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the incidence of bacterial meningitis in infants and children has decreased since the routine use of conjugated vaccines targeting * haemophilus influenzae * type b, * streptococcus pneumoniae *, and * neisseria meningitidis *. however, this infection continues to be associated with considerable mortality and morbidity if not treated effectively with empirical antimicrobial therapy. diagnosis still rests on clinical signs and symptoms, and cerebrospinal fluid analysis. this position statement outlines the rationale for current recommended empirical therapy using a third \ - generation cephalosporin and vancomycin for suspected bacterial meningitis. it also provides new recommendations for the use of adjuvant corticosteroids in this setting. once antibiotic susceptibilities of the pathogen are known, antimicrobials should be reviewed and modified accordingly. recommendations for treatment duration as well as audiology testing are included. the present statement updates a canadian paediatric society position statement on bacterial meningitis revised in 2008 \. the purpose of this statement is to review the current epidemiology of bacterial meningitis in children older than 2 months of age and provide guidelines for the empiric management of non \ - hospital \ - acquired suspected bacterial meningitis in previously healthy children in canada. it does not address meningitis associated with cerebrospinal fluid ( csf ) shunts or meningitis caused by organisms such as * escherichia coli * and other enterobacteriaceae. referral to other resources and, preferably, consultation with an infectious diseases specialist are recommended in such cases. viral meningoencephalitis caused by herpes simplex or other viral pathogens is also beyond the scope of the present statement ; however, this diagnosis should be considered in the proper clinical contexts. importantly, meningitis caused by * mycobacterium tuberculosis * ( tb ) can present with symptoms that are similar to other forms of bacterial meningitis, especially in areas with high tb rates. however, while diagnosis and management of tb meningitis are clinically distinct processes and morbidity remains high, this infection is also beyond the scope of this statement. in canada, the hib vaccine has been provided in public programs in all provinces and territories since 1998 \. hib meningitis is now very rare and occurs primarily in unimmunized
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or partially immunized children, or in individuals who are immune \ - incompetent or immunosuppressed. it is worth noting that disease due to other serogroups ( i. e., non \ - b ) has been increasing in all parts of canada, but particularly in northern populations \ ] \ - \ ]. publicly funded infant immunization programs using heptavalent conjugate vaccines against * s pneumoniae * ( pcv7 \ ), which contained the capsular serotypes 4, 6b, 9v, 14, 18c, 19f, and 23f, were offered in all provinces and territories by 2005 \. the incidence of pneumococcal meningitis in the united states and canada decreased significantly in all age groups following the introduction of pcv7 \ ] \ - \ ]. in canada, the number of meningitis cases caused by * s pneumoniae * reported to immunization monitoring program active ( impact ) hospitals decreased from 75 to 20 cases annually between 2000 and 2007, and there was an 87 \. 5 % decrease in cases of invasive pneumococcal disease ( which includes meningitis and isolation of pneumococcus from normally sterile sites ). however, the phenomenon of serotype replacement, with increases in the relative and absolute incidence of 19a, 15b, 6a, and other serotypes not present in pcv7, did occur here and elsewhere \ ] \ ] \ ] \ ] \ - \ ]. a 13 \ - valent pneumococcal conjugate vaccine ( pcv13 \ ) has now replaced the pcv7 vaccine. the pcv13 vaccine includes the seven serotypes in the pcv7 vaccine and an additional six serotypes ( 1, 3, 5, 6a, 7f, and 19a ). in 2010, a significant proportion of invasive pneumococcal isolates from children \ < 2 years of age were serotypes included in pcv13 and not in pcv7 \. as of 2011, all canadian immunization programs had completed the conversion to pcv13 \. one recent study, using isolates collected from normally sterile clinical sites since 2010, determined that the pcv13 serotypes in canada declined from 66 % ( 224 of 339 \ ) to 41 % ( 101 of 244 ; p \ < 0 \.
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001 \ ) in children \ < 5 years of age, and from 54 % ( 1262 of 2360 \ ) to 43 % ( 1006 of 2353 ; p \ < 0 \. 001 \ ) in children ≥5 years of age. serotypes 19a, 7f, 3, and 22f were the most common serotypes in 2012, with 19a decreasing from 19 % ( 521 of 2727 \ ) to 14 % ( 364 of 2620 ; p \ < 0 \. 001 \ ) \ ]. the incidence of meningococcal disease in children and adults has decreased significantly since the introduction of routine meningococcal serogroup c immunization programs \ ] \ - \ ]. the impact of the introduction of the quadrivalent conjugated a, c, y, and w meningococcal vaccine for adolescents is not yet known because this vaccine is not part of publicly funded programs in all provinces and territories. two vaccines that target serogroup b ( bexsero, ( novartis canada ) and trumemba ( pfizer canada ) ) are now licensed in canada, though both are only publicly funded for persons at increased risk for meningococcal disease \ ]. meningitis caused by group b streptococcus ( gbs, also referred to as * streptococcus agalactiae * ) remains an important cause of meningitis in infants up to 90 days old \ ]. although * listeria monocytogenes * is an uncommon cause of meningitis beyond the neonatal period, it should be considered when specific host risk factors, such as immunosuppression, are present, or if brain stem infection is the initial presentation. antimicrobial susceptibility of the major pathogens # streptococcus pneumoniae meningitis susceptibility breakpoints should always be applied in the setting of presumed or confirmed meningitis, given the requirement for adequate drug levels in the central nervous system ( cns ). * s pneumoniae * breakpoints have been specifically designed for interpretation in the context of meningitis. the organism is penicillin \ - susceptible if minimal inhibitory concentration ( mic ) is ≤0 \. 06 mcg / ml penicillin, and penicillin \ - resistant if mic is ≥0 \. 12 mcg / ml \ ]
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. using current criteria for antimicrobial susceptibility, the save study analysed 6001 invasive isolates of * s pneumoniae - from adults and children in canada \ ]. there was a significant increasing prevalence of penicillin \ - susceptible isolates from 2011 to 2015 \. in 2015, using non \ - meningitis and meningitis breakpoints, 99 % and 89 \. 5 % of isolates respectively were parenteral penicillin \ - susceptible, and 99 \. 7 % and 97 \. 3 % were susceptible to ceftriaxone, using similar infection site criteria \ ]. the proportion of isolates represented in pcv10 or pcv13 vaccines, including 7f, and 19a, decreased over the same time period. of serotypes, only 68 \. 1 % of 19a serogroup isolates were penicillin \ - susceptible using meningitis breakpoints. of note, the rate of multidrug \ - resistant * s pneumoniae - ( 11 \. 8 % ) in children 1 \ - \ < 2 years of age was higher than in other age groups, possibly due to selection pressure from higher rates of antibiotic use \ ]. # neisseria meningitidis in the past several years, many countries, notably belgium, australia, and several countries in latin america, have reported increasing prevalence ( ranging from 30 % to 80 % ) of * n meningitidis * with reduced susceptibility to penicillin \ ] \ - \ ]. in the united states, ciprofloxacin \ - resistant * n meningitidis * has also emerged \ ]. one report from ontario indicated that the percentage of strains with reduced susceptibility to penicillin between 2000 and 2006 was 21 \. 7 % \ ]. surveillance data of 408 canadian isolates of * n meningitidis * analyzed at the national microbiology laboratory from 1996 to 2010 showed 18 \. 6 % with reduced susceptibility to penicillin, although no endemic isolates were resistant to ciprofloxacin ( personal communication, raymond tsang, national microbiology laboratory ( winnipeg, manitoba ) ). there is one report of an * n meningitidis - serogroup y isolate in canada with penicillin resistance \ ]. # haemophilus influenzae while hib is now an uncommon cause of
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meningitis in children, it as well as other * h influenzae - serotypes should still be considered in a child who is not fully immunized or unimmunized, or from an area in northern canada with a higher incidence of invasive * h influenzae *. increasingly, hib and other typeable strains of * h influenzae * have shown increased beta \ - lactamase production, ranging from 4 % to 42 %, making these isolates resistant to ampicillin \ ]. because of this trend, ceftriaxone or cefotaxime should be used as empiric therapy, pending susceptibility testing. # streptococcus agalactiae penicillin is currently the drug of choice for infection caused by group b streptococcus ( * s agalactiae * ). however, empirical coverage with cefotaxime or ceftriaxone in infants would be reasonable until culture results are available. current susceptibility data reaffirm the empiric management of suspected meningitis with ceftriaxone and vancomycin until susceptibility results are available. infants with meningitis often present with nonspecific findings of fever, poor feeding, lethargy ( or decreased interaction with caregivers ), vomiting, and irritability. they sometimes have a rash. inconsolable crying, prolonged or worsening irritability, or progressive lethargy are also important clinical features that may indicate a cns focus such as meningitis. nuchal rigidity is uncommon in infants. older children are more likely to have specific symptoms related to meningitis, such as headache, nuchal pain or rigidity, and impaired consciousness, as well as other nonspecific symptoms \ ]. patients should undergo a full examination, including respiratory status and detailed neurological examinations, to detect focal neurological signs, posturing, cranial nerve abnormalities, and assessment of level of consciousness. a lumbar puncture ( lp ) for csf analysis ( cell count, glucose and protein levels, microbiological culture and molecular detection of bacterial dna ( if clinical suspicion is high and bacterial cultures are negative ), and viral studies where appropriate, as well as consideration for specific testing for tb in high \ - risk children ) is indispensable for the definitive diagnosis of meningitis. multiplex polymerase chain reaction ( pc
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##r ) testing is often helpful if cultures of blood or csf are negative, and should be pursued with the microbiology laboratory when needed. an lp should always be attempted unless there are contraindications, such as coagulopathy, cutaneous lesions at the proposed puncture site, signs of herniation, or an unstable clinical status such as shock. if papilledema, new onset seizures, focal neurological deficits, or decreased level of consciousness or coma are present, an lp should be deferred until imaging ( a contrast \ - enhanced computed tomography and / or magnetic resonance imaging of the head ) is performed, and the risk of potential herniation is ruled out. although there are no specific studies involving children, herniation following an lp in meningitis is rare in the absence of focal cns lesions \ ] \ ]. because timely empiric antimicrobial therapy is critical to treatment, antimicrobial administration should not be delayed when imaging studies are not immediately available or an lp cannot be performed. blood cultures using weight \ - based volumes should be obtained before starting antimicrobial therapy. in general, in a setting of bacteremia, when there is either a clinical diagnosis of meningitis on presentation or the csf parameters are consistent with meningitis ( despite negative cultures ), the patient should be managed as a bacterial meningitis case. other investigations, such as urine culture, pharyngeal culture, or chest radiograph, should be performed as clinically indicated. managing suspected or confirmed meningitis because the prognosis of meningitis depends on treating infection before clinically severe disease ensues, the timely administration of empirical antimicrobial therapy ( ) is critical. antimicrobials should be administered without delay when meningitis is suspected or confirmed. also, the careful, ongoing assessment and appropriate management of hemodynamic status is required. an lp should be performed to support the diagnosis, but if an lp is not possible, antimicrobials should be given empirically irrespective of the delay in obtaining an lp, and the patient should be transferred to a facility where an lp can be performed. one study involving adults showed that a delay in starting antimicrobial treatment was one of three independent variables associated with poor prognosis. the other two factors were the severity of clinical state at presentation and the isolation of non \ - pen
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##icillin \ - susceptible * s - pneumoniae \ ] \ ]. other factors to consider in the choice of antimicrobials are the child ’ s age and underlying diseases or risk factors such as immunodeficiency. for example, if there is an underlying immunodeficiency, then * listeria * is a possible risk and ampicillin should be added to the empirical regimen. management should also include monitoring for early complications associated with acute meningitis ( e. g., syndrome of inappropriate antidiuretic hormone secretion and increased intracranial pressure ). the bacterial organisms most likely to cause community \ - acquired meningitis in healthy, immunized children \ > 2 month of age are * s pneumoniae * and * n meningitidis *, but * e coli * and gbs should also be considered in infants up to 3 months of age. as mentioned previously, hib is still occasionally observed in incompletely immunized patients, but other encapsulated * h influenzae * cases are being diagnosed with increasing frequency. in canada, where penicillin \ - resistant * s pneumoniae * is known to occur, empiric therapy using a third \ - generation cephalosporin ( ceftriaxone or cefotaxime ) is recommended. in areas where there have not been cephalosporin \ - resistant * s pneumoniae * cases, this single drug may be adequate empiric therapy. however, pending culture results, most experts recommend adding vancomycin to the third \ - generation cephalosporin to protect against the possibility of a cephalosporin \ - resistant * s pneumoniae *, which has emerged in some parts of canada. third \ - generation cephalosporins also provide adequate empiric coverage for * n meningitidis * and * h influenzae *, because both organisms remain susceptible to these agents. if there are contraindications to third \ - generation cephalosporin use, other alternatives ( such as meropenem ) may be used and the early advice of an infectious disease expert should be requested. close contacts of patients with meningococcal disease should receive chemoprophylaxis. hib chemoprophylaxis should be administered to all occupants of contact households with infants \ < 12 months old ( who have not completed the primary hib
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immunization series ), children \ < 4 years old who are incompletely immunized, or immunocompromised children of any age. any index case of hib aged \ < 2 years and not treated with cefotaxime or ceftriaxone should also receive chemoprophylaxis at the end of therapy. public health should be consulted regarding management of possible contacts in child care and school. steroids as adjuvant therapy in adults, multiple studies and meta \ - analysis have determined that adjuvant empiric steroids offered clinical benefit resulting in slightly lower mortality rates and reduction in hearing losses \ ] \ - \ ]. studies in sweden and denmark, where adult patients who received steroids were compared with those who did not, concluded that there was likely some mortality benefit, although rapid diagnosis and treatment made historical comparisons difficult \ ] \ ]. based on the potential benefit and the low risk profile of 24 h to 48 h of initial dexamethasone therapy, the european guidelines recommend empiric dexamethasone for both adults and children with suspected or proven meningitis \ ]. a landmark study in children who received empiric steroids in the management of acute bacterial meningitis due mainly to hib showed that when they were administered just before or within 2 h of antimicrobials, there was a reduction in severe hearing loss ( rr 0 \. 34, 95 % ci 0 \. 20 to 0 \. 59 \ ) \ ]. subsequent trials in children have focused mainly on pneumococcal meningitis, and all have been weakened by the heterogeneity of clinical severity at presentation, making conclusions regarding beneficial effects of steroid use in children much less definitive \ ]. a descriptive study of children in the united states between 2011 and 2014 reported that only 8 \. 1 % of 6665 children received empiric steroids on admission with suspected meningitis or encephalitis \ ]. dexamethasone should be considered for infants and children with meningitis when csf gram stain testing shows gram \ - negative coccobacilli consistent with * h influenzae *. if hib is subsequently identified by molecular testing or cultured within 48 h, steroids should be continued for a total duration of 4 days. when hib has not been positively identified within 48 h, steroids should be discontinued. based
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on likely similar pathogenesis in adult meningitis, empiric steroids can be considered for infants and children with presumptive * s pneumoniae - meningitis. in this setting also, steroids should be discontinued if pneumococcus is not identified within 48 h. the recommended dose of dexamethasone is 0 \. 6 mg / kg / day in four divided doses administered every 6 h immediately before, concomitant with, or within 4 h of administering the first dose of antimicrobials. clinical benefit is probably greater when steroids are received earlier within this 4 h window. there is a higher risk for rebound of fever after steroids are discontinued, but if all other parameters indicate improvement and the clinical diagnosis continues to support bacterial meningitis alone, fever alone does not indicate need for additional testing. there is insufficient information at the present time to recommend other types of adjuvant therapy. modifying therapy after laboratory cultures or molecular diagnosis become available when cultures and antimicrobial susceptibility data are available, therapy should be adjusted accordingly. as mentioned previously, an * s pneumoniae * isolate is considered susceptible to penicillin when the mic is ≤0 \. 06 mcg / ml. however, an isolate is considered susceptible to cefotaxime or ceftriaxone when the mic is ≤0 \. 5 mcg / ml, intermediately susceptible when mic is 1 \. 0 mcg / ml, and resistant when mic is ≥2 \. 0 mcg / ml \ ]. vancomycin is active against cefotaxime \ - or ceftriaxone \ - resistant strains. treatment should be modified according to, depending on the results of the csf culture and sensitivity. see for dosage recommendations for antimicrobial agents. generally, repeat csf sampling is not required in the context of common pathogens, unless a child does not clinically improve with initial therapy. when meningitis is caused by * s pneumoniae *, repeat csf sampling at 48 h may be considered if the patient has received dexamethasone or if * s pneumoniae - is resistant to penicillin or cefotaxime / ceftriaxone. for meningitis due to gbs, some experts recommend documentation of csf sterilization at 24 h to 48 h after initiation of therapy \ ]. although not discussed in this
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statement, repeat csf culture at 24 h to 48 h is recommended for meningitis caused by gram \ - negative enteric pathogens ( e. g., * e coli * ). cns imaging is recommended when there is failure of sterilization of csf, or if neurological symptoms or other specific complications develop during the course of treatment. duration of treatment treatment of bacterial meningitis should always be with intravenous antimicrobials to achieve high csf levels. the recommended length of treatment varies with the pathogen and the clinical course of infection. recommended length of therapy for uncomplicated meningitis due to * s pneumoniae * is 10 to 14 days ; due to hib, 7 to 10 days ; and due to * n meningitidis *, 5 to 7 days. recommended therapy for uncomplicated gbs meningitis is 14 to 21 days, and may be longer if cerebritis or ventriculitis is present. formal audiology assessment should be performed as soon as possible after diagnosis of meningitis for all children affected ( and always before discharge from hospital ) to optimize management in the event of hearing loss \ ].
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the prevention of pain in neonates should be the goal of all caregivers because painful exposures have the potential for deleterious consequences. those neonates at greatest risk for neurodevelopmental impairment due to preterm birth ( eg, the smallest and sickest ) are also most likely to be exposed to the greatest number of painful stimuli in the neonatal intensive care unit ( nicu ). although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underutilized for routine minor, yet painful, procedures. every health care facility caring for neonates should implement an effective pain prevention program that includes strategies for the following : routinely assessing pain ; minimizing the number of painful procedures performed ; effectively using pharmacological and nonpharmacological therapies for the prevention of pain associated with routine minor procedures ; and eliminating pain associated with surgery and other major procedures. the present updated statement is intended for health care professionals caring for neonates ( preterm to one month of age ). the objectives are to : 1. emphasize that, despite increased awareness of the importance of pain prevention, neonates in the nicu continue to be exposed to numerous painful minor procedures daily as part of their routine care ; 2. present objective means of assessing neonatal pain by health care professionals ; 3. describe effective strategies to prevent and treat pain associated with routine minor procedures ; and 4. review appropriate methods to prevent and treat pain associated with surgery and other major procedures. for more information, please refer to, which can be found in pediatrics 2006 ; 118 ( 5 \ ) : 2231 \ - 41 or online at. the prevention of pain in neonates is an expectation of parents. however, there are major gaps in our knowledge regarding the most effective way to accomplish this. the prevention of pain is important not only because it is an ethical expectation, but also because of potential deleterious consequences of repeated painful exposures. these consequences include altered pain sensitivity ( which may last into adolescence ) and permanent neuroanatomical and behavioural abnormalities, as found in animal studies. it appears that altered pain sensitivity can be ameliorated if effective pain relief is provided. the present updated statement deals primarily with pain prevention. assessmentof pain and stress in the neonate 1. caregivers should be trained to assess newborns for pain using multidimensional tools
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. 2. newborns should be assessed for pain routinely, and before and after procedures. 3. the chosen pain scales should help guide caregivers in the provision of effective pain relief. reducing pain from bedside care procedures neonates in the nicu often experience painful procedures during routine care, such as needle insertions, suctioning, gavage tube placement and tape removal, as well as stressful disruptions, including diaper changes, chest physical therapy, physical examinations, environmental stimuli and nursing evaluations. despite increased awareness by caregivers that neonates in the nicu frequently experience pain, effective pain relief for these routine procedures is often underutilized. 1. care protocols for neonates should incorporate a principle of minimizing the number of painful disruptions in care as much as possible. 2. a combination of oral sucrose / glucose and other nonpharmacological pain reduction methods ( nonnutritive sucking, kangaroo care, facilitated tuck, swaddling and developmental care ) should be used for minor, routine procedures. 3. topical anesthetics can be used to reduce pain associated with venipuncture, lumbar puncture and intravenous catheter insertion when time permits, but are ineffective for heel stick blood draws. repeated use of topical anesthetics should be limited. 4. the routine use of continuous infusions of morphine, fentanyl or midazolam in chronically ventilated preterm neonates is not recommended due to concern about shortterm side effects and lack of long \ - term outcome data. reducing pain from surgery 1. any health care facility providing surgery for newborns should have an established protocol for pain management. this requires a coordinated, multidimensional strategy and should be a priority in perioperative management. 2. sufficient anesthesia should be provided to prevent intraoperative pain and stress responses to decrease postoperative analgesic requirements. 3. pain should be routinely assessed using a scale designed for postoperative or prolonged pain in newborns. 4. opioids should be the basis for postoperative analgesia after major surgery in the absence of regional anesthesia. 5. postoperative analgesia should be utilized as long as pain assessment scales document that it is required. 6. acetaminophen can be used after surgery as an adjunct to regional anesthetics or opioids, but there
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are inadequate data on pharmacokinetics at gestational ages under 28 weeks to permit calculation of appropriate dosages. reducing pain from other major procedures analgesia for chest drain insertion should comprise all of the following : 1. general nonpharmacological measures ; 2. slow infiltration of the skin site with a local anesthetic before incision unless there is life \ - threatening instability. if there is inadequate time to infiltrate before the insertion of the chest tube, local skin infiltration after achieving stability may reduce later pain responses and later analgesic requirements. 3. systemic analgesia with a rapidly acting opiate, such as fentanyl. chest drain removal analgesia for chest drain removal should comprise the following : 1. general nonpharmacological measures ; and 2. a short \ - acting, rapid \ - onset systemic analgesic. this topic will be discussed further in a statement by the american academy of pediatrics and the canadian paediatric society. retinal examination and surgery for retinopathy of prematurity 1. although there are insufficient data to make a specific recommendation, retinal examinations are painful, and pain relief measures should be utilized. a reasonable approach would be to administer local anesthetic eye drops and oral sucrose. 2. retinal surgery should be considered major surgery, and effective pain relief, based on opiates, should be provided. pain relief for circumcision should always be provided. the american academy of pediatrics has published a separate statement on this subject. for more information, please refer to the full text of this position statement ( pediatrics 2006 ; 118 : 2231 \ - 2241 or ). # canadian paediatric society : fetus and newborn committee members : keith j barrington md ( chair ) ; joanne embree md ( board representative ) ; haresh kirpalani md ; koravangattu sankaran md ; hilary whyte md ; robin whyte md liaisons : dan farine md, society of obstetricians and gynaecologists of canada ; david keegan md, maternity and newborn care committee, college of family physicians of canada ; catherine mccourt md, health surveillance and epidemiology, public health agency of canada ; alfonso solimano md, neonatal \ - perinatal medicine section, canadian paediatric society ; ann stark md, committee on fetus and
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newborn, american academy of pediatrics ; amanda symington, neonatal nurses # american academy of pediatrics : committee on fetus and newborn, section on surgery and section on anesthesiology and pain management principal authors : keith j barrington md, fetus and newborn committee, canadian paediatric society ; daniel g batton md, committee on fetus and newborn, american academy of pediatrics ; g allen finley md, section on anesthesiology and pain management, american academy of pediatrics ; carol wallman, national association of neonatal nurses, liaison to the american academy of pediatrics disclaimer : the recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. variations, taking into account individual circumstances, may be appropriate. internet addresses are current at time of publication.
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cannabis is the most common illicit drug used worldwide and it is used frequently by canadian teenagers. cannabis use during adolescence can cause functional and structural changes to the developing brain, leading to damage. marijuana use in this age group is strongly linked to : cannabis dependence and other substance use disorders ; the initiation and maintenance of tobacco smoking ; an increased presence of mental illness, including depression, anxiety and psychosis ; impaired neurological development and cognitive decline ; and diminished school performance and lifetime achievement. rates of acute medical care and hospitalization for younger children who have ingested cannabis unintentionally are increasing. ongoing debate concerning cannabis regulation in canada makes paying close attention to the evidence for its health effects and ensuring that appropriate safeguards are in place, vital public health priorities. cannabis refers to various psychoactive preparations of the plant * cannabis sativa *, including marijuana ( the dried and crushed leaves and flower buds ), hashish ( the resin of flower buds ) and cannabis extracts ( i. e., oils or wax ). common terms for marijuana include ‘ pot ’, ‘ grass ’ and ‘ weed ’. cannabis can be inhaled ( as smoke or vapour ) or ingested, depending on its form. when smoked, joints ( cannabis cigarettes ), blunts ( cannabis cigars ) and pipes ( from personal devices to large, shared bongs ) are commonly employed. a growing trend in e \ - cigarette use by youth has led to the more recent practice of ‘ vaping ’ cannabis. ‘ edibles ’ or marijuana \ - infused food products in various formats, including cookies and candies, may attract teens who wish to avoid smoking. although some study participants claim that recreational cannabis use has positive effects, most of the scientific literature has focused on its deleterious outcomes. in light of the current public debate on the decriminalization and legalization of cannabis in canada, paediatricians and other health care providers need to be aware of the physical and mental health issues that are specific to cannabis use by youth as well as the risks to younger children of unintentional exposure. cannabis use for medical purposes has been addressed in a recent position statement from the canadian paediatric society. # incidence and prevalence cannabis is the world ’ s most widely used illicit drug. in 2010, canadian youth ranked first for cannabis use among 43 countries and regions across europe and north america, with one \ - third of youth ( regardless of gender ) having tried cannabis at least once by age 15
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. regional variations in the frequency of cannabis use exist, with atlantic and western provinces in canada reporting higher use than other regions. indigenous youth are particularly at risk ; nearly two \ - thirds of 15 \ - to 19 \ - year \ - old inuit participants from an earlier study in nunavik, quebec, self \ - reported past \ - year use. in ontario, 13 \. 8 % of 7th to 12th graders reported past \ - month use for 2015, while 12th graders reported the highest daily use, at 5 \. 6 %. frequency of use increases as students progress through high school, yet global use among canadian youth has declined since the turn of the century. a concerning inverse relationship exists such that as the perceived harm related to cannabis use decreases, the frequency of cannabis use increases. the effect of legalizing cannabis on rates of use in adolescents in some parts of the usa is under preliminary study. although early reports from colorado and washington do not appear to indicate a significant increasing prevalence among adolescents, colorado has recently reported one of the highest state prevalences for cannabis use in adolescents, while other states experienced a decline in use during the same period. colorado has also reported increasing rates of use as students progress through high school, while perceptions of risk declined among youth in both states. # the effects of cannabinoids on the adolescent brain scientific research over the last 15 years has established that the human brain continues to develop into a person ’ s early 20s. concern is rising that exposure to cannabis during this important developmental period causes greater adverse effects in adolescents compared with older adults, whose brains are fully developed. one of the main chemicals responsible for the perceptual and emotional changes associated with cannabis is delta \ - 9 \ - tetrahydrocannabinol ( delta \ - 9 \ - thc ), which stimulates the cannabinoid receptors. these receptors modulate the secretion of gamma \ - aminobutyric acid and glutamate within the central nervous system, two neurotransmitters that have significant neurodevelopmental effects on the brain. the frontal cortex, responsible for higher order cognitive processes such as judgment and decision making, is undergoing rapid change and, as such, is more susceptible to thc –. the endocannabinoid system, which is involved in the maturation of cortical neuronal networks through the modulation of dopamine, is affected concurrently. when exogenous thc
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enters the system, it targets receptors in much higher quantities than endogenous cannabinoids and ‘ floods ’ receptors, with two main results : a system that is no longer working as effectively and toxic changes to the neurons involved. structural changes on mri have also been documented in youth who use cannabis regularly. they show lower brain volumes, different folding patterns and thinning of the cortex, less neural connectivity and lower white matter integrity, all of which indicate damage by thc. finally, functional mri studies in adolescents who use cannabis regularly have demonstrated increased neural activity, which means the brain is working harder to perform tasks. in other words, the brain must overcome or compensate for altered integrity caused by the effects of cannabis use. importantly, the thc content of marijuana available today is two to four times higher than from typical products used 40 years ago, a factor likely to magnify impact on the adolescent brain. the experience of being ‘ high ’ described by users encompasses a wide range of sensations, with euphoria, distorted perception and relaxation being the most common. some users experience extreme anxiety and ‘ panic attack ’ \ - like symptoms. documented areas of impairment include short \ - term memory, performance of complex mental tasks, attention and judgment. reaction times and motor skills are also compromised. many occasional users of cannabis only experience the intended effects of a high, but risks for an adverse experience still exist, especially for regular users. cannabis \ - impaired driving is now more prevalent among adolescents than alcohol \ - impaired driving. in 2015, 9 \. 8 % of ontario students in grades 10 to 12 with a driver ’ s licence admitted to having driven after using cannabis at least once during the previous year. one meta \ - analysis revealed that cannabis use more than doubled the risk of being in a motor vehicle accident. simulation studies have identified the deficits associated with driving under the influence of cannabis, with a lowered ability to stay within a lane being the driving skill most affected. according to a recent survey, only 48 % of canadian teens 16 to 19 years of age recognized the danger of driving under the influence of cannabis, compared with 79 % who recognized the risk of driving under the influence of alcohol. in fact, both cannabis and alcohol impair driving significantly, and it is likely that the effects are cumulative. however, while blood ethanol levels are readily measurable and can establish recent use, reliable laboratory markers of acute cannabis use are still under investigation. persistence of metabolites in urine for as
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long as 77 days after cessation of cannabis use has been described. furthermore, consuming cannabis \ - infused edibles may inadvertently result in toxicity because absorption can take hours, compared with minutes when smoking. an individual who does not yet feel an effect may over \ - consume, and the unintended consumption of edibles manufactured to look like sweets by younger children is particularly concerning. in colorado, rates of unintentional ingestion in children \ < 9 years of age increased by 34 % after legalization. thirty \ - five per cent of these cases required hospitalization for overdose symptoms, including severe drowsiness and respiratory depression. # cannabis use disorder ( cud ) and cannabis withdrawal syndrome ( cws ) it is estimated that one in six adolescents who use cannabis during their adolescence will meet criteria for dependence. cud, a new dsm \ - 5 diagnosis, integrates cannabis abuse and dependence into a single entity. cud is defined as a problematic pattern of cannabis use leading to clinically significant impairment in areas of function or distress within a 12 \ - month period. usually, adolescents experience the following functional impairments : reduced academic performance, truancy, reduced participation and interest in extracurricular activities, withdrawal from their usual peer groups and conflict with family. the 12 \ - month prevalence of cud among north american adolescents is just above 3 %, with males and older youth being disproportionately affected. cws appears for the first time as a psychiatric diagnosis in the dsm \ - 5. cws is defined by experiencing at least two of five psychological symptoms — irritability, anxiety, depressed mood, sleep disturbance, appetite changes — and at least one of six physical symptoms — abdominal pain, shaking, fever, chills, headache, diaphoresis — after cessation of heavy cannabis use. heavy cannabis use is defined as daily or near daily use for at least a few months. withdrawal symptoms commonly occur 24 h to 72 h after last use and persist for 1 to 2 weeks. sleep disturbance is often reported for up to 1 month. cws may impede cannabis cessation and precipitate relapse. # cannabis use related to tobacco and other substances cannabis use is closely tied to the use of other substances, particularly alcohol and tobacco. problem drinking among adolescents is strongly associated with cannabis use. the use of marijuana and cigarettes at age 18 is predictive of heavy drinking at age 35. eighty per
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cent of young cannabis users also smoke tobacco, indicating a strong link between these two drugs. cannabis use is also linked to tobacco via ‘ mulling ’ : the addition of tobacco to cannabis cigarettes. mixing the two substances aids combustion and constitutes a significant exposure to nicotine. using both tobacco and cannabis concomitantly contributes significantly to symptoms of cannabis dependence because withdrawal symptoms following the simultaneous cessation from two substances are more severe than from one alone. regarding other drugs, one prospective, longitudinal study demonstrated that cannabis use during adolescence is associated with a sixfold increase in future ecstasy consumption. a study from france of adults and adolescents reported past \ - year use of illicit drugs at 0 \. 4 % among cannabis nonusers, compared with 25 % among regular cannabis users. a recent trend has been the consumption of synthetic cannabinoids, known colloquially as ‘ k2 ’ or ‘ spice ’, which can be one hundred times more potent than thc and have greater potential for toxic effects, including acute renal failure and death. # cannabis, depression and anxiety research suggests a strong association between daily cannabis use and depression in adolescents and young adults. however, a causal relationship has not been established. epidemiological studies suggest that heavy cannabis use is associated with an increase in mood disorders, especially in individuals who may already be vulnerable to major depressive episodes. one study demonstrated a threefold higher risk for major depressive episode. recent data suggest that cannabis use starting in adolescence and continuing into young adulthood is required for the association of cannabis with depression, and the data confirming a specific association between cannabis use and anxiety disorders is weaker. however, one large cohort study found an association between frequent cannabis use and the incidence of anxiety symptoms in young adulthood. it also appears that social anxiety disorder and post \ - traumatic stress disorder are risk factors for developing problematic patterns of cannabis use. # psychotic disorders and schizophrenia cannabis can produce an acute / transient psychosis in adolescents, even without a history of prior mental illness. diverse psychotic symptoms have been reported, such as depersonalization, de \ - realization, dream \ - like euphoria, disorientation, delusions, hallucinations and paranoid ideation. the strongest evidence of a direct effect of cannabis on perception and cognitive function comes from research involving healthy volunteers, who developed transient symptoms resembling schizophrenia after intravenous thc was administered. in some adolescents, acute / transient psychotic symptoms persisted for days, prompting consultation for medical or psychiatric evaluation
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. large longitudinal studies have demonstrated that more than 50 % of youth who develop such symptoms will develop a future psychotic disorder. although the absolute risk for developing psychosis is low, the risk for developing a psychotic outcome of any nature is increased by 40 % in individuals who have used cannabis during their lifetime. a strong association between heavy cannabis use and psychosis has been documented repeatedly in the literature. the association appears to be temporally related, demonstrates a dose – response relationship and is biologically plausible. one meta \ - analysis provided evidence of a relationship between cannabis use and onset of psychotic illness, thus supporting the hypothesis that cannabis use plays a causal role in the development of psychosis in some individuals, especially those who have a family or personal history of psychosis. overall, individuals with a psychotic disorder show higher rates of cannabis use than those experiencing other mental disorders, with the exception of substance use disorder. more specifically, schizophrenia usually emerges toward the end of adolescence or in early adulthood, and accumulating evidence points to a causal relationship with heavy cannabis use. the prevalence of schizophrenia is about 1 % in the adult population, and the risk of developing this illness is doubled in heavy cannabis users. recent data indicate that using high \ - potency cannabis represents an even greater risk. # school performance, cognitive decline and lifetime achievement the relationship between cannabis use and academic performance is complex. while direct causation between use and level of performance is uncertain, there are undeniable associations between cannabis use in youth and lower educational attainment. this relationship could be due to the fact that students who do not do well in school are more likely to use cannabis. alternatively, cannabis use and substandard educational attainment may have common risk factors. however, the observation that cognitive function, particularly working memory, is impaired both acutely and in the days following cannabis use suggests a direct link between cannabis use and reduced educational achievement. short \ - term impairment in cognitive performance can lead students to fall behind, thus placing them at a disadvantage for future learning. also, individuals who begin using cannabis in early adolescence or who chronically use cannabis are at risk for long \ - lasting cognitive impairments. specifically, deficits in decision \ - making skills, concept formation and planning have been reported, and studies suggest that cannabis users are less likely to complete high school. scientific research is equivocal regarding the association between iq and cannabis. two recent longitudinal studies involving sets of twins indicated that the iq scores of cannabis users
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declined significantly over time though not significantly more than in their non \ - cannabis \ - using twin. one large cohort study had previously found that iq scores declined significantly among heavy cannabis users who were followed prospectively from adolescence to middle age. a dose – response relationship was also found, such that the longer the duration of use, the greater the effect on iq. if heavy cannabis use was sustained throughout follow \ - up, iq scores dropped an average of 10 points. also, when persistent users started heavy cannabis use during adolescence, their cognitive decline was greater than in individuals who started using after 18 years of age. all the factors described above may contribute to higher unemployment levels, involvement in criminal activity, greater social assistance requirements as well as compound the lower levels of life satisfaction reported by heavy cannabis users. while there are probably multiple explanations for the association between cannabis use and lower lifetime achievement, regular use can act as both cause and consequence. the point to bear in mind is that cognitive impairments have been linked to cannabis and some of these effects have a greater impact when cannabis is used in adolescence. among all trajectories of cannabis use, nonusers consistently have the most favourable socioeconomic and health outcomes at age 29, whereas early heavy users have the least. youth should not use cannabis recreationally because its many potentially harmful effects are serious. these effects are present in the entire population ; however, the developing brain is especially sensitive to the negative consequences of cannabis use. canadian youth are at significant risk for developing cud and, possibly, for doubling their risk of having a psychotic illness. driving under the influence of cannabis increases the risk for motor vehicle accidents. where cannabis has been legalized in the usa, children are requiring emergent medical care at greater rates due to unintentional ingestion. the potential extension of the legal cannabis industry in canada has raised a dilemma regarding the most appropriate age for its legal use, which should minimize harm to children and youth, the population most vulnerable to the product. on the one hand, prohibiting cannabis use until the mid \ - 20s would protect adolescents during a period of critical brain development. on the other, adolescents and young adults are already experimenting frequently with marijuana. aligning the legal age for cannabis use with that for other legally controlled substances, notably alcohol and tobacco, would help ensure that youth who have attained age of majority have access to a regulated product, with a known potency. also, they would be less liable to engage in high
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\ - risk illegal activities to access cannabis. cannabis legislation will have a significant impact on the lives and health of children and youth, and safeguards are necessary. based on the physical and mental health risks, and with many legal, financial and public safety issues at stake, policy makers — with support from physicians and the public at large — must continue to limit access to cannabis. to protect children and adolescents from the harms associated with recreational cannabis use and cannabis dependence, the canadian paediatric society recommends the following : - prohibit sales of all cannabis products to children and youth under the legal age for buying tobacco products and alcohol ( 18 or 19 years, depending on location ). - consider limiting the concentration of thc in cannabis that 18 \ - to 25 \ - year \ - olds can purchase legally. - enact and rigorously enforce regulations on the cannabis industry to limit the availability and marketing of cannabis to minors. these regulations must : - prohibit dispensaries from being located close to elementary, middle and high schools, licensed child care centres, community centres, residential neighbourhoods and youth facilities. - prohibit the sale of cannabis products by means of self \ - service displays or dispensing devices. - mandate strict labelling standards for all cannabis products, including a complete and accurate list of ingredients and an exact measure of cannabis concentration. - mandate package warnings for all cannabis products, including known and potential harmful effects of exposure ( e. g., to young children and the fetus during pregnancy ), similar to messaging on cigarette packaging. - mandate and enforce strict marketing and promotional standards, including a ban on all cannabis industry \ - related advertising and on the sponsorship of events, activities or permanent facilities by the cannabis industry. - mandate and enforce a ban on the marketing of cannabis \ - related products using strategies or venues that attract children and youth, including ( but not limited to ) ‘ candy \ - like ’ edibles, ‘ giveaways ’ and promotion through social media. - restrict the online sales of all cannabis and related products only to individuals identified as being older than the legal drinking age in the province or territory where they reside. - extend and align existing anti \ - tobacco legislation at all government levels to include cannabis ( i. e., prohibiting smoking in public venues, smoking in cars where a child is present ). - fund public education campaigns to reinforce that cannabis is not safe for children and youth by raising awareness of the harms associated with cannabis use and dependence
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. these campaigns should be developed in collaboration with youth leaders and should include messages from young opinion \ - leaders. - invest in the development and implementation of programs for routine roadside detection of cannabinoids and determine suitable consequences for youth who are found to be under the influence. - increase funding for the research, prevention and treatment of substance use in adolescents and young adults. - increase funding for mental health promotion and for treating mental illness in this age group. - consult with indigenous communities on adapting legislation, preventative measures and / or interventions to meet local conditions and cultural requirements. - actively monitor the impacts on youth of changes to cannabis legislation. health care providers should : - be aware of and communicate the health risks related to cannabis use. - screen all children and youth for cannabis exposure and / or use and educate adolescents and families on the health risks and harms associated with cannabis. - provide anticipatory guidance to parents and older children on the potential health risks of cannabis use.
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- current : management of … management of hiv \ - exposed and hiv \ - infected children # principal author ( s ) jl robinson ; canadian paediatric society, paediatr child health 2010 ; 15 ( 6 \ ) : 379 the management of hiv \ - exposed and hiv \ - infected children has been improved by the introduction of new testing methods and of new antiretroviral agents. whenever practical, such children should be cared for in consultation with paediatric infectious disease physicians with hiv expertise. physicians caring for these children should refer to the united states national institutes of health guidelines, which are continuously updated. physicians should keep in mind that the availability date of new antiretroviral agents and of paediatric formulations of antiretroviral agents differs in canada versus the united states, with variation in which country first licenses these products. issues on testing for hiv infection in pregnancy, benefit of early detection and prevalence of disease can be found in a previous canadian paediatric society statement titled “ ”. this document replaces the previous canadian paediatric society statement published in 2004 \. # infectious diseases and immunization committee members : robert bortolussi md ( chair ) ; jane finlay md ; jane c mcdonald md ; heather onyett md ; joan l robinson md ; elisabeth rousseau \ - harsany md ( board representative ) liaisons : upton d allen md, canadian pediatric aids research group ; charles ps hui md, cps liaison to health canada, committee to advise on tropical medicine and travel ; nicole le saux md, immunization program, active ; larry pickering md, american academy of pediatrics ; marina i salvadori md, cps liaison to health canada, national advisory committee on immunization consultants : james kellner md ; noni e macdonald md ; dorothy l moore md principal author : joan l robinson md 1. robinson jl ; canadian paediatric society, infectious diseases and immunization committee. testing for hiv infection in pregnancy. paediatr child health 2008 ; 13 : 221 \ - 4 \. disclaimer : the recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. variations, taking into account individual circumstances, may be appropriate. internet addresses are current at time of publication.
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human herpes simplex virus ( hsv ) infection in neonates can result in devastating outcomes, including mortality and significant morbidity. all infants are potentially at risk for neonatal hsv infection. this position statement reviews epidemiology, transmission and risk factors, with a focus on intrapartum infection. it considers diagnosis and prognosis according to infection category, along with testing modalities and limitations. recommendations for managing newborns known to have been exposed intrapartum to hsv are based on expert opinion because a randomized trial to compare management options is not feasible. guidance is provided for the empirical management of infants with suspected clinical sepsis, including those who do not respond to antibacterial therapy. the present statement replaces a 2006 position statement by the canadian paediatric society. key words : * acyclovir ; cns ; encephalitis ; sem ; sepsis * estimated rates of neonatal human herpes simplex virus ( nhsv ) infection vary across different regions of the world. \ ] \ ] in canada, the infection occurs in approximately one per 16, 500 newborns, which corresponds to approximately six per 100, 000 live births. \ ] transmission to newborns can occur with either genital herpes simplex virus ( hsv ) type 1 ( hsv \ - 1 \ ) or hsv type 2 ( hsv \ - 2 \ ). worldwide, an estimated 75 % of nhsv cases are caused by hsv \ - 2 and 25 % by hsv \ - 1 \. \ ] one canadian prospective study analyzing reports in the period between 2000 and 2003 found that 63 % of cases were due to hsv \ - 1 \. \ ] studies from ontario ( conducted in 2000 to 2001 \ ) \ ] and british columbia ( in 1999 \ ) \ ] investigating infants potentially at risk for hsv \ - 2 detected hsv \ - 2 antibodies in 10 % and 17 % of pregnant women, respectively. many factors influence the transmission of hsv infection to newborns, including the nature of maternal infection, the mode of delivery, the duration of rupture of membranes and the use of intrapartum instrumentation. maternal genital hsv cases may be classified as follows : \ ] - newly acquired - first \ - episode primary infection ( mother has no serum antibodies to hsv \ - 1 or \ - 2 at onset ) ; - first \ - episode nonprimary
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infection ( mother has a new infection with one hsv type in the presence of antibodies to the other type ) ; or - recurrent ( mother has pre \ - existing antibodies to the hsv type that is isolated from the genital tract ). the most common and important category of nhsv acquisition is intrapartum. even for hsv \ - 1, \ > 75 % of cases of nhsv are acquired during delivery from genital disease that is often newly acquired and asymptomatic. \ ] newborns may also acquire hsv infection through in utero or postnatal transmission. although rare, in utero hsv infection can have teratogenic effects such as skin lesions or scars, central nervous system ( cns ) disorders and chorioretinitis. \ ] postnatal infection can be acquired from the infant ’ s mother or from nonmaternal sources ( eg, relatives or hospital personnel with orolabial herpes or asymptomatic shedding of hsv \ - 1 \ ). \ ] \ ] in most cases of nhsv infection, there is no known history of maternal genital hsv because mothers have never had or have never noticed external genital lesions. studies show that 75 % to 90 % of individuals who are seropositive for hsv \ - 2 were unaware of their infection. \ ] all infants, therefore, must be considered to be potentially at risk for nhsv infection. seropositive women intermittently shed hsv in their genital tracts, with 10 % to 20 % of individuals with hsv \ - 2 shedding on any given day, as detected by polymerase chain reaction ( pcr ) testing. \ ] the category of maternal infection at time of delivery influences the likelihood of nhsv acquisition, presumably because mothers who have had an hsv infection transmit hsv \ - neutralizing antibodies to their infant across the placenta, provided that their infant is not born before 32 weeks ’ gestation. \ ] \ ] \ - \ ] thus, infants born to mothers who have a first \ - episode primary infection at time of delivery are at the highest risk for acquiring hsv, with transmission rates of up to 60 %, because their mother had no pre \ - existing neutralizing antibodies to transmit. \ ] for infants born to mothers who have first \ - episode nonprimary infections, the transmission rates are in the order of ≤30 % because crossrea
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##ctive antibodies are present. the lowest risk of neonatal transmission occurs with maternal recurrent infection ( at \ < 2 % ) because type \ - specific antibodies are present. \ ] delivery by elective cesarean section markedly reduces but does not eliminate the risk for newborn infection. \ ] \ ] women with recurrent genital hsv are commonly prophylaxed with acyclovir ( acv ) or valacyclovir from 36 weeks ’ gestation until delivery. in this context, antiviral therapy near the end of pregnancy can lower recurrence of genital hsv and shedding at delivery ; \ ] however, it is not clear whether this prophylaxis translates to a reduced risk for nhsv infection. guidelines regarding the role of cesarean delivery and the indications for acyclovir are published \ ] \ ] \ ] but are not specifically addressed in the present statement. obstetrical procedures that can cause scalp abrasions or a break in the infant ’ s skin during labour and delivery may increase risk of nhsv transmission to a newborn infant. fetal scalp sampling and monitoring, use of forceps and vacuum \ - assisted deliveries \ ] \ ] \ - \ ] should be avoided if possible when maternal genital lesions are present. \ ] early or prolonged rupture of membranes may also increase risk. # categories and outcomes of nhsv infection classifying nhsv infections can help to guide diagnosis and management, and is important for assigning prognosis. \ ] intrauterine nhsv infections are rare, accounting for \ < 5 % of cases. the classification of infection acquired in the perinatal, natal and postnatal periods is as follows : - disseminated hsv ; - localized cns hsv ; - skin, eye and mucous membrane ( sem ) infection. there may be overlap among the different syndromes. disseminated disease involves multiple organs, notably the liver and lungs. in most cases, the initial symptoms of nhsv infection present within the first four weeks of life. occasionally, disease presents for the first time between four and six weeks after birth ; \ ] therefore, infants up to 42 days of age should be fully evaluated for nhsv when clinical features are consistent with nhsv. newborns with intrauterine infection present at birth or shortly thereafter. the absence of skin lesions does not negate the possibility of an nhsv diagnosis. one study showed that 39 % of
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infants with disseminated disease did not have skin lesions at any time during their illness, while 32 % with cns disease and 17 % with sem disease did not develop skin lesions. \ ] nhsv infection should be considered in neonates with sepsis syndrome, particularly when this condition is accompanied by liver dysfunction and even when there is no known history of maternal hsv and the infant has no skin vesicles. one study reviewed 32 infants with perinatal hsv, noting that 50 % of cases came to medical attention with nonspecific complaints and 75 % of these had fever alone. nonspecific presentation occurred primarily in infants whose symptoms started at \ < 21 days of age. \ ] also, hsv should be considered in neonates with fever, irritability and abnormal cerebrospinal fluid ( csf ) findings, particularly when accompanied by seizures. however, a normal initial csf examination does not necessarily exclude the diagnosis of an nhsv cns infection. \ ] infants who present with disseminated disease are less likely to survive than infants with sem or cns disease. data suggest that dissemination is more common with newly acquired maternal hsv, presumably because there has not been sufficient time to transfer neutralizing antibodies in utero. \ ] \ ] before antivirals, an estimated 85 % of infants with disseminated hsv disease and 50 % with cns disease died. \ ] treatment with acv ( 60 mg / kg / day ) has resulted in one \ - year mortality rates from disseminated and cns disease of 29 % and 14 %, respectively. \ ] a mortality rate of 15 \. 5 % was reported in a canadian study that documented cases occurring over a three \ - year period ( october 2000 to september 2003 \ ). \ ] among survivors enrolled in two studies of parenteral acv for which follow \ - up data were available at 12 months of age, 25 % of patients with disseminated disease exhibited neurological complications, compared with 70 % with cns infection alone. \ ] among neonates with sem disease ( without apparent cns disease ), long \ - term neurological sequelae have also been documented. \ ] \ ] however, more recent studies demonstrate no sequelae ; therefore, it appears likely that those infants with sequelae had unrecognized cns infection. \ ] # laboratory diagnosis it is important for the clinician to speak with a laboratory specialist or
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infectious disease consultant when nhsv is suspected, particularly in settings where testing for nhsv is performed less frequently. expert consultation is important because the utility of testing modalities varies according to sample type, and the laboratory must provide general as well as centre \ - specific advice on the types of specimens to send for testing. each specific laboratory test for hsv has important limitations. therefore, test results should be interpreted with careful consideration of the clinical context and results from nonspecific investigations including an electroencephalogram, computed tomography or magnetic resonance imaging, liver transaminase levels and platelet count. hsv may be detected by viral culture, direct immunofluorescent antibody staining or enzyme immunoassays. however, pcr testing of csf, skin lesions, mucous membranes and blood is thought to be more sensitive and is now offered by most laboratories. the detection of the virus in superficial cultures may represent skin contamination by intrapartum exposure if samples are obtained within the first 24 h after birth. \ ] when samples obtained \ > 24 h after birth are positive, they are more likely to represent active viral replication than contamination. prospective studies regarding the utility of periodic surveillance cultures in the early diagnosis of nhsv infection are lacking for infants exposed to active genital lesions. caution should be exercised when using a negative csf hsv pcr to rule out cns hsv, particularly when the sample is obtained in the early stages of illness ( the first 24 h to 48 h ). if the index of suspicion is high, yet the csf pcr is negative, there are two options that could be considered. a repeat csf pcr within 72 hours of starting acyclocir is likely to be positive in infants with cns hsv. alternatively, one could complete 21 days of iv acyclovir for possible cns hsv. because cns disease can be very subtle, any patient with suspected nhsv infection should have a lumbar puncture performed for csf hsv pcr testing as soon as it is clinically feasible to do so, unless there is a contraindication to performing a lumbar puncture. cns nhsv infection may occur despite ‘ normal ’ csf cell counts and biochemical features, particularly in the early stages of infection. therefore, the csf hsv pcr test should be performed even when these parameters are normal. the evaluation of hsv viremia
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using pcr is less well established than csf pcr testing. \ ] \ - \ ] one study that evaluated hsv viral load in serum and csf using a real \ - time pcr assay found that patients with disseminated disease had higher viral loads in their sera, while patients with cns infection had higher viral loads in their csf. \ ] viral loads were also higher in patients who succumbed to hsv disease, suggesting that this measure may be useful for assessing prognosis in nhsv cases. a poorer prognosis has also been associated with persistence of hsv in the csf of patients on acyclovir. \ ] there is limited experience with pcr testing of respiratory specimens but a positive result from a nasopharyngeal specimen of an infant with pneumonia makes it highly likely that the infant has disseminated nhsv infection. infant serology is not useful for diagnosing nhsv for three main reasons. first, transplacental immunoglobulin ( ig ) g antibodies cannot be differentiated from igg produced by the infant. second, the ability of some severely affected infants to make antibodies is impaired. third, the commercially available assays for hsv igm antibodies have only variable and limited reliability. # managing nhsv infections intravenous acyclovir is the treatment of choice for treating nhsv. the dose is 60 mg / kg / day in three divided doses administered every 8 h, assuming that renal function is normal. \ ] the duration of therapy is dictated by the category of disease. for sem disease, the duration of therapy is 14 days, while for disseminated or cns disease, the minimum duration of treatment is 21 days. oral acv has limited bioavailability, resulting in inadequate drug levels for treatment ; \ ] consequently, parenteral therapy is required. the use of higher doses of acv is associated with neutropenia and adequate hydration is necessary to reduce the risk of nephrotoxicity. \ ] a topical agent ( eg, 1 % trifluridine ) is recommended for use with parenteral acv in neonates with ocular disease. \ ] given the potential for significant neurological sequelae in survivors of nhsv infection, affected infants should have a structured follow \ - up program that allows for neurodevelopmental, ophthalmological and hearing assessments. there has been research
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into the role of suppressive antiviral therapy in infants with nhsv infections. a recent randomized, double \ - blinded, placebo \ - controlled trial evaluated infants with cns hsv or disseminated hsv with cns involvement, while a second, parallel trial evaluated infants with sem hsv disease. the study demonstrated improved developmental outcome in infants with cns involvement who were randomly assigned to receive six months of treatment with oral acv versus placebo. \ ] for infants with sem disease, the only benefit was a decreased incidence of skin recurrences but this can prevent the need for a lumbar puncture and readmission for repeat intravenous acv with recurrences before 6 weeks of age. \ ] \ ] # # laboratory diagnostics for nhsv infections - whenever a diagnosis of nhsv is being considered, it is essential to order laboratory testing for hsv in addition to performing skin and mucous membrane examinations : - the standard tests for hsv include csf pcr and swabs of vesicular lesions and mucous membranes. also, blood for hsv pcr may be tested if disseminated nhsv is suspected. following discussion with the laboratory, a nasopharygeal specimen should be tested when the infant has pneumonia. serum hepatic transaminase levels should be measured to provide supporting evidence for disseminated hsv infection. - when evaluating nhsv infection in exposed asymptomatic infants, mucous membrane swabs should be obtained from the mouth, nasopharynx and conjunctivae * at least - 24 h after delivery. additional swabs may be obtained ( eg, from sites of scalp electrodes, if present ). - pcr testing for csf hsv dna is the diagnostic method of choice for cns hsv. - for all the above tests, clinicians and laboratory staff should work together to minimize the turn \ - around time for test results. - infection, when an infant is delivered by caesarean section before rupture of membranes the risk for nhsv is very low. assuming that the infant is well, mother and child can be discharged pending results of the mucous membrane and nasopharyngeal swabs taken at 24 h of life. reliable caregivers should be made aware of the signs of nhsv infection. some experts also recommend testing blood with pcr, if the
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test is available. if hsv is detected on a swab or in blood pcr, the infant should be managed as a case of nhsv. note : with respect to the above, some experts recommend performing csf cell count, chemistries and pcr when mucous membrane swabs are taken ( ie, a complete work \ - up ). - first clinical episode of genital herpes infection, when an infant is delivered vaginally or by caesarean section after rupture of membranes an infant ’ s mucous membrane swabs should be obtained and acv started. it remains controversial whether this testing should be performed at birth ( with the risk being detection of surface contamination ) or at 24 h of life. some experts also recommend testing blood with pcr, if the test is available. if the infant ’ s swabs or blood pcr are positive, csf pcr must be obtained to determine the duration of acv therapy. if the infant ’ s swabs are negative, the infant should receive acv for 10 days despite negative swabs. note : some experts recommend performing csf cell count, chemistries and pcr when mucous membrane swabs are taken ( ie, a complete work \ - up ). - recurrent hsv at delivery – infant delivered by caesarean section use the same approach as for first \ - episode infections before membrane rupture. - recurrent hsv at delivery – infant delivered vaginally obtain mucous membrane swabs at 24 h and the infant may be discharged pending results. some experts also recommend testing blood for pcr, if the test is available. acv therapy would only be indicated when the swabs or blood pcr are positive or when the infant develops signs and symptoms of nhsv infection. # # managing asymptomatic term infants whose mothers have no active lesions at delivery ( including women on acv prophylaxis ) an infant whose mother has a history of hsv but no active lesions at delivery should be observed for signs of nhsv but does not require acv therapy. mucous membrane swabs are not routinely recommended for this infant. in scenarios in which the first clinical evidence of hsv was documented during the third trimester or near delivery, clinicians may consider mucous membrane swabs. parents and caregivers should be educated about the signs and symptoms of nhsv. # # managing the neonate with
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symptoms compatible with nhsv disseminated hsv can mimic bacterial sepsis, and clinicians need to consider possible nhsv infection in unwell infants \ < 6 weeks of age. pending laboratory confirmation, consider investigations and treatment of nhsv for the following at \ - risk patients : - infants started on iv antibiotics for suspected sepsis ( especially infants presenting with seizure or yielding abnormal csf ) who do not improve rapidly and have negative bacterial cultures at 24 h incubation. - infants admitted with pneumonia of uncertain etiology who do not improve after 24 h on antibiotics, especially if the radiographic picture is consistent with viral pneumonia. - infants with unexplained bleeding from venipuncture sites or an unexplained, documented coagulopathy. - infants started on iv antibiotics for suspected sepsis who are found to have unexplained hepatitis. # # treatment and follow \ - up of infants with nhsv infections - early therapy with intravenous ( iv ) acv improves the prognosis for all three presentations of nhsv. therefore, infants should be started on iv acv before laboratory confirmation of nhsv, as soon as the infection is suspected clinically. - the dose is 60 mg / kg / day in three divided doses administered every 8 h, assuming that renal function is normal. treatment duration should be 14 days if the disease is limited to the skin, eyes or mouth, and a minimum of 21 days if the infection involves the cns or is disseminated. - for infants with cns disease, csf should be sampled near the end of a 21 \ - day course of therapy. if the pcr remains positive, treatment should be extended with weekly csf sampling and acv stopped when a negative result is obtained. - in combination with parenteral acv, neonates with ocular involvement should initially receive a topical ophthalmic agent such as trifluridine. an ophthalmology consultation is essential. this may inform the decision to use combination therapy versus monotherapy depending on disease severity. - oral acv is contraindicated for the acute treatment of nhsv because drugs levels are too low. levels from oral acv are only high enough for suppressive therapy. - suppressive therapy with oral acv ( 300 mg / m2 per dose administered three times per day ) should be given for six months to infants with cns disease. a tool for calculating body surface area can be found
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at : www. csgnetwork. com / bsacalc. html. data are less convincing for sem or disseminated disease, but suppressive therapy may still be offered. - follow \ - up is necessary to detect and manage adverse effects related to suppressive acv treatment as well as for the neurodevelopmental sequelae of nhsv. complete blood count, and urea and creatinine levels should be checked monthly for adverse effects, and the dose of acv adjusted for growth. infants should be followed in a program that enables their evaluation for the neurodevelopmental, ophthalmological and aural consequences of nhsv infection. # # preventing nhsv infections strategies to prevent nhsv, including the identification of high \ - risk pregnancies, caesarean delivery, maternal antiviral therapy, and anticipatory guidance for prospective mothers and partners, are largely beyond the scope of this statement. however, the following recommendations are especially pertinent to special care nurseries and neonatal intensive care units. # # general infection control measures comprehensive infection control guidelines are available, \ ] but three specific target groups warrant attention here : * neonates with hsv infection and exposed neonates * - neonates with hsv infection should be managed using contact precautions when mucocutaneous lesions are present and until lesions have crusted. - asymptomatic neonates whose mothers have active hsv lesions should be managed using contact precautions until the end of the incubation period ( day 14 \ ) or until samples from the infant taken after the first 24 h of life are negative. some experts do not recommend contact precautions if an exposed infant is born by caesarean section and membranes are ruptured \ < 4 h to 6 h. * mothers with active hsv * - mothers who are in hospital should be on contact precautions until their lesions have crusted. - mothers with herpes labialis should wear a disposable mask when caring for their infant \ < 6 weeks of age, until lesions are healed ( crusted and dried ). advise these mothers not to kiss their infant. there is no contraindication to breastfeeding unless there are herpetic lesions on the breast. - mothers with skin lesions should keep them covered whenever their newborn is present. * staff with orofacial or skin lesions * - staff with skin lesions due to hsv must practice meticulous hand hygiene
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. individuals who have contact with infants should keep their lesions covered. if this is not possible, direct care of neonates should be avoided. - some experts recommend wearing a surgical mask to cover orolabial lesions because these cannot be covered by dressings. - staff with active herpetic whitlow should avoid contact with neonates.
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ankyloglossia ( ‘ tongue \ - tie ’ ) is a relatively common congenital anomaly characterized by an abnormally short lingual frenulum, which may restrict tongue tip mobility. there is considerable controversy regarding its diagnosis, clinical significance and management, and there is wide variation in practice in this regard. most infants with ankyloglossia are asymptomatic and do not exhibit feeding problems. based on available evidence, frenotomy cannot be recommended for all infants with ankyloglossia. there may be an association between ankyloglossia and significant breastfeeding difficulties in some infants. this subset of infants may benefit from frenotomy ( the surgical division of the lingual frenulum ). when an association between significant tongue \ - tie and major breastfeeding problems is clearly identified and surgical intervention is deemed to be necessary, frenotomy should be performed by a clinician experienced with the procedure and using appropriate analgesia. more definitive recommendations regarding the management of tongue \ - tie in infants await clear diagnostic criteria and appropriately designed trials. key words : * ankyloglossia ; breastfeeding ; frenotomy ; infant ; tongue \ - tie * ankyloglossia ( ‘ tongue \ - tie ’ ) is a congenital anomaly observed in newborns and children, and is characterized by an abnormally short lingual frenulum. the tight frenulum can cause decreased tongue mobility to varying degrees. associations between tongue \ - tie, lactation problems, speech disorders and other oral motor disorders ( eg, problems with swallowing or licking ) have been inconsistent, and are an ongoing source of controversy within the medical community. \ - one survey of otolaryngologists, paediatricians, speech pathologists and lactation consultants reported significant disparities within and among these groups with regard to their approaches to ankyloglossia and their beliefs regarding its association with feeding, speech and social problems. dentists are similarly divided on the topic. with a renewed emphasis on the benefits of breastfeeding ( which the canadian paediatric society fully supports ), there is more pressure to diagnose ankyloglossia as a barrier to successful breastfeeding, thus increasing the demand for frenotomy. the present statement specifically focuses on the evidence surrounding the association of ankyloglossia and breastfeeding difficulties in infants, and the efficacy of frenotom
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##y in the context of ankyloglossia and breastfeeding difficulties. the present statement replaces the previous canadian paediatric society document revised in 2011 \. several studies have been published in the interim. there is neither a universally accepted definition of ankyloglossia nor practical objective criteria for diagnosing this condition. historically, definitions have been based on either anatomical characteristics of the lingual frenulum ( ie, the degree of fusion between the child ’ s tongue and the floor of the mouth ) or on functional impairment ( ie, an inability to protrude the tongue past the incisal edge of the lower gingiva and other signs of decreased tongue mobility ). \ - in one classification system, ankyloglossia ( types i and ii ) is characterized by insertion at the tip of the tongue ( type i ) or slightly behind the tip ( type ii ), while posterior ankyloglossia is characterized by a thickened frenulum ( type iii ) or a submucosal frenulum ( a flat, broad mound ) that restricts movement at the base of the tongue ( type iv ). these definitions are seldom used in the literature and rarely in the clinical domain. hazelbaker developed a descriptive assessment tool for lingual frenulum function ; however, it is complex, lengthy and has not been validated in a controlled manner. criteria used to diagnose ankyloglossia show considerable variation, and there is no accepted standard. the lack of a consistent definition further fuels controversy regarding this condition and its clinical significance. the tongue is fused to the floor of the mouth in early development. cell death and resorption free the tongue, with the frenulum left as the only remnant of initial attachment. the lingual frenulum typically becomes less prominent as a natural process of the child ’ s growth and development, when the alveolar ridge grows in height and the teeth begin to erupt. this process occurs during the first six months to five years of life. ankyloglossia can be classified based on the degree of fusion remaining between the tongue and the floor of the mouth. there may be a genetic predisposition to ankyloglossia. this congenital anomaly typically occurs in isolation. the reported prevalence of ankyloglossia in infants is variable in the literature, reflecting the lack of a consistent definition. estimates range from 4 \. 2 % to 10 \. 7 %
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in newborns. \ - the role of a short lingual frenulum as a cause of breastfeeding difficulties has been described in multiple anecdotal reports linking ankyloglossia to poor latch, maternal nipple pain and trauma, suboptimal infant weight gain, infant breast refusal and low maternal milk supply due to poor milk removal. \ - to nurse successfully, an infant must latch on to the areola using the upper gum ridge, buccal fatty pads and tongue. suckling begins with forward movement of the jaw and tongue. the tongue helps to make a better seal, but with minimal action. the anterior edge of the tongue thins, cupping upward to begin a peristaltic ripple back toward the throat. at the same time, the lower jaw squeezes milk from the ductules. it is clear that restriction of tongue movement must be extreme to interfere with sucking and swallowing. it also appears that some mothers have particular breast, nipple or milk ejection characteristics that allow them to successfully breastfeed an infant with ankyloglossia. ultrasound studies suggest that the mechanism of poor feeding in tongue \ - tied infants is due to restricted tongue movement, such that it may cause pain and / or trauma of the nipple, poor milk removal and unsustainable attachment to the breast. frenotomy appears to restore sucking movements more analogous to breastfeeding infants without tongue \ - tie. # ankyloglossia and breastfeeding difficulties several studies have examined the association of ankyloglossia with breastfeeding difficulties. one study compared the rates of ankyloglossia in infants attending outpatient clinics for breastfeeding difficulties with the general population of normal term newborns, and reported a higher incidence of ankyloglossia in infants with breastfeeding difficulties ( 12 \. 8 % versus 3 \. 2 % ). another study recruited a cohort of 201 newborns with ankyloglossia and reported a high incidence of feeding difficulties ( 44 % ), but did not find a relationship between tongue \ - tie length and breastfeeding difficulties. this study also demonstrated that 56 % of infants with tongue \ - tie can still feed adequately. one prospective trial showed a higher incidence of latching difficulties ( 19 % versus 0 % ) and breastfeeding difficulties ( 25 % versus 3 % ) in a group of 36 neonates with ankyloglossia compared with a control group of neonates
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with no ankyloglossia. thirty ( 83 % ) of the 36 infants with ankyloglossia were successfully breastfed during the study period, compared with 33 ( 92 % ) of the 36 control infants ( p \ = 0 \. 29 \ ). the duration of breastfeeding was similar in both groups. this study also found no significant difference between ankyloglossia grades ( moderate versus mild ) or frenulum thickness in infants experiencing breastfeeding difficulties. # managing ankyloglossia management of tongue \ - tie is usually conservative, requiring no intervention beyond parental education, lactation support and reassurance. in cases of ankyloglossia and significant breastfeeding difficulties, there is some evidence that frenotomy can improve feeding. it remains controversial which tongue \ - ties need to be surgically released and which can be left to observation. several studies, including recent randomized controlled studies, have been conducted to evaluate the effectiveness of frenotomy in the setting of ankyloglossia with breastfeeding difficulties ( table 1 \ ). \ - the limitations of these randomized controlled trials and prospective trials are substantial, and include the following : - variability and poor definition for diagnosing ankyloglossia, leading to unclear inclusion criteria ; - small trial size ; - most studies involved near \ - total crossover of the control group to the frenotomy arm of the study, precluding a fair assessment of outcomes and making it difficult to interpret findings ; - the objective outcome measurements were often limited and based on the observation of one feed ; - no reports of demographic information were included ( ie, first \ - time versus experienced mothers with later birth order infants ) ; - poorly defined outcomes ( eg, ‘ feeding improvement ’ ) in some cases. blinding of observers and mothers in such studies is very difficult to achieve. in one study, 100 % of supposedly masked experienced mothers correctly identified division of tongue \ - tie in their infant. careful consideration must also be given to the ability of a new mother to respond objectively about improved breastfeeding when her infant has just undergone a procedure to which she consented. furthermore, there is a surprising paucity of literature describing the ‘ normal ’ breastfeeding learning curve for mother and infant. this lack, along with the fact that a control group was seldom preserved during trials, makes it difficult to determine whether breastfeeding difficulties would have improved with time and
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conservative management ( ie, natural history ). in addition to the studies described, several other prospective cohort studies have shown an association of ankyloglossia with breastfeeding difficulties as well as the benefit of frenotomy in infants with ankyloglossia who present with breastfeeding difficulties. \ - however, these studies also share some of the limitations cited above. therefore, while several randomized trials and some cohort and cross \ - sectional prospective studies have shown some effectiveness for frenotomy in newborns who are having difficulties with breastfeeding due to ankyloglossia, they all have significant limitations. # frenotomy procedure if a tongue \ - tie release is deemed necessary, a referral to an otolaryngologist or a physician with experience performing this procedure should be made. appropriate analgesia should be provided for the procedure. unfortunately, there is also a paucity of literature regarding effective analgesia for frenotomy. case reports have cited the use of acetaminophen, lidocaine and sucrose for analgesia, but none of these have been studied. benzocaine was studied in a randomized controlled trial and was shown to be ineffective compared with placebo. release of the tongue \ - tie appears to be a minor procedure, but may cause complications such as bleeding, infection or injury to wharton ’ s duct. from the limited literature, the incidence of minor complications appears to be rare. a simple incision or ‘ snipping ’ of a tongue \ - tie ( frenotomy ) is the most common procedure performed for partial ankyloglossia. there is a risk that postoperative scarring may limit tongue movement even further, necessitating reoperation. excision with lengthening of the ventral surface of the tongue, or a frenuloplasty release, are more complicated procedures. both entail less postoperative scarring but carry the inherent risks associated with general anesthesia. specialized private clinics are now performing frenotomy by laser ablation, but available data regarding the safety or efficacy of this procedure are limited. ankyloglossia is relatively common in the newborn population. most of the time, ankyloglossia is an anatomical finding without significant consequences for infants affected by this condition. current evidence appears to show that most newborns with this condition are still able to breastfeed successfully. based on available
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evidence, frenotomy cannot be recommended for all infants with ankyloglossia. there is no absolute relationship between ankyloglossia and breastfeeding difficulties. if an association between significant tongue \ - tie and major breastfeeding problems is identified and surgical intervention is deemed to be necessary, frenotomy should be performed by a clinician experienced with the procedure, using appropriate analgesia. consultation with a health care professional who has expertise in breastfeeding is recommended before referring a child for frenotomy. clear criteria are needed for the diagnosis of ankyloglossia, along with specific attention to characteristics of infants for whom a frenotomy would be of value to improve feeding. identifying the specific characteristics of ankyloglossia that may guide the clinician in determining which infants are more likely to benefit from frenotomy is crucial for prognosis. also, with respect to study design, future studies should include larger sample sizes and avoid crossover among study groups. it is important to rule out other oral anomalies that may be causing breastfeeding difficulties. a thorough intraoral examination, including inspection of the tongue and its function, should be performed in newborns, particularly when there are feeding difficulties. the mother should then be interviewed regarding breastfeeding ( latch, nipple pain, discomfort ) and the feeding observed. if difficulties are identified, referral to a health care provider with experience in breastfeeding support should be considered. # cps community paediatrics committee members : carl cummings md ( chair ) ; sarah gander md ; ruth b grimes md ; barbara grueger md ( past member ) ; larry b pancer md ; anne rowan \ - legg md ; ellen p wood md ( board representative ) liaisons : fabian p gorodzinsky md, cps community paediatrics section principal author : anne rowan \ - legg md 1. messner ah, lalakea ml. ankyloglossia : controversies in management. int j pediatr otorhinolaryngol 2000 ; 54 ( 2 \ - 3 \ ) : 123 \ - 31 \. 2. wright je. tongue \ - tie. j paediatr child health 1995 ; 31 ( 4 \ ) : 276 \ - 8 \. 3. griffiths dm. do tongue ties affect breastfeeding? j hum lact 2004 ; 20 ( 4 \ ) : 409 \ -
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14 \. 4. kupietzky a and botzer e. ankyloglossia in the infant and young child : clinical suggestions for diagnosis and management. pediatr dent 2005 ; 27 ( 1 \ ) : 40 \ - 6 \. 5. rowan \ - legg a ; canadian paediatric society, community paediatrics committee. ankyloglossia and breastfeeding. paediatr child health 2011 ; 16 ( 4 \ ) : 222 \. 6. hogan m, westcott c, griffiths m. randomized, controlled trial of division of tongue \ - tie in infants with feeding problems. j paediatr child health 2005 ; 41 ( 5 \ - 6 \ ) : 246 \ - 50 \. 7. ricke la, baker nj, madlon \ - kay dj, defor ta. newborn tongue \ - tie : prevalence and effect on breast \ - feeding. j am board fam pract 2005 ; 18 ( 1 \ ) : 1 \ - 7 \. 8. ballard jl, auer ce, khoury jc. ankyloglossia : assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. pediatrics 2002 ; 110 ( 5 \ ) : e63 \. 9. messner ah, lalakea ml, aby j, macmahon j, bair e. ankyloglossia : incidence and associated feeding difficulties. arch otolaryngol head neck surg 2000 ; 126 ( 1 \ ) : 36 \ - 9 \. 10. o ’ callahan c, macary s, clemente s. the effects of office \ - based frenotomy for anterior and posterior ankyloglossia on breastfeeding. int j pediatr otorhinolaryngol 2013 ; 77 ( 5 \ ) : 827 \ - 32 \. 11. hazelbaker ak. the assessment tool for lingual frenulum function ( atlff ) : use in a lactation consultant ’ s private practice. pasadena : pacific oaks college, 1993 \. 12. amir lh, james jp, donath sm. reliability of the hazelbaker assessment tool for lingual frenulum function. int breastfeed j 2006 ; 1 ( 1 \ ) : 3 \ - 8 \. 13. segal lm, stephenson r, dawes m, feldman
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p. prevalence, diagnosis, and treatment of ankyloglossia : methodologic review. can fam physician 2007 ; 53 ( 6 \ ) : 1027 \ - 33 \. 14. notestine ge. the importance of the identification of ankyloglossia ( short lingual frenulum ) as a cause of breastfeeding problems. j hum lact 1990 ; 6 ( 3 \ ) : 113 \ - 5 \. 15. berg kl. tongue \ - tie ( ankyloglossia ) and breastfeeding : a review. j hum lact 1990 ; 6 ( 3 \ ) : 109 \ - 12 \. 16. geddes dt, kent jc, mcclellan hl, garbin cp, chadwick lm, hartmann pe. sucking characteristics of successfully breastfeeding infants with ankyloglossia : a case series. acta paediatr 2010 ; 99 ( 2 \ ) : 301 \ - 3 \. 17. garbin cp, sakalidis vs, chadwick lm, whan e, hartmann pe, geddes dt. evidence of improved milk intake after frenotomy : a case report. pediatrics 2013 ; 132 ( 5 \ ) : e1413 \ - 17 \. 18. wight ne. management of common breastfeeding issues. pediatr clin north am 2001 ; 48 ( 2 \ ) : 321 \ - 44 \. 19. geddes dt, langton db, gollow i, jacobs la, hartmann pe, simmer k. frenulotomy for breastfeeding infants with ankyloglossia : effect on milk removal and sucking mechanism as imaged by ultrasound. pediatrics 2008 ; 122 ( 1 \ ) : e188 \ - 94 \. 20. dollberg s, botzer e, grunis e, mimouni fb. immediate nipple pain relief after frenotomy in breast \ - fed infants with ankyloglossia : a randomized, prospective study. j pediatr surg 2006 ; 41 ( 9 \ ) : 1598 \ - 600 \. 21. jensen d, wallace s, kelsay p. latch : a breastfeeding charting system and documentation tool. j obstet gynecol neonatal nurs 1994 ; 23 ( 1 \ ) : 27 \ - 32 \. 22. berry j, griffiths m
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, westcott c. a double \ - blind, randomized, controlled trial of tongue \ - tie division and its immediate effect on breastfeeding. breastfeed med 2012 ; 7 ( 3 \ ) : 189 \ - 93 \. 23. matthews mk. developing an instrument to assess infant breastfeeding behaviour in the early neonatal period. midwifery 1988 ; 4 ( 4 \ ) : 154 \ - 65 \. 24. emond a, ingram j, johnson d, et al. randomised controlled trial of early frenotomy in breastfed infants with mild \ - moderate tongue \ - tie. arch dis child fetal neonatal ed 2014 ; 99 ( 3 \ ) : f189 \ - 95 \. 25. dennis cl. the breastfeeding self \ - efficacy scale : psychometric assessment of the short form. j obstet gynecol neonatal nurs 2003 ; 32 ( 6 \ ) : 734 \ - 44 \. 26. buryk m, bloom d, shope t. efficacy of neonatal release of ankyloglossia : a randomized trial. pediatrics 2011 ; 128 ( 2 \ ) : 280 \ - 8 \. 27. melzack r. the short \ - form mcgill pain questionnaire. pain 1987 ; 30 ( 2 \ ) : 191 \ - 7 \. 28. ngerncham s, laohapensang m, wongvisutdhi t, et al. lingual frenulum and effect on breastfeeding in thai newborn infants. paediatr int child health 2013 ; 33 ( 2 \ ) : 86 \ - 90 \. 29. post e, daamen j, balemans w. snipping of a “ tongue tie ” in neonates with ankyloglossia and breastfeeding problems : outcomes and complications. arch dis child 2012 : 97 ( suppl 2 \ ) : a486 \. 30. kumar m, kalke e. tongue \ - tie, breastfeeding difficulties and the role of frenotomy. acta paediatr 2012 ; 101 ( 7 \ ) : 687 \ - 9 \. 31. sethi n, smith d, kortequee s, ward vm, clarke s. benefits of frenulotomy in infants with ankyloglossia. int j pediatr otorhinolaryngol 2013 ;
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77 ( 5 \ ) : 762 \ - 5 \. 32. dollberg s, marom r, botzer e. lingual frenotomy for breastfeeding difficulties : a prospective follow \ - up study. breastfeed med 2014 ; 9 ( 6 \ ) : 286 \ - 9 \. 33. ovental a, marom r, botzer e, batscha n, dollberg s. using topical benzocaine before lingual frenotomy did not reduce crying and should be discouraged. acta pediatr 2014 ; 103 ( 7 \ ) : 780 \ - 2 \. 34. catlin fi. tongue \ - tie. arch otolaryngol 1971 ; 94 ( 6 \ ) : 548 \ - 57 \. disclaimer : the recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. variations, taking into account individual circumstances, may be appropriate. internet addresses are current at time of publication.
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while tobacco is sacred in many indigenous cultures, the recreational misuse of commercial tobacco is highly addictive and harmful. tobacco misuse is the leading preventable cause of premature death in the world. smoking rates among canadian indigenous youth are at least three times higher than for their non \ - aboriginal peers, an alarming statistic on many levels. the tolls on health from extensive tobacco use range from disproportionately high individual mortality and morbidity to heavy socioeconomic burdens on indigenous communities. paediatric health care providers are uniquely positioned to collaborate with community stakeholders to prevent and treat tobacco misuse in young people and their families, while understanding the cultural value of tobacco for many indigenous peoples. targeted interventions can positively impact length and quality of life, improve overall health and decrease the immense social and human costs of tobacco misuse. the term ‘ tobacco misuse ’ encompasses the recreational use of cigarettes, cigarillos, pipes, chewing tobacco, snuff and electronic cigarettes, but not the traditional use of tobacco by indigenous groups for medicinal and ceremonial purposes. there is debate about which term should be used to collectively refer to first nations, inuit and metis peoples. the authors acknowledge that these populations are distinct but also recognize that there are similarities in their circumstances and health outcomes. whenever possible, specific data are reported for individual populations. for this position statement, the word ‘ indigenous ’ is used synonymously with ‘ aboriginal ’ to address all three groups. # the traditional use of tobacco sacred tobacco use and the recreational use of commercial tobacco, especially cigarette smoking, have separate purposes and functions. the medicinal and ceremonial use of tobacco by first nations peoples predates european contact. tobacco is offered up and ceremonially burned to establish a direct link with the spiritual world. with the traditional use of tobacco, inhalation is minimal. by contrast, the recreational use of commercial tobacco, which involves inhaling the smoke of commercial products having a high content of nicotine and toxic additives, is addictive and harmful. first nations elders maintain that using tobacco recreationally is disrespectful of tradition. the assembly of first nations promotes traditional tobacco, * nicotiana rustica *, for ceremonial use, not commercial tobaccos, such as cigarettes. the use of commercial tobacco for ceremonial purposes would send a confusing message to children and youth. tobacco use is not traditional for some first nations peoples, e. g., communities in british columbia. nor is it part of inuit
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traditions ; the inuit did not begin using tobacco until about one hundred years ago. health professionals working with indigenous communities need to acknowledge and address both the value of traditional tobacco use and the consequences of misusing commercial tobaccos with the families they see in practice. in canada in 2012, 11 % of youth 15 to 19 years of age were current smokers. smoking rates in canadian indigenous youth remain alarming, but in 2012 they were 31 % in metis youth, 33 % in first nations youth and 56 % in inuit youth. in nunavut, the rate rises to 65 %. the overall smoking rate among canadian youth has decreased, from 25 % in 1985 to 11 % in 2012, but a similar decline has not been seen among canada ’ s indigenous youth, especially in girls, which indicates a widening gap in health \ - related behaviours. despite increasing rates of quit attempts, smoking rates remain significantly higher in indigenous youth than in their non \ - indigenous peers. # risk factors # # early age of smoking initiation the average canadian indigenous person initiates smoking at age 12, several years earlier than other canadians ( who on average begin to smoke at age 19 \ ). a younger age of onset is associated with a higher risk for nicotine addiction. # # access to tobacco and modelling by parents and peers the influence of parents and peers is a primary factor causing children and youth to start smoking. young people are particularly influenced by people around them and cannot access legal tobacco products unless an older individual purchases products for them. research conducted collaboratively with aboriginal teen focus groups in interior british columbia revealed that family played an important role in teen smoking initiation. the youth smoking survey found that 82 % of smokers in grades 6 to 9 reported obtaining their cigarettes from friends, family members or other social sources. easy access to cigarettes and having a best friend who smokes are two powerful predictors that a young person will start smoking. by contrast, a supportive home environment ( smoke \ - free, with emotional and social supports ) is significant for preventing indigenous youth from starting to smoke. high rates of household crowding, coupled with high overall smoking rates in indigenous homes, lead to high numbers of in \ - home smokers and the normalization of smoking behaviours, thus increasing the likelihood of exposed children and youth becoming smokers themselves. # # other addictions and mental health problems tobacco use is associated with other addictive behaviours, such as higher levels of alcohol consumption and gambling, both of which are more
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prevalent in indigenous youth than in their non \ - indigenous peers. mental health problems are also a significant risk factor for addictions. young people with higher depression scores are at greater risk for smoking. low self \ - esteem, stress, boredom and low academic achievement all affect the initiation of tobacco use in indigenous children and youth. a study of saskatoon first nations youth found that not having a happy home life and suicide ideation were independent risk indicators for smoking. this finding may be especially significant in areas like nunavut, where suicide rates are up to 11 times higher than the national average. recognizing and addressing the roles of emotional trauma and colonization in the development of addictions will be crucial to reducing rates of tobacco addiction among indigenous peoples. # # unemployment and poverty smoking is more prevalent among the poor and the unemployed. the unemployment rate for aboriginal people is high, at 13 \. 9 % compared with 8 \. 1 % for non \ - aboriginal people. furthermore, there is a 30 % median income gap between aboriginal people and other canadians. # the health tolls of tobacco use # # exposure in utero smoking during pregnancy increases the risk of perinatal mortality, preterm birth, low birth weight, congenital abnormalities such as gastroschisis, and sudden infant death syndrome ( sids ). smoking is also associated with decreased breast milk volumes and shorter breastfeeding durations. it also increases the risk of behavioural problems and reduced academic achievement in children. all of these issues are more prevalent in the indigenous, compared with the general population. in nunavut, 60 % to 80 % of pregnant women report smoking in pregnancy, a rate five times higher than the canadian average. nunavut also has the highest rates of preterm births and low \ - birth \ - weight infants in canada. in a study in northern quebec, 92 % of women reported smoking during pregnancy. a study in manitoba found that 61 % of aboriginal women smoked during pregnancy, versus 26 % of non \ - aboriginal women. # # exposure during childhood in canada, indigenous children are involuntarily exposed to environmental tobacco smoke at home and in cars more often than young canadians overall ( 37 \. 3 % versus 19 % and 51 \. 0 % versus 30 \. 3 %, respectively ). as a result, they are at increased risk for respiratory illnesses, ear infections, sids, cancer, neurocognitive deficits and behavioural problems. a study
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of indoor air quality in nunavut revealed that reduced ventilation and overcrowding were strongly associated with lower respiratory tract infection rates. smokers were present in 94 % of these households and nicotine levels exceeded average levels in one \ - quarter of the dwellings under study. exposure to tobacco smoke, especially from a parent, is associated with increased prevalence of otitis media, a significant preventable cause of childhood hearing loss. indigenous children worldwide have the highest prevalence of otitis media and hearing loss, with some northern indigenous communities experiencing otitis media rates as high as 40 times those found in the urban south. moreover, second \ - hand smoking exposure significantly increases the risk for childhood invasive meningococcal disease. canadian indigenous populations experience infant mortality rates that are three times higher than for non \ - indigenous, with sids reported as a leading cause. researchers have established that sufficient evidence is now available ‘ to infer a causal relationship between exposure to second \ - hand smoke and sudden infant death syndrome ’. co \ - sleeping, high rates of infection and low breastfeeding rates are also contributory, but smoking likely plays a significant role. # # cancer, cardiovascular disease and type ii diabetes indigenous populations in north america are exhibiting an increased prevalence of cancer, cardiovascular disease and type ii diabetes, believed to be related to the adoption of western lifestyles and habits, including cigarette smoking. a study in northwestern ontario found an association between high rates of cigarette smoking in aboriginal adolescents 15 to 19 years of age, high blood pressure and high homocysteine levels, both indicators for an early \ - onset effect. along with cardiovascular disease, cancer is a leading cause of death in the indigenous population. canadian inuit have the highest rates of lung cancer in the world. # # deaths caused by tobacco misuse for long \ - time smokers, the chance of dying from smoking \ - related causes, either directly or indirectly, is one in two. long \ - time smokers lose an average of 22 years of life. among first nations young adults, the risk of premature death from smoking \ - related causes has been shown to be as high as 50 %. among british columbia ’ s first nations populations, up to 8 \. 3 % of infant deaths were found to be potentially preventable if smoking were eliminated from households, compared with 1 \. 4 % of all canadian infant deaths. # # health care and societal costs the canadian centre on substance abuse estimated that the direct health care costs related
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to tobacco misuse were over $ 4 \. 3 billion annually. the high rates of addiction and poverty in indigenous communities that are exacerbated when smokers divert funds to buy tobacco have far \ - reaching consequences for society as well as for individuals ( lost productivity being just one example ). # what works in preventing and treating tobacco misuse by indigenous youth? # # strategies that target the individual having health care providers who inquire about individual tobacco use and provide strong messaging at clinic visits around abstinence may help to prevent children and youth from starting to smoke. counselling has been shown to be effective in the treatment of adolescent smokers. however, much more research in this area is needed. the ‘ 5as ’ model for behaviour change provides a sequence of evidence \ - based clinician and office practice behaviours ( ask, advise, assess, assist, arrange ) that can be applied in primary care settings to address smoking prevention and cessation. - ask about tobacco use and environmental exposure to tobacco smoke. - advise to quit. - assess willingness to quit. - assist with counselling, pharmacotherapy and local supportive resources. - arrange follow \ - up. nicotine replacement therapies ( nrts ), such as transdermal patches and nicotine gums, are recommended only for regular smokers. bupropion and varenicline are safe and effective in adults but should be used with caution in adolescents. the canadian paediatric society ’ s adolescent health committee has published specific guidance on promoting smoking cessation and preventing smoking initiation in this age group. it is especially difficult for indigenous youth to stop smoking when their parents or siblings smoke, and indigenous youth have indicated that family support is an important factor in encouraging them to quit using tobacco. it may be more effective for health care providers to address smoking in the whole family context, with focus on counselling parents about the harmful effects of environmental tobacco smoke exposure and providing them with smoking cessation resources and treatment. most parents who smoke ( 85 % ) consider it acceptable for their child ’ s paediatrician to prescribe an nrt for them, but few do so. in view of the high smoking rates during pregnancy among indigenous, especially inuit, women, prescribing pharmacotherapies for women in pregnancy for whom counselling has been ineffective may have important benefits as a harm reduction strategy. health care providers should be aware of the non
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\ - insured health benefits program ( nihb ). the federal health coverage plan for eligible first nations and inuit peoples ( but not metis ) provides drug coverage for all smoking cessation pharmacotherapy agents. however, first nations smokers appear to use nrts less often than other canadian smokers, even when they are highly motivated to quit, a finding probably related to the underutilization of physician services and a generally greater unwillingness to use drug therapy. use of these agents would increase if the need for a physician prescription was eliminated and efforts were made to increase awareness of their effectiveness. health care providers should become familiar with local cessation supports available to or targeting indigenous smokers, such as telephone quit \ - lines, community cessation groups, mentorship by elders or healing spiritual or cultural practices. one should not assume that all indigenous young people want programming specific to their indigenous traditions. however, a holistic approach that addresses psychosocial and socioeconomic factors, such as unemployment, housing, domestic violence, other addictions, mental health problems and past trauma, are more likely to reduce tobacco use in this population. it is essential that comorbid mental health problems, such as depression, anxiety and post \ - traumatic stress disorder, be identified and treated at the same time. higher quit rates have been demonstrated for indigenous smokers using quit \ - lines compared with the general population. quit \ - lines are cost \ - effective and can reach a large proportion of smokers. a national project is underway to make quit \ - lines available in all provinces and territories, with a special effort to include inuit and first nations smokers. physical activity builds resiliency among indigenous youth, and participation in organized sport may be a protective factor against tobacco use for this population. when addressing tobacco misuse, health care providers working with indigenous peoples must be aware of, and sensitive to, their historic mistrust of conventional medicine and the impacts of colonization on health and recovery from disease. # the community there are limited data on the effectiveness of population \ - based smoking cessation strategies in indigenous communities. however, a canada \ - wide environmental scan of tobacco cessation strategies for first nations, inuit and metis peoples found that successful initiatives included the following components : they were culturally relevant ; they involved local orientation and facilitation ; they were flexible, responsive and holistic ; they included facilitator training ; they highlighted traditional activities, knowledge and values
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; they recognized contemporary lifestyles ; they cooperated with existing systems and resources ; they showed a high degree of respect and trust in the individuals and groups involved ; and they created partnerships. elders in indigenous communities represent a culturally relevant but often underused resource. communities might consider drawing upon their wisdom and influence to help decrease tobacco exposure. efforts to address peer smoking, to de \ - normalize smoking and to create supportive tobacco \ - free environments for youth may increase the success of smoking prevention and cessation programs for young smokers. culturally appropriate strategies and tools should also be translated into the language with which young people are the most comfortable. however, what is culturally appropriate for one indigenous community may be less appropriate for another. targeted examples include ‘ our ancestors never smoked ’, a compilation of inuit elders ’ reflections highlighting their people ’ s distinct history with tobacco. a smoking prevention program that was culturally adapted for indigenous children in alberta and that incorporated the medicine wheel ( symbolizing the spiritual, mental, emotional and physical aspects of health ), was found to significantly reduce future smoking intentions when compared with standard approaches. examples of community \ - based practice include tool kits for schools and community centres, structured smoke \ - free challenges ( e. g., ‘ quit and win ’ ), mass media campaigns and targeted local programs to reduce exposure to second \ - hand smoke. mass \ - reach health communication interventions that include social media are emerging as effective means to target specific audiences, such as youth. school \ - based quit and win challenges that reward successful student participants and validate the decision to be smoke \ - free have been widely implemented across canada. smoking cessation counselling provided by telehealth videoconferencing was shown to be effective in rural and remote regions of alberta and the northwest territories. # public policy although the health tolls of tobacco misuse are more significant than alcohol \ - related costs and outcomes, there is no minimum legal age for tobacco use in canada. the legal age to purchase cigarettes is 19 in most provinces and territories and age 18 years in alberta, saskatchewan, manitoba and quebec. however, canadian children and youth are starting to smoke much earlier than this. the who and health canada have advocated for and secured the passage of legislation to : ensure tobacco \ - free environments ( e. g., smoke \ - free indoor and outdoor public spaces ) ; standardize legal age limits for the use and purchase of tobacco products, including e \ - cigarettes ; penal
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##ize the sale or supply of tobacco products to minors ; eliminate unsupervised sales ( e. g., through vending machines, online merchants ) ; require health warnings on tobacco products ; and ban advertisements and sponsorships by tobacco companies. where there are penalties in place for selling or supplying tobacco to minors, there should be an extra push to strengthen and enforce those penalties as additional deterrents. the canadian paediatric society has called for a ban on smoking in vehicles with occupants \ < 16 years of age, yet many provinces and territories with the highest smoking rates have not adopted this legislation. taxation is a proven effective tobacco control strategy. rates of tobacco use vary inversely with price, and youth are especially sensitive to price increases on cigarettes. raising the price of cigarettes is an important determinant of youth smoking behaviour, and it is important to enforce tobacco control strategies that eliminate access to cheaper sources of tobacco, such as tax \ - free or contraband products. the 2006 / 2007 youth smoking survey found that contraband cigarettes accounted for about 17 \. 5 % of all cigarettes smoked by adolescent daily smokers in canada overall, and for more than 25 % in the provinces of ontario and quebec. to date, important national surveys such at the canadian tobacco use monitoring survey and the youth smoking survey have excluded the most high \ - risk regions in canada, namely nunavut, the northwest territories and yukon. to drive future indigenous \ - specific policy, national studies need to anticipate challenges and institute measures to ensure adequate data collection from regions with the highest prevalence of smokers in the country. community \ - based participatory approaches that develop tobacco prevention and cessation strategies focused on local conditions and needs are proving to be the most effective. sustained funding is badly needed to conduct research and implement evidence \ - based programs. the high prevalence of tobacco use and misuse among indigenous peoples, compared with the general population, remains a major public health challenge, with long \ - term implications for infants, children, youth and pregnant women who are exposed to second \ - hand smoke. preventing and reducing tobacco misuse among indigenous children and youth requires family \ - centred, culturally appropriate, multi \ - faceted approaches that are rooted in community and supported at every government level. the following recommendations to prevent smoking initiation and promote smoking cessation among indigenous children and youth were generated through consensus and prepared collaboratively with a number of canadian indigenous and non \ - indigenous groups
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guidelines
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6b069d1e603ff216cef25a03989c818b9bf18d8e
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. # # for health care providers - understand the distinction between traditional and commercial tobacco use and how such practices apply to some ( not all ) canadian indigenous groups. - ask about and document family smoking and exposure to tobacco smoke at all health appointments. - use the ‘ 5as ’ method to provide anticipatory guidance and cessation counselling. - become familiar with and inform families about local smoking prevention and cessation resources. provide in \ - office contact and other information regarding community and supportive programs. - be aware of and prescribe nrts for regular teenage smokers. while the state of the evidence appears to be promising, it is not yet sufficient to recommend the regular use of bupropion and varenicline in youth. ( note that all these therapies are covered for first nations and inuit people by health canada ’ s non \ - insured health benefits program. ) - initiate family \ - centred smoking cessation interventions in accordance with your scope of practice ( e. g., by prescribing pharmacotherapy for parents, as appropriate ). - focus on tobacco use in pregnancy and consider using nrt for women who are pregnant and for whom counselling has been ineffective. - assess, refer and address comorbid mental health and addiction problems along with smoking cessation, as needed. - initiate tobacco prevention counselling earlier in aboriginal communities because of the younger smoking initiation age. - be a role model : take steps to quit smoking if you are regular smoker. # # for indigenous communities and governments ( federal / provincial / territorial ) - advocate for the use of traditional tobacco ( * n rustica * ) instead of commercial tobacco ( especially cigarettes ) for ceremonial purposes. - use culturally appropriate school \ - based and community interventions, including social media, to target indigenous children and youth. - enact and enforce a minimum legal age limit for tobacco use. - enact, strengthen and enforce penalties for selling and supplying tobacco products ( including e \ - cigarettes ) to minors. - enact and enforce indoor and outdoor smoke \ - free bans on non \ - traditional tobacco use. - enact and enforce legislation to ban smoking in vehicles with occupants \ < 16 years of age. - eliminate the unsupervised sale of tobacco products ( e. g., through vending machines and online ). - enact and enforce measures to prevent the sale of contraband tobacco products ( e. g.,
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guidelines
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6b069d1e603ff216cef25a03989c818b9bf18d8e
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levy a surcharge on non \ - traditional tobacco to match off \ - reserve prices ). - ensure that tax revenues are used for smoking prevention and cessation education and programming. - ensure access to tobacco cessation and prevention services for all indigenous people. # # for researchers - strengthen data collection about tobacco use and misuse among indigenous communities. - promote community \ - based participatory research to evaluate and identify best practices for culturally appropriate prevention and cessation strategies for indigenous children and youth.
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guidelines
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e15dd3adaaf8aea55cb10ee728d96a87c61b922c
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the use of silver nitrate as prophylaxis for neonatal ophthalmia was instituted in the late 1800s to prevent the devastating effects of neonatal ocular infection with * neisseria gonorrhoeae *. at that time – during the preantibiotic era – many countries made such prophylaxis mandatory by law. today, neonatal gonococcal ophthalmia is rare in canada, but ocular prophylaxis for this condition remains mandatory in some provinces / territories. silver nitrate drops are no longer available and. ocular prophylaxis is not effective in preventing chlamydial conjunctivitis. applying medication to the eyes of newborns may result in mild eye irritation and has been perceived by some parents as interfering with mother \ - infant bonding. physicians caring for newborns should advocate for rescinding mandatory ocular prophylaxis laws. more effective means of preventing ophthalmia neonatorum include screening all pregnant women for gonorrhea and chlamydia infection, and treatment and follow \ - up of those found to be infected. mothers who were not screened should be tested at delivery. infants of mothers with untreated gonococcal infection at delivery should receive ceftriaxone. infants exposed to chlamydia at delivery should be followed closely for signs of infection. in the event of a shortage of erythromycin,. the present statement replaces a statement on neonatal ophthalmia published in 2002 by the canadian paediatric society ’ s infectious diseases and immunization committee. this update is indicated because in canada, the epidemiology and antibiotic susceptibility of * neisseria gonorrhoeae *, as well as the availability of products for prophylaxis, have all changed, raising concerns about the utility of the previously recommended strategy. neonatal ophthalmia, a relatively common illness, is defined as conjunctivitis occurring within the first four weeks of life. originally, this term only referred to cases caused by * n gonorrhoeae *, but the term currently encompasses any conjunctivitis in this age group. * n gonorrhoeae - now accounts for \ < 1 % of reported cases of neonatal ophthalmia in the united states, while that due to * chlamydia - * trachomatis -
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e15dd3adaaf8aea55cb10ee728d96a87c61b922c
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ranges from 2 % to 40 %. other bacteria such as * staphylococcus - species, * streptococcus - species, * haemophilus - species and other gram \ - negative bacterial species account for 30 % to 50 % of cases. much less commonly, neonatal conjunctivitis is caused by viral infections ( herpes simplex, adenovirus, enteroviruses ). infectious conjunctivitis must be distinguished from eye discharge secondary to blocked tear ducts and from conjunctivitis due to exposure to chemical or other irritants. in most instances, neonatal ophthalmia is a mild illness. the exception is ophthalmia due to infection with * n - * gonorrhoeae *. without preventive measures, gonococcal ophthalmia occurs in 30 % to 50 % of infants exposed during delivery \ - and may progress quickly to corneal ulceration, perforation of the globe and permanent visual impairment. infants at increased risk for gonococcal ophthalmia are those whose mothers are at risk for sexually transmitted infections ( stis ). historically, the purpose of prophylaxis for neonatal ophthalmia was to prevent devastating neonatal eye infection due to * n - * gonorrhoeae *. silver nitrate prophylaxis against * n - * gonorrhoeae - ophthalmia neonatorum, first used by dr carl crede in 1880, was a significant preventive medicine triumph at a time when there was no effective treatment available for gonorrhea. nevertheless, silver nitrate was not a perfect agent because it caused transient chemical conjunctivitis in 50 % to 90 % of infants. also, some parents were concerned that the practice could interfere with mother \ - infant bonding. silver nitrate eye drops are no longer available in canada. tetracycline and erythromycin ointments have been considered to be acceptable alternatives for preventing gonococcal ophthalmia. however, * n - * gonorrhoeae - strains isolated in canada in 2012 showed considerable resistance to these agents, with tetracycline at 30 % and erythromycin at 23 %. whether this resistance can be overcome by the high local antibiotic levels achieved by topical application is unknown, and there are no recent studies of the efficacy of
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guidelines
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e15dd3adaaf8aea55cb10ee728d96a87c61b922c
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ophthalmia prophylaxis with these agents. in canada, erythromycin has been the only antibiotic eye ointment available for use in neonates since tetracycline ophthalmic ointment became unavailable. povidone \ - iodine has been considered for prophylaxis, but this agent may not be effective and has been associated with a 5 % rate of chemical conjunctivitis. gentamicin ointment was used for newborn ocular prophylaxis during in the united states in 2009, but resulted in reports of severe ocular reactions. other ophthalmic antibiotic preparations have not been evaluated in newborns. therefore, it is questionable whether universal ocular prophylaxis for neonatal gonococcal ophthalmia remains an effective option in canada. of note, universal ocular prophylaxis was abandoned decades ago in several high \ - income countries including denmark, norway, sweden and the united kingdom. one study from the united kingdom showed that this change did not increase the rate of blindness due to gonococcal ophthalmia. however, the canadian medical protective association established that in 2013, neonatal ocular prophylaxis was required by law in alberta, british columbia, ontario, prince edward island and quebec. in british columbia, prophylaxis may be waived if a parent makes a written request. in new brunswick, the law requiring prophylaxis was repealed in 2009 \. no current legislation was found for the remaining provinces and territories. infants born to women with untreated chlamydia infection at delivery have a 50 % risk of acquiring chlamydia, a 30 % to 50 % risk of developing neonatal conjunctivitis and a 10 % to 20 % risk of developing chlamydia pneumonia. topical ocular prophylaxis does not prevent transmission from mother to infant, does not reliably prevent neonatal conjunctivitis and does not prevent pneumonia. \ - oral erythromycin prophylaxis of infants born to untreated mothers has been used in the past but has not been recommended since the association between erythromycin and pyloric stenosis was recognized. routine prenatal screening for * c trachomatis - and treatment of identified infections during pregnancy is the preferred option for preventing neonatal conjunctivitis and other
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guidelines
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e15dd3adaaf8aea55cb10ee728d96a87c61b922c
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infections in newborns caused by this organism. close clinical follow \ - up of exposed infants is recommended. the public health agency of canada recommends testing conjunctival and nasopharyngeal secretions of symptomatic infants and treating those who show positive results. a recent meta \ - analysis concluded that evidence from randomized and quasirandomized trials regarding the efficacy of prophylactic agents used to prevent gonococcal and chlamydia conjunctivitis was not of high quality. moreover, all of the agents reviewed had clinically significant failure rates. rates of neonatal ophthalmia caused by * n - * gonorrhoeae - and * c - * trachomatis - declined significantly in north america through the 1980s due to the decreased prevalence of these infections in the general population, and the institution of routine prenatal screening and treatment of these stis in pregnancy. in the united states in 2002, the rate of neonatal ophthalmia was 8 \. 5 per 100, 000 births. national surveillance of neonatal ophthalmia was discontinued in canada in 2000 because of low incidence. current rates of infection can be estimated from reported cases of chlamydia and gonorrhea in infants \ < 1 year of age, for whom the average national rate between 2000 and 2011 was six per 100, 000 for chlamydia infection and 0 \. 5 per 100, 000 for gonorrhea. in ontario, the combined rate of chlamydia and gonococcal ophthalmia in 2004 was 4 \. 5 per 100, 000 \. there were no reported cases of neonatal gonococcal ophthalmia in alberta between 2005 and 2013, but rates of chlamydial ophthalmia ranged from 0 to 12 \. 2 per 100, 000 per year, with a reported rate of 7 \. 5 per 100, 000 in 2013 \. in areas of the world where prenatal screening and treatment are not available and prevalence of gonococcal infections is high, vision loss from neonatal gonococcal ophthalmia continues to occur and ocular prophylaxis with silver nitrate continues to be an important and cost \ - effective intervention., 0 \. 5 % erythromycin base can be used and may be effective in some cases, depending on the antibiotic sensitivity of
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guidelines
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circulating strains. povidone \ - iodine or gentamicin ointment should not be used because of high rates of adverse topical effects. to prevent potential cross \ - contamination, single \ - use tubes of erythromycin are used. before administration, each eyelid is wiped gently with sterile cotton to remove foreign matter and to permit adequate eversion of the lower lid. a line of antibiotic ointment, sufficiently long to cover the entire lower conjunctival area, is placed in each lower conjunctival sac, taking care to prevent injury to the eye or the eyelid from the tip of the tube. the closed eyelids are massaged gently to help spread the ointment. after 1 min, excess ointment is gently wiped from the eyelids and surrounding skin with sterile cotton. to prevent neonatal ophthalmia caused by * n gonorrhoeae - and * c trachomatis *, the canadian paediatric society recommends the following : # neonatal ocular prophylaxis : - neonatal ocular prophylaxis with, may no longer be useful and, therefore, should not be routinely recommended. - paediatricians and other physicians caring for newborns, along with midwives and other health care providers, should become familiar with local legal requirements concerning ocular prophylaxis. - paediatricians and other physicians caring for newborns should advocate to rescind ocular prophylaxis regulations in jurisdictions in which this is still legally mandated. - jurisdictions in which ocular prophylaxis is still mandated should assess their current rates of neonatal ophthalmia and consider other, more effective preventive strategies, as outlined below. # screening and treatment of pregnant women : - all pregnant women should be screened for * n gonorrhoeae - and * c - * trachomatis - infections at the first prenatal visit. - those who are infected should be treated during pregnancy, tested after treatment to ensure therapeutic success and tested again in the third trimester or, failing that, at time of delivery. their partners should also be treated. women who test negative but are at risk for acquiring infection later in pregnancy should be screened again in the third trimester. rescreening for * n gonorrhoeae *, * c trachomatis - and other stis should be considered in the third trimester
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guidelines
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e15dd3adaaf8aea55cb10ee728d96a87c61b922c
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for women who are not in a stable monogamous relationship. - processes should be in place to ensure communication between physicians and others caring for a woman during pregnancy, and those who will care for her newborn. information regarding maternal sti screening, treatment and risk factors is crucial to the well \ - being of the newborn, and must be available to all health care providers caring for the newborn at and following delivery. - pregnant women who were not screened during pregnancy should be screened for * n gonorrhoeae - and * c trachomatis - at delivery, using the most rapid tests available. # managing newborns exposed to * n gonorrhoeae * : - a system should be established to ensure that all infants born to mothers found to have untreated * n gonorrhoeae - infection at delivery are treated. - if the mother ’ s test results are not available at discharge, a plan must be in place to ensure that she can be contacted promptly if the results are positive. the mother must also be advised to watch her infant for eye discharge in the first week of life and told whom to contact immediately if this symptom develops, or if the child is unwell in any way. when there is doubt about maternal compliance with this recommendation and the mother is considered to be at risk for gonococcal infection, administering one dose of ceftriaxone should be considered for the infant before discharge. - infants born to women with untreated * n gonorrhoeae - infection at the time of delivery, including those born by caesarian section, should be tested and treated immediately without waiting for test results. - infants exposed to * n gonorrhoeae - who appear to be * healthy - at birth, both term and preterm, should have a conjunctival culture for * n gonorrhoeae - and receive a single dose of ceftriaxone ( 50 mg / kg to a maximum of 125 mg ) intravenously or intramuscularly. the preferred diluent for intramuscular ceftriaxone is 1 % lidocaine without epinephrine ( 0 \. 45 ml / 125 mg ). this intervention is both safe and effective. biliary stasis from ceftriaxone is not considered to be a risk with a single dose. ( ceftriaxone is contraindicated in newborns receiving intraven
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guidelines
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e15dd3adaaf8aea55cb10ee728d96a87c61b922c
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##ous calcium. a single dose of cefotaxime \ is an acceptable alternative. ) - if the exposed infant is * unwell - in any way, blood and cerebrospinal fluid cultures should also be performed. infants with established gonococcal disease require additional investigation and therapy in consultation with a specialist in paediatric infectious diseases. # managing newborns exposed to * c trachomatis * : - infants born either vaginally or by caesarian section to mothers with an untreated chlamydia infection should be closely monitored for symptoms ( eg, conjunctivitis, pneumonitis ) and treated if infection occurs. routine cultures should not be performed on asymptomatic infants. - prophylaxis of exposed newborns is not recommended because of the association of macrolides with pyloric stenosis, but may be considered when infant follow \ - up cannot be guaranteed.
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guidelines
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1f54213dd0122047f9f55b99e63c36a4356385c7
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hospital \ - acquired acute hyponatremia is increasingly recognized as a cause of morbidity and mortality in children. it has been attributed primarily to the use of hypotonic intravenous ( iv ) fluids to maintain fluid and electrolyte requirements. this practice point outlines current understanding of the problem and summarizes recent research dealing with this issue. detailed recommendations are made for the prescription of iv maintenance fluids in children between one month and 18 years of age. the use of isotonic fluid ( d5w. 0 \. 9 % nacl ) is recommended in most circumstances. hypotonic iv fluids containing less than 0 \. 45 % nacl should not be used to provide routine iv fluid maintenance requirements. key words : * acute hyponatremia ; intravenous fluid prescription ; maintenance intravenous fluids * hyponatremia, defined as a serum sodium ( na ) \ < 135 mmol / l, has become increasingly recognized as a cause of morbidity and mortality in hospitalized children. \ ] \ - \ ] in recent years there have been many reports of serious morbidity, including severe neurological injury, as well as many deaths among children who developed hospital \ - acquired hyponatremia while receiving iv fluids. \ ] \ - \ ] a case \ - control study reported that 40 of 432 ( 9 % ) of hospitalized children on iv fluids who had a normal baseline serum na had a subsequent serum na \ < 136 mmol / l. \ ] other studies have shown an incidence of hyponatremia in hospitalized children as high as 24 %. \ ] hyponatremia has been attributed primarily to the use of hypotonic maintenance iv fluids. the administration of such fluids provides a source of electrolyte \ - free water ( efw ) to a population of children who are at risk for increased antidiuretic hormone ( adh ) secretion. \ ] \ ] \ ] clinical sequelae of acute hyponatremia ( a decrease in na over ≤48 h ) result from acute cerebral edema, and may include headache, lethargy and seizures, and potentially even respiratory and cardiac arrest secondary to brain stem herniation. these outcomes are more likely to be seen with severe acute hyponatremia ( na \ < 130 mmol / l ). because of their higher brain / intracranial volume ratio, children are at increased risk
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guidelines
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1f54213dd0122047f9f55b99e63c36a4356385c7
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for these sequelae compared with adults. the routine practice of providing hypotonic maintenance iv solutions, usually containing 20 mmol / l to 30 mmol / l of na, is based on holliday and segar ’ s seminal paper published in 1957 \ ] and translates to the use of 0 \. 2 % nacl / dextrose 5 %. these recommendations were based on caloric expenditure in healthy children, and electrolyte composition was derived from that of human and cow ’ s milk. it has been recognized that the great majority of hospitalized children are at risk of nonphysiological antidiuretic hormone ( adh ) secretion — due to nausea, stress, pain, pulmonary and central nervous system disorders, surgical interventions, and commonly used medications such as morphine sulfate — which implies that holliday and segar ’ s traditional recommendations for administering hypotonic iv fluids are probably inappropriate. the high percentage of efw in hypotonic iv fluids ( 78 % efw ) compared with normal saline ( 0 % efw ), in combination with an impaired ability to excrete water as a result of adh secretion, places hospitalized children at increased risk of developing acute hyponatremia. iv fluid prescription practices for children vary widely among physicians both within and between hospitals. a cross \ - sectional survey carried out in multiple hospitals in the united kingdom revealed that 77 of 99 children receiving iv fluids during one day of a specified week were receiving hypotonic solutions. twenty \ - one of the 86 children ( 24 % ) who had serum electrolytes measured were found to be hyponatremic, and the vast majority of these were receiving hypotonic iv fluids. \ ] to avoid the development of acute hyponatremia, it has been recommended that isotonic 0 \. 9 % nacl / dextrose 5 % ( normal saline with dextrose ) should be the standard maintenance iv solution. \ ] \ ] \ ] \ ] normal saline contains 154 mmol / l of na, which is isotonic with respect to the cell membrane. this suggestion has raised concerns regarding the potential for hypernatremia and salt and water overload. \ ] however, unless the child has an impaired ability to excrete na, a renal concentrating defect, significant water loss or prolonged fluid restriction, these risks appear to be largely theoretical. the risk of developing hyperchlore
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guidelines
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1f54213dd0122047f9f55b99e63c36a4356385c7
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##mic metabolic acidosis has been recognized in the context of rapid isotonic saline infusion delivered perioperatively \ ] but has not been reported in the trials of iv saline used for maintenance requirements in children to date. initial prospective trials comparing the tonicity of iv fluids were primarily focused on surgical and intensive care populations, with some smaller studies including children admitted to medical units. \ ] \ - \ ] five systematic reviews and meta \ - analyses published in 2014 / 2015 all concluded that maintenance isotonic fluids posed a lower risk of hyponatremia when compared with hypotonic fluids. \ ] \ - \ ] two specifically commented, however, that the evidence focused on surgical and intensive care populations, with insufficient data to allow generalization of the recommendations to children on medical wards. \ ] \ ] more recently, three randomized controlled trials have addressed the issue of tonicity of iv maintenance fluid and hyponatremia in both medical and surgical paediatric populations. \ ] \ - \ ] the first study, from australia, is the largest to date, having randomized 690 children with medical and surgical diagnoses to isotonic ( 140 mmol / l sodium ) or hypotonic ( 77 mmol / l sodium ) fluids. \ ] the study fluids were continued until patients were receiving less than 50 % of their maintenance requirement by iv, to a maximum of 72 h. the primary outcome was the occurrence of hyponatremia, defined as a serum sodium \ < 135 mmol / l with a minimum decrease of 3 mmol / l from baseline to make it clinically significant. the investigators concluded that isotonic fluids led to a lower risk for hyponatremia compared with hypotonic fluids ( 4 % versus 11 % ; p \ = 0 \. 001 \ ), with no increase in adverse effects. \ ] the second study was canadian, with a similar design to the australian trial. \ ] one hundred and ten children, all on a general paediatric medical unit, were randomized to isotonic ( 0 \. 9 % nacl, or 154 mmol / l sodium ) or hypotonic ( 0 \. 45 % nacl, or 77 mmol / l sodium ) iv maintenance solutions. there was no difference between the two groups in the primary outcome, mean serum sodium at 48 h ( p \ = 0 \. 60 \ ). however, there were two cases
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guidelines
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1f54213dd0122047f9f55b99e63c36a4356385c7
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of hyponatremia in the hypotonic group compared with none in the group receiving isotonic fluids. the third trial studied a combined medical and surgical paediatric population, and was conducted in mexico. \ ] one hundred and fifty \ - one children were randomized to one of two hypotonic solutions ( 0 \. 3 % saline or 0 \. 45 % saline ) or to isotonic maintenance fluids ( 0 \. 9 % saline ). the mean serum sodium at 8 h, the primary outcome, was lower in both hypotonic fluid groups compared with the group receiving isotonic fluids ( p \ < 0 \. 0001 \ ). these recent rcts have broadened the scope of available literature on iv maintenance fluid tonicity in paediatrics, and have continued to consistently find that, compared with hypotonic fluids, isotonic maintenance solutions decrease the risk of iatrogenic acute hyponatremia, without an increase in significant side effects. the following recommendations \ ] \ - \ ] apply to the prescription of iv maintenance fluids in children one month corrected age to 18 years of age, excluding patients with renal or cardiac disease, diabetic ketoacidosis, severe burns or other underlying conditions that significantly affect electrolyte regulation. # general principles 1. any child in hospital who requires iv fluids should be considered at risk for developing hyponatremia due to increased risk of adh secretion. at particular risk are : - children undergoing surgery - children with acute neurological or respiratory infections ( eg, meningitis, encephalitis, pneumonia and bronchiolitis ). 2. oral fluids are generally very low in na content ( hypotonic ). where the total fluid intake ( tfi ) is a combination of oral and iv fluids, both need to be accounted for. 3. because infants and young children have limited glycogen stores, dextrose should be part of the iv maintenance fluid prescription ( eg, d5w. 0 \. 9 % nacl or d5w. 0 \. 45 % nacl ) if no other source of glucose is provided. 4. the approach to prescribing iv fluids should be as cautious as that for medications, with close attention paid to indications, monitoring, the type of fluid and the volume / rate of administration. 1. baseline serum electrolytes ( na, k, glucose
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guidelines
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1f54213dd0122047f9f55b99e63c36a4356385c7
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, urea, creatinine ) should be measured when starting iv fluid therapy in hospitalized children. 2. children receiving maintenance iv fluids should have their serum electrolytes checked regularly, with patients who may be at high risk of impaired renal water excretion checked daily if not more frequently. 3. all children receiving iv maintenance fluids should have their intake / output carefully monitored, as well as a daily weight measurement. 4. clinicians should be aware of the symptoms of hyponatremia, which may include headache, nausea and vomiting, irritability, decrease in level of consciousness, seizures and apnea. # prescription of iv fluids for maintenance requirements 1. in children whose serum sodium is normal at baseline but who are considered to be at particularly high risk of adh secretion ( eg, peri \ - or postoperative ; with respiratory or neurological infections ) the use of isotonic saline ( d5w. 0 \. 9 % nacl ) is recommended. 2. for other hospitalized children whose serum sodium is normal, the options are d5w. 0 \. 9 % nacl or d5w. 0 \. 45 % nacl. the first option is preferred, especially when serum na is in the low normal range ( 135 mmol / l to 137 mmol / l inclusive ). 3. hypotonic iv fluids containing \ < 0 \. 45 % nacl should not be used to provide routine fluid maintenance and should not be generally available on paediatric wards. 4. when serum electrolyte results are not yet available, it is recommended that d5w. 0 \. 9 % nacl be initiated as the maintenance iv fluid. 5. if the serum sodium is 145 mmol / l to 154 mmol / l, then d5w. 0 \. 45 % nacl should be initiated and frequent monitoring of the serum sodium performed. 6. ringer ’ s lactate is commonly used in the operating room but the absence of dextrose and presence of lactate make it generally inappropriate for maintenance iv therapy, especially in young children. note that these recommendations are not intended for use in infants and youth outside the one month to 18 year age group.
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guidelines
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3ac241b5cbe8fbda76808419bc8fb8845784b6ef
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an increase in * clostridium difficile - infection incidence has been observed among hospitalized children in the united states. the present statement, targeted at clinicians caring for infants and children in community and institutional settings, summarizes the relevant information relating to the role of * c difficile - in childhood diarrhea and provides recommendations for diagnosis, prevention and treatment. significant differences between adult and paediatric risk factors and disease are discussed, along with emerging therapies. the relationship between age and disease severity in children with a newly emergent and more fluoroqinolone \ - resistant strain of * c difficile - ( north american pulse \ - field type \ - 1 \ ) remains unknown. the importance of antimicrobial stewardship as a preventive strategy is highlighted. this statement replaces a previous canadian paediatric society position statement on * c difficile - published in 2000 \. key words : * cdi ; colitis ; diarrhea ; immunocompromise ; megacolon ; metronidazole ; nap1 ; vancomycin * # epidemiology and risk factors * clostridium difficile - is a spore \ - forming bacterium found in soil, hospital environments, child care facilities and nursing homes. \ ] \ ] person \ - to \ - person spread by the fecal \ - oral route is the primary mode of transmission, with health care facilities being a notably common and problematic setting for infection. spores are transferred to patients mainly on the hands of health care staff who have touched a contaminated surface or item. infants and children are significantly more likely to carry * c difficile - asymptomatically in the gastrointestinal ( gi ) tract than are adults. \ ] it is estimated that 15 % to 63 % of neonates, 3 % to 33 % of infants and toddlers younger than two years of age, and up to 8 \. 3 % of children older than two years of age are asymptomatic carriers. \ ] infants and young children rarely develop symptoms, possibly because of immature surface receptors for these microbes, and because they are protected by maternal antibodies acquired transplacentally or in breast milk. \ ] the incubation period from exposure to onset of symptomatic * c difficile - infection ( cdi ) is an estimated median of two
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to three days. \ ] \ - \ ] a history of therapy with antibiotics or antineoplastic agents is present in most adult patients with cdi. \ ] in the united states, an increase in cdi incidence has been observed among hospitalized children. \ ] \ ] duration of hospital stay, older age \ ] and exposure to multiple antibiotic classes are risk factors for paediatric cdi. \ ] among children with severe disease, complications are infrequent. the recurrent infection rate is similar to rates reported in adults ( approximately 25 % ). \ ] virtually all antimicrobials used in humans have been associated with cdi, including those used for surgical prophylaxis. \ ] it has been suggested that the relative risk of therapy with a given antimicrobial agent and its association with cdi depends on the local prevalence of strains that are highly resistant to the antimicrobial being used ; such agents increase the risk for cdi by suppressing the growth of susceptible microbial flora. \ ] chemotherapy is associated with an increased risk for cdi, possibly due to the antimicrobial properties of chemotherapeutic agents, the effects of immunosuppression and neutropenia, and changes in the gut mucosa. in one paediatric study, comorbid diagnoses associated with cdi included inflammatory bowel disease and other diseases associated with immunosuppression or antibiotic administration. \ ] the prominence of * c difficile - in hiv \ - infected adults in the united states suggests that underlying immunosuppression likely contributes to increasing the risk for cdi. \ ] the humoral immune response is important in influencing the risk for cdi, as evidenced by the fourfold increase in risk for cdi in patients who are either newly infected with hiv or lack pre \ - existing immunity to * c difficile *. \ ] \ ] hypogammaglobulinemia is associated with an increased risk for cdi. \ ] \ ] antibodies from previous exposures confer some protection. other risk factors include gi surgery \ ] or manipulation of the gi tract, including tube feeding. \ ] some studies have suggested an association between the use of stomach acid \ - suppressing medications, primarily proton pump inhibitors, and cdi, \ ] \ - \ ] while others suggest the association exists simply because patients with classic
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3ac241b5cbe8fbda76808419bc8fb8845784b6ef
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risk factors for cdi \ ] \ - \ ] are likely to receive acid \ - suppressing medications. in one paediatric report, h2 receptor antagonists were actually associated with decreased colonization by * c difficile *. \ ] a previously uncommon strain of * c difficile - ( north american pulse \ - field type \ - 1 \ ] ; currently designated as nap1 / b1 / 027 \ ) has recently emerged, with variations in toxin genes and a tendency to resist fluoroquinolones. \ ] this strain is now widely distributed in several regions of the world, including canada. \ ] \ - \ ] while outbreaks and severe disease have been reported mostly in adults, paediatric disease is also being reported. \ ] \ - \ ] in one canadian study, patients 60 to 90 years of age infected with nap1 / b1 / 027 were approximately twice as likely to die or to experience a severe cdi \ - related outcome, compared with individuals who were infected with a non \ - nap1 / b1 / 027 cdi. \ ] the relationship between age and disease severity in children with this strain is unknown. recent reports have challenged the belief that * c difficile - is less pathogenic in young infants and children. \ ] \ ] in one study, 26 % of paediatric disease that was treated as cdi occurred in children younger than one year of age and 5 % of all cases occurred in infants younger than one month of age. it has been speculated that one reason for this finding may be related to the emergence of the nap1 strain. if such strains are associated with greater pathogenicity relative to non \ - nap1 strains, the very small minority of infants who acquire * c difficile * \ - related disease may be more likely to be clinically recognized. however, this relationship has not been proven and additional research is required. important pathophysiological features of * c difficile - include heat resistance of the spore ( allowing environmental persistence ), acid resistance of spores and toxin production. their acid resistance allows spores to pass readily through the stomach, enabling germination in the small bowel on exposure to bile acids. \ ] pathogenic strains of * c difficile - produce two distinct toxins : toxin a is an enterotoxin ; and toxin b is a cytotoxin. both are high \
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- molecular \ - weight proteins capable of binding to specific receptors on intestinal mucosal cells. toxin a can disrupt neuronal function and cause the aberrant release of calcium. \ ] \ ] \ ] toxin b exerts its effect on leukocytes by altering the chemotaxis of neutrophils, the activation of macrophages and mast cells, and the induction of inflammatory mediator release. \ ] \ ] \ ] the end result of toxin activity in the intestine is fluid secretion, mucosal damage and interstitial inflammation. \ ] \ ] \ ] # clinical presentation of illnesses attributed to * c difficile * the presence of toxin \ - producing * c difficile - in stool is associated with a wide spectrum of gi manifestations, ranging from asymptomatic carriage to pseudomembranous colitis. the high rates of asymptomatic carriage in infants and young children make the diagnosis of * c difficile * \ - associated disease extremely problematic in this age group. a case definition of cdi includes the presence of symptoms ( usually diarrhea ) and either a stool test result that is positive for * c difficile - toxins or colonoscopic findings demonstrating pseudomembranous colitis. watery diarrhea is the most frequent manifestation of cdi in children. because the toxins produced by * c difficile - can cause intestinal cell water secretion, watery diarrhea may result. however, because the organism is found so frequently in asymptomatic children, it is difficult to prove that * c difficile - is the cause of this syndrome, which is often mild. symptomatic illness may be mild, moderate or severe. while clinical judgment is required to assign severity and guide treatment ( ), mild \ - to \ - moderate illness is usually characterized by watery diarrhea, low \ - grade fever and mild abdominal pain. \ ] mild illness typically involves watery diarrhea without systemic toxicity and, typically, fewer than four abnormal stools per day. \ ] moderate illness is typically four or more abnormal stools per day, with no systemic toxicity ( though mild abdominal pain and low \ - grade fever may be present ). severe disease involves evidence of systemic toxicity ( eg, high \ - grade fever, rigors ). severe illness may be complicated by h
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##ypotension, shock, peritonitis, ileus or megacolon. in this regard, * c difficile - is a well \ - established cause of pseudomembranous colitis. characteristic features include progressively severe diarrhea, abdominal pain, fever, leukocytosis, systemic toxicity, and stool containing blood, mucous and leukocytes. the most severe manifestation of pseudomembranous colitis is toxic megacolon, which may lead to intestinal perforation. severe or fatal disease is rare in children ; however, complications are more likely to occur among neutropenic children with hematological malignancies or those treated with hematopoietic stem cell transplantation, \ ] infants with hirschsprung ’ s disease and patients with inflammatory bowel disease. # laboratory diagnosis * c difficile - disease can only be firmly diagnosed once its toxin ( s ) is identified. however, it is also important to note that children can be asymptomatic hosts of toxin \ - producing strains. it is generally recommended that testing for * c difficile - or its toxins should be performed only on diarrheal stool, unless ileus due to * c difficile - is suspected. while bacterial culture has been the benchmark for other forms of testing, it is not clinically practical for testing cdi due to the slow turnaround time. also, while the overall sensitivity of culture testing is approximately 95 %, \ ] its specificity is low. laboratory testing methods have been reviewed. tests used for diagnosis are : - the enzyme immunoassay ( eia ) for glutamate dehydrogenase ( gdh ), which is present in almost all strains of * c difficile *, including strains that do not produce toxin ; - eia for toxins a and b ; and - a cell cytotoxin assay that typically demonstrates cytotoxicity of stool for human foreskin fibroblast cells. - molecular assays based on nucleic acid amplification tests ( naat ) eia toxin testing has been the primary mode of testing until recently but is hampered by its lack of sensitivity, while cytotoxin assays are labour \ - intensive and expensive. a strategy that has been proposed is a two \ - step method using gdh \ ] \ ] as the
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3ac241b5cbe8fbda76808419bc8fb8845784b6ef
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initial screening, followed by the toxin eia or ( preferably ) a cell cytotoxin assay as the confirmatory test for gdh \ - positive stool specimens. polymerase chain reaction testing is rapid, sensitive and specific, and appears promising in addressing toxin testing concerns. \ ] \ ] significant variations exist in testing methodologies and kits used in different canadian laboratories. while polymerase chain reaction testing is increasingly being used, further evaluation of its utility in different settings is warranted. naats have sensitivity and specificity comparable to eias and do not have to be part of a multi \ - step testing algorithm. while many centres are moving to naats, additional paediatric data are warranted, given the asymptomatic carriage of toxigenic strains of * c difficile - in children \ < 5 years of age. # preventing cdi a detailed review of strategies to prevent cdi is beyond the scope of this statement, and current protocols have been summarized elsewhere. \ ] infection prevention and control strategies are important for preventing the spread of cdi. strategies include but are not limited to : - meticulous hand hygiene ; - identifying and removing environmental sources of * c difficile *, and using chlorine \ - containing or other sporicidal cleaning agents to eliminate environmental contamination in areas associated with increased rates or outbreaks of cdi. alcohol \ - based hand hygiene products do not kill * c difficile - spores ; - contact precautions for the duration of symptoms ( 48 h with no diarrhea ) ; - use of private rooms or cohorting. stool should not be retested once symptoms abate. the decision to isolate patients should be based on symptoms alone because stools often remain toxin \ - positive despite cure. while several factors contribute to the risk for cdi, the importance of antimicrobial pressure cannot be overstated. the implementation of antimicrobial stewardship initiatives in institutions is regarded as a key step in reducing cdi risk. \ ] emerging data from meta \ - analyses suggest that probiotics may be beneficial in preventing cdi. \ ] \ - \ ] however, additional research is needed to better define which probiotics work the best and in which patient groups, including children. \ ] much of the evidence for treatment approaches to cdi has been derived from adult populations and extrapolated to children. however, the vast differences between cdi in
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3ac241b5cbe8fbda76808419bc8fb8845784b6ef
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infants and young children versus adults limit this approach. the high frequency of * c difficile - and its toxins in the gi tract of healthy infants and children confounds the diagnosis of * c difficile - disease in a child with mild \ - to \ - moderate watery ( nonbloody ) diarrhea with toxin present in the stool. in many cases, the illness resolves without specific treatment. even if a decision is made to treat * c difficile *, clinicians should be aware of the possible presence of another pathogen. in all cases of antibiotic \ - associated diarrhea, the offending agent should be discontinued immediately, if possible. in situations in which antibiotic therapy cannot be stopped ( eg, treatment of infective endocarditis ), an antibiotic less commonly associated with cdi or one from a different class may be considered, when this is feasible without compromising care. one report found that removing antimicrobial pressure on the normal bowel flora was curative in 15 % to 25 % of immunocompetent patients. 6 ] for patients with moderate \ - to \ - severe diarrhea and * c difficile - toxin, specific therapy is indicated. individuals with severe or complicated cdi should be started on treatment as soon as the diagnosis is suspected as opposed to waiting for laboratory confirmation. metronidazole ( given orally ) is the treatment of choice in most cases of * c difficile - colitis in children ( ). in adults, oral vancomycin is the agent of choice for severe * c difficile - colitis. \ ] in the most severe cases, this agent ( given orally, or rectally if ileus is present ) may be used in conjunction with metronidazole ( which can be given intravenously because enterohepatic circulation deposits some drug in the gut ). \ ] vancomycin has no efficacy for cdi if given intravenously. colectomy may be required in intractable cases. treatment does not eradicate * c difficile - or the toxin from the stool. asymptomatic patients, if tested, should not be treated again simply because the stool test is positive. the above agents are associated with clinical relapse rates of 15 % to 35 %. \ ] such relapses do not imply
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drug resistance and, typically, the initial regimen will result in prompt improvement with the first recurrence. the risk of a second recurrence does not appear to be related to the choice of drug ( vancomycin or metronidazole ) used to treat a first recurrence. repeated courses of treatment may be needed in some patients. metronidazole treatment is not recommended for chronic, long \ - term use because of theoretical concerns regarding neurotoxicity. \ ] for the treatment of the second or later recurrence of cdi, a tapered and / or pulse regimen with oral vancomycin is usually preferred. one tapered regimen is as follows : after the usual daily treatment dose of vancomycin for 10 to 14 days, vancomycin is administered at the same mg per dose but given two times per day for one week, then once per day for one week, and finally every two or three days for two to eight weeks. the goal is that * c difficile - vegetative forms will be kept in check while allowing restoration of the normal flora. the management of intractable cases and multiple recurrences is challenging and consultation with individuals experienced in managing these cases is advised. investigational agents have been used with varying degrees of success. some agents ( cholestyramine, colestipol and other anion \ - exchange resins ) bind vancomycin and may render the drug ineffective if used concurrently. rifaximin appears promising, but there is the potential for the development of resistance during treatment. \ ] \ ] rifaximin is not available in canada, but rifampin, which is available, may also have some efficacy. a randomized trial among adults indicated that the use of oral * saccharomyces boulardii - in combination with oral vancomycin or metronidazole decreased the number of recurrences but had no beneficial effect on the initial episode. \ ] the canadian paediatric society has determined that while there is no available current evidence to support the use of probiotics to treat * c difficile - in either children or adults, there may be a role for probiotics in preventing relapses in patients with recurrent cdi. \ ] however, although the risk is believed to be low, the use of * s boulardi
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##i - has been associated with fungemia in immunocompromised patients and in patients with central venous lines. \ ] other agents used to treat cdi include teicoplanin, which is likely to be as effective as vancomycin, \ ] bacitracin and fusidic acid. the latter two agents were shown to be associated with lower efficacy or higher recurrence compared with vancomycin and metronidazole. \ ] \ ] fidaxomicin is now licensed in canada for individuals 18 years of age and older. fidaxomicin is expensive but has been shown to be noninferior to vancomycin for initial treatment of cdi and associated with a lower rate of recurrence only for non \ - nap1 strains. \ ] \ ] other investigational treatment agents include nitazoxanide, tinidazole, intravenous immunoglobulin and fecal transplants. fecal transplants for recurrent cdi have been used successfully and studied in adult patients \ ] \ - \ ] but to a lesser extent in children. \ ] \ ] the use and timing of fecal transplants versus vancomycin taper regimens for recurrent cdi is not known at the present time. in a randomized trial, duodenal infusion of donor feces was found to be more effective for the treatment of cdi than standard vancomycin therapy. \ ] a recent proof \ - of \ - principle study demonstrated that a stool substitute mixture comprising multiple species of bacteria showed promise in the treatment of antibiotic \ - resistant * c difficile - colitis. \ ] further research is warranted on these approaches to treatment. cdi is currently the subject of candidate vaccine trials in europe and north america. \ ] \ - \ ] - * c difficile * \ - associated colitis should be considered in any patient who is receiving or who has received antibiotics within the previous 12 weeks, and who has the following signs : bloody diarrhea with or without systemic toxicity, fever and abdominal pain. - * c difficile * \ - associated diarrhea should be considered in immunocompromised patients who are receiving or have received antibiotics or chemotherapy within the previous 12 weeks, and who have any diarrheal illness ( either watery or bloody ). - * c di
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##fficile * \ - associated diarrhea should only be diagnosed if toxin is detected in the stool. culture of the bacteria is not sufficient evidence to support the diagnosis in symptomatic patients. - the testing of stool samples from asymptomatic patients or from patients whose symptoms have resolved is not recommended ; a positive test is of no clinical significance in these patients. - diarrheal disease in previously healthy infants younger than one year of age is not likely to be due to * c difficile * ; testing for * c difficile - is not routinely recommended for these infants. - in addition to the recommended infection control and prevention measures, \ ] the canadian paediatric society fully supports the implementation of antimicrobial stewardship initiatives in all hospitals as a component of strategies to prevent transmission of cdi. # # first \ - line therapies - mild illness. children with mild * c difficile * \ - associated diarrhea do not require antibiotics. if the illness is precipitated by antibiotics, these should be stopped, if possible. parents should be advised to seek help if symptoms worsen or if a child has not improved within 48 h. - moderate illness. the treatment of choice for initial episodes of moderate cases of * c difficile * \ - associated colitis ( along with discontinuing the offending antibiotic, if possible ) is oral metronidazole ( 30 mg / kg / day in four divided doses for 10 to 14 days ; maximum 2 g / day ). - severe illness. the treatment of choice for severe, uncomplicated * c difficile * \ - associated colitis ( along with discontinuing the presumed offending antibiotic, if possible ) is oral vancomycin ( 40 mg / kg / day in four divided doses for 10 to14 days ; maximum 500 mg / day ). - treat severe, complicated cdi ( with ileus, megacolon, shock, peritonitis or hypotension ) with vancomycin ( oral, or rectal if ileus is present ; 40 mg / kg / day in four divided doses for 10 to 14 days ; maximum 500 mg / day ) * and - with intravenous metronidazole ( 30 mg / kg / day in four divided doses for 10 to 14 days ; maximum 2 g / day ).
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- the regimens used to treat patients with first episodes of c difficile \ - associated colitis can be repeated for the first recurrence or one can use oral vancomycin. * second or later recurrences * - second or later recurrences should typically be treated with vancomycin, using a tapered and / or pulsed regimen. an acceptable tapered regimen is as follows : - 40 mg / kg / day in four divided doses for 10 to 14 days - ( 10 mg / kg per dose, maximum 125 mg / kg per dose ) ; then - 10 mg / kg per dose twice per day for one week ; then - 10 mg / kg per dose once per day for one week ; and finally, - 10 mg / kg per dose every two or three days for two to eight weeks. # # second \ - line and experimental therapies - beyond the use of metronidazole and vancomycin as above, other therapies should only be considered on a case \ - by \ - case basis and in consultation with a specialist in infectious diseases.
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81dcea4c989936bddea0a6466a7ba42335c18f59
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croup is one of the most common causes of upper airway obstruction in young children. it is characterized by sudden onset of barky cough, hoarse voice, inspiratory stridor and respiratory distress caused by upper airway inflammation secondary to a viral infection. published guidelines for the diagnosis and treatment of croup advise using steroids as the mainstay treatment for all children who present to emergency department ( ed ) with croup symptoms. dexamethasone, given orally as a single dose at 0 \. 6 mg / kg, is highly efficacious in treating croup symptoms. despite the evidence supporting the use of steroids as the cornerstone of croup treatment, there is significant practice variation among physicians treating croup in the ed. this practice point discusses evidence \ - based management of typical croup in the ed. # background and epidemiology most children with croup have mild and short \ - lived symptoms, with \ < 1 % of cases experiencing severe symptoms. however, croup accounts for significant rates of ed visits and hospitalizations in canada, with one population \ - based study in alberta reporting that 3 \. 2 % to 5 \. 1 % of all ed visits in children \ < 2 years of age were related to croup. less than 6 % of children presenting to ed with croup symptoms require hospitalization and when they are admitted, it is usually for a short stay. endotracheal intubation is rare ( at 0 \. 4 % to 1 \. 4 % of hospitalized cases ) and death is exceptionally rare ( at 0 \. 5 % of intubated cases ). there is considerable variation in clinical practice for croup. in small canadian centres, children with croup are less likely to receive steroids than in larger centres, while the use of antibiotics and beta \ - agonists ( which are rarely indicated in the care of children with croup ) is more frequent than in larger centres. # etiology and pathophysiology croup is caused by viral infections of the respiratory tract and most commonly by parainfluenza types 1 and 3 viruses. other implicated viruses are influenza a and b, adenovirus, respiratory syncytial virus and metapneumovirus. these infections cause generalized airway inflammation and edema of the upper airway mucosa. the sub
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##glottic region becomes narrowed, causing upper airway obstruction and the symptoms typically associated with croup. # clinical presentation classical croup symptoms have a rapid onset and include barky cough, inspiratory stridor, hoarseness and respiratory distress. nonspecific symptoms of an upper respiratory illness usually precede the typical croup symptoms, which often worsen at night. typical croup usually affects children between 6 months and 3 years of age. symptoms are short \ - lived, usually lasting 3 to 7 days. in 60 % of patients, the barky cough disappears after 48 hours. in \ < 5 % of cases, symptoms may last longer than five nights and \ < 5 % of children experience more than one episode. in canada, croup season peaks over the fall and winter. # differential diagnosis children who present with croup at \ < 6 months of age or whose symptoms are recurrent, prolonged or unusually severe require further assessment to rule out congenital or acquired airway narrowing. prolonged duration of croup symptoms associated with fever may be seen with secondary bacterial infection. less than 1 % of children with croup have severe or life \ - threatening symptoms, but there are several other life \ - threatening conditions that may present with stridor. toxic appearance, drooling and dysphagia are important red flags suggestive of more serious conditions ( ). the severity of the child ’ s respiratory distress on presentation to the ed should guide management ( ). clinical scores used in research studies have not been shown to improve clinical care. most clinicians characterize respiratory distress as mild, moderate, severe or impending respiratory failure. using this classification, an algorithm for the outpatient management of croup in children was developed through expert consensus. children presenting with severe distress or impending respiratory failure should be referred to paediatric intensive care or to anaesthesia for advanced care when clinical response to initial treatment is poor or not sustained. # # general care children should be made comfortable and health care providers must take special care not to frighten them during assessment and treatment. there is no evidence to support the treatment of croup with the use of humidified air. mist tents separate children from their caregivers, can disperse fungus and therefore are not recommended. the use of antipyretics is beneficial for reducing fever and discomfort. the clinical benefit of corticosteroids in croup is well established \
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- and should be considered for treating all children presenting with croup and symptoms ranging from mild to severe. improvement generally begins within 2 to 3 hours after a single oral dose of dexamethasone and persists for 24 to 48 hours. one recent cochrane review analyzed results from 38 randomized controlled trials ( n \ = 4299 \ ) associating corticosteroids with clinical improvement as measured by westley croup scores at 6, 12 and 24 hours. dexamethasone was the corticosteroid tested in most ( 31 / 38 \ ) of these clinical trials. two studies compared oral dexamethasone with oral prednisolone. in one study, dexamethasone was found to be superior, and in the other, both therapies were equally effective. administering corticosteroids by the oral or intramuscular route is as efficacious or superior to the nebulized form of medication. adding inhaled budesonide to oral dexamethasone was not found to provide extra benefit in children admitted with croup. from a practical perspective, oral dexamethasone is less associated with vomiting. the oral route is preferred. when the child with croup has persistent vomiting or significant respiratory distress, administering corticosteroids by the intramuscular route may be indicated. the dexamethasone dose used in most clinical trials is 0 \. 6 mg / kg / dose. it is unclear from studies using doses of 0 \. 15 mg / kg to 0 \. 3 mg / kg whether these smaller doses are equally effective. one meta \ - analysis of six studies suggested that a higher dose could be more beneficial in children with severe disease. overall, children treated with corticosteroids have fewer return visits or admissions to the hospital. fully one \ - half of children with mild croup treated with corticosteroids are unlikely to need further medical care for ongoing symptoms. their sleep is improved and their parents report less stress. in children with moderate to severe croup treated with corticosteroids, there was a reported average reduction of 12 hours in length of stay in the ed or hospital. there was a 10 % reduction in the need for treatment with nebulized epinephrine and a 50 % reduction in both the number of return visits and in hospitalization rates. there have been no adverse events associated
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with a single dose of corticosteroids for treatment of croup. nebulized epinephrine is recommended for moderate to severe croup. reports of administering epinephrine in children with severe croup have demonstrated a lower number of cases requiring intubation or tracheotomy. when compared with a placebo, nebulized epinephrine improved signs of respiratory distress within 10 to 30 minutes of initiating treatment. clinical effect is sustained for at least 1 hour, but disappears after 2 hours. the first prospective trial assessing safe discharge after treating paediatric outpatients with a combination of dexamethasone and nebulized epinephrine, and including observation for 2 to 4 hours, supported the safety of this measure. there were no adverse outcomes. these results, along with data from two retrospective cohort studies, clearly support the safe discharge of children, providing that symptoms of croup do not recur 2 to 4 hours after treatment. traditionally, racemic epinephrine has been used to treat children with croup. racemic epinephrine is not readily available in canada. however, one randomized controlled trial demonstrated that nebulized 1 : 1000 l \ - epinephrine is safe and equally effective. equivalent doses of either 0 \. 5 ml racemic epinephrine or 5 ml of 1 : 1000 l \ - epinephrine are equally effective. these standard doses can be used in all patients irrespective of their age and weight. a heliox or helium \ - oxygen mixture can reduce respiratory distress in children with severe croup. a possible mechanism of action is that the lower density of helium gas decreases airflow turbulence in a narrowed airway. heliox is occasionally used in severe cases to avoid intubation. heliox has not been shown to improve croup symptoms when compared with standard treatments and therefore is not routinely recommended. # # other therapies
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ce257cc15132c7300718598840c5524d9eb1b8f4
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head lice ( * pediculus humanus capitis * ) infestations are not a primary health hazard or a vector for disease, but they are a societal problem with substantial costs. diagnosis of head lice infestation requires the detection of a living louse. although pyrethrins and permethrin remain first \ - line treatments in canada, isopropyl myristate / st \ - cyclomethicone solution and dimeticone can be considered as second \ - line therapies when there is evidence of treatment failure. head lice ( * pediculus humanus capitis * ) are a persistent and easily communicable cause of infestations, particularly in school \ - aged children \ \. unlike body lice, head lice are not a primary health hazard, a sign of poor hygiene or a vector for disease \ \, but they are a common societal problem \ and relatively expensive to treat. the annual cost of treating head lice in the united states is estimated to be at least us $ 500 million \. the present practice point updates a previous canadian paediatric society document from 2008 \ and highlights newer treatment products. it also reviews more recent information concerning treatment failures. head lice are wingless, 2 mm to 4 mm long ( as adults ), six \ - legged, bloodsucking insects that live on the human scalp \. infested children usually carry less than 20 mature head lice ( and often \ < 10 \ ) at a time, which live 3 to 4 weeks if left untreated \ \ \. head lice live close to the scalp surface, which provides food, warmth, shelter and moisture \ \. the head louse feeds every 3 to 6 hours by sucking blood, injecting saliva simultaneously. after mating, the adult female louse can produce five or six eggs ( nits ) per day for 30 days, each ‘ glued ’ to a hair shaft near the scalp \ \. the eggs hatch 9 to 10 days later into nymphs that molt several times over the next 9 to 15 days to become adult head lice \. the hatched empty eggshells remain on the hair but are not a source of reinfestation. nymphs and adult head lice can survive for only 1 to 2 days away from the human host \. while eggs can survive away from the host for up to 3 days, they
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require the higher temperatures found near the scalp to hatch \. an infestation with lice is called pediculosis and usually involves less than 10 live lice \. itching occurs if the individual with lice becomes sensitized to antigenic components in the saliva injected as the louse feeds \ \. on the first infestation, sensitization commonly takes 4 to 6 weeks \ \. however, some individuals remain asymptomatic and never itch \. in cases with heavy infestations, secondary bacterial infection of the excoriated scalp may occur. head lice are spread mainly through direct head \ - to \ - head ( hair \ - to \ - hair ) contact \ \. lice do not hop or fly, but can crawl rapidly ( 23 cm / minute under natural conditions ) \. the role of fomites in transmission is controversial \. two studies from australia suggest that in the home, pillowcases present only a small risk \, while in the classroom, carpets pose no risk \. pets are not vectors for human head lice \. because head lice move quickly, their detection requires a degree of expertise and experience. one israeli study \ involving experienced parasitologists found that using a fine \ - toothed lice comb was four times more effective and twice as fast as visually examining the scalp to detect live head lice and diagnose an infestation. another study \ documented that health care providers and lay personnel frequently overdiagnose or misdiagnose pediculosis \ and often fail to distinguish active from past infestations, particularly when relying on nit detection only. school nurses were adept at spotting nits but less able to distinguish active from past infestations. a viable nit is most likely to be found less than 0 \. 6 cm away from the scalp \. it is seen on microscopy as an intact, hydrated mass or developing embryo \. without microscopy, the ability to distinguish viable from nonviable nits is difficult, which is why diagnosing an infestation by nit detection alone is not reliable \. finding nits close to the scalp is, at best, a modest predictor of possible active infestation. while one study from georgia \ found that having ≥5 nits within 0 \. 6 cm of the scalp was a risk factor for infestation in children, \ < 32 % of such cases were
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actively infested \. for children with less than five nits close to the scalp, only 7 % became actively infested. therefore, having nits close to the scalp does not necessarily indicate that a live infestation is underway or will occur. well \ - established treatment options for a proven head lice infestation include topical insecticides and oral agents. noninsecticidal products that have been approved by health canada since the last canadian paediatric society statement was published in 2008 can all be obtained over the counter. lists the topical insecticides ( pyrethrins and permethrin 1 % ) currently available in canada for treating head lice infestations, with their active ingredients, methods of use and other guidance. two other products, malathion lotion ( 0 \. 5 % ) and crotamiton lotion ( 10 % ), are not available in canada. both pyrethrins and permethrin have minimal percutaneous absorption and favourable safety profiles \. to minimize exposure elsewhere on the body to a topical insecticide, do not sit a child in the bath to rinse hair. instead, protect the skin with towels and rinse well, using cool water. lindane is no longer considered acceptable therapy for head lice because of the potential risks for neurotoxicity and bone marrow suppression following percutaneous absorption \ \. the food and drug administration in the usa has issued periodic advisories concerning the use of lindane \ - containing products for the treatment of lice and scabies. neurological side effects have been reported in people who used lindane correctly, although the most serious outcomes, including death and hospitalizations, occurred after multiple applications or oral ingestion. a safe interval for the reapplication of lindane has not been established \. the pharmaceutical use of lindane has also been banned in california since 2002 due to concerns about its presence in waste water. a follow \ - up study published in 2008 showed a marked reduction of lindane levels compared with levels before the california ban \. the who has recently recategorized lindane as a probable carcinogen \. an increasing resistance of head lice to pyrethrins, permethrin and lindane has been reported. in 2010, marcoux et al. \ found a resistant allele ( r allele ) frequency in 133 of 137 head lice populations tested for
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canada, which could explain treatment failure rates. however, because these products are effective in more cases than these data imply, the precise relationship between r allele and treatment failure remains unclear. rule out the following much more common possibilities before considering resistance \ \ : - misdiagnosis or over \ - diagnosis. a true diagnosis requires detecting live lice before treatment ; and - reinfestation after a previous treatment. if two permethrin applications 7 days apart do not eradicate live lice, consider administering a full treatment course using a medication from another class. note especially that topical insecticides may normally cause scalp rash, itching or a mild burning sensation \. be sure to remind families that itching after treatment with a topical insecticide is not a symptom of reinfestation. as with the initial diagnosis, diagnosing a reinfestation requires the detection of live lice. if post \ - treatment itching is bothersome, a topical steroid and / or an antihistamine may provide relief \. topical noninsecticidal products health canada has approved the use of a new noninsecticidal product containing isopropyl myristate 50 % and st \ - cyclomethicone 50 % ( resultz, nycomed \ - takeda canada inc. ) for the treatment of head lice in children ≥4 years of age. this product works by dissolving the insect ’ s waxy exoskeleton, causing dehydration and death. the product is applied to a dry scalp and rinsed off in 10 minutes. because this product is not ovicidal, a second application 1 week later is recommended. several small phase ii trials ( 200 to 300 participants only ) have demonstrated efficacy and minimal side effects, the most common being mild erythema and pruritis of the scalp \ – \. a noninsecticidal product containing 92 % concentration of silicone oil dimeticone ( nyda ) is also available in canada \ \. silicone oil dimeticone affects the insect ’ s breathing apparatus and is effective against lice, nymphs and egg embryos. a second treatment is recommended after 8 to 10 days. this product is not recommended for use in children less than 2 years of age. to date, neither toxicity nor resistance are reported to be at issue. benzyl alcohol lotion 5 % ( ulesfia lotion ) is also approved for
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use in canada. benzyl alcohol is highly effective against live lice but is not ovicidal. a second treatment 9 days after the first treatment is required for a full treatment course. benzyl alcohol lotion is approved for use in individuals 6 months to 60 years of age, and skin irritation is the only common side effect \. this product is quite expensive compared with most other head lice treatments. oral head lice therapies data to support the use of oral agents in treating head lice are limited. although trimethoprim \ - sulfamethoxazole was used to treat head lice in one randomized trial \, both alone and in combination with topical permethrin, concerns have since been raised about the diagnostic criteria used and this drug ’ s potential for promoting bacterial resistance and reducing its value in other settings if use against head lice becomes widespread \. there are no published large trials for trimethoprim \ - sulfamethoxazole, and it is not approved for use in canada against head lice. there have been reports \ \ regarding both the oral and topical use of ivermectin, an antihelminthic agent, to treat head lice. treatment consists of two single oral doses of 200 µg / kg spaced 7 to 10 days apart. ivermectin is potentially neurotoxic and should not be used in children who weigh less than 15 kg \. this drug is available in canada only through health canada ’ s special access programme \. while topical ivermectin 0 \. 5 % is now available in the united states, it is not yet approved in canada. a study of concentrations from 0 \. 15 % to 0 \. 5 % found best results of being louse \ - free with 0 \. 5 % \. a second study of 0 \. 5 % topical ivermectin found 94 \. 9 % of treated individuals to be louse \ - free after 2 days. occasional cases of minor eye irritation and mild skin burning were the only reported side effects \. there is little evidence to support wet combing as a primary treatment for head lice \ \. in a randomized trial of 4037 school children in wales, uk \ the mechanical removal of lice by combing wet hair with a fine \ - toothed comb every 3 to 4 days for 2 weeks was compared with two applications of topical 0 \
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. 5 % malathion lotion, 7 days apart \. wet combing resulted in a cure ( no detection of live lice after 2 weeks ) in 38 % of cases, while the malathion treatment cured 78 % of cases \. another study combining wet combing with topical 1 % permethrin treatment did not improve on results obtained with permethrin treatment alone when assessed at day 2, 8, 9 and 15 ( combing 72 \. 7 %, no combing 78 \. 3 % ) \. while vinegar has been suggested as a home remedy to aid wet combing, there are no studies showing its benefit. a number of household products, such as mayonnaise, petroleum jelly, olive oil, tub margarine and thick hair gel, have been suggested as treatments for head lice. applying a thick coating of such agents to the hair and scalp and leaving it on overnight theoretically occludes lice spiracles and decreases respiration \. however, these products are not very effective at killing of lice compared with topical insecticides \. there are no published trials on the safety or efficacy of such home remedies. while natural products ( e. g., tea tree oil ) and aromatherapy have been used to treat head lice, efficacy and toxicity data are not available to support either therapy \ \. one small study in israel \ found that a product containing coconut, anise and ylang ylang oils, applied to hair three times at 5 \ - day intervals, was as successful as the control pediculicide. using flammable, toxic and dangerous substances like gasoline or kerosene to treat head lice or using products intended for treating lice in animals are not recommended under any circumstances. school and child care head lice and nit policies there is no sound medical rationale for excluding a child with nits or live lice from school or child care. a full course of treatment and avoiding close head \ - to \ - head activities are recommended. the american academy of pediatrics and the public health medicine environmental group in the uk also discourage ‘ no nit ’ school policies \ \ \. the families of children in the same classroom or child care group where a case of active head lice has been detected should be alerted. information on diagnosis and management of head lice from a credible source should be shared, along with clear messages that head lice are neither a disease
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risk nor a sign of lack of cleanliness. the role of environmental decontamination data on whether disinfecting personal, school or household items decreases the likelihood of reinfestation are lacking \ \. because lice live close to the scalp, nits are unlikely to hatch at room temperature \ \ and environmental cleaning is not warranted. at most, washing items in close or prolonged contact with the head ( e. g., hats, pillowcases, brushes and combs ) may be warranted. wash such items in hot water ( ≥66°c ) and dry them in a hot dryer for 15 minutes. storing any item in a sealed plastic bag for 2 weeks will kill both live lice and nits \ \. the role of health care providers given the prevalence of head lice infestations and the anxiety they cause — for children, parents and child care or school staff — health care providers are uniquely qualified to dispel myths and provide accurate information on diagnosis, misdiagnosis and management strategies \. be sure to reinforce with parents and local school authorities that while head lice infestations are common, they do not indicate uncleanliness or spread disease. clinicians should provide parents with the most up \ - to \ - date information on head lice, helping to dispel long \ - held myths. key messages include : - head lice infestations are common in school children but are not associated with disease spread or poor hygiene. - head lice infestations can be asymptomatic for weeks. - misdiagnosis of head lice infestations is common. diagnosis requires detection of live head lice. detecting nits alone does not indicate active infestation. - environmental cleaning or disinfection following the detection of a head lice case is not warranted. head lice or nits do not survive for long away from the scalp. clinicians should provide the following advice about treatment of head lice : - treatment with an approved, properly applied, topical head lice insecticide ( two applications 7 to 10 days apart ) is recommended when a case of active infestation is detected. - when there is evidence of treatment failure — detection of live lice — using a full course of topical treatment from a different class of medication is recommended. - the scalp may be itchy after applying a topical insecticide but itching does not indicate treatment resistance or a
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reinfestation. - topical insecticides can be toxic. take care to avoid unnecessary exposure and, when indicated, minimize skin contact beyond the scalp. - excluding children with nits or live lice from school or child care has no rational medical basis and is not recommended. - for children ≥2 months of age, permethrin and pyethrins are acceptable treatments for confirmed cases of head lice. dimethicone can be used in children ≥2 years of age. myristate / st \ - cyclomethicone can be used in children ≥4 years of age. benzoyl alcohol lotion is comparatively expensive but can be used in children ≥6 months of age. schools and child care facilities should consider that : - excluding children with nits or live lice from school or child care has no rational medical basis and is not recommended.
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cee156fe753224ab2397d2c72906efeb3765dec7
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- current : dieting in adolescence dieting in adolescence # principal author ( s ) sm findlay ; canadian paediatric society, paediatr child health 2004 ; 9 ( 7 \ ) : 487 \ - 91 concern with weight and shape is extremely common during the adolescent years. in addition to being exposed to the very real health risks of obesity and poor nutrition, teenagers are being exposed to the unrealistically thin beauty ideal that is portrayed in the media. unfortunately, this overemphasis on the importance of being thin is internalized by youth who equate thinness with beauty, success and health. through media exposure, teenagers are also exposed to a number of ways to lose weight and achieve this thin ideal. the sources of information available on health and nutrition are often dubious and unreliable, motivated less by scientific evidence than by fad trends and financial incentives. the net result is that many teenagers feel the cultural pressure to be thinner than is required for good health, and may try to achieve this goal through poor and sometimes dangerous nutritional choices. recent canadian data demonstrate that nearly one \ - half of ontario teenagers ( 12 to 18 years ) attending public school feel unhappy about their weight. even among preadolescents, a significant number of children have a desire to be thinner. it is not surprising, therefore, that strategies aimed at changing one ’ s weight and shape are also extremely prevalent. canadian cross \ - sectional data suggest that more than one in five teenage girls are ‘ on a diet ’ at any given time. american \ -, australian and british data also suggest similar high rates of attempted weight loss among adolescents. a recent review of adolescent dieting indicated that 41 % to 66 % of teenage girls and 20 % to 31 % of teenage boys have attempted weight loss at some time in the past. definition of dieting teenagers ’ reasons for dieting are varied, but body image dissatisfaction and a desire to be thinner is the motivating factor behind the majority. attempts to lose weight can be associated with different behavioural changes such as alterations in eating habits and / or exercise frequency. dieting is a poorly defined behaviour that undoubtedly has various meanings to patients and professionals alike, but to most, it suggests an intentional, often temporary, change in eating to achieve weight loss comparing studies of dieting status and degrees of dieting are problematic due to variations in definitions ; however, there is consistency in defining self \ - induced emesis, laxative use and
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diet pill use as unhealthy or extreme dieting \ -. in many studies, chronic dieting ( more than 10 diets in a year ), fad dieting, fasting and skipping meals are also classified as unhealthy strategies. many authors refer to the use of these behaviours to achieve weight loss as disordered eating if the behaviours are not sufficiently severe to warrant a diagnosis of an eating disorder. the spectrum of behaviours captured by dieting represents a range from healthy to unhealthy. the choices made by a teen on a diet may be consistent with recommendations for healthy living, such as increasing fruit, vegetable and whole grain intake, moderate reductions in fat intake, and increased exercise. however, a significant percentage of teenagers, girls in particular, engage in unhealthy behaviours to control weight. recent canadian data reported that 8 \. 2 % of ontario girls aged 12 to 18 years and 4 % of british columbian girls reported self \ - induced vomiting as a weight control strategy. several large cross \ - sectional studies have investigated the frequency of specific weight control practices \ -. fasting, skipping meals and using crash diets are frequent ( 22 % to 46 % ). self \ - induced emesis has been found to occur in 5 % to 12 % of adolescent girls. laxative and diuretic use is less frequent ( 1 % to 4 % ), as is diet pill use ( 3 % to 10 % ). smoking cigarettes to control weight is reported by 12 % to 18 % of adolescent girls. risk factors for dieting determinants of dieting in teenagers are broad, therefore, identifying which teenagers are most at risk of dieting and health \ - compromising weight loss strategies is challenging ( ). in general, dieting and disordered eating behaviours in teenagers increase in frequency with age and are more prevalent among girls. although there are some variations in socioeconomic status and ethnic groups, it is clear that no group is immune from body dissatisfaction and weight loss behaviours. not surprisingly, girls who consider themselves overweight and are dissatisfied with their bodies are more likely to diet and are also more likely to engage in unhealthy weight loss behaviours. as the degree of overweight increases, so does the risk of dieting and disordered eating. however, despite this association, it is important to recognize the high prevalence of dieting among normal and even underweight teenagers. in one cross \ -
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sectional american study, 36 % of normal weight girls were dieting, compared with 50 % of overweight girls and 55 % of obese girls. distortion of body image is common among adolescents who frequently ‘ feel fat ’ even at a normal weight. it is clear that the perception of being overweight is a factor in a teenager ’ s decision to attempt weight loss, regardless of whether they are actually overweight. the majority of canadian teenagers are at a normal weight, and many dieting teenagers seen in a clinical setting are, in fact, in a healthy weight range. there are many individual factors that distinguish dieters from nondieters. in several large cross \ - sectional studies \ -, self \ - esteem was found to be a strong factor differentiating teenagers who engage in unhealthy weight control practices from those who do not, even when controlled for body mass index ( bmi ). these same studies report that other positive attributes, such as having a sense of control over one ’ s life, family connectedness, having positive adult role models and positive involvement in school, protect youth from unhealthy dieting. not surprisingly, studies \ - have also shown that parental criticism of a child ’ s weight, pressure to diet and parental role modeling of dieting are associated with increased dieting rates and increase risk of extreme dieting behaviours. body dissatisfaction and unhealthy weight loss practices have been found to be more common in teenagers affected by a chronic illness ( diabetes, asthma, attention deficit disorder and epilepsy ). teenagers who experience significant psychiatric symptoms, particularly depression and anxiety, are more likely to engage in extreme dieting practices. a history of weight \ - related teasing is also predictive of body dissatisfaction, weight loss attempts and eating disturbance. peer group influence also has an impact because girls whose friends value thinness and engage in unhealthy weight loss strategies are also themselves more likely to engage in unhealthy weight control strategies. vegetarianism in adolescence is associated with some positive nutritional choices, such as increased fruit, vegetable and fibre intake ; however, girls who are vegetarians are more likely to report dieting and certain disordered eating behaviours, such as self \ - induced emesis and laxative use. for some teenagers, vegetarianism may occur along with unhealthy eating behaviours. other identified risk factors include involvement in weight \ - related sports, such as dance and gymnastics, and early puberty. studies have
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demonstrated that teenagers who engage in other risk activities, including substance use, unprotected sex and illegal activity, are also more likely to engage in health \ - compromising weight loss strategies. a prospective study also found that adolescent girls who are concerned about their weight or who are dieting are more likely to initiate smoking. this evidence suggests that disordered eating in teenagers clusters with other health \ - compromising behaviours. consequences of dieting although adolescent dieters may make some positive choices, changes are often temporary and we must consider possible physiological and psychological adverse effects of dieting, particularly, in light of the evidence that dieting is unlikely to be effective at achieving sustained weight loss. the majority of teenagers who diet do so without any apparent sequelae, but they may be putting themselves at risk of consequences with little chance of tangible benefit. unfortunately, few studies have addressed possible negative consequences because most dieting in teenagers is done in an unstructured way and decisions on how to go about losing weight are haphazard and often short \ - lived. several reviews of the consequences of dieting have been undertaken, but unfortunately, the conclusions pertain to dieting adults, in whom rapid physical and psychological change is not occurring. # physical consequences dieting is associated with potential negative physical health consequences. nutritional deficiencies, particularly of iron and calcium, can also pose short \ - and long \ - term risks. in growing children and teenagers, even a marginal reduction in energy intake can be associated with growth deceleration. disordered eating, even in the absence of substantial weight loss, has been found to be associated with menstrual irregularity, including secondary amenorrhea in several cross \ - sectional studies \ -. the long \ - term risk of osteopenia and osteoporosis in dieting girls, even in the absence of amenorrhea, is of considerable concern as well. the medical complications of any purging behaviour, such as self \ - induced emesis, laxative use or diuretic use, are well \ - established, as are the risks associated with stimulant weight loss medications. # psychological consequences the short \ - and long \ - term psychological effects of dieting and food restriction on adolescents is largely unknown. studies in adults suggest that chronic dieting is associated with a variety of symptoms including food preoccupation, distractibility, irritability, fatigue and a tendency to overeat,
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even binge eat. while it is not known if these effects are also true for children and youth, these symptoms could have serious implications on the immature adolescent who is undergoing rapid social and psychological development. many lifestyle habits are established during the adolescent years and alterations in the eating habits of children and adolescents could have lifelong implications for dysfunctional eating. it is recognized that teenagers with lower self \ - esteem are more likely to diet, often in an attempt to feel better about themselves if weight loss is successful. the process of dieting may make the situation worse and have a further negative impact on the young person ’ s self \ - esteem because, during childhood and adolescence, self \ - esteem is, in part, defined by successes and failures. one study examined the self \ - esteem of children before and after participation in a structured weight loss program and concluded that a decline in self \ - esteem and perception occurred. an adolescent study found that self \ - esteem was negatively impacted by participation in a 12 \ - week multidisciplinary weight loss program for obese teenagers. these studies were small and it is not possible to draw conclusions, but we should consider the negative impact of dieting, particularly unsuccessful dieting, on a young person ’ s self \ - esteem. there are no data available on the impact of self \ - directed dieting on the self \ - esteem of youth. one of the most worrisome issues to be considered is the relationship between dieting, disordered eating and eating disorders. teenage dieting is the usual antecedent to anorexia and bulimia nervosa. in prospective studies, dieting has been associated with a fivefold to 18 \ - fold increased risk of developing an eating disorder. however, it is unclear whether dieting causes, triggers or represents the first stage ( prodrome ) to the illness. the relationship between dieting and binge eating is also controversial. the national task force on the prevention and treatment of obesity concluded in 2000 that in overweight and obese adults, dieting was not associated with eating disorder symptoms including binge eating. the review focused mainly on adults in structured weight loss programs and did not address the widespread use of self \ - directed dieting or the impact of dieting on children and adolescents. several other studies have documented the risk of binge eating among dieting teenagers and a review of the psychological consequences of food deprivation in adults concluded that deprivation resulted in a tendency to overeat
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and even binge eating. finally, there is mounting concern that dieting in preadolescents and adolescents may have the paradoxical effect of resulting in excess weight gain over time. in a recent large \ - scale study involving over 15, 000 children ( nine to 14 years old ) followed over a three \ - year period, it was observed that dieters gained significantly more weight than matched nondieters. the authors concluded that self \ - directed dieting in this age group was not only ineffective, but may promote weight gain. summary and recommendations to clinicians weight dissatisfaction is frequent for teenagers in north america. behaviours to control weight are very common and exist on a spectrum from healthy to potentially dangerous. the most important risk factors for unhealthy weight control behaviours are dissatisfaction with weight, obesity and low self \ - esteem. teenagers who engage in unhealthy dieting are at risk for other health \ - compromising behaviours, including substance use, smoking and unprotected sex. most dieting in teenagers is not associated with negative consequences but we must consider the physical and psychological sequelae, including eating disorders, binge eating and low self \ - esteem. teenagers who diet are at risk of excess weight gain over time. the canadian paediatric society ’ s recommendations are as follows : - for normal and overweight teenagers, encourage eating according to the canada food guide. discourage fad diets, fasting, skipping meals and dietary supplements to achieve weight loss. advise teenagers to be wary of any weight loss scheme that tries to sell them anything, such as pills, vitamin shots or meal replacements. - for normal and overweight teenagers, encourage age \ - appropriate physical activity in accordance with healthy active living guidelines. teach teenagers that there are a variety of reasons to exercise, not just to control weight. - given the high prevalence of dieting behaviours in adolescent girls, screening should be included as part of routine health care. this screening can easily be incorporated into the frequently used adolescent home, education, activities, drugs, dieting, safety, sexuality, suicide / depression ( headdsss ) interview. - teenagers who are concerned about weight or shape should be educated about the difference between ‘ healthy weight ’ and ‘ cosmetically desirable weight ’. for teenagers, these may be very different, because many teenagers want to be thinner than is required for good health. teenagers should be encouraged to accept a realistic weight for themselves. calculating bmi
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and comparing it with bmi percentile curves is the most reliable way to assess whether a teen is in a healthy weight range. - clinicians should be aware that many weight loss attempts in teenagers are not required or justified on the basis of improved health and may reflect other issues in the adolescent ’ s life, such as low self \ - esteem, being teased about weight, family pressure to achieve a certain ideal or a serious psychiatric illness such as an eating disorder. for many dieting teenagers, the behaviour is not really about their weight. - for teenagers engaging in more severe weight loss practices, screening for eating disorders should be done promptly and early referral made for assessment. - educate dieting teenagers about the health risks of self \ - induced vomiting, laxative and diuretic use, diet pills and crash diets. - there is a paucity of data on effective interventions for obese adolescents ; however, assessment and intervention should be undertaken in accordance with evidence \ - based and best practice guidelines. there is no evidence that commercial weight loss programs are safe or effective for children or teenagers. where available, referral to a multidisciplinary paediatric obesity program may be beneficial.
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20ea0a749f6da381ab113d995afc404ce8bfcc47
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pulse oximetry screening is safe, noninvasive, easy to perform and proven to enhance detection of critical congenital heart disease in newborns. however, this test has yet to be adopted as routine practice in canada. the present practice point highlights essential details and recommendations for screening, which research has shown to be highly specific, with low false \ - positive rates. optimal screening for critical congenital heart disease should include prenatal ultrasound, physical examination and pulse oximetry screening. screening should be performed between 24 hours and 36 hours postbirth, using the infant ’ s right hand and either foot to minimize false \ - positive results. newborns with abnormal results should undergo a thorough evaluation by the most responsible health care provider. when a cardiac diagnosis cannot be excluded, referral to a paediatric cardiologist for consultation and echocardiogram is advised. pulse oximetry screening ( pos ) in newborns has been shown to enhance the detection of critical congenital heart disease ( cchd ) –. while many programs around the world have recommended and adopted screening, it is not yet standard practice in canada. this practice point presents highlights and recommendations from a recently published, canadian paediatric society \ - endorsed position statement from the canadian cardiovascular society and canadian pediatric cardiology association. throughout this practice point, the term ‘ newborn ’ includes both term and late preterm infants ( born between 34 0 / 7 weeks and 36 6 / 7 weeks gestational age ) being cared for in locations outside the neonatal intensive care unit ( nicu ). # what is critical congenital heart disease? congenital heart disease ( chd ) is the most common congenital malformation, with a prevalence of 12 / 1000 live births in canada. approximately one \ - quarter of these newborns have cchd, defined as more severe and often duct \ - dependant lesions that require intervention early in life for optimal outcome ( ). # why do we need to do more? early diagnosis remains crucial for cchd because delay increases morbidity, mortality and disability. one us study estimates that 30 % of cchds are diagnosed more than 3 days after birth, while a study from northern england reports 25 % of cchds are diagnosed following discharge from hospital. in a study from sweden, deaths from unrecognized cchd occurred at a rate of 4 \. 6 / 100, 000 live births. a one \ - time survey from the canadian paedia
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##tric surveillance program ( cpsp ) showed that 36 % of responders had been involved in a late \ - presenting cchd case, of which 52 % of the responders recalled the case requiring resuscitation. current screening with prenatal ultrasound is limited by low sensitivity. in alberta, from 2007 to 2010, only 50 % of newborns with chd requiring surgery before 1 year of age were diagnosed prenatally. this detection rate was similar to rates found in large studies in the usa and uk. detection rates are improving overall but are influenced by regional expertise and other mediating factors. physical examination findings may be limited by lack of examiner expertise or confidence, and some types of cchd may not present with clinical features — such as a murmur, cyanosis, tachypnea or laboured breathing — before discharge. a study from norway showed that hospitals without pos were only able to detect 77 % of cchds by clinical features before discharge. # how can pos help? pos can identify otherwise clinically undetectable degrees of cyanosis and should be used adjunctly with prenatal ultrasound and newborn physical examination to reduce the diagnostic gaps in detecting cchds. in one large, multicentre swedish study, hospitals reported a seven times higher positive predictive value with pos compared with physical examination ( 20 \. 69 % versus 3 \. 06 % ) and a much higher likelihood ratio for detecting cchd ( 344 \. 8 versus 32 \. 4 \ ). sensitivities of 82 % to 92 % have been reported by adding pos to prenatal ultrasound and newborn physical examination. applying results from one study that indicated a prenatal detection rate of 50 % of infants with cchds, pos could potentially detect an additional 35 / 100, 000 newborns with these heart anomalies. in canada, where 388, 729 births were reported in 2014, applying an incidence for cchd of 3 / 1000 births and a prenatal detection rate of 50 %, 583 cases of cchd await detection after birth. the implementation of pos could detect an additional 136 cases of cchd per year before the appearance of symptoms. the cpsp survey found that 83 % of the general paediatrician responders were aware of pos but only 26 % were screening. # how does pos measure up as a screening test? pos is safe, noninvasive,
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20ea0a749f6da381ab113d995afc404ce8bfcc47
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easy to perform and widely available. in one systematic review of 229, 421 neonates, pos was shown to have a high specificity ( at 99 \. 9 % ) and a moderately high sensitivity ( at 76 \. 5 % ). studies from the usa and uk also report that pos is cost \ - neutral to cost \ - effective for detecting cchd –. abnormal, particularly false \ - positive ( fp ) pos results can help with detection of other causes of hypoxemia, including important infections and respiratory disorders requiring intervention. the potential reach of pos is comparable to more established newborn screening practices. cchds are as common in newborns as cystic fibrosis ( 0 \. 5 / 1000 births ), hearing loss ( 1 to 3 / 1000 \ ) and hypothyroidism ( 1 / 4000 \ ), and fp rates are similar or better for pos ( at 0 \. 05 % to 0 \. 5 % ) compared with universal newborn hearing screening ( 0 \. 5 % to 4 % ) and newborn thyroid screening ( 2 % ). # who should be screened? all term and late preterm infants should be routinely screened. pos has not been adequately studied in preterm newborns or in the nicu setting relative to cut \ - off values for normal and abnormal. while pulse oximetry is an important monitoring tool for newborns with signs of chd, such as organic murmurs or other cardiac findings, the pos protocol described here is intended for use in asymptomatic newborns in nonacute care settings. # when should newborns be screened? pos can be performed at any time after birth but is recommended for infants 24 hours to 36 hours of age. one meta \ - analysis showed fp rates of 0 \. 05 % screening after 24 hours ( versus 0 \. 50 % before 24 hours ) without significant impact on sensitivity. this 10 \ - fold increase in fp rate could significantly impact resource utilization, especially when transportation is required to access cardiology services. screening between 24 hours and 36 hours allows for flexibility, such that testing becomes part of the daily schedule but does not need to happen in the early morning hours, when a positive result could impact workload and resources unnecessarily. some centres administer pos at the time of the newborn hearing assessment, the first bath, or alongside other routinely scheduled evaluations. screening for
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