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Introduction Rh sensitization occurs when Rh(D)-negative women develop anti-Rh(D) antibodies following exposure through pregnancy or transfusion. Rh disease may cause jaundice, anemia, neurological impairment, and death. It is rare in countries where Rh Immune Globulin (RhIg) is used. Canadian Rh sensitization and disease rates are unknown. Methods This survey-based study was conducted using a Canadian Paediatric Surveillance Program questionnaire sent to Canadian paediatricians and paediatric subspecialists to solicit Rh disease cases from May 2016 to June 2018. Paediatricians reported Rh-positive infants ≤ 60 days of age, born to Rh-negative mothers with RhD sensitization. Results Sixty-two confirmed cases of infants affected by Rh(D) sensitization were reported across Canada. The median gestational age of neonates was term, age at presentation was 2 hours, and hemoglobin at presentation was 137.5 g/L (33 to 203 g/L). The median peak bilirubin and phototherapy duration were 280 µmol/L (92 to 771 µmol/L), and 124 hours, respectively. Thirty (48%) infants received Intravenous immune globulin (IVIG) (median two doses). Seventeen (27%) received one to three simple transfusions; 10 (16%) required exchange transfusions. Six (10%) infants presented with acute bilirubin encephalopathy, and less than five presented with seizures. Fourteen mothers with affected infants were born outside of Canada. Discussion Rh disease continues to exist in Canada. Additional efforts are needed to raise awareness of Rh disease, prevent disease, and minimize sequelae when it does occur. The ongoing global burden of Rh Disease, as well as the possibility of emerging Rh immunoglobulin refusal are among factors that could be taken into consideration in future prevention efforts.

ObjectiveTo evaluate trends in organisms causing early-onset neonatal sepsis (EONS). Congruent with recent reports, we hypothesized there would be an increase in EONS caused by Escherichia coli.Study DesignNational data on infants admitted to neonatal intensive care units from 2009 to 2014 were compared to previously reported data from 2003 to 2008. We report 430 cases of EONS from 2009 to 2014. Bivariate analyses were used to analyze the distribution of causative organisms over time and differences by gestational age. Linear regression was used to estimate trends in causative organisms.ResultsSince 2003, there has been a trend of increasing numbers of cases caused by E coli (PConclusionsWith the majority of EONS cases now caused by E coli, our findings emphasize the importance of continued surveillance of causative organism patterns and developing approaches to reduce cases caused by E coli.

Background Insertion of an umbilical venous catheter (UVC) is a required skill for pediatric residents to learn and perform effectively. However, there is known variability in the ability of residents to perform this essential neonatal skill. Objective The objective of our study was to create a competency-based curriculum for umbilical vein catheter insertion using a human umbilical tissue simulated model, and to assess the feasibility of the curriculum on resident learners during their neonatology rotations. Methods We evaluated the curriculum by assessment of resident learning, reactions, and behaviours. Performance was assessed using the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). Results A total of 14 residents were included for analysis. The majority were 'senior' residents (postgraduate year (PGY)-3 and PGY-4 n = 10; PGY-1 n =4), and they reported a wide range of previous experience with UVC insertion prior to this curriculum implementation. The residents' reaction to the curriculum was overwhelmingly positive. All residents maintained or improved in their knowledge assessment. O-SCORE results showed improvement in UVC insertion before and after curriculum completion for both junior (2.5 +/- 0.71 to 4.5 +/- 0.41) and senior (3.55 +/- 0.42 to 4.95 +/- 0.15, p < 0.001) residents. The mean improvement in O-SCORE was greater for junior residents than senior residents. Conclusion The results of this study demonstrate the feasibility and emerging impact of a competency-based curriculum using simulation for procedural skills.

OBJECTIVE: To inform a shared care model between developmental and behavioural (DB) and mental health specialists and primary care physicians by having members of primary care family health teams (FHTs) report on strengths of and barriers to providing care for children with DB disorders and mental health concerns. DESIGN: Qualitative study using semistructured focus groups. SETTING: Academic and community-based FHTs in Toronto, Ont. PARTICIPANTS: Primary care physicians, nurses, allied health professionals, and family medicine trainees within the participating FHTs. METHODS: Nine focus groups were conducted with FHT members, and transcripts were analyzed for key themes using an inductive thematic analysis approach. MAIN FINDINGS: Eighty-four participants across 9 sites were interviewed. Six sites were academically affiliated and 3 were community based. Participants described their roles in the care of children with DB disorders as primarily “referral agent” but also as “long-term supporter” and “health care coordinator.” Family health team members expressed the desire to “learn” and “do more” for these children but noted numerous barriers to providing care, captured in 4 overarching themes: limited training beyond how to screen, lack of service knowledge, limited time and communication, and cumbersome access to mental health and dual diagnosis services. CONCLUSION: Primary care physicians are in the unique position of being able to provide longitudinal care for children with DB and mental health disorders. However, they perceive barriers to providing care that can affect access to services, service quality, and health outcomes for these children and their families. The health system might benefit from addressing these barriers by providing more training for primary care physicians in the longitudinal care of children with mental health and DB disorders, and by improving communication between FHTs and DB and mental health specialists regarding service navigation and emerging comorbidities. A shared care model integrating DB and mental health specialists into primary care might be one approach that warrants implementation and research.

Background At our inner city hospital, we developed a shared care model between family health teams (FHTs), pediatricians and developmental pediatricians to care for children with mental health and developmental disorders. In phase one of our study, 84 FHT members participated in focus groups to inform the development of our clinic. Family physicians described their role as “referral agent”, “long term supporter” and “healthcare coordinator”. They expressed the desire to “learn” and “do more”, but noted barriers to providing care, including limited training, lack of service knowledge, limited communication, and cumbersome access to mental health and dual diagnosis services. Phase One was completed and accepted for publication. Phase Two describes the implementation of our clinic using a mixed methods approach and report preliminary findings. Objectives To evaluate the first two years of implementation of the developmental clinic housed within a family health team (FHT) an obtain feedback from members of the shared care model. Design/Methods Mixed methods were used including chart review of all patients referred to the clinic and semi structured interviews with primary care physicians, pediatricians and developmental pediatricians regarding their roles in managing children with developmental and mental health disorders, as well as use and impact of the developmental clinic. Results A total of 115 charts were reviewed between Feb 2016 and Jan 2018. Of all patients seen, 34% were female 64% male and 2% transgender. Ages ranged from 1-17 years. Eighty-one percent had an existing diagnosis and were referred for re-assessment while 43% received a new diagnosis: ASD (72%), ADHD (11%), GDD (11%), learning disorder (3%), Anxiety (1%), Other (1%). There was an 8% no show rate. Providers endorsed improved communication through use of a shared EMR for documentation and messaging, and improved service knowledge through availability of a pediatric service navigator who also used EMR to document service and funding applications. Longer term follow up, namely the roles and responsibilities of pediatrics vs. developmental pediatrics vs. primary care remained unclear. Conclusion Implementation of the shared care model for this population with primary care is feasible, and does address some stated barriers to care, including improved communication, increased service knowledge, and provision of reassessments. Further areas to develop include clarifying the roles and responsibilities of the different healthcare providers of children with mental health and developmental disorders, and determining what is needed for long-term follow up and transitional care.

Background Newborn infants are at increased risk of requiring respiratory support with a mechanical ventilator. Nasal continuous positive airway pressure (nCPAP) is the most commonly used non-invasive respiratory support. Current nCPAP support is not synchronized to an infant’s breathing efforts, and can contribute to patient discomfort, skin breakdown, and interference with mother-infant bonding. An alternative to nCPAP is negative pressure ventilation. Our NeoVest was developed as a wearable vest that utilizes Neurally Adjusted Ventilator Assist (NAVA) technology to synchronize with the infant’s own respiratory drive and control. NeoVest and NAVA have demonstrated efficacy/feasibility in preliminary experiments emulating neonatal respiratory distress in animal models. Before implementation of this new technology in NICUs, it is important to assess the perspectives of NICU multi-disciplinary staff and parents to optimize design and understand its impact. Objectives The objective was to assess both clinicians’ and NICU parents’ perceptions of the NeoVest as compared with traditional nCPAP devices. Design/Methods Nurses, respiratory therapists and NICU parents at St. Michael’s Hospital in Toronto, Canada were invited to participate in the study. Research Ethics Board approval was obtained for this study. Parents were approached if their baby has previously been on CPAP. After consent, participants attended simulations that demonstrated the utility of the NeoVest. After the simulation, participants completed a survey that assessed their satisfaction and stress level regarding use of the NeoVest in a clinical setting. Numeric Likert scale responses and free text comments were collected from participants and analyzed. Free text comments were assessed using the principles of thematic analysis. Results Thirty clinicians (16 nurses, and 14 RTs), and 4 parents answered the survey. Almost all respondents were excited by the new technology and believed the use of simulation in the NICU was beneficial. Respondents reported that the NeoVest would not add stress to their roles in the NICU, and the majority of clinicians also believed that the NeoVest will improve care of the infant patient. Parents and clinicians both suggested that nCPAP can cause stress, and that the NeoVest would be preferred. One of the major themes regarding how the NeoVest may improve care from the perspective of both parents and clinicians was improved parent-child bonding through improved eye contact. Clinicians also believed it would reduce irritation, maintain skin integrity and have less complications as compared to nCPAP. The major themes with respect to clinician concerns about the NeoVest included: examining the neonate, umbilical line access, and the learning curve for new technology. The major themes with respect to parental concerns included: interference with skin to skin and holding their child. Conclusion Survey responses were overall favourable for introduction of new NICU technology, in this case a novel breathing device: the NeoVest. Although small, this cohort provided invaluable insight regarding the NeoVest’s impact on future patient populations. This highlights the importance of patient feedback in innovation. Next steps include a pilot study assessing the feasibility and efficacy of the NeoVest in the clinical setting, with re-administration of the questionnaires to compare reality and simulation.

BACKGROUND: Umbilical line placement is an essential skill and it is one of the most common procedures practiced in neonatal intensive care units by pediatric trainees. The Royal College of Physicians and Surgeons of Canada (RCPSC) requires that pediatric residents become proficient at inserting umbilical lines and demonstrate effective, appropriate, safe and timely performance of this skill during their training. Clinical exposure to procedures can be variable among pediatric residents and its questionable whether residents receive adequate training in procedural skills during the residency. There is an urgent need to supplement curriculum to teach this life-saving skill using best practices. OBJECTIVES: 1) Create a realistic simulation model using human umbilical tissue and develop a competency-based curriculum utilizing just-in-time video teaching and deliberate practice. 2) Assess the feasibility and impact of developing, implementing, and evaluating this curriculum on both learners and teachers during a four week neonatology rotation. DESIGN/METHODS: Junior and Senior pediatric trainees will be identified a priori at the start of each 4 week block and approached for participation. Parents will be approached for permission to use residual umbilical cords prior to placental disposal. Residents will be exposed to umbilical line insertion curriculum during the first rotation. It will consist of: a structured introductory teaching session, followed by one or more attempts of umbilical line insertion (the skill) in a safe simulated environment. Opportunity for self-assessment, feedback from the supervisor, and reflection on a plan for improvement will be provided. We will evaluate the curriculum with pre and post testing, based on: trainee reaction, learning (knowledge (indication for UVC placement, steps needed, complications), as well as behavior (performance evaluation using adapted OSATS/O-SCORE). Clinical implications will be sought from trainees at the end of their rotation and 6 months following rotation completion. RESULTS: Institutional REB approval was secured. To date, 7 trainees have completed the curriculum (4 PGY3/4 and 3 PGY1s). We anticipate at least 18 more in the next six months. All the residents were highly engaged and appreciative of the curriculum.Obtaining umbilical cords from placentas was feasible with only 2/9 refusals to date. None of the junior trainees had prior experience inserting UVC lines. Senior residents had variable experience (# of insertions varied from 3–20) prior to the curriculum. Most junior (2/3) and senior (3/4) residents improved their pre/post knowledge scores. For senior residents, most had good knowledge and skills to begin with, three out of four residents had an improvement in Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). Senior residents only required 2 or 3 attempts in order to be assessed as independently able to preform. For junior residents, all had a score of 2/5 prior to the video demonstration. All improved performance signaficantly O-SCORE to either 4 or 5/5. All three junior residents initially were not able to perform a UVC insertion independently. By the end of three simulations, they were all able to perform the task independently as per teacher assessment. Resident reaction to the study was favorable for all seven trainees. Two of seven residents reported that it contributed to improved confidence in actual UVC insertion during the rotation. CONCLUSION: As medical education shifts towards competency based education, it becomes ever more important to develop a methodology to ensure that we have a proven framework from which to teach and assess competence of skills. We hypothesize that by completing a curriculum utilizing simulation, deliberate practice and just-in-time teaching, residents at various levels will be able to achieve proficiency in umbilical line insertion, a potentially life-saving skill in neonatology.

BACKGROUND Retinopathy of prematurity (ROP) is a disorder of retinal development in the low birthweight preterm infant. Eye screening is routinely performed for infants at risk of developing this disorder. While these examinations help prevent blindness, they can be physiologically stressful for infants, with changes in oxygen saturation, blood pressure and heart rate occurring during the exam and increased apneic episodes reported the 24–48 hours period afterward. The cause of these increased apneic episodes is not currently known. OBJECTIVES To evaluate the effect of decreasing light simulation during mydriasis on the frequency of stressful episodes after ROP screening. DESIGN/METHODS Multi-centre randomized study. This study was approved by hospital ethics boards at all sites. After informed consent was obtained, infants with a birthweight RESULTS A total of 51 infants were enrolled; 28 randomized to the masked group and 23 to the control group. 10 and 13 infants were on ventilator support at the time of examination in each group, respectively. There was a 57.7% decrease in the total number of all stressful events in the masked group compared to controls in the 12 hour post exam period (Rate Ratio 0.42, 95% CI 0.2–0.9, P=0.024). There was a 61.3% decrease in the number of bradycardic events in the masked group compared to controls (RR 0.39, 95% CI 0.2–1.0, P=0.042). Heart rate was significantly higher in both groups after the exam (Effect by time P=0.04), with no difference in between groups (Effect by group P=0.31). There was no significant difference seen in either group in respiratory rate or oxygen saturation at 2 or 4 hours after the ROP examination compared to baseline. Risk factors that were associated with increased stress included: younger gestational age (RR=1.32 95%CI [1.2–1.5] per week), lower birthweight (RR=1.39 [1.2–1.5] per 100g), ventilator support around the time of exam (RR=2.67 [1.3–5.6]), diagnosis of intraventricular hemorrhage (RR=3.78 [1.9–7.3]), and hyponatremia (RR=3.42 [1.8–6.6]). No adverse events occurred while using eye masks. CONCLUSION The infants who wore a phototherapy mask during pupillary dilation had lower rates of stressful episodes following screening for retinopathy of prematurity, particularly lower episodes of bradycardia.

Importance Although screening examinations for retinopathy of prematurity (ROP) prevent blindness, they are physiologically stressful for infants. Photosensitivity during mydriasis may contribute to postexamination stress, and reducing light stimulation may make infants more comfortable. Objective To determine the effect of a phototherapy mask worn during mydriasis on infant stress in the 12-hour period following ROP screening. Design, Setting, and Participants The Effect of Eyemasks on Neonatal Stress Following Dilated Retinal Examination (MASK-ROP) randomized clinical trial with patient recruitment from April 2016 to June 2017 at neonatal intensive care units at St Michael’s Hospital and Sunnybrook Health Sciences Center in Toronto, Ontario, Canada. A consecutive series of infants with birth weight of less than 1500 g and/or gestational age of less than 32 weeks undergoing their first ROP screening were analyzed beginning in July 2017. Analysis was intention to treat. Interventions Patients were randomized to wear a phototherapy mask for a minimum of 4 hours after dilating drop instillation in addition to standard comfort measures. Main Outcomes and Measures Number of desaturation, bradycardic, or apneic events during the 12-hour postexamination period. Results Of 51 infants who were examined, 28 (54.9%) were randomized to the treatment group (ie, used a mask) and 23 (45.1%) to the control group. Overall, 10 (35.7%) and 13 infants (56.5%) received ventilator support at the time of examination in the treatment and control groups, respectively. The mean (SD) gestational age was 27.9 (2.4) weeks, 32 (63%) were boys, and the mean (SD) birth weight was 1058.6 (312.0) g. The number of all stressful events were lower in the treatment group compared with controls in the 12-hour postexamination period, adjusted for events prior to examination and ventilation status (mean [95% CI] events, 1.0 [0.6-1.8] vs 1.7 [1.0-1.7]; rate ratio [RR], 0.57; 95% CI, 0.3-1.2;P = .12). Risk factors associated with increased stress included younger gestational age (RR, 1.32; 95% CI, 1.2-1.5 per week), lower birth weight (RR, 1.39; 95% CI, 1.2-1.5 per 100 g), ventilator support around the time of examination (RR, 2.67; 95% CI, 1.3-5.6), intraventricular hemorrhage (RR, 3.78; 95% CI, 1.9-7.3), and hyponatremia (RR, 3.42; 95% CI, 1.8-6.6). No adverse events occurred while using eye masks. Conclusions and Relevance This randomized clinical trial found that light sensitivity may play a role in stress observed in the late postexamination period. However, unequal distribution of infants receiving ventilator support placed certain neonates at higher risk of stress, and the clinical significance of this intervention’s benefit could not be concluded with confidence. Trial Registration ClinicalTrials.gov identifier:NCT03824782

BACKGROUND: Probiotic bacteria are defined as live nonpathogenic bacteria species that normally reside in the GI tract of healthy infants. In VLBW preterm infants probiotics have played a defined role in the prevention of NEC. The use of probiotics has now increased across Canada including neonates and infants who are not at high risk for NEC, and is thought to improve ‘feeding tolerance’. Probiotics are now also increasingly being given to former NICU patients by parents. The role of probiotics in more mature preterm infants has been poorly studied however and its use in these infants extends to beyond the NICU period. OBJECTIVES: To determine whether the administration of probiotics: Florababy (FB), Biogaia (BG) compared with no supplementation is beneficial to the preterm infant born between 30–33+ weeks gestation. DESIGN/METHODS: Institutional Research Ethics Board (REB) approval was obtained. A comparative prospective chart review of neonatal patients from 30–33 weeks completed gestation (GA) were analyzed from the Neonatal Intensive Care unit at St. Michael’s hospital prospectively, from 2015–2018. A convenience sample of neonates (inborn and retro-transferred) who were treated as per routine clinical orders (FB, BG or no treatment) were then included for analysis. Exclusion criteria included congenital gastrointestinal/surgical abnormalities, families unable to communicate in English and infants that were apprehended by children’s services. The primary outcome was feeding tolerance, estimated through the following variables: time to full feeds, number of aspirates/emesis, spells with feeds and other symptoms of gastroesophageal reflux disease. Secondary outcomes included: incidence of Necrotizing enterocolitis (NEC), bloody stools and length of stay. RESULTS: A total of 110 infants were analyzed (60% male). 40 infants received FB, 30 received BG treatment and 40 infants received no probiotic treatment during their neonatal stay. The mean gestational age of the cohort was 31.4 weeks (+/- standard deviation (SD) 1.9 weeks). Mean birth weight was 1659 grams (+/- 223 grams). Breast milk was used exclusively 67.2% of all infants, including donor milk. 18 of the 110 (16.3%) infants demonstrated symptoms of feeding intolerance however there was no statistical difference amongst the three groups (FB n=7, BG n=3, control =8). There was no difference noted in the days to full feeds (mean 8.8 +/ 2.2 days). 11 out of the 110 (10%) infants presented with blood in their stool at some point during their hospitalization, with no differences between groups (n=2 BG, FB n=5, BG n=2, control n=4). No NEC was observed. Groups were not statistically different with respect to LOS (mean 36.6 +/10.7 days). Those infants with feeding intolerance did have a lower gestational age, lower birth weight, longer length of stay and lower gestational age did correspond with more days on TPN and longer times to reach full feeds. Symptoms of feeding intolerance were not higher in thoses who received formula (Kruskal-Wallis test p =0.5708). Our study was limited by design and numbers of charts analyzed. CONCLUSION: In our comparative cohort study of preterm infants with a gestational age of 30–33 weeks, we found no advantage to routine use of probiotics. Although our study is limited by design and patient numbers we feel that the use of probiotics (and/or discontinuation of probiotics) needs to be thoughtful since there are cost implications to these medications, and parents often give them to their babies following NICU discharge.