentreAssistant ProfessorUniversity of TorontoToronto, Canada

William Feldman, MD, FRCPC

Professor Emeritus of PediatricsUniversity of Toronto

Editor, Annals of the Royal College

of Physicians and Surgeons ofCanada

Ottawa, CanadaContributors

O

Norma Goggin, MBBCh, MRCP

Lecturer in Ambulatory Paediatrics,

Department of Child Health

Royal Free and University College Medical

School

University College London

Royal Free Hospital

London, United Kingdom

Ronald Gold, MD, MPH, FRCPC

Honorary Consultant

The Hospital for Sick Children

Professor Emeritus of Pediatrics

Faculty of Medicine

University of Toronto

Toronto, Canada

Eudice Goldberg, MD, FRCPC

Head, Division of Adolescent Medicine

The Hospital for Sick Children

Associate Professor of Pediatrics

Division of Pediatric Neurology

IWK-Grace Health Centre

Associate Professor, Department of

Division of Pediatric Medicine

The Hospital for Sick Children

Professor of Pediatrics

University of Toronto

Toronto, Canada

Moshe Ipp, MBBCh, FRCPC, FAAP

The Hospital for Sick ChildrenAssociate Professor

University of TorontoToronto, Canada

Sheila J Jacobson, MBBCh

Division of Pediatric MedicineThe Hospital for Sick ChildrenAssistant Professor in PediatricsUniversity of Toronto

Kevin B Laupland, MD, FRCPC

Division of Infectious DiseasesAlberta Children’s HospitalFellow, Infectious Diseases and CriticalCare

University of CalgaryCalgary, Canada

Katherine A Leonard, MD, FRCPC

Adolescent Health ServiceNorth York General HospitalPediatric Department/Teen ClinicCentenary Health Centre

North York, Canada

Brian W McCrindle, MD, MPH, FRCPC

Staff CardiologistThe Hospital for Sick ChildrenAssociate Professor of PediatricsUniversity of Toronto

Toronto, Canada

vi Evidence-Based Pediatrics

Golda Milo-Manson, MD, MHSc, FRCPC

Developmental Pediatrician

Bloorview-MacMillan Centre

The Hospital for Sick Children

North York General Hospital

Assistant Professor

University of Toronto

Toronto, Canada

Michael E.K Moffatt, MSc, FRCPC

Health Sciences Centre

Professor and Head, Department of

Pediatrics and Child Health

University of Manitoba

Winnipeg, Canada

Arne Ohlsson, MD, MSc, FRCPC

Director, Evidence Based Neonatal Care

and Outcomes Research

Staff Neonatologist

Mount Sinai Hospital

Professor, Departments of Pediatrics,

Obstetrics and Gynecology, and Public

University of Toronto Faculty of Medicine

Head, Division of Pediatric Medicine

Hospital for Sick Children

Toronto, Canada

Hema Patel, MD, MSc, FRCPC

Ambulatory Care Pediatrician

The Montreal Children’s Hospital

Assistant Professor in Pediatrics

Vibhuti Shah, MD, MRCP(UK)

Department of Newborn andDevelopmental PediatricsResearch Fellow in NeonatologySunnybrook and Women’s College HealthSciences Centre

Toronto, Canada

Amir Shanon, MD, MPA

Director, Department of MedicalProfessionals

Ministry of HealthTel Aviv, Israel

Michelle Kiran Shouldice, MSc, MD,

FRCPCSection Head, Pediatric OutpatientConsultation

The Hospital for Sick ChildrenAssistant Professor

University of TorontoToronto, Canada

Michael B.H Smith, MBBCh, FRCPC

Division Head in Pediatric MedicinePhysician Leader Acute and Chronic CareIWK Grace Health Centre

Assistant Professor in PediatricsDalhousie University

Halifax, Canada

Lynne J Warda, MD, FRCPC

Pediatric Emergency PhysicianChildren’s Hospital, WinnipegMedical Director, IMPACT—The InjuryPrevention Centre of Children’sHospital, Winnipeg

Assistant Professor, Department ofPediatrics and Child HealthUniversity of ManitobaWinnipeg, Canada

Contributors vii

This book is dedicated to infants, children, and adolescents, and to the physicians who care for them The recipients and providers of

health care all benefit when the care is evidence based.

Preface O

Appropriate medical care for infants and children has three components The first consists

of the clinical skills of the practitioner to provide the preventive, diagnostic, and tic interventions that are required to maintain health and to solve clinical problems The sec-ond component is the practitioner’s awareness of the need to ascertain the patients’ andparents’ knowledge of the nature of the problem and their values regarding how it should besolved The third component, and by no means the least important, is the practitioner’sdetermination that all interventions—preventive, diagnostic, therapeutic, and rehabilita-tive—should only be offered when the evidence that the intervention does more good thanharm has been thoroughly reviewed

therapeu-The purpose of this book is to provide the physicians and nurses who care for infantsand children with the best available evidence regarding the benefit/risk ratios underlyingtheir interventions

To quote those who have made the concept of “evidence-based medicine” recognizedthroughout the world: “ evidence-based medicine involves the integration of our clinicalexpertise, and our patients’ values, with the best available research evidence.”1

As the editor of Evidence-Based Pediatrics, I was faced with a number of challenges The

first was the choice of topics and problems to be included in the book Because the likeliestreaders are those engaged in the frontline provision of child health care, I decided that theemphasis would be on the most prevalent problems that pediatricians, family physicians, andnurses would face in day-to-day practice

Although only a few rare conditions are discussed, the “red flags” that should alert thepractitioner that a rare or serious condition may be causing the child’s problems, are high-lighted throughout the book

The second challenge was the choice of authors Having practiced as a primary care atrician, a subspecialist, and mainly as a general consultant pediatrician, I was aware thatpediatricians in all three categories have valuable perspectives regarding child health care Ichose, therefore, not to select chapter writers on the basis of whether they were primary-carepediatricians, general consultants, or subspecialists, but rather on the basis of their clinicalexpertise and their knowledge and practice of evidence-based pediatrics Thus, some of theauthors are in busy primary care practices, some are hospital-based general consultants, andsome are subspecialists

pedi-Finally, the challenge of how to evaluate the quality of the evidence and the strength ofthe recommendations required careful consideration I chose the system of evaluation of evi-dence used by the Canadian Task Force on the Periodic Health Examination.2A similar sys-tem has also been used by the U.S Preventive Services Task Force.3In this system (Table 1),the highest quality (level I) of evidence is that obtained from properly conducted random-ized controlled trials (RCTs), and the lowest level (level III) is that derived from opinions ofauthorities or expert committees, or from descriptive studies An “A” recommendation, usu-ally based on level I evidence, advises the practitioner to perform the intervention becausethe benefit/risk ratio is clearly high A “C” recommendation advises the practitioner that theevidence either to use or not use a particular intervention is poor An “E” recommendationadvises that the intervention should not be used, either because the evidence is good that themaneuver is ineffective or is actually harmful The “B” and “D” recommendations are based

on “fair” evidence that the maneuver should (B) or should not (D) be performed

This system of grading the evidence and recommendations was chosen because it hasbeen widely used throughout North America for at least 20 years and appears to be wellunderstood and accepted In correspondence with a colleague, who practices and teachesFamily Medicine, the system is described as having “real clinical utility as a way to summa-rize evidence I know of no other that is better or more transparent.” As he states, “In my dis-cussions with practicing family doctors, they have often said that they really want the bottomline What they mean is that at the community level, they need to know concisely and in atimely fashion (without having to search out the original studies) what they should do withthe patient in the office Having “A”, “B”, “C”, etc is helpful and straightforward.”4

I hope the readers of this book will find the evidence and the recommendations concise,timely, helpful, and straightforward

William Feldman, MD, FRCPC

QUALITY OF EVIDENCE

I: Evidence obtained from at least one properly randomized controlled trial.II-1: Evidence obtained from well-designed controlled trials without randomizationII-2: Evidence obtained from well-designed cohort or case-control analytic studies,preferably from more than one center or research group

II-3: Evidence obtained from comparisons between times or places with or without theintervention Dramatic results in uncontrolled experiments (such as the results oftreatment with penicillin in the 1940s) could also be included in this category.III: Opinions of respected authorities, based on clinical experience, descriptive stud-ies or reports of expert committees

C: There is poor evidence regarding the value or harm of the intervention;

recom-mendations may be made on other grounds

D: There is fair evidence to support the recommendation that the intervention not

Contents O

Preface ix

1 Problems of the Newborn: Prevention and Management 1

Vibhuti Shah, MD, MRCP, Arne Ohlsson, MD, MSc, FRCPC

2 Health Maintenance Visits: a Critical Review 17

Norman R Saunders, MD, FRCPC, Michelle Shouldice, MSc, MD, FRCPC

3 Immunization 39

Ronald Gold, MD, MPH, FRCPC

4 Nutrition Problems in Childhood 65

R.I Hilliard, MD, EdD, FRCPC

5 Acute Rhinitis and Pharyngitis 83

Michael B.H Smith, MBBCh, FRCPC

6 Otitis Media 103

Moshe Ipp, MBBCh, FRCPC, FAAP

7 Asthma 123

Patricia Parkin, MDM FRCPC, Norma Goggin, MBBCh, MRCP

8 Pneumonia and Bronchilotis 155

Kevin B Laupland, MD, FRCPC, H Dele Davies, MD, MSc, FRCPC

9 Croup 177

Mark Elliott Feldman, MD, FRCPC

10 Common Cardiovascular Problems 191

J.M Dooley, MBBCh, FRCPC, K.E Gordon, MD, MS, FRCPC

14 Injury Prevention: Effectiveness of Primary Care Interventions 267

Lynne J Warda, MD, FRCPC

15 Fever 283

Amir Shanon, MD, MPA

16 Screening for Anemia in Infants and Toddlers 293

Michael E.K Moffatt, MD, MSc, FRCPC

17 Urinary Tract Problems in Primary Care 301

20 Common Sleep Problems in Children 383

Darcy L Fehlings, MD, MSc, FRCPC, Golda Milo-Manson, MD, MHSc, FRCPC

21 Common Skin Disorders 401

Sheila Jacobson, MBBCh

22 Learning Disabilities and Attention Deficit Hyperactivity Disorder 415

Saul Greenberg, MD, FRCPC

23 Challenges in Adolescent Health 439

Debra K Katzman, MD, FRCPC, Katherine A Leonard, MD, FRCPC,

Eudice Goldberg, MD, FRCPC

Index 461

xii Contents

even after adjusting for maternal age, parity, marital status, and infant’s gender.7If groups ofall education levels had the same low rates as that of the higher-education group, the num-ber of fetal and infant deaths would be reduced by approximately 20 percent.

Significant variations in survival rates exist among neonates admitted to different dian neonatal intensive care units.8“Benchmarking” techniques can be used to improve thecare and outcomes in a unit with marked variance from the norm.9

Perinatal surveillance is a system of data collection, data analysis, and response The dian Perinatal Surveillance System (CPSS) plans to collect and analyze data on all recognizedpregnancies in Canada, regardless of their outcome — abortion, ectopic pregnancy, stillbirth,

Cana-or live birth — and the data on the determinants of health during the first year of life Suchdata collection and analysis will allow for benchmarking at a national, regional, or local level.9

Standardized perinatal records carried by the pregnant woman would increase her feeling ofhaving control over her antenatal care and also would facilitate data collection.10,11

ANTENATALINTERVENTIONS TOIMPROVEPERINATALOUTCOMES

The Cochrane Library is the best single source of reliable evidence on the effects of tal/neonatal health care.2It currently includes 149 full reviews and 24 protocols from thePregnancy and Child Birth Review group and 73 reviews and 21 protocols from the Neona-tal Review group.2As new reviews are added quarterly and old reviews are updated regularly,the Cochrane Library should be made available in the delivery/postpartum areas and con-sulted for the most up-to-date information A new “obstetric wheel” that is an improvement

perina-on the existing obstetric calendar wheels has been developed.12,13It incorporates based information in an innovative way It should facilitate prenatal care, education, andcommunication and foster realistic expectations about the likely timing of delivery

evidence-RESUSCITATION

All health-care givers attending deliveries should be trained in neonatal resuscitation inaccordance with the latest guidelines by the American Academy of Pediatrics (AAP) and theAmerican Heart Association.14

EXAMINATION ATBIRTH

If at all possible, the examination of the newborn should take place in the presence of at leastone of the parents so that any deviation from the norm can be discussed with the parentsand any questions can be answered Proper hand-washing prior to the examination is essen-tial The hips and the genital and anorectal areas should be examined last Table 1–1 lists thechronological steps that will facilitate the physical examination of the newborn infant, causeminimal amount of stress, and reduce the risk of nosocomial infections Admission and dis-charge examinations of the newborn should be done on two separate occasions

VITAMINK

To prevent hemorrhagic disease of the newborn, vitamin K1should be given as a single muscular dose of 1.0 mg within the first 6 hours after birth to all newborns with a birthweight >1,500 g; if the birth weight is <1,500 g, 0.5 mg should be given.15The pain response

intra-to an intramuscular injection of vitamin K1 may be less, if given shortly after birth.16

OPHTHALMIANEONATORUM

Ophthalmia neonatorum is defined as conjunctivitis with discharge occurring in the firstmonth of life Untreated, it can lead to blindness, especially if the infectious agent is

Neisseria gonorrhea Etiologic agents may be chemical (topical antimicrobial agents),

bac-terial, or rarely viral, such as herpes virus, molluscum contagiosum, and papilloma virus.Neonates present with redness of the conjunctiva, swelling of the eyelids, and purulent dis-

2 Evidence-Based Pediatrics

charge Gonococcal ophthalmia neonatorum tends to start earlier and be more severe thanchlamydial infection The efficacy of single-dose topical antimicrobial prophylaxis in pre-venting ophthalmia neonatorum has been established Universal ocular prophylaxis, which

is a routine practice in Canada and the United States, should be administered as soon aspossible (within 1 hour) after birth.17One percent silver nitrate,180.5 percent erythromycin,

or 1 percent tetracycline ointment19-21have comparable efficacy in preventing

conjunc-tivitis caused by most bacterial pathogens, including penicillin-sensitive Neisseria

gonor-rhea Although Chlamydia trachomatis is sensitive to erythromycin, tetracycline, and silver

nitrate, the evidence supporting the efficacy of these agents has not been established.22-23

Recent studies24,25 evaluating the efficacy of 0.5 percent erythromycin, 1 percent silvernitrate, and 2.5 percent povidone-iodine as prophylactic agents demonstrated that the use

of povidone-iodine was associated with fewer cases of ophthalmia neonatorum and wasfound to be more effective against chlamydial conjunctivitis as compared with the othertwo agents The potential advantages of povidone-iodine include a broader antibacterialspectrum, and an antiviral spectrum, which includes herpes simplex and human immun-

Problems of the Newborn: Prevention and Management 3

Table 1–1 History and Examination of the Newborn*

• Family, obstetric, and labor history

• Weight, length, head circumference (growth in relation to gestational age)

• Presence of any unusual facial features (facial nerve palsy) or external

malformations/deformations Normal eyes Normal sucking reflex

• Head (fontanels, sutures, presence of cephalic hematoma, caput succedaneum, vacuum extraction

or forceps marks), nostrils patent, palate intact, normally formed external ears

• Vital signs (pink in room air, normal breathing pattern [absence of flaring of nostrils, grunting, retractions, stridor], heart rate, perfusion, level of consciousness, tone, normal temperature)

• Skin (cyanosis, jaundice, rash, abrasion, petechiae, distribution of hair)

• Auscultation of chest and heart (air entry equal on both sides, heart sounds heard best to the left

of the midline, regular heart rate, no murmur detected)

• Examination of the abdomen (shape, masses, size of liver/spleen)

• Normal umbilical cord with three vessels

• Presence of femoral pulses Absence of inguinal masses

• Genitalia (descended testes, normal sized penis without hypospadias, ambiguous genitalia, hyperpigmentation of genitalia, vaginal secretions)

• Neurological: presence of neonatal reflexes (symmetric Moro reflex: no brachial plexus injury, presence of grasp reflex)

• Hips (dislocation: ultrasound examination for confirmation)

• Normal cry

• Spine (deep pinonidal sinus, hair-tuft: ultrasound examination to rule out/in spina bifida occulta)

• Anus (patency)

• Any concerns raised by family members or attending health-care workers to be addressed

*to be performed after birth and at discharge from hospital in the presence of a family member

odeficiency virus (HIV); it is less costly and can be prepared locally Further studies areneeded to assess its effectiveness and possible toxicity in ophthalmia neonatorum Theavailability of effective ocular prophylaxis, however, does not diminish the importance ofprenatal screening for and appropriate treatment of maternal gonococcal and chlamydialinfections.

METABOLICSCREENING

Guthrie developed newborn screening for inborn errors of metabolism, using dried bloodsamples on filter paper in the 1960s.26Since then screening for phenylketonuria (PKU) andcongenital hypothyroidism (CH) has been recommended for all newborns prior to dischargefrom the nursery in the developed countries; screening for other disorders is highly variable.Phenylketonuria, a disorder of phenylalanine metabolism has an incidence of 1:10,000 to1:25,000 births in North America.27Without treatment, affected individuals develop severemental retardation, seizures, spasticity, eczema, and autistic-like behavior Since the imple-mentation of screening and early dietary interventions, these manifestations have rarelydeveloped in children born after the mid-1960s.28-32The AAP and the American Academy ofFamily Physicians recommend screening of all newborns prior to discharge from the nurs-ery and repeat screening at 1 to 2 weeks of age for infants discharged prior to 24 hours.33

Similar recommendations have been published by the Canadian Task Force, except thatrepeat screening be performed at 2 to 7 days of age for infants discharged prior to 24 hours

of age.34Premature infants and those with illnesses should be tested at or near 7 days of age.There is a growing concern that the practice of early discharge from the nursery may lead to

a falsely negative screening result as the test is most reliable when performed at 24 to 48 hours

of age, 24 hours after the first protein feed.35

Congenital hypothyroidism, also detected by newborn screening, has an incidence of1:3,600 to 1:5,000.36Deficiency of the thyroid hormone leads to mental retardation, if notdiagnosed early and treated Most infants appear to be clinically normal until 3 months ofage; therefore laboratory tests are the only reliable means of diagnosing CH Treatment issimple and effective, with thyroid hormone replacement Screening has been extremelysuccessful in eradicating severe mental retardation resulting from CH However, despiteearly diagnosis through screening, children with severe CH (ie, those with marked retar-dation of bone age and/or low circulating thyroxine [T4] before treatment) have lower IQthan children with less severe CH.37Recent studies suggest that this developmental gap may

be closed with early treatment (within 2 weeks of birth), using a higher dose of roxine.38

to breast feed during the preconception period or in early pregnancy were more likely to

4 Evidence-Based Pediatrics

breast feed longer than mothers who made their decision later.51,52Also, mothers with vious breast-feeding experience were noted to have high initiation and duration rates.53

pre-Recently, breast-feeding difficulties have been compounded by a trend toward early charge of newborns and mothers Both the CPS54 and AAP55 have set standards for early dis-charge, which include breast-feeding criteria, and emphasize the need for an early follow-upvisit for newborns discharged less than 48 hours after birth Two of the best measures ofbreast-feeding adequacy include infant weight and elimination patterns.56 Traditionally,physicians have been trained to accept a weight loss of 10 percent of birth weight as normal;however, by redefining excessive weight loss as 8 percent of birth weight, more at-risk infantscould be targeted for early interventions A newborn’s elimination pattern is also a sensitiveindicator of adequacy of milk intake Usually, within a day or two after the initiation ofbreast-feeding, a newborn should be voiding urine six to eight times and passing more thanfour yellow, seedy “milk” stools per day

dis-There are few contraindications to breast-feeding, and these include maternal HIVinfection, active tuberculosis, or drug abuse and galactosemia in the infant.57,58The use of asmall number of maternal medications prohibits breast-feeding (eg, cytotoxic and immuno-suppressive drugs and gold salts) Comprehensive tables of drugs that are safe or con-traindicated are available to the physician for reference.59

In newborns, structural defects such as cleft lip and palate, and alterations in ical functions such as in Down syndrome or hydrocephalus require special management tofacilitate breast-feeding.60

neurolog-In 1989, the World Health Organization (WHO) and the United Nations Children’s Fund(UNICEF) jointly launched the “Baby-Friendly Hospital Initiative,” which emphasized the cre-ation of a hospital environment friendly to mothers and babies This initiative was based onprincipals summarized in a joint statement issued by the two organizations in 1989 to sup-port, protect, and promote breast-feeding.61,62A baby-friendly code of practice standards wasdrafted by the UNICEF and WHO (Table 1–3) To date, no hospital in Canada has beenassigned as baby-friendly by the UNICEF, whereas in a less technologically developed coun-try such as the Sultanate of Oman, all delivery units have been designated as “baby-friendly.”63

In summary, optimizing breast-feeding outcomes begins in the perinatal period witheffective breast-feeding education and screening for lactation risk factors Early initiation ofnursing, bedside instruction in the proper breast-feeding technique, rooming-in, and avoid-ance of pacifiers and unnecessary supplementation of breast-fed infants fosters successfulbreast-feeding during hospital stay Early follow-up of infants after hospital discharge should

be advocated to assess the effectiveness of breast-feeding

Problems of the Newborn: Prevention and Management 5

Table 1–2 Advantages of Breast-Feeding

• Provides ideal nutrition for infants and contributes to their healthy growth and

development 40,41

• Reduces incidence and severity of infectious disease, thereby lowering infant morbidity and mortality 42,43

• Protects against allergies 44,45

• Contributes to women’s health by reducing the risk of breast and ovarian cancers, and by

increasing the spacing between pregnancies 46,47

• Provides social and economic benefits to the family and the nation

• Brings mother and baby together emotionally as well as physically, and helps to build a secure and loving relationship

Postpartum hospital stays have decreased markedly over the past two decades from 4.1 days

to 2.6 days between 1970 and 1992 in the United States66and from 5.3 days in 1984 to 1985

to 3.0 days in 1994 to 1995 (including cesarean sections) in Canada.67Since 1992, the length

of stay has further decreased, with many infants being discharged at 24 hours or less aftervaginal birth, and at 72 hours or less after cesarean birth Similar reductions have also beenobserved in other jurisdictions such as the United Kingdom, Australia, and Scandinavia.68-71

This trend that began as a consumer-driven movement has now been generalized, out adequate study, to all low-risk newborns.72The theoretical advantages of shorter post-partum hospital stay are economic (eg, fewer hospital days), medical (eg, reduction in thenumber of iatrogenic events such as cross-infection), increased breast feeding,73psychoso-cial (eg, parental preference, facilitation of bonding and attachment, enhanced family inter-actions),74 improved patient satisfaction,73 and better postpartum adjustment.61 Thepotential disadvantages are social (eg, other parental preference, fewer opportunities toteach breast-feeding and parental skills) and medical (inability or failure to detect medicalproblems that become apparent only after 24 to 72 hours of age) The AAP47and the CPS,

with-in conjunction with the Society of Obstetricians and Gynecologists of Canada,54have lished guidelines that list explicit criteria for discharge prior to 48 hours Two reviews pub-lished recently concerning early newborn discharge conclude that the definitive study of

pub-6 Evidence-Based Pediatrics

Table 1–3 “Ten Steps to Successful Breast-Feeding”

1 Have a written breast-feeding policy that is routinely communicated to all health care staff.

2 Train all health-care staff in the skills necessary to implement this policy.

3 Inform all pregnant women about the benefits and management of breast-feeding.

4 Help mothers initiate breast feeding within 1 hour of birth.

5 Show mothers how to breast feed, and how to maintain lactation even if they are separated from their infants.

6 Give newborn infants no food or drink other than breast milk unless medically indicated.

7 Practice rooming-in: allow mothers and infants to stay together 24 hours a day.

8 Encourage breast-feeding on demand.

9 Give no artificial teats or pacifiers (also called dummies and soothers) to breast-feeding infants.

10 Foster the establishment of breast-feeding support groups and refer mothers to them on

discharge from hospital or clinic.

With permission from World Health Organization/United Nations Children’s Fund: Protecting, promoting and supporting breastfeeding: the special role of maternity services, a joint WHO/UNICEF statement 1989 Geneva, Switerland.

early newborn discharge has not been done.75,76 Both groups conclude that publishedresearch to date provides little information on the consequences of shorter hospital stays

or varying postdischarge practices for the low-risk population Most of these studies wereapplied under restricted circumstances or were too small to detect a clinically significanteffect on important outcomes No adequately designed studies have examined early dis-charge without additional postdischarge services A recent Canadian study concluded that

a decrease in the mean length of stay from 4.5 days to 2.7 days, without community

follow-up, was associated with increased re-admission rate in the first 2 weeks of life.77The mainreasons for re-admission were jaundice and dehydration Thus, decisions regarding the tim-ing of discharge of the newborn should be individualized and made by the practitioner onthe basis of the “unique characteristics of each mother and newborn,” the ability and con-fidence of the parents to care for the newborn, the support system at home, and the access

to appropriate follow-up

NEONATALHYPERBILIRUBINEMIA

Between 25 and 50 percent of full-term and a higher percentage of preterm infants developclinical jaundice Jaundice results from accumulation in the skin of unconjugated (indirect)lipid-soluble bilirubin derived from the breakdown of heme-containing proteins in thereticuloendothelial system In the liver, unconjugated bilirubin is converted to water-solubleconjugated (direct) bilirubin by glucuronyl transferase enzyme and excreted through the bileinto intestines and out through the feces Neontal hyperbilirubinemia (NHB) can be broadlycategorized into two groups:

Physiologic Jaundice

1 In the term infant, jaundice usually appears by the 2nd or 3rd day of life, peaks between

102 and 136 mmol/L (6 to 8 mg/dL) by 3 days of age, with a maximum level of

204 mmol/L (12 mg/dL), and then declines

2 In the preterm infant, the peak level may be 170 to 204 mmol/L (10 to 12 mg/dL) by the5th day of life, with a maximum level of 255 mmol/L (15 mg/dL) without any specificabnormality of bilirubin metabolism

Factors responsible for physiologic jaundice include increased red blood cell volume,decreased red blood cell survival, increased ineffective erythropoiesis and turnover of nonhemoglobin heme proteins, increased enterohepatic circulation, and defective conjugationdue to decreased activity of glucuronyl transferase in infants

Pathologic or Nonphysiologic Jaundice

This type is characterized by the following:

1 Jaundice visible within the first 24 hours of life

2 Hemolysis due to maternal isoimmunization, G-6-PD deficiency, spherocytosis, or othercauses

3 A rise in serum bilirubin of more than 8 to 9 mmol/L (0.5 mg/dL) per hour

4 Signs of underlying illness in any infant (vomiting, lethargy, poor feeding, temperatureinstability)

5 Elevation of serum bilirubin requiring phototherapy

6 Jaundice persisting after 8 days in a term infant or after 14 days in a preterm infant

A bilirubin level that justifies consideration for phototherapy should mandate gation of the cause of hyperbilirubinemia Management should include pertinent history ofmother, description of labor and delivery, physical examination, and infant’s clinical course.Table 1–4 lists the initial and subsequent laboratory investigations that should be under-taken

investi-Problems of the Newborn: Prevention and Management 7

Treatment for jaundice includes adequate hydration, phototherapy, and exchange fusion The goal of treatment is to avoid bilirubin concentrations that may result in ker-nicterus The effectiveness of phototherapy is related to the area of exposed skin and theradiant energy and wavelength of the light.78-82It causes bilirubin to be changed by struc-tural photoisomerization into water-soluble lumirubin, which is excreted in the urine.78

trans-Double or triple phototherapy is recommended to optimize the exposed skin surface and,thus, the efficacy of phototherapy Except the eyes, all areas of the body should be exposed

to light Exchange transfusion is performed when phototherapy fails to control the risingbilirubin levels

In 1994, the AAP issued a “practice parameter” with the aim to assist pediatricians andother health-care providers in managing hyperbilirubinemia in a healthy term infant withoutrisk factors.83The Fetus and Newborn Committee of the CPS has recently published guidelinesthat recommend lower levels of bilirubin at which to start phototherapy (Figure 1–1).84

The current practice of early discharge of neonates means that jaundice is often not sent/recognized at the time of discharge.85Appropriate parental education regarding feed-ing, signs of dehydration, and jaundice must be implemented in those nurseries where earlydischarge of neonates is practiced Testing for serum bilirubin concentrations must be avail-able on an outpatient basis, with adequate follow-up in place

pre-Bhutani and colleagues developed a nomogram for healthy term and near-term infants

by which an hour-specific total serum bilirubin before hospital discharge can predict whichinfant is at high (values > 95th percentile), intermediate (values between the 40th and 95thpercentiles) or low risk (below the 40th percentile) for developing clinically significanthyperbilirubinemia.86The intermediate zone was further divided into lower intermediate(between the 40th and 75th percentiles) and upper intermediate (between the 76th and 95thpercentiles) zones In their study, the likelihood ratio for developing clinically significantjaundice was increased 14-fold in the high-risk zone, 3.2-fold in the upper intermediate zone,0.5-fold in the lower intermediate zone, and none in the low risk zone Thus, in conjunctionwith the practice parameter, a universal predischarge total serum bilirubin measurementwould facilitate targeted intervention and follow-up in a safe manner

8 Evidence-Based Pediatrics

Table 1–4 Laboratory Investigation for Hyperbilirubinemia in Term Newborn Infants

Indicated (if bilirubin plasma/serum concentrations reach phototherapy levels)

• Total or unconjugated bilirubin concentration

• Conjugated bilirubin concentration

• Blood groups (mother and infant) with direct antibody test (Coombs’ test)

• Hemoglobin and hematocrit

Optional (in specific clinical circumstances)

• Complete blood count including manual differential white cell count

• Blood smear for red cell morphology

• Reticulocyte count

• Glucose-6-phosphate dehydrogenase screen

• Serum/plasma electrolytes and albumin or protein concentrations

With permission from Fetus and Newborn Committee, CPS Approach to management of hyperbilirubinemia in term newborn infants Pediatr Child Health 1999; 161-4.

cific protective effect of breast-feeding against SIDS has not been proven; however it should

be promoted because of its other well-documented benefits.89

LEVEL OFEVIDENCE

Table 1–6 outlines the quality of evidence and recommendations for interventions for ferent neonatal conditions

dif-10 Evidence-Based Pediatrics

Table 1–7 Websites that Provide Up-to-date Information Related to Perinatal/Neonatal Care

• American Academy of Pediatrics: http://www.aap.org

• British Association of Perinatal Medicine: http://www.bapm-London.org

• Canadian Pediatric Society: www.cps.ca

• Canadian Perinatal Surveillance System — Laboratory Center for Disease Control:

http://www.hc-sc.gc.ca/hpb/lcdc/brch/reprod.html

• Cochrane Library (abstracts of Cochrane reviews): http:hiru.mcmaster.ca/cochrane/

• Cochrane Library (full Cochrane neonatal reviews): http://silk.nih.gov/silk/cochrane

• Society of Obstetricians and Gynecologists of Canada: http://www.medical.org

• The College of Family Physicians of Canada: http://www.cfpc.ca

Table 1–6 Interventions in the Neonatal Period, the Quality of Evidence and Recommendations

Quality of Condition Intervention Evidence Recommendation

Ophthalmia Universal ocular prophylaxis I, II-1, Good evidence to neonatorum within one hour of birth II-3 recommend ocular

with 1% silver nitrate prophylaxis in solution, 0.5% erythromycin, newborns (A) 1% tetracycline ointment or

2.5% povidone-iodine solution

Hemorrhagic disease Prophylactic use of II-2, III Good evidence to

of the newborn vitamin K at birth (1 mg recommend

by intramuscular route) prophylaxis (A) Phenylketonuria (PKU) Newborn screening prior II-2, Good evidence to ensure and congenital to discharge from the hospital II-3,III screening for PKU and hypothyroidism (CH) Infants discharged prior to 24 CH (A)

hours of age should have a repeat screening test between

2 and 7 days Breast-feeding Promote breast- feeding II-2 Good evidence to counsel

women regarding breast-feeding (A) Sudden infant death “Back to sleep” campaign II-2, II-3, III Good evidence to support syndrome “sleeping on the back” (A)

INFORMATIONAVAILABLE ON THEINTERNET

Table 1–7 lists websites of different organizations providing information on tal care

perinatal/neona-REFERENCES

1 Ohlsson A Randomized controlled trials and systematic reviews: a foundation for evidence-based perinatal medicine Acta Pediatr 1996;85:647-55.

2 The Cochrane Library The Cochrane Library Issue 2 1999 Update Software Ltd.

3 Guyer B, MacDorman MF, Martin JA, et al Annual summary of vital statistics — 1997 Pediatrics 1998;102:1333-49.

4 Joseph KS, Kramer MS Recent trends in Canadian infant mortality rates: effect of changes in istration of live newborns weighing less than 500 g Can Med Assoc J 1996;155:1047-52.

reg-5 Joseph KS, Kramer MS, Marcoux S, et al Determinants of preterm birth rates in Canada from

1981 through 1983 and from 1992 through 1994 N Engl J Med 1998;339:1434-9.

6 Kramer MS Determinants of low birth weight: methodological assessment and meta-analysis Bull WHO 1987;65:663-737.

7 Chen J, Fair M, Wilkins R, Cyr M, Fetal and Infant Mortality Group of the Canadian Perinatal Surveillance System Maternal education and fetal and infant mortality in Quebec Health Rep Stat Can 1998;10:53-65.

8 Lee SK, Ohlsson A, Synnes AR, et al Mortality variations and illness severity (SNAP-II) in dian NICUs [abstract] Pediatr Res 1999;45:248A.

Cana-9 Mohr JJ, Mahoney CC, Nelson EC, et al Improving health care, Part 3: Clinical benchmarking for best patient care Quality Improvement 1996;22:599-616.

10 Elbourne D, Richardson M, Chalmers I, et al The Newbury maternity care study: a randomized controlled trial to assess a policy of women holding their own obstetric records Br J Obstet Gyn 1987;94:612-9.

11 Lacy B, Bartlett L, Ohlsson A A standard perinatal care record in Canada: justification, ability and feasibility J Soc Obstet Gyn Can 1998;20:557-65.

accept-12 Grzybowski S, Nout R, Kirkham CM Maternity care calendar wheel Improved obstetric wheel developed in British Columbia Can Fam Phys 1999;45:661-6.

13 Kirkham CM, Gryzbowski S Maternity care guidelines checklist To assist physicians in menting CPGs Can Fam Phys 1999;45:671-8.

imple-14 Bloom RS, Cropley C, AHA/AAP Neonatal Resuscitation Program Steering Committee Textbook

of neonatal resuscitation Elk Grove Village, Illinois: American Academy of Pediatrics, ican Heart Association; 1994.

Amer-15 Fetus and Newborn Committee Canadian Pediatric Society, Committee on Child and Adolescent Health, College of Family Physicians of Canada Routine administration of vitamin K to new- borns Pediatr Child Health Care 1997;2:429-31.

16 Bergqvist LL, Baumann P, Katz-Salamon M, et al The stress of birth modifies the response to pain during the first hours after birth [abstract] Pediatr Res 1999;45:350A.

Problems of the Newborn: Prevention and Management 11

17 Canadian Task Force on the Periodic Health Examination Periodic health examination, 1992, update 4 Prophylaxis for gonococcal and chlamydial ophthalmia neonatorum Can Med Assoc J 1992;147:1449-54.

18 Crede CSR Die Verhutung der Augenentzundung der Neugeborenen Arch Gyn 1881;18:367-70.

19 Lund RJ, Kibel MA, Knight GJ, van der Elst C Prophylaxis against gonococcal ophthalmia torum A prospective study S Afr Med J 1987;72:620-2.

neona-20 Hammerschlag MR, Chandler JW, Alexander ER, et al Erythromycin ointment for ocular phylaxis of neonatal chlamydial infection JAMA 1980;244:2291-3.

pro-21 Bell TA, Sandstrom KI, Gravett MG, et al Comparison of ophthalmic silver nitrate solution and

erythromycin ointment for prevention of natally acquired Chlamydia trachomatis Sex Trans

popu-27 Allen DB, Farrell PM Newborn screening: principles and practice Adv Pediatr 1996;43:231-70.

28 Berman PW, Waisman HA, Graham FK Intelligence in treated phenylketonuric children: a opmental study Child Develop 1966;37:731-47.

devel-29 Hudson FP, Mordaunt VL, Leahy I Evaluation of treatment begun in first three months of life in

184 cases of phenylketonuria Arch Dis Child 1970;45:5-12.

30 Williamson ML, Koch R, Azen C, Chang C Correlates of intelligence test results in treated phenylketonuric children Pediatrics 1981;68:161-7.

31 Azen CG, Koch R, Friedman EG, et al Intellectual development in 12-year old children treated for phenylketonuria Am J Dis Child 1991;145:35-9.

32 Koch R, Yusin M, Fishler K Successful adjustment to society by adults with phenylketonuria J Inherited Metabolic Dis 1985;8:209-11.

33 U.S Preventive Services Task Force Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions Baltimore: Williams & Wilkins; 1989 p 115-9.

34 Feldman W Screening for phenylketonuria In: Canadian Task Force on the Periodic Health Examination, editors The Canadian Guide to Clinical Preventive Health Care Ottawa: Min- ister of Public Works and Government Services Canada; 1994 p 179-88.

35 Charles S, Prystowsky B Early discharge, in the end: maternal abuse, child neglect, and physician harassment Pediatrics 1995;96:746-7.

36 Committee on Genetics Newborn screening fact sheets Pediatrics 1996;98:467-72.

12 Evidence-Based Pediatrics